Delivering brief interventions for children above a healthy weight

Delivering Brief Interventions for Children above a Healthy Weight

Sammi: Good evening everybody and welcome to this evening’s Brief Interventions for Children above a Healthy Weight webinar. We are joined by our presenters this evening, Ms Stavroula Zandes and Dr James Best. And my name is Samantha and I will be your host for this evening. So, before we jump in I would like to make an Acknowledgment of Country. We recognise the traditional custodians of the land and sea on which we live and work, and we pay our respects to Elders past and present.

Alrighty, so our presenter this evening as I mentioned, is Ms Stavroula Zandes. So, Stav has a background in psychology and counselling and worked with the Cancer Council of Victoria for 20 years in tobacco control in a range of roles including training clinicians to engage in the behaviour change conversation. This inspired her to establish in 2013 Health & Wellbeing Training Consultants, an education and training business. Her training sessions focus on behaviour change and effective communication including motivational interviewing. Stav is currently lecturing and tutoring at Monash University in the School of Public Health and Preventative Medicine. So, welcome Stav.

And our facilitator this evening, Dr James Best. James is the current Chair of the RACGP Child and Young Person’s Health Network. He works as a GP on the south coast of New South Wales and his practice has a paediatric focus. So, thank you for joining us, James.

James: Thank you, Sammi. And welcome to everybody and thank you for attending our webinar this evening. I am just going to run through the learning outcomes as always at the beginning. So by the end of this online activity we should be able to, deliver brief interventions and / or aspects of motivational interviewing when working with children above a healthy weight and their families. We want you to be aware of the environmental and psychosocial effects of being above a healthy weight. We are going to try and use sensitive and non-stigmatising language when talking with children and their families and carers about weight status. And also understand how to utilise available resources and referral pathways to support children who are above a healthy weight where appropriate. So hopefully we will be able to get through those learning outcomes this evening.

Now, what we are going to start out with, is we are just going to do a quick poll just on how confident are you in delivering a brief intervention on weight management for children and their families. So if you can just click on one of those five options from very confident to not confident or do not know, and we will just wait for those answers to come in. And while we are waiting for those answers to come in, we will just have a bit of a think about what are some of the barriers that you have in your practice about delivering you know, that brief intervention on weight management for children and families. What are the things that concern you when it comes to raising the topic and discussing it and what might stop you doing that, in terms of comfort internally from your opinion or your concerns or externally, like things that are in your practice or how your day runs. So we are just waiting for those answers to come through.

Sammi: So I have just closed that off now. We had most people vote so I will just share those results with you now, so that you can see. So we had 0.0% of people say they were very confident. 19% fairly confident, 52% a bit confident, 26% not confident and 4% were not sure. So.

James: So we have kind of got one leg on either side of the fence there a bit.

Sammi: Yes, we certainly do.

James: But no one is very confident, so hopefully we can get that figure up tonight. What do you think of that, Stav?

Stavroula: Yes, absolutely I am really thrilled that people have joined into this evening’s webinar and I am hoping that yes absolutely, you will feel a lot more confident following the session.

Sammi: Awesome. So let us jump right in then and move onto our first slide.

Stavroula: Well, hello everyone and welcome to this evening’s webinar. I am so thrilled that you have taken time out of your evening to spend with us and to focus on delivering brief interventions and supporting families and children to achieve a healthy weight and support them to make some positive lifestyle changes. I wanted to start off though by highlighting the significant investment that New South Wales Health have placed in tackling childhood obesity, and in particular delivering and supporting interventions across four strategic directions as highlighted on the slide. So, not only placing significant investment in community and in schools but also looking at social marketing campaigns, looking at creating healthier environments to enable better choices, but also as part of the work that we are doing, creating a routine advice and clinical engagement strategy which is about the way that we as a whole system manage and prevent childhood obesity. And this webinar has been funded by New South Wales Health and is very much about focussing on the prevention and management of childhood obesity as part of routine clinical care. But also focussing on how we can do this in all New South Wales Health facilities. How we can do this briefly but also effectively so we can engage with the patient and support them to make some positive lifestyle changes. And this is the really important role that you can play as general practitioners, you are part of the healthcare system, you are a trusted source of information and support and we are hoping that tonight’s webinar really gives you the information and the confidence to be able to move forward in this space and support families and children who are above a healthy weight.

So, why is it so important and why is New South Wales Health investing in this area? Because we know that reducing childhood overweight and obesity is a priority due to the very high statistics, and as you can see, childhood overweight and obesity has pretty much doubled from 1985 to 2004 and while rates are now stable, they still remain very high, making this sort of childhood obesity a very important and very serious public health issue. Which means that we all need to engage in the conversation. We all need to sing the same song, whether we are working as a general practitioner, whether we are working within the hospital healthcare setting or whether we are a dental practitioner and we are working to improve the child’s oral health.

So, we also know from the research that it is very difficult to reverse childhood obesity, to reverse obesity. And in particular what I wanted to highlight on this slide is that there are two high risk periods for weight gain, around three years of age where one in four children are above a healthy weight and this is when families are starting to establish their sort of, lifestyle choices that they are making as a family. But we also then have a cohort of young people, teens who during their school years are also developing their independence, they are developing the choices that they are making and this is also a critical intervention period for us to engage with conversation and for us to support some positive lifestyle changes. We know that obesity in childhood and adolescence is a major risk factor and particularly at the extremes of BMI for a range of chronic health issues which we will cover in the next slide.

James: And also, I found this slide, this graph I should say, really interesting Stav. I mean you know, it starts out pretty high. You know, 25% and then you get that big jump in the teenage years. So they are two really different domains rally aren’t they in terms of the way we need to really think about it. We need to think about you know, little kids and getting their behaviours correct and then also establishing that set up for adulthood through the teenage years.

Stavroula: Yes, absolutely. And when we are thinking about those little kids or toddlers, we often hear parents say, oh they are a chubby baby they will be fine, they will grow out of it. But we need to be mindful of those conversations because they may not grow out of it, and that is why it is so important. I am not going to take you through the detail of this slide, you already know this information and how important it is for us to engage in the conversation.

But what I do want to highlight is the psychosocial aspect which tends to fall off the agenda sometimes when we are engaging in this conversation. We know that children who are above a healthy weight often do have poor self-esteem. Often do have poor body image. This can develop into chronic anxiety and depression. We know that they are often stigmatised, whether that is from their peers or their family, or the media, or even health care professionals. And this really impacts a young person’s emotional and psychological wellbeing. And that is why it is very important that we engage in the conversation and we do so in a very respectful and non-stigmatising way.

We also know that if we go to the next slide, that being above a healthy weight impacts school readiness. It impacts participation in school activities and can lead to serious mental health concerns. When you hear and work with occupational therapists or physiotherapists and they tell you stories such as, I am currently working with kids who are struggling to walk to the play area, who are struggling to play with other kids, this is heartbreaking that such a large cohort of the population are struggling to get out there and have some fun in the playground with their peers. So we know that it impacts many aspects of their lives and this is why it is so important that we do have this conversation and do nip it in the bud quite early.

We also need to be mindful that if we go to the next slide, that it is not just about eat less, move more. We often hear this, especially from parents, oh they just need to get off their devices and do some more exercise or they just need to be more mindful of what they are eating. But we also need to be more mindful of the other influences, those other determinants of health that also contribute to children and adults becoming above a healthy weight. We do live…

James: It is all those…

Stavroula: Go on, James.

James: It is a big judgy too I think just to say, eat less and move more, when you have got all these different things you know sort of pushing you in this direction. So we have got to realise that sometimes it is really hard to push back against some of these influences.

Stavroula: Oh absolutely and when you think about our environment and how obesogenic it is, everywhere we go it is very difficult to make a sort of a health promoting or a positive lifestyle choice when you might have junk food that is available at a very cheap price, or you might go into a health care service and there is a vending machine full of soft drinks and maybe the water is quite expensive and you might think, well I will just purchase a soft drink. So, we are living in an obesogenic environment and we need to be mindful of this when we are having these conversations that it is more than just being mindful of what you eat and do a little bit more physical activity.

James: And interesting some of the responses to that initial poll we put up were, you know about parents’ belief that the more weight was fine, or you know, finding the correct language to communicate with people about this. So this is all about these other influences that go into the individual.

Stavroula: Absolutely. And even the cultural influences can play a huge role because culture, how we perceive culture and how being above a healthy weight is perceived within the culture can often sometimes be a bit of a challenge. How am I going to have this conversation with this particular cultural group, where they actually value a chubby baby or they might think, they want him to develop into a rugby player, so they do want him to be quite solid. So we need to be mindful of that as well. So let us have a look at what we can do, so what are we aiming to do in practice and what we are aiming to do, is deliver what we call brief interventions. So we acknowledge that in practice you are pressed for time. You do not have time to have lengthy conversations, so how can we do this quickly and briefly? And how can we do it within a 30 second to a three minute to a five minute mark? How can we also do this however, when there are so many misconceptions, when you might be thinking well I do not have time to deliver this and you might be thinking, I do not want to damage the relationship with my patient? I do not want to upset them, I do not want them to get angry, I want them to come back, I want to have this collaboration and build this ongoing trust and rapport. Or maybe you might be thinking, well you know parents do not want to talk about it, it is a taboo subject, it is quite sensitive. It is becoming normalised now. It is sort of parents think, well my child looks like every other kid in the primary school so I am not sure what you are talking about. So we need to be mindful of these misconceptions and I am sure James you have also heard a lot of these in practice.

James: Oh yes, and I hear it from other GPs and I think it is understandable that we can sometimes think this way, but we have got to remember that brief is brief firstly, and also we are so uniquely placed, we have this huge amount of trust, you know, we have just ranked number one again, the most trusted health profession, just above the pharmacists yet again, fantastic. And so you know, we have this pretty unique position and people actually do trust us generally. So we have this unique opportunity where we can really, you know there are a lot of people out there who do want to talk about it but are too embarrassed. But sometimes you can really get a win by just raising the topic.

Stavroula: Absolutely. And people are looking for that weight management advice, you know being able to set some realistic goals. There is so much information in this space that even health professionals get confused. Are we eating too many eggs, not enough eggs? Do we go for full cream milk, skinny milk? And so can you imagine the public who may have poor health literacy, who may be illiterate in other areas of their life, and now they are wondering whether to follow the paleo diet or some quackery pill that we know has no strong evidence base. So they are looking for GPs in terms of their advice and support around this space, and they trust the information that you are presenting, and they want to know how their child’s growth is progressing just like when you measure a child’s temperature, they ask you, hey Doc, what is the child’s temperature, is little Johnny okay? You know, how is he progressing?

James: Absolutely. And I think that comes back to a basic principal. You need to weigh kids. And you need to graph them, chart their BMIs and I think that is the basic thing that we need to get into good habits like that. That when you go to an optometrist, you expect them to check their visual acuity as the first thing they do. We think here, we should do their growth. It is just the basics.

Stavroula: Absolutely. It is part of standard checks.

James: And it is a good entry point. If they are standing on the scale, A, we can talk about it.

Stavroula: Absolutely. And you can check in how you are going. How are you feeling and have some of those conversation starters which we will look at this evening as part of today’s webinar. We also know from the research with regards to smoking cessation, that having these conversations with GPs and other clinicians provides a great motivator for people to go away and make an attempt. And this also applies to having this conversation. I am going away, you are planting the seed and I am thinking about it because you have asked, you have taken the time to ask me about my health, or ask how little Johnny is progressing. So let us have that conversation and let us move forward in terms of making those positive lifestyle changes.

So, as part of this conversation, there are a number of considerations that we need to mindful of and if we go to the next slide, we do acknowledge that it is a sensitive, clinical discussion. You know I have heard many, many clinicians say it is taboo and I do not want to go there and I do not want to upset my patient. But let me ask you a question. If you do not raise it and do not engage in conversation, what exactly are you saying with your silence? Are you pretty much saying that hey, you know what, little Johnny is above a healthy weight but I do not have time, or I am not going to raise it right now. And possibly that parent might walk away and think, well they have not raised it, little Johnny looks like all the other kids so I am just going to assume that everything is okay and I am going to keep living my life as I am living it. And if we do not raise it, do we lack compassion by saying that it is okay, when it is really not okay? And having been in the space for 20 years in smoking cessation, I remember quite vividly having this same conversation with clinicians about smoking. I am not asking about them about their smoking, I am not asking them to quit. But they have just had a major heart attack. Yes, I know, but I am not going to ask them, it is their choice and their business. Now we do not even blink an eyelid when we reflect on smoking and we ask those questions about smoking cessation. So we are doing the same in this space about checking children and having that conversation if they are above a healthy weight. We know that many parents cannot accurately identify their child’s weight status, but we also know that many health professionals cannot identify a child’s weight status just by looking at the children that they are seeing in practice. We cannot identify them. And that is why we need data. And that is why we need to do the gross assessments. So we are working from some data. We are working from an evidence base and then we can move forward with that type of information. As we have highlighted, parents are comfortable having these conversations with health professionals and it is great to hear and it does not surprise me that GPs have been cited as the most trusted professional. I totally agree with that, and so do patients. So they do feel comfortable. And I think it is your approach. How you engage in the conversation and today’s webinar is all about how we can do this in a very respectful and sensitive way. And of course, we are talking about lifestyle changes. We are not focussing on weight loss. So this is an ongoing conversation where we are reinforcing some of these key themes and principles, reinforcing positive lifestyle changes and just like when we are talking about smoking or you know, taking medication, you do not take one pill and it is all over red rover. It is an ongoing conversation that we are having to ensure that we see long term changes and these changes can be maintained and sustained over time.

So, a number of considerations that we acknowledge. It is important however to do these gross assessments and we have some good data and good research that highlights exactly that, that health professionals only correctly identified children’s weight status 55% of the time, and even those who did correctly identify only eight out of 20 were correct and the same with parents, parents struggle as well. 79% of mothers failed to identify their child as being above a healthy weight and the same with that last dot point. So it is not just health professionals, it is also parents and carers and this is why it is very important that we collect the data, we plot that data on the BMI growth chart, and then we engage in conversation with the parent or the carer.

And if we go to the next slide, what we are also aiming to do is really focus on family-based lifestyle interventions. We are not just focussing on the child. We are focussing on what the family can do together as a team to support these positive lifestyle changes and as you can see from the research or the data there, we see meaningful decreases in overweight in both children and adolescents which is fantastic news as well as significant improvements in their sort of physiology which again is significant in terms of reducing chronic ill health in the long term. And I imagine James, that would see this in practice that when you are having this conversation with families, that you are actually approaching the whole family, that you are not singling out the child.

James: Oh yes, I mean this is normal GP stuff isn’t it? Where I work, I work in Nowra on the South Coast where there is a lot of overweight and obesity and people come in on mass in the family and you have got parents and brothers and sisters and they are all the same shape sometimes, and so, but they are all eating poorly, and they are all making the same habits together. And the parents do not necessarily have insight into that. So if you are educating the child and the parent at the same time, and I think yes, so this is once again normal GP stuff, and it is really delivering it in a positive way that we can get healthier, that we can look better and feel better about ourselves and so rather than judging you know, poor mothering or something like that, you know, it really is a whole family conversation.

Sammi: That is great.

Stavroula: What I love about this – what was that, sorry?

Sammi: Sorry, I was just going to say that that ties in really well. There was a comment that came through that it can be really difficult to talk about it without sounding like it singling out the children but as a whole family, lifestyle intervention, that fits in well.

Stavroula: Absolutely and I was also going to mention that when you are working with adolescents, you know, they are really forming their independence and part of forming that independence is making choices, and you can always have that conversation with the adolescent. What choices are you making? Because every time that you choose a sugary drink or a V drink or those Red Bull Energy drinks, that is a choice that you make. But you could also choose water and how empowering is that for a young person which then can inspire the whole family because the young person might then say, Mum, I prefer you do not buy Coca Cola in droves, maybe let us focus on drinking more water or maybe we could put fruit in a glass of water or in a jug and put that in the fridge. So it works both ways. Adolescents are also supporting their parents and parents are supporting their children.

So what can we do in terms of having these conversations? How can we get our language right? And what is very important in order to not come across as stigmatising or judgy is to use what we call neutral language. So we are moving away from telling people that you are obese or that you are a bit of a chubber, and we are using terminology such as you are above a healthy weight which very much focuses on the health and wellbeing of the individual. Last thing that we want to do it upset people.

James: It is a subtle thing, isn’t? I have even been guilty in this webinar of using the wrong term, so I must apologise for that. I have got to change my language, I have got to say above a healthy weight. And it is subtle, but it probably does make a difference.

Stavroula: Absolutely. And what we know from the research is that this language has been tested with children and their families and they see this as a very neutral way to engage in conversation because it is just talking about, you are above a healthy weight, so what can we do moving forward?

James: It is healthy. You know, that is positive. So we are aiming for positive.

Stavroula: It is very positive and this is the first step, that we are focussing on making positive lifestyle changes to improve your overall health and wellbeing, not only your physical health, but also improve your mental health because now there is also some very strong research linking what we eat to our mental health and vice versa. As part of our conversation with our clients, it is also important to reflect on how we approach the conversations. Now if we go onto the next slide, I have just got some information here about motivational interviewing and a lot of you will already do this intuitively in practice, where you are already asking some open-ended questions where you are acknowledging and validating what your patient is saying. You are already mindful of your body language and this is very important because your patient is reading everything about you. They are reading your visual signs, your facial expressions, your body language and sort of pretty much judging you in those first instances as to whether I am going to listen to what you have to say or pretty much switch off. And I am sure James you have many stories to tell in regards to how our body language affects our communication.

James: Yes. But it really is, it is so often about shutting up as a GP. You have what is called the golden minute at the beginning, you know where you let the patient… because, if you want to change somebody you have got to find out where they are first, and I think this is the core of motivational interviewing. It is where are you? Before we start trying to move you. And there are you know, Peter Evans is an idiot, do not take any notice of him! You have just got to ask, where are you coming from first, and I want to hear what you have got to say.

Stavroula: Absolutely. And that is what I love about motivational interviewing, because you are asking the how? questions or the what? questions. You know, how do you feel about this information I have just highlighted that little Johnny is above a healthy weight – what do you think about that? How do you feel about that? I think it is really important to explore your patients thoughts and feelings because if they believe that BMI does not make sense of is not based on sound evidence, then you can work with that and you can disprove that and highlight what the evidence actually does tell you. Otherwise if you are not exploring their thoughts and their feelings, we will go away and we will have no idea whether we have actually made a difference in conversation because we have not taken the time just to ask them, well what do you think about this? How do you feel? Sometimes I might even say, well what do you think about all of this mumbo jumbo? Just to get them talking. Just to get them thinking about the conversations that we are having. And what I love about motivational interviewing, is that it was designed for the angry patient. It was designed for the patient with resistance, who is possibly in denial, a pre-contemplator. That is the cohort. If you have got a motivated patient, you go straight into action stage.

James: There is a lovely quote from Osler from you know 100 years ago or something where the answer is within the patient. And you know, this was way, way before motivational interviewing was a thing. And you know, but that is true, just let them, where is a patient coming from and they will often come up with it if you just let them talk.

Stavroula: Absolutely. And that is what I love about it. It comes from a strengths-based approach, so we are really tapping into the patient’s strengths and asking them well, what could you do? You have highlighted that you drink four cans of Coke a day. How could you change this? What could you do? How could you replace this with water if that is what you want to do? So we are planting the seed but also asking them to reflect on what they could do. Because you could offer them a million and one suggestions and they will say, yes I have tried that and it did not work, no that is too hard, no failed. Well, what could you do? What could you do? Tell me. Teach me. That can be very, very powerful moving forward.

James: And you get that, to use motivational interviewing jargon, you get that change talk, don’t you?

Stavruola: Absolutely. And that is what we are looking for. That change talk.

James: They probably have got, oh you said I would be able to do this, okay!

Stavroula: Exactly. And that is what I love about it because then you paraphrase, you reflect that back to the patient and the patient thinks, wow, this doctor has actually been listening to what I have to say and they have not gone into advice-giving mode which is the traditional approach where the clinician gives advice. You have come to me for help and I am going to give you your advice. But what happens when we tell people what they should be doing? You know, you should lose weight. You should stop smoking. You should stop drinking.

James: They retreat into the bunker.

Stavroula: Exactly. Yes, they retreat. They put their defences up, their barriers up and I often call them the smiling assassin because now they start to smile and they nod and say, oh yes Stav I will do that and they walk away doing nothing. We do not want any smiling assassins in practice. So let us move on and have a look at, what do you do James to support this conversation, or effective communication in practice?

James: I am always looking for that answer to come out of the patient’s mouth rather than my mouth. Even if I have got to, so I am prompting, prompting, prompting and I have this little image of a soccer ball running along a line or a field, and if the ball starts drifting off one side I just tap it back to the line. So I am just trying to facilitate is the technical expression. Just tapping it along the line just keeping it in the direction I want it to be going. Let us get back to your weight conversation, what do you think? What other concerns do you have? What other thoughts do you have? So, it is really just that tapping along of trying to get the patient… I sometimes use a technique where I am thinking, what percentage of words are coming out of my mouth versus the patient’s mouth. And I am always trying to keep it tilted so that more are coming out of the patient’s mouth.

Stavroula: Yes, absolutely.

James: If they say they are going to do something, they are so much more likely to do it, than if you tell them to do something.

Stavroula: Absolutely. And that is the key theme of motivational interviewing, that it is patient-centred care. We handball it back to the patient and we ask them to reflect on what they will do moving forward. Absolutely. And that is highlighted on this slide. I mean, use your clinical judgement. You do this in practice every day. You do this intuitively and you know, use those opportunities to involve the practice nurses in the clinical flow.

James: Yes, I think the practice nurse is a really good thing and measuring the weight is a real conversation starter. Using graphs, you know, and I think a lot of GPs will weigh in, do the growth and height. A lot of GPs will put them on the weight and height percentiles. I do not think many GPs use the BMI charts which we probably should be, and I think the first thing that I would probably like the audience to reflect on, is that it is another step and I think it is a good step to do.

Stavroula: Yes, and when we get to highlighting the BMI charts I will show case an example as to how you can present this back to the patient. So it actually sticks and they are more likely to sort of go away and think about that conversation that you have been having.

James: And there is a question here from one of our participants tonight, about any reference on BMI and health outcomes in children. You have anything in that direction, Stav? Or maybe we can get back to you on that.

Stavroula: Yes, let us get back to them. Let us keep moving and when we look at the BMI chart I will explore that further in terms of how do we have this conversation.

James: Fantastic.

Stavroula: Okay. So, what is important is that we are mindful of the type of patient that we are seeing. Obviously if we are working with a young person, we will tailor our approach and so too we will tailor our approach when we are working with parents and carers. For a young person, it might be about improving their fitness or playing sport. For a parent, they might be reflecting on, well this is all very well and good, doctor, but I cannot afford to be healthy eating. Because there is a myth that healthy eating is expensive. But we have a fabulous website here, pro.healthykids.nsw.gov.au which is on the screen there below and if you click on this website, there are lots of practical tips and ideas and resources including tips for cost effective cooking and healthy food shopping for families who might be vulnerable who might be thinking about the cost and so on. So, I really encourage you and I will highlight the website a little bit more as we progress through the webinar, but I really encourage you to take a look at that website and in particular have a look at how patients can shop economically and if they are really struggling, do refer them on to a dietician because a dietician can also help them shop more economically as well.

So this also applies to engaging with adolescents. James, how do you engage with adolescents because I sometimes get patients who say yes, whatever or haha, or I am not sure. You know, what do you do in practice to really connect with young people?

James: Yes. I think all GPs really know about that HEADS model for adolescents which works so well, because you are going from the less tricky conversations sort of to the potentially more tricky conversations and also I think there is a really good technique where you do this thing of bridging the consult, where you see that they are coming together with their parent and then you normalise by saying, well normally when I am seeing someone your age I actually have a chat with you for a few minutes by yourself and then get the parent back in afterwards, if that is okay with both of you. And you always get a yes. Or nearly always. And so it just gives that bridging of you are becoming an independent person so you can actually spend some time talking with the doctor by yourself. So I think they are sort of the usual engaging adolescents. I think the language you use is really important with adolescents. You do not try and be an adolescent yourself. And just treat them with respect. I am going to treat you like I would talk to someone who can make their own decisions and I respect what you have got to say. And that really it is a cultural competency. If you think as adolescence as a culture, and I am interested in what you are about and not only am I interested, but I am curious – I love that word, curious – I am curious with respect and so that is really what the adolescent wants to hear. I think if you talk to adolescents in that manner, usually you get a fantastic rapport. Because they are not used to it a lot of the time. And so I think that that can be a really good way to get through to them.

Stavroula: I totally agree and what you have highlighted, those two important points, asking for permission is a great way to engage with all patients very, very quickly, and often you will get a yes, yes that is no problem I am open to it, what do you have to say. But also coming from that place of curiosity, that I am curious about you and I want to learn more about you and you know, what are your interests? What motivates you? What are you passionate about? And sometimes you might talk about something other than health and wellbeing, but that is okay because those few moments that you spend on engaging with a young person will really build your trust and rapport very, very quickly and then you can get to those more difficult or confronting conversations.

James: And if you do have a conversation with them separately, it is really interesting how different the conversations are. Like you know when the parent is not there. It is like they are sort of relaxing, their guard is down. They drop their guard a bit. Oh yes I know, mum is always going on about that, or something. And then they tell you the real reason you know, why they are thinking the way they are thinking. So, yes it can be a really useful way to get through.

Stavroula: Absolutely. So we will keep moving and we do have a case study which we will work from as we take you through the Four A’s approach. So, the Four A’s approach is what we do call a brief intervention model and a lot of you will already be familiar with the Four A’s or the Five A’s. It was initially developed for smoking cessation and has been so successful globally that now they are applying the Three A’s or the Four A’s or the Five A’s to a range of health and wellbeing issues. So I am going to take you through the Four A’s and sort of spend a little bit more time on each of the A’s. And this is very much about providing brief intervention. And this screen shot is what the website looks like, so on the top right-hand corner we have got some online learning modules, we have got some videos which highlight a CG working with a parent, and highlights those difficult patients. And do have a look at the videos when you have a spare moment. They do not go for very long. And then we have a range of resources. So we have BMI growth charts which you can download and print. We have the Eight for a Healthy Weight, or the Eight Healthy Habits fact sheet, and lots of other resources for you to use in your practice when you are working with your patients.

So, let me take you through the Four A’s and then we will work on a case study to put this into practice. So let us start off with the first A which is making an Assessment. So again, this is part of your routine care, what you do already intuitively, where obviously you are seeking permission and then you are measuring the child’s growth and weight, height and growth status and then are plotting their BMI on the growth chart. And that is the chart there to your right which is available again from the website. And this is then when we start to have that conversation about well, you know, what are the results? Where is little Johnny plotting? And even if little Johnny is plotting within a healthy weight range, I think it is very important to acknowledge that and say, well what are you doing as a family to keep little Johnny so well? Because you want to also be mindful and pick up, may be they are not doing so well and maybe something else is going on here. So we are just basically collecting data because we are an evidence based practitioner and then we want to work with this data moving forward. And on the website, you also have a BMI calculator which calculates the BMI for you.

We then move into Advise and if you go onto the next slide, all we are doing here is then having a conversation with the parent. We are exploring little Johnny’s BMI. We are exploring with the parent whether they have heard of this before, whether they have seen this before. We are raising the issue in a non-stigmatising way, and if possible, we start to then highlight a couple of key messages for them to take some action, whether it is about eating breakfast every day or drinking water instead of a sugary drink. So all we are doing here and now is bringing the attention to the growth chart. And what I love about this is that we are now looking at the growth chart. So we do not even have to maintain eye contact with our patient because all our focus is on the chart and we can actually describe this in a traffic light system. If you are working with patients whose literacy may be low, or may not really understand what you are talking about, you could talk about you know, the red as okay, well we need to be mindful of what is going on here and try and nip this in the bud and let us focus on a couple of strategies to move forward.

So we then move into Assistance, where we then start to discuss in a little bit more detail. Now what I love about the Four A’s is that you do not have to do all of this in sort of, in order. They are not static. You can move from one A to the other, and you can move through the A’s quite quickly, or you may decide to spend a little bit more time here. So, as part of Assistance you may just spend a couple of minutes highlighting some sort of healthier options or focussing on increasing physical activity or maybe getting to bed early, or drinking some water. And then having that conversation with the parent about what they could be doing as a family because we all could improve our health and wellbeing by focussing on some of these healthier lifestyle choices.

So that is part of Assistance, and then as part of that Assistance, how do we actually start the conversation? And we have got a suggested discussion on the slide there, and we also encourage you to have a look at the website because we do have a whole list of conversation starters. And what I love about this conversation starter is that it is very simple, it is very straightforward without judgment and then I am asking for permission. Is it okay if I show this to you? And all I am doing is flipping the BMI growth chart over. You can have these double sided and on the back of the growth chart, we have these Eight Healthy Habits. And you do not have to highlight all of them. You could just pick one. Or you could ask the parent, what do you think about this? Have you thought about this before? Could you reduce little Johnny’s screen time? Tell me about your breakfast options. Tell me about little Johnny’s sleep patterns. So it is a really nice way to engage in conversation quite quickly and focus on one or two goals.

And if we go onto the next slide, we have you know, a couple of points there about practical goal setting, but James I imagine that this is, GPs already do this quite well so I am not going to spend time on this. Just be as specific as possible and as practical as possible. Not asking little Johnny to lose 30 kg. Let us just focus on setting small goals as a starting point. And problem solving is also an important component of that.

Then the final A, is we arrange a follow up. And this is what the clinical flow chart looks like, depending on the child’s percentile in terms of their BMI. We have a number of free programs which are available that I am going to take you through in a moment. But of course, if they are above the 95^th percentile, we do encourage you to refer to those specialist services or refer to a dietician and so on.

But let us have a look at some of the free programs first, because these are free. And I cannot emphasise this enough. So, this Go4Fun program is a 10 week evidence based program run during school term, two hour sessions once a week, where the whole family is involved. So, the first hour focuses on you know, nutrition and information and then the second hour, the children go out and play and then there is a focus on behaviour change and goal setting with the family. So it is delivered by a qualified professionals and there are a number of versions available. So we have the standard program which is available across most of New South Wales. We have a tailored program for Aboriginal and Torres Strait Islander populations delivered by Aboriginal Go4Fun promoters and health educators. So very, very tailored for this cohort. And then we have an online program for populations who cannot get to the face-to-face program, whether it is distance or possibly maybe their children have behavioural issues, or they just cannot get to it, and that is totally fine. So we encourage them to enrol in the online program which is just as effective as the face-to-face program. And as you can see on the slide, there are a number of significant improvements there you know, we know and acknowledge that GPs’ time is limited.

James: Can I just say, that this is a game-changer for GPs. A lot of GPs are using it but I think there is still a lot of our GPs who are not aware that this exists and it is a freebie and it is 20 hours of proper stuff. And you know, it is a no-brainer. And this is a really good thing to refer to. There is a very high Aboriginal population where I live and the Aboriginals go, and you see it everywhere and it really is making a difference. So I really encourage our audience to sign up for it and to use it and to tell all your friends. Yes. Is it in other states as well?

Stavroula: Not at this stage, not that I am familiar with. Just in New South Wales. So it is very unique to New South Wales, and the more referrals that you make into the program, then the more programs are offered. So please do refer into this free program.

Then there is also another free program which is called Get Healthy Information and Coaching Service. And this is available for children 16 years and over, and the whole family can be involved. So I am often encouraging parents to ring up the coaching service and have that conversation with the counsellors, with the dieticians, with the exercise physiologist. They can receive up to six months of coaching, up to 13 phone calls, plus they can re-enter and re-enrol into the program. They can receive additional support via SMS. It focuses on maintaining a healthy weight. Physical activity, alcohol reduction. But also even healthy weight gain in pregnancy. And again, this is another free service. So, I encourage you to refer on to this free service where whole families can be involved and adolescents can have those conversations with qualified professionals as to what they could be doing moving forward.

Sammi: I would like to note Stav as well, that it is something that we have had some really good feedback on these programs, and a huge thing that GPs found really beneficial from both of them is the access to the professionals that you get because for dieticians and exercise physiologists, if you are referred on to them, you can sit on waiting lists and it can take a while to get into them. These programs give you access to them quickly and free.

Stavroula: Yes, absolutely. And what we know is that when a health professional makes a referral, the patient is much more likely to stick with that referral rather than self-referral. So we do encourage referrals from you. It is very, very important to connect them as you mentioned Sammi, to qualified professionals who can assist them straight away.

Sammi: Exactly. And it keeps you in the loop as well. So these programs offer as well the opportunity on the referral forms that you can get updates on the patient. So you will actually get feedback on the programs on these patients if they request that they would like that. So, you are getting the assistance. You are being kept in the loop. You are not referring them off and then disappearing into the abyss. You will be kept in contact with, which is really great as well.

Stavroula: Yes, absolutely. So there is that collaboration. And then you can share that information with your patient.

Sammi: Exactly.

Stavroula: Great, okay. So let us recap. So, we have the Four A’s. And just to recap again, as part of Assessment, we are focussing on taking the growth assessment, plotting the height and weight on the BMI growth chart and calculating that weight status. We then Advise by engaging in conversation and highlighting the results of that BMI growth chart, but also starting to introduce some sort of positive lifestyle changes. As part of Assist, we can spend a bit more time here, or set some practical goals, also acknowledge and affirm those within the healthy weight range, what they are doing well to keep so healthy, and the final A is to then refer to Appropriate services with a follow up consultation. So you can do this quite quickly within a minute or two or a little bit more extensively within five minutes, depending on your time, depending on the conversation that you are having.

So for the last part of the webinar, I would now like to focus on a case study and what we could be doing as part of this case study to support George. And if you go to the next slide, we have George. James, what do you think about George?

James: George is a 12-year-old fellow. He is at 1.65 cm tall and he weighs 63 kg which is interesting. And he visits your practice with his mother, Pauline. He last came two years ago. He has got a family history of type 2 diabetes and he is having difficulty sleeping through the night and concentrating at school. Pretty common sort of stuff. His family lives in an apartment, which is also interesting.

Stavroula: So what could we do? How can we raise the issue?

James: Yes, well it comes back to that initial conversation. Is you know, just a simple prodding question, you know like this: George is growing up so quickly, when was the last time someone measured his height and weight? We routinely measure all children here to see that they are growing well. Is it okay if I do it today? And I even would not use that many words perhaps. I would just go, I measure all kids. So just jump on the scale. So…

Stavroula: Nice, I love it.

James: So, you know, and I do measure all kids. So, you know everyone expects it when they come in that they are going to get measured. And all of a sudden you have got a conversation starter. So I think that that is your entry point. And how do you think that is going? That sort of question, a simple prod, let us get you talking about what mum thinks of George or Pauline thinks of George.

Stavroula: And what is George’s BMI? Do we have his BMI?

James: 23.1

Stavroula: Okay.

James: What do you think of that?

Stavroula: What could we do next? Or how could we have that conversation? What could I say to the child if they are above a healthy weight? And again, this is just a suggestive text. If you feel it is a bit wordy, feel free to break it down further. But you could just go straight to that second paragraph. I have plotted how George is growing. It shows that he is above a healthy weight. Have you seen this before? What do you think of this?

James: Exactly. It is a just a simple, well what do you think? And because you do not know what they think, that is the thing. They might think it is completely fine. They might think it is terrible. They may say, oh we are all heavy boned in our family. You know all that sort of stuff. You know, so they may even want him to be that big.

Stavroula: Yes absolutely, you need to have that conversation.

James: He is going to be a rugby player he has got to be big, or something. So yes, where are they?

Stavroula: Yes, how do they feel? What do they think? Let us have that conversation and then this moves us into Assessment – Assisting sorry, Assisting. How could we assist? What could we suggest?

James: So you are also Advising also as well. You are sort of, let us talk about some healthy weight stuff. If they are concerned about it, if they kind of do know about it already that it is a problem and they want to hear what you have got to say. You know, so then we are starting to think, well what do we want to do here and how quickly do we want to do it? What changes can we implement? What do you think is possible, Pauline?

Stavroula: Exactly. What do you think is possible? What could we focus on? What is important to you? And if there are a number of priorities, it is important to flesh those out and explore those, because it may not just be a priority for Pauline at the moment. Maybe she has something else going on, maybe she is breaking up with her partner or maybe she has just been made redundant.

James: Yes, yes. I had a patient today actually that was like this, and you know I asked how many times a week that they were having soft drinks and it was four or five times a week that she was buying soft drink for the kids, and I said do you think we could get rid of that because their teeth look a bit ordinary as well. And she said, well I like it. I was the mum who wanted the soft drink. And so you know, you never know.

Stavroula: No, you never know. What does the audience think about this question? Have they put up any ideas of what they might suggest? Or how you could raise this with George or his mother. Do we have any responses?

James: Increase physical activity, reduce screen time, healthy eating, reducing edible food – I am not sure what they are getting at there, or what are the risks in reactivating anorexia nervosa, bulimia and children with undiagnosed? I think that is an interesting point but I really do not see that, we are talking about healthy stuff here. We are not, and so I think you are pretty safe raising overweight stuff with kids if you are doing it in a positive health-based way rather than in an instructional way.

Stavroula: But having said that, if you feel that oh, this conversation may trigger this young person along that pathway, then use your clinical judgement. And maybe have a private conversation with mum or the carer or the dad. If you feel that, oh I am not so sure about this.

James: For sure.

Stavroula: Absolutely. But from the research, the research tells us exactly what you have suggested James, that if you approach in a very supportive and respectful way, non-stigmatising way, then this conversation will not impact the child’s you know, self-esteem or their self-image. It is just about making positive lifestyle choices that are lifelong. You know that will improve your health and wellbeing into adulthood and so on.

James: And someone has also mentioned about raising the family history of diabetes can be a useful starting point, because everyone is scared of diabetes these days.

Stavroula: Absolutely.

James: So I think that is a really good point.

Stavroula: Absolutely. And as the participants have highlighted, encourage that incidental exercise, limit the screen time. You know, choose healthy snacks. So work with Pauline, work with George, reflect on what they could do as a family and maybe set some short term practical goals moving forward. Yes. Then the final A brings us to Arrange. So, what could we do in terms of supporting George? Well, straight away refer them into the Go4Fun program. You could refer the parents of the family into the Get Healthy Coaching Service. And there we have some other referral pathways which we do acknowledge that at times as Sammi has highlighted, there are huge waiting lists. So do get them initially into those free programs first to get them started, to get them thinking about making positive lifestyle choices.

James: And as all GPs know, some of the paid for services or the public services, you know in terms of multidisciplinary clinics and things like that, they can be hard to get into, or even non-existent. So it depends on what you have got locally. So sometimes you do have some fantastic stuff locally, but this new free online stuff is really a bit of a game-changer.

Stavroula: Absolutely. And the referral pathways are also available through Medical Director and Best Practice, is that correct?

Sammi: Yes it is.

Stavroula: Great, excellent. So use Medical Director, use Best Practice. Pull up those referral forms and do refer on into these free programs.

Sammi: And there has been a couple of questions come through from some interstate participants. At this time, Go4Fun is only available to New South Wales residents. That goes for the online program as well. But the Get Healthy Information and Coaching Service is also available in Queensland and South Australia, so you can log on if you are from those states to go there. And the Get Healthy program is for those who are 16 and up.

Stavroula: Great, excellent. Well great to see that other states also have the Get Healthy Coaching Service. Thanks for sharing that, thank you.

Okay. That pretty much brings us to coming to a close of the webinar. So this evening’s webinar was very much about introducing a brief intervention, so highlighting the Four A’s for children, for families, for kids who are above a healthy weight. We introduced motivational interviewing and just highlighted the importance of asking open-ended questions and reflecting on our body language and reflecting on our active listening skills. We highlighted the importance of using non-stigmatising language such as being above a healthy weight or well-above a healthy weight because we want to bring people on side and focus on those positive lifestyle choices. We have encouraged you to reflect on the resources available and in particular, the eight Healthy Habits resource which is available on the website. But also to think about some practical goal setting and really work with the family, work with the young person as to what they could be doing, what would they like to focus on first? What is important to them, and then highlighting some of those referral pathway options such as Go4Fun and the Get Healthy Information and Coaching Service, and obviously the more specialised services for children who are well-above a healthy weight.

If you would like further information, there are a number of other webinars that may be of interest to you that are available, so whether it is about having conversations about healthy growth, tackling childhood obesity part 1 and part 2, focussing on different socioeconomic and culturally diverse backgrounds as well as commercial building models. We have an additional Healthy Kids for Professionals training by Dr Georgia Rigas and Dr Shirley Alexander. And there are some additional webinars there about lifestyle intervention and Go4Fun referral, as well as engaging adolescents in conversation about healthy weight and lifestyle behaviours.

As part of this evening’s webinar, there is a lot of information available on line in terms of resources, so some of this you may have already seen or it may be new to you. But I do encourage you to have a look at these resources to support the conversation that you are having with children and their families. And I think we have another slide that highlights the additional resources available.

James: Well, thank you very much, Stav. So we have come back to our learning outcomes as we always do at the end of the activity and just to look through them again. We have talked about delivering brief interventions and / or aspects of motivational interviewing when working with children above a healthy weight and their families. And, hopefully, we are more aware of the environmental and psychosocial effects of being above a healthy weight. We might hopefully now be able to more confidently use more sensitive and non-stigmatising language when talking with children and their families or carers about their weight status. And also to utilise available resource, and I think we certainly have found some new ones for many of us tonight, and referral pathways to support children who are above a healthy weight where appropriate.

Sammi: That is great, thanks James. And we are coming right up on 8.30 now. We do have two minutes left. James was there any pressing questions that came through that you would think?

James: Well someone asked if there are some excellent MI resources available on line which there are, including links to Miller and Rollnick who sort of started off the whole process. Someone has asked there about if we are doing the Four A’s, is it in one consultation? Well sometimes, yes and sometimes, no. And sometimes you would even be doing it again on another consultation. So you know, it is like HEADS you can just fiddle around with it, you know and see how it is going. We have another one. How do we – I am not sure about that question, I will leave that one. What about children who are 14 or 15 years old? They cannot be referred to Go4Fun or Get Healthy.

Stavroula: Go4Fun is for seven to 13-year-olds and the Get Healthy Coaching Service is for 16 years and over. But I think, look they might make some exceptions so do make those referrals and siblings can also be involved in the Go4Fun program as well.

James: Someone has also mentioned refer to ParkRun which I absolutely concur. Which is a great way of getting kids active. And also, how can we reduce screen time? That is a good question.

Stavroula: How long is a piece of string?

James: You know, my first answer to that, is measure it, because people have no idea how long the kids are on screens for a lot of the time and it is a battle. You know, there are strategies you know that you can, first of all measure it, absolutely. And then define and negotiate, especially with the kids coming into adolescence. But let us talk about what is important to you. Because grabbing a phone off an adolescent is tantamount to a criminal offence in their eyes, so negotiating beforehand is a much better way.

Stavroula: Yes, absolutely. Setting those boundaries, but having the conversation as a collaborative approach. So let us work on this together and what could we do together as a family?

Sammi: Absolutely. Awesome. And that brings us right up on 8.30 so I would like to thank Stav and James for joining us this evening and everybody who joined us online as well, we really hope you enjoyed the session and we hope you enjoy the rest of your evening.