Good evening everybody, it is 7:30 so we will make a start. Welcome to the third and final of three webinars in the Healthy Kids for Professionals series. Tonight’s webinar is lifestyle intervention and tonight we are joined by Dr Georgia Rigas and Shay Saleh who is a Go4Fun representative from NSW Health.
Georgia is a General Practitioner and Bariatric Medical Practitioner at St George Hospital in Kogarah. She is also the current Chair of RACGP Obesity Management Network.
Shay is the Go4Fun State Project Officer in the office of Preventative Health at NSW Ministry of Health.
Georgia and Shay, thanks for joining us.
Thank you for having us.
Before we get started I just want to do a quick acknowledgement 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, present and emerging.
I am going to hand over to Georgia now and she will take us through the learning outcomes for tonight’s session.
Thank you very much for that. I would like to welcome you all this evening and for joining us here tonight for our final webinar for this year. I would like to begin with the learning objectives for tonight’s webinar. So by the end of this evening you will be able to discuss a child’s weight status with their parent or carer, describe the elements of the Go4Fun Program to a family including positive outcomes, integrate referrals of eligible 13 to 17 year olds to the Go4Fun Program into routine consultations and finally, to explain the expectations of follow up communication once a child has been enrolled into the Go4Fun Program.
As it was mentioned only a moment ago, this is the final instalment of a three part webinar series titled Healthy Kids for Professionals. Please refer to the first two webinars for more detailed information on identifying and raising the issue of weight in young people. If you were not present for either or both of those first two webinars, I encourage you to access those recordings because they are available for viewing via the RACGP website in the coming weeks.
Approximately 1 in 5 children in Australia are above a healthy weight and this is also true for the state of NSW and hence this is why it is one of our Premier’s health priorities with a view to reduce these worrying statistics. The language that I am introducing here today has been tested in children and their families. A healthy weight is defined as being in the 5th to under 85th centile, above a healthy weight is the 85th and 95th centile and then well above a healthy weight is the 95th centile and above. This can be used as a screening tool as well as a guide of the individual health risk. It is not to be used to label children but rather in seeing improvements in the health of that particular child or adolescent has experienced. Most of the children/adolescents who come to clinical practices to see us in general practice; when they come they don’t come for obesity, it is usually f or something else. From my clinical experience it is often the psychosocial aspects, and so we see high rates of depression, bullying at school, we see children who are suffering from urinary incontinence and other issues that are embarrassing them and therefore there are high drop outs from school. We also note that these children have lower quality of life because they are not completing their schooling and therefore find themselves in the poorer socioeconomic groups. It may very well be physical issues and in this diagram I can see a variety of health pathologies ranging from the pulmonary, gastrointestinal, musculoskeletal, the endocrine which is fairly common, cardiovascular and whilst it does not happen very often, I have committed to memory, there have been in my say last 12 years of working with people with obesity, I have come across two young females in their early 20s with idiopathic intracranial hypertension and whilst it doesn’t happen often it is a very serious problem and therefore I do encourage you, if you do have a young person who is suffering from a headache, obviously look for the most common pathology first but have benign idiopathic intracranial hypertension as one of your top five differentials.
If I am going to be honest and up front, it is physical issues such as chaffing between the thighs or recurrent thrush between the skin folds or exertional dyspnoea and therefore they cannot participate in sport at school, these are the common physical complaints that parents and/or the carers may bring their child in with. So we need to listen attentively to the story that the child or adolescent has to share because it takes quite a bit of courage for them to be sharing such intimate concerns that they have. It is also important to validate their concerns and their feelings in an empathetic manner.
However, it is imperative that we dispel the two commonly held beliefs. The first being, puppy fat, oh it is harmless. The second one being, oh they will grow out of their puppy fat. If those were true, we would not be seeing so many of the children/adolescents progressing to having obesity as adults.
So in Australia there are many initiatives to address child overweight and obesity and as Georgia mentioned, in 2015 the NSW Premier announced the target of reducing obesity rates in children by 5% over 10 years. This would bring down the prevalence from about 21.5% to 16.5% which is a mammoth effort. That equates to 62,000 more children who are a healthy weight by 2025. The NSW Premier’s priority is just one example, other states have done or are preparing to commence similar initiatives. In NSW we are approaching this complex problem from many different angles and most states are doing the same. NSW Health has a comprehensive evidence based approach in place with more than 35 actions state wide under four umbrellas and GPs can really make a big difference in the first two boxes. The first box shows a suite of setting base programs to address the issue including the Go4Fun program that we will be discussing in more detail later, that GPs can refer their patients to. The second box is making weight status assessment routine, height and weight measurements are a core component of standard paediatric practice.
General practitioners play a crucial role in identifying and also managing children that are above a healthy weight.
Firstly, we are a trusted member of the community often having known the children and their families for many years. One of the foundations on which general practice was founded was the ethos of continuity of care. For many people GPs are the first and probably the only contact they have with the medical system here in Australian and therefore it is a very important role that we play. Most importantly, as most of us here tonight will attest, as GPs we are champions in chronic disease management; we have an excellent track record because we have been doing it for years. Not only do we have the experience but we also have the infrastructure in place, as well as an integrated team to offer a world class service to our patients. Therefore, we are very well suited and very well placed in assessing children’s weight status as part of our normal growth assessment.
in the most recent NSW school physical activity and nutrition survey, nearly three quarters of parents of overweight children and one third of parents of children who were obese were unable to identify that their child was above a healthy weight and this is why the GPs role in screening is so vital.
I encourage you all to go to webinar two for a more in depth information on raising the issue of weight with parents and carers of children and adolescents. However it is imperative that we use sensitive language that is, above a healthy weight, rather than the terms obesity and overweight. The literature tells us time and time again that people who are overweight or have obesity will have a significant degree of stigma and discrimination and we certainly do not want to add to this.
I would also like to point out here that the whole idea is a family focused message. We do not want the family to become overwhelmed but at the same time we do want to encourage them and to engage them. As you will see here, there are quite a few interventions that families can work towards. We ask that as health professionals we give them the opportunity to choose which one or two of these goals they think they can start with and essentially work at it slowly over time. Remember we want little wins that are sustainable rather than something that is not sustainable. Reassure them that they don’t have to follow every single point every single time, however, we want them to follow most of these healthy messages most of the time and that way we are moving away from that mentality which is you are either doing the full diet or you are not. We just want to shift the focus to healthy habits and hopefully ones that they will continue to follow as adults.
So let’s change gears now and talk about what we can actually do in our daily practice. Some of you may be familiar with the picture here in front of us. It is a BMI for age chart which is gender specific and it is a fantastic tool. It comes in both a paper form as well as an electronic form that is incorporated in the most common clinical software. It allows for routine weight status assessment and if we do this routinely for all patients, young and old, just like the RACGP red book suggests, then this will help to remove the stigma associated with weighing and measuring patients. These type of resources can also help health care professionals in raising the family where their child is on the growth chart and most importantly, when they engage with various therapeutic tools such as the Go4Fun program it allows us to show them how well their child is progressing, but remember we need to frame this as a health issue.
Most of us in clinical practice are very aware of the 4 A’s; Assess, Advise, Assist and Arrange and I highly recommend that for those of you who have not as yet gone to this website, to definitely use it. It has an amazing abundance of various resources that are both great for the clinician but also for families. It is free and there is open access to anyone. The range of resources include the BMI for age and gender charts that I just spoke about on the previous slide, there are a host of great fact sheets that you can print out and give to your patients and there are also online modules that we can complete in our own time when we want to further our professional development. There is also a fantastic assessment flow chart which we can see here on the right side of the screen. This was discussed in great detail at the preceding webinar but it is a great way for GPs to understand how they should be managing patients who are above a healthy weight and where they can go for help.
So we are just going to change gears a little and go into referral options and the first thing we are going to do is just explain the important components of a lifestyle intervention to be effective.
So it needs to be multidisciplinary and include the following features; firstly a nutritional dietary component, a physical activity component, a behaviour change component and family involvement. This leads us to the Go4Fun program. It is a healthy lifestyle program that aims to reduce childhood obesity by supporting families of eligible children in adopting a healthier lifestyle. It includes family focus, increasing physical activity, nutrition theory, behaviour change and goal setting. The program is completely free and is delivered by qualified health professionals such as dietitians and exercise physiologists. It is run in NSW only but there are similar services in most states.
The program is for children 7 to 13 years old and are above a healthy weight meaning they are above the 85th percentile for their age and sex. They also need to live in NSW and have a parent or carer, such as a grandparent or adult sibling, who can attend each session with them.
So what do the sessions involve? Go4Fun is a 10 week program that runs parallel with school terms. There are local programs that run all over the state, often in community venues such as leisure centres, sports clubs and school halls. The program runs once a week with each session lasting two hours; in the first hour it involves both children and parents or carers learning about healthy eating and in the second hour they separate so that children engage in some game based activities while their parents or carers attend a behaviour change session.
I am going to change views again now and actually take a pause and I would like to ask the audience, has anyone used the Go4Fun program? So please give us some feedback and just share your experiences.
So we have someone who just made their first referral and another one who said it worked well. I am going to share my experience shortly. Thank you for your feedback, we will wait just another moment or so.
So what I can read from here, someone has mentioned that there is no programs in my work area. If that person is happy to provide a bit more information as to where they are based and if that is in NSW then the Go4Frun Team would be able to reach out and make contact. If not, then we might be able to point you in the right direction as to what similar services might be relevant in your particular state or territory.
And if we don’t have Go4Fun programs running in your area, we do have an online version which I will explain a bit later which can cater to those family’s needs as well.
Excellent. There is a comment here; unfortunately many parents cannot find the time so I am about changing their minds that this is a priority and a health issue. I totally agree with you that it is a very important health issue and I suppose you may not be able to hook them in in the first time, it is not something that is going to be easy to do in one consultation, it might take a couple of consultations before you get a parent or carer engaged and sometimes it might mean it is the other carer, so you might find that one particular carer might not be as concerned because they are genetically lean, so they cannot be empathetic, but maybe their partner has weight concerns or had weight concerns and therefore understands the potential journey that this child may have ahead of them. So don’t give up, that is my key message to you, don’t give up because we have a duty of care to children in our practice.
I am having a little look. Yes, I do want to comment on the person who said that the communication with the GP could be better. Excellent timing because we have just developed a suite of different letters and reports specifically for health professionals. Those are currently in place so you will find that our feedback to GPs has improved significantly, based on the needs that have been identified by the health professionals. Somebody has also made a comment about long-term effects, especially on behaviour of whole family. There is a DCP trial that is happening at the moment that is following families after 12 and 18 months, so we await the results of those and I do have a little picture of a child four years after the program that can show you some of the long-term benefits of the program.
Excellent. Thank you for your feedback and feel free to continue to be sending messages across and that way myself, Shay and our colleagues will be able to respond to your concerns, questions and your comments.
I personally have made a few referrals and I can concur with one of the comments there that the communication was not as great say five or six years ago, but we live and learn from the feedback and therefore, to Go4Fun’s credit, things have really just improved exponentially. I have referred families and please note I said families, I am not referring an individual to Go4Fun because the whole family has to make some changes there and engage in the service because the child cannot do it on their own.
As a clinician, I like to see what we do and what they do in conjunction with us results in clinically meaningful weight loss. Now I can imagine that some people may look at the results that I am about to go through and turn their nose up and say, oh a reduction in waist circumference by 1.3 cm or a drop in BMI by only 0.5, you know, as if this is going to make a difference or change. Well, let me tell you, yes it does and the studies do support this. I unfortunately in my work see a lot of people across the time course, so the youngest patient I have that I am assisting with a paediatric endocrinologist is 7 and the eldest is in their 70s. So I have am caring for people along various decades and different time points in their life and one common theme that we see from the literature but also clinical practice is that when children and adolescents are putting on weight they are on a weight gain trajectory and that is continuing to go up. Only a minority are able to change that. Essentially what we are seeing with the Go4Fun program is for a program to actually be able to change the course that these kids are on and therefore they are no longer on that very steep weight gain curve. This is really encouraging that we can actually do something as a community service and potentially life changing things will happen for these kids. So it is great that we can do something to help these kids.
But let’s have a look also at the positives. We are seeing that there is less sedentary time, they are more physical, they have more fruit and vegetable intake and improved self-esteem, therefore more likely to complete school and go on and develop a trade or go to university and therefore have better quality of life down the track. So hopefully some of these lessons that they are learning they will keep with them as adults and therefore hopefully making a dent on this obesity epidemic.
Now it is encouraging to see that so many families are engaged. I wanted to show you these pie charts. As you can see on the left, 74% of the program is delivered in socioeconomically disadvantaged communities and I find that very encouraging because these invaluable services are going to those who are disadvantaged and needing it the most. As we can see on the pie chart on the right, close to a third of families who are accessing such services are from rural or regional communities. Therefore, reiterating once again, ethnic minorities including special communities that may need extra assistance are seeking this invaluable resource.
We have had a couple more questions that I will just answer. Somebody has asked if there is anything similar like this for adults. The Get Healthy service might be a good option, it is a free telephone coaching service where anyone over the age of 16 can set goals, whether it is for weight loss, whether it is to improve their eating habits, whether it is to increase their physical activity, it is again a free service. Someone has asked how often this program runs in a year. We have hundreds of programs that run all over NSW throughout the year and so there is always an option to refer a family to and I will explain the different options soon. The cost for families again, it is completely free, there is no cost for families for doing the Go4Fun program if they are eligible, so if they are 7 to 13 years old, they are above a healthy weight and they live in NSW there is no cost to those families.
So, we have three versions of the Go4Fun program. It should cater to different family’s needs. The Mainstream version has been delivered since 2011 and it is the standard 10-week face to face program that we have discussed in previous slides. The second one is a culturally adapted program for Aboriginal and Torres Strait Islander families. The last one is Go4Fun online that seems to be quite interesting for some of you. It is our newest one and it is a Telehealth version of the program. We will discuss the last two versions in the next couple of slides. I just want to make the point that GPs can refer their patients to any version of the program but you don’t need to worry, the centralised registration process will establish the most suitable version of the program to reduce the burden on health professionals. The main task for GPs is to simply refer into the program.
So, I will go through the Aboriginal Go4Fun program. It is very similar to the Mainstream version in that it is face to face, it is a cultural adaption that is delivered over 10 weeks. So what are the modifications? It includes culturally appropriate resources, co-delivery with Aboriginal organisations, the presence of an Aboriginal support person, simplified messaging, room on the program for additional community members and more flexibility around the eligibility such as not needing a parent or primary carer, it can be a responsible adult such as an aunt. At the moment we have 44 programs running in a range of locations across NSW this financial year and while the program has been adapted for Aboriginal communities it is open to all families, to non-Aboriginal families as well who may have an affiliation with an Aboriginal family.
Now onto Go4Fun online. It is our most recent version of the program and it is a non face to face version. It was developed because there is a need to provide families who are unable to attend face to face programs with an alternative. Some examples are geographical barriers, there is no program nearby, the program is too far away for them to attend, working families, custody issues where there are issues getting to the program or children with additional needs. Quite often we see them in the priority groups that Georgia mentioned before. So this Telehealth version follows the same principles as the Mainstream version. It is still run for 10 weeks, it is still designed for children and their families and the content is very similar, it is just delivered in a different format. The program involves 10 online modules, weekly phone calls to check the family’s progress and set goals, an online community and text messages. Families also receive resources in the mail such as exercise equipment and handouts and the big favourite is the Garmin fitness tracker that you see down the bottom. On the right hand side you can see an example of what families learn in the online modules. The thing on the right shows an interactive game of building your own healthy breakfast and so far we see positive results from families and strong compliance to the online version.
So, what do families say about the program? Well, we receive great feedback from them when they have completed it. Kaitlan’s mum has reached out to us to let us know how the changes she has made to her lifestyle has resulted in some significant clinical results. Kaitlan was diagnosed with Hashimoto’s and when she went back for a follow up blood test after completing the program her thyroid levels had levelled out and she no longer needed medication. Kim Pickin’s daughter has learnt to make healthier choices all on her own and she has even reigned in the rest of the family from going overboard on Easter. Thomas was the one I referred to a bit earlier. He was referred to Go4 Fun by his paediatrician and four years on he continues to make healthier choices.
So, how can you register into the program? We have two ways; families can self-refer and health professionals can refer patients. Families can self-refer by calling our 1800 number or going to our website. Health professionals can also refer children into the program. Health professional referrals are our second highest form of referrals and are currently sitting at about 15% of all referrals into the program. There are a few different ways that GPs can refer into the program, including using clinical software such as Medical Director, Best Practice, through Health Pathways, through Healthy Kids for Professionals and through our website. Health professionals can also discuss the program with families and encourage them to self-refer as well. So, we will describe some of these referrals for health professionals in the following slides.
The first one is how to refer using Medical Director. You can find our referral form in Medical Director under the search words up the top that say Go4Fun child obesity program NSW. Here is a screen shot of what it would look like. The referral form should auto-populate with your patient’s details and the form also has some instructions of where to send the referral form. The next is referring through Best Practice. You can find the form by searching Go4Fun referral form and then select your patient from the database and here is a screen shot of how to search for the patient you would like to refer, so you simply just pop in their name and once that is done this is a final screen shot about how your patient’s information is auto-populated into the form and the form again has instructions about where to send the completed referral form. So, the next one is Healthy Kids for Professionals, you can also refer kids through the Healthy Kids for Professionals website, you will find the referral form under the Arrange tab. This section also contains more resources such as a Go4Fun flyers and posters. You will also find information on referral to secondary and tertiary services here and I did mention that the referral form is also on our website. At the moment our website does exist, we are going to rebuild it and the health professional section will be more apparent, so I would stick to the first few options for now.
For some dinosaurs like me who like to use pen and paper, you can download a hard copy of the referral form and send it across. There are also some really good resources that you can hand out to the parents and/or the child and adolescent. The referral pads are very useful and patients have picked up brochures from the waiting room and come in and asked about it and have also seen posters in my room and have asked about it. So, it is a very good way of opening the discussion into this very important health condition.
Now, most of you on this webinar may share the same bugbear that I do. You refer someone to a service and then you never hear back and you are not sure about what the outcome was. I call it the Bermuda Triangle of Referrals. However, for me, the peace to resistance with the Go4Fun program is that we get progress reports and they send these back to us the referring GP and the communication that they provide is fantastic, it is very useful and it allows me as the GP and my other health professional colleagues to know what advise has been given so that I am on the same page as them and that we are all giving the same clear consistent message. It also helps me open conversation with either the patient and/or their carers just to see how things are going and to reinforce these healthy key messages but it also keeps us in the loop just so we are aware of how well they are engaging or not and also to acknowledge the hard work that they are doing and to encourage them to keep at it. I also feel that the really good communication that we get from the Go4Fun groups from their excellent communication is that they are validating how important we as GPs are in caring for our patients over the course of their life. So, not only do we get a progress report to say the child and their family have commenced the program and are engaged, we also get one at the end of the program so we can compare baseline and what they have achieved. It also identifies areas for improvement that I and my primary health care team can help to continue the discussions with and to encourage the maintenance of the existing skill sets that have been acquired. It also identified families that have maybe dropped out and this is important for us to know, so that way when we see them opportunistically for something else we can enquire what the barrier was, was it anything else that we could troubleshoot and also to re-enter that discussion and the dialogue about how important it is to maintain the health and wellbeing of the child. So, any health messages that have been passed on we will reiterate and also to continue the good work that the Go4Fun program has started.
Examples of the GP letter, this is quite indicative of what we get. It is quite easy to read, the outcomes are clearly identified. This is the BMI for age and gender chart. It shows you where the child started at baseline and then you see how they have progressed throughout the program. The kids and adolescents that I use it on are really chuffed because they look at me when I have plotted the dots and they go “is this a good thing?” and I go “yes it is, you get two thumbs up, you are doing really well” and because, like I said I am a dinosaur and I actually give them a paper copy, I get the young ones to decorate and put glitter on their booklets to make it their own and that way they feel that this is something to be proud of, it is like a report card to be proud of. So, we see where they started and then we see where they progressed. For me I think it is fantastic, we see how their fruit intake has gone up, their water intake has improved, we see reductions in their body mass index, how much sedentary time they have had etc, so these are clear messages that even down the track if the child wants to re-engage and do things on their own or a family member just wants to continue the healthy messages they are very clear, they are written but also visual because we are aware that English is not always the first language of many parents and families that we care for in primary care but also the Go4Fun program.
I just wanted to make the point that if your patient chooses to self-refer and they know who their GP is, their GP will still get that feedback as well. If anyone does have questions that they would like to send through, please do send them through or if you have any comments about your own experiences please send them through as well.
I see a question pop up now; there is a comment here, unfortunately many parents cannot find the time. What would you say about that Shay while I put my thinking cap on?
Well I am wondering what these types of parents are, if they are working parents for example and cannot commit to attending a program for two hours every single week, perhaps Go4Fun online is a really good option for them.
Yes, I think that is fair. Sometimes and you tell me Shay if this is appropriate or not; if as are many families, we are a two parent working family, if the parents are working and they have say grandmother who lives at home and she is actually the one who does the cooking and child raising, is it okay for grandmother or the carer, it does not have to be one of the biological parents if they are at work?
Yes absolutely, because that grandparent plays such a significant role and is able to make those changes as a carer and we do get quite a bit of grandparents come to the program.
That’s great. Other questions that I have here. Are they encouraged to nominate a GP if they self-refer?
Yes, we do ask them who their GP is and if they have their GPs details. It is important and we are trying to increase our bank of health professionals so that they constantly get that feedback once they are onto a program.
GEORGIA: I think this is important because we are meant to be following up our patients for life and we hold their medical record, so we need to have as much information so we can see the big picture. There is nothing worse, as I said before the Bermuda Triangle of Referrals, where they get sent out but we never know what happens as there are so many missing pieces on the jigsaw puzzle.
Just asked, what time of the day usually are these programs run? Quite often they are after school, they usually start anywhere between 4 and 5:30. We do occasionally have some Saturday programs, so they are designed to be after school programs or at a time that families can commit.
Okay I see another question here that might be suitable for me to address. When do you decide about the role of bariatric surgery, metformin or medicines? So, essentially I will break it up into two parts. Firstly, there is pharmacotherapy; metformin or any other medication. There are not many medications that are TGA approved for use in children and adolescents. The only exception is Phentermine, the TGA says from the age of 12. I have spoken to paediatric endocrinologists like Shirley Alexander and Louise Baur for the Westmead Children’s Hospital as they do offer an Obesity Service. Their expert opinion is that it should be a paediatric endocrinologist that decides if a child/adolescent needs metformin or any other medications and then as we do with other health conditions, a shared care arrangement. If the paediatrician/endocrinologist starts a medication and we have good communication then we can continue to prescribe it as long as they are having reviews by their endocrinologist as is required.
Part two of the question, with bariatric surgery this is a hot topic at the moment. The referral for bariatric surgery has to be done to a clinic that is very experienced in doing bariatric surgery in adolescents, the guidelines are quite grey at the moment, the reason being the NHMIC guidelines do stipulate age of 18 and above are considered adults and that is fine. Then there is a shade of grey for around the 15 to 18 years of age where a paediatric endocrinologist feels that the adolescent has explored all the other medical therapies and has not been able to respond to those therapies appropriately and may benefit from bariatric surgery then the decision may be made. These decisions are not made lightly whether it be for children or adolescents. They need to have been seen by a paediatric endocrinologist and usually a psychologist to understand the demands that bariatric surgery requires for its patients. Now I am not going to lie and say that surgery has not been done in younger people. I was at an international conference last month and some of us may have heard of a 3 year old child in the Middle East somewhere who had had bariatric surgery, however, at the conference last month apparently that was old news, apparently in India they did bariatric surgery on an 18 month old, somewhere in that age group and I nearly fell off my chair. I actually asked the person next to me, “did I hear correctly?”. So, there are countries who are pushing the boundaries a bit but Australia is very conservative so the summary to both parts of the question are, that in the right case possibly these therapies are appropriate but it has to be done in consultation with a whole group with a multidisciplinary team approach.
There have been a couple more questions that have come through. Someone has asked if parents cannot participate due to a lack of the English language, is there any other option? We did a review of our program about a year ago and we looked at it from the angle of health literacy so that it is able to cater for a range of audiences. While the program is still delivered in English, it is a lot more visual, a lot of the adaptations taking into account a range of different cultures so that it is not just a case of white bread and brown bread, we have incorporated a lot of the cultural ones as well.
Someone has asked if there is any arrangement for kids living in split families. We have had children where there is shared custody and they have been able to successfully complete the program. It often involves both parents playing an active role and attending sessions at different times in different weeks but it can be done.
In terms of programs in rural areas, that is one that somebody else has asked; we do have face to face programs both the Mainstream and the Aboriginal versions running in some rural areas, otherwise I would probably recommend Go4Fun online for these families. If you do have any other questions please do send them through.
I am going to go back to the slides now. Re-entry into the program. So, while the program is designed so that the family only enters it once, we do allow re-entry into the program especially if the child does have a health professional referral form completed. We understand that sometimes there are special circumstances that occur that get in the way of completing the program and some of these are custody issues, special family circumstances, illnesses, emergencies or if the child’s weight status has worsened with time. So we do accept re-entry into the program in those situations.
I am seeing that we have a few more questions if that’s alright Shay. One member of the audience enquired about the medication that I mentioned. The medication name is phentermine, one of the trade names is Duromine or Metermine but as I mentioned earlier, it has to be done under the care of a paediatrician or a paediatric endocrinologist with a specific interest in obesity management because these children and adults when they are treated need to be monitored quite often.
Another question was the stigma, are we adding to it because we are measuring these kids? Well I would like to bring you back to the RACGP red book, we have the 9th edition but even the preceding edition we did have, as one of the preventative health guidelines, that we as GPs should be measuring BMI and waist circumference in adults but we should also be doing the BMI for age and gender charts for children. Now, we are great at completing those blue books from the age 0 to 5 years charting their growth, development, immunisations, everything, we are like gold star for that but as soon as those kids have their immunisations and off to school they fall off the radar and then they only come in if they have a sore ear or a runny nose or something else. So, it is incumbent on us as the GP to make sure that we just continue to measure and monitor the health and growth of these children and if we have a blanket policy where we measure the growth parameters of children, adolescent and even adults as they come in at least a couple of times a year, then there will be no stigma as it is not like you are isolating and picking out those that are above a healthy weight. If you are doing it across the board (a) you are doing them a good service and (b) you are not adding to the stigma and the discrimination.
We have also had a question about whether a patient who lives in Canberra can undertake the online version of the program. Unfortunately because it is delivered by NSW Health the family needs to live in NSW to be able to do any version of the program including the online one.
Just trying to read some of the questions to see what we can do. I appreciate one of the earlier comments because one of the GPs has written to say that they too struggle sometimes engaging families.
Sometimes it might be asking the child specific questions when they have come up for an upper respiratory tract infection or whatever they have come in for, just ask them how things are going, any problems at school, is everyone nice to them, do they do any sport or do they get huffed and puffed, do they get chosen for the soccer team or the football team or whatever and through the responses that they give while their parent is still there, then important themes such as school bullying or no I don’t play because I am always the last one that is ever chosen, I never get chosen to play sport or no I don’t have friends because people say that I sweat a lot and I am stinky; really sad things. Those that are in clinical practice and those that are parents know that kids unfortunately have no filter, they just say what is on their mind and often don’t realise that they are hurting people’s feelings. So if a child discloses these kind of things where their carer is with them then that is kind of like a hook, where you can say to the parent/carer, you know there are things that we can do to help this child just to feel better about themselves. So that might be one of the ways that you can hook in or start to engage the parent/carer but if they are not interested say that’s okay but do you mind if I bring it up down the track again, seek permission to open it up again at a later date.
We have also had a comment about coming across families from certain cultures where weight is seen as a sign of prosperity and how to deal with families where chubbiness is celebrated I guess. We have covered that a little bit in either the first or the second webinar, so we do encourage you to go back to one of those as it does go into detail on how to deal with that particular scenario.
This is a very interesting comment. It was a GP commenting on a particular scenario that they came across. I met a set of parents who brought their child for immunisation and the BMI was well above a healthy weight range at 18 months, the child could not bear his weight but the parents basically said, oh it’s a chubby baby we are not bothered, and they were not concerned that he was not able to walk yet.
I suppose this is where pulling out the BMI for age and gender chart and showing a little dot or a star saying this is where your child is and this is where all the other 18 month old children are. Explain that if the child continues on this path that there is a real reality that you will outlive your child, that they will die before you. This is one of the sad realities that we have at the moment that we may be seeing that these children will be dying before their parents if they reach morbid obesity which is now reclassified as class 3 obesity in adults. It is a tough one. Especially like you said, some cultures do deem that having chubby children is a sign of prosperity but as I said earlier that is one of the things that we need to work against as health professsionals and to explain that this is an important health issue.
There is another very interesting one about weight gain in adolescents on medications due to mental illness. For those of you that have adolescent children or have dealt with adolescents in clinical practice, the adolescent years are challenging with or without medications for mental illness or without any issues pertaining to excess weight. So, that in addition to mental illness and in addition to weight is basically almost a recipe for headaches for the GP but also quite alarming and distressing for the adolescent and their family. I have had scenarios where the adolescent and/or their parent have said, oh we are reluctant to start any medication because we are reluctant to add more weight and though I can read them the literature and say look these medications are apparently meant to be weight neutral or not gain weight, I suppose you have to give it a couple of months trial and if the adolescent is starting to gain weight then maybe consider changing the medication. Alternatively, if you see that they are actually having a great therapeutic response to that particular pharmacotherapeutic agent with respect to their depression or mental health concern but their appetite has been stimulated, then engaging the other members of your team such as the dietitian and psychologists would be priceless because often but not always these adolescents and adults are the same, many of them may find that they turn to food for comfort when they are feeling times of stress or feeling quite low and therefore we want to teach them skills so that they can deal with these feelings in a more constructive rather than a destructive way and to change the pathological relationship they have with food. With the dietitians, there are times where we have put adolescents on partial very low energy diets. I say partial because it is hard to get them to comply with things generally let alone a very strict low energy diet but sometimes they are agreeable to doing a very low energy diet or like two days on one day off diet etc, when I say diet I mean healthy eating as in an adolescents world eating healthy is a diet. So anything that we can engage them with to try to increase their health literacy and their knowledge about what is considered healthy nutritious food versus sometimes food and better management of their emotions and how to not turn to food for comfort and also the importance of exercise. It is kind of a vicious cycle as often when people have mental health issues they are not as interested in exercising but we know that exercise helps improve mental wellbeing and so we need to encourage them do so, so it is important to engage the whole team on this one.
I will just go back to the slides. So why should GPs refer to Go4fun. Firstly, it complements the patient care provided by you their GP. It gives you something to offer your patients in need of a treatment program. It produces significant positive results. It is completely free. Patients receive great resources and incentives for doing the program. We have different versions to suit most family’s needs. GP referrals are often the motivation that families need to make changes and we often hear this anecdotally from many parents where they have seen the program around a lot or they know they need to do something about their child’s weight but it isn’t really until their GP has a conversation with them and encourages them to do the program that they take that step. GPs are also well placed as they are a trusted source and often the only point of contact that children have with the health system and importantly GPs can address children’s weight status as part of normal growth assessment and that takes away some of the taboo of having that conversation and finally the feedback that is provided to GPs on their patient’s outcomes.
Great, thanks for that Shay. From my point of view I think that GPs should refer to Go4Fun because of the excellent feedback that we get from the Go4Fun coordinators and they epitomise the model of ideal model of care that we want. It is patient focused and family focused, all the team members both the Go4Fun and the primary health care team are on the same page and also they are well placed, so that way each of us can help address any issues that the family members may be encountering when they are at Go4Fun or when they come and see us in general practice. It also gives us as a GP the opportunity to make a difference for that individual and it is not often that we find ourselves being able to do that. So, I often get that feel good feeling once I refer families to the Go4Fun program.
I have another question here about the very low energy diets that I mentioned a couple of moments ago. Do you think as a GP we can recommend very low energy diets? Well I am going to answer it in two parts. Obviously, this evening’s webinar is on children and adolescents so I am going to direct the answer to that. If as a GP you have some experience in very low energy diets in adults and then you have a teenager who might be 15, 16 or 17 years of age, so they are obviously post pubertal and 100 kg/150 kg and they exist because they come to my clinic, and you have an experienced dietitian then there is no reason why you cannot start them on it as long as you are comfortable with the very low energy diets, you spend the time explaining to them how it works, give them supportive materials and make sure you follow them up regularly, but they do work and as I said earlier, a full program of all three meals in the day to be replaced is a hard ask on adults let alone teenagers but a partial program where they may replace one or two meals a day might be just doable, especially given the ad hoc eating behaviour that teenagers are notorious for having.
There is a question, do you measure the long term effects of this program and you mentioned that earlier Shay didn’t you?
Yes, there is a study and the results have not been completed just yet but we have done a bit of long term measurements into the session.
That’s great and we look forward to hearing about that hopefully in the New Year.
I think we had a question about whether there is a similar program in the ACT. We are not exactly sure about the exact program but we can get back to you if we find something similar.
Okay I am just scanning to see if there are any questions that we have overlooked.
I might while Shay and I have a look through these questions that are already on the screen, but I am just wondering if you are comfortable to feedback and just tell us if you are more likely to refer to Go4Fun now that you have heard tonight’s webinar?
Is there anything further that you would like to know about the Go4Fun program because we are lucky we have Shay here and she can answer just about every question. Okay while you are typing in your answers and it is great to see, we have seen a lot of people reply Yes, Yes, I will, so that is great and that is encouraging. It is great to hear from some GPs who are saying they are more likely to raise weight management as a priority and yes it is a priority, even our Premier has identified it as a priority and also GPs have identified it as a priority. Recently the RACGP published the Health of a Nation Report for 2017 and obesity was identified as one of the major concerns of today and also the future. Therefore, that is why this year we are holding a GP 17 and ALM for paediatrics and we are going to talk about that shortly and last year we did one for adults. So we are constantly trying to improve the knowledge base and up-skill GPs and you may have heard recently that our college president made an announcement that the RACGP acknowledges and recognises obesity as a chronic disease. So we are now the first medical college in Australia to have done that and we are hoping this will have a ripple effect on other medical colleges in Australia and then hopefully the AMA. So for those older GPs who may have recollections of over 10/15 years ago when there was explicit criteria that excluded obesity from care plans, well the current guidelines and the guidelines for the last five years have not had any exclusion criteria. So now that obesity is recognised as a disease there is no reason for us not to be using care plans. Care plans can be used for children, there are no age restrictions. So, if children would benefit from seeing a dietitian and exercise follow up, what we would normally do in adults is refer to a dietitian and an exercise physiologist and psychologist, here at Go4Fun you have it all in one, so this is an amazing resource and it makes it easier for the family to engage and comply because they can get everything in the one spot. In adult obesity as was mentioned in one of the comments earlier it is all a bit fragmented, so kudos to Go4Fun.
I can see that we are still getting some questions coming in that will require a bit of talking. I do want to mention that we will be running two more webinars early in 2018 and we will use some of the questions that you are asking to develop some of that content. If you deal have any immediate questions do feel free to email us. We will put our emails up at the end. Send your questions across and we will get back to you.
So finally, just a reminder that there is an upcoming active learning module at GP17 in exactly one week that will go into detail on weight management resources just to support health professionals and we do hope to see your there.
Absolutely, and just a note on that ALM, it does have limited positions and it is actually only available to GPs who have already registered for GP17. You need to be attending the conference to register for this ALM.
So, unfortunately we have run out of time and as discussed earlier, feel free to submit any questions and the questions that we have not had an opportunity to, we will be able to email you in the very near future.
Absolutely, and we will just flick to our last slide that has some contact information so that you are able to contact us and again you can email us through any pressing questions that you have and we can get back to you offline, so don’t stress if you have asked a question that has not yet been answered, we certainly can get back to them offline. Other than that, that wraps up this evening’ session for us. Please note that this is a QI and CPD activity and to receive your points you will need to complete the evaluation that will pop up on your screen once you close this session. Otherwise thanks very much for joining us tonight. We really hope that you found it useful and Georgia and Shay, thank you very much for coming in and joining us tonight as well, it has been fantastic.
Thank you and I look forward to seeing you all at GP 17 next week. Good night.