We are joined tonight by our presenters Dr Shirley Alexander and Dr Kim Seng Lim. So they will be presenting the webinar tonight and answering your questions as they come through as well.
Dr Kim Seng Lim is a general practitioner at Mt Druitt Medical Centre. He is also the Vice President of the Australian Medical Association in New South Wales. Dr Shirley Alexander is a staff specialist paediatrician at Children’s Hospital at Westmead. She is also head of the Children’s Hospital Institute of Sports Medicine and Weight Management Services.
Before we get started I would just like to do an acknowledgement of country. We would like to recognise the traditional custodians of the land and sea on which we live and work.
That’s about it, I think we are ready to get started. I will hand over to Dr Lim now to talk you through an overview of this webinar.
Welcome to this webinar fellow general practitioners and doctors. So, firstly, an overview of this webinar. In this webinar, first of all Shirley will talk about a summary of the previous webinar which was raising the issue and addressing some of the questions raised there. Then we will talk about how we assist and arrange as per the Ask, Assess, Assist and Arrange process for managing children who are above a healthy weight and then we will go through some difficult scenarios. By the end of this online activity we should be meeting the following objectives. So, ideally we should be in a position to be able to discuss and feel confident discussing weight with children and families using appropriate and non-stigmatising language, provide appropriate advice about family focus health behaviours, to have an awareness of and discuss existing support programs and services that are available to children and families and specifically also be aware and know how to utilise the Go For Fun Program for or two which we can refer children who are above a healthy weight. So, I am going to pass over to Shirley now to give us a brief summary of webinar one and more about obesity.
Thank you Kim. So welcome everybody. It is great to have so many people online and come back again. So I am going to give a short summary of what we did in the webinar with Georgia last month I think it was and just to say that the first webinar actually was recorded and it will be available for viewing on the RACGP website in a couple of weeks’ time, so rather than potentially posing additional questions for that at the moment it might be worthwhile having a look at that first and then you can maybe, if you want to, email some questions to the email addresses that you got the last time.
So, just to recap, in the last webinar we highlighted that it is now really recognised that children with overweight and obesity or children above and severely above a healthy weight range is a major issue, so much so that it is one of the few, or the only childhood condition of the 12 premiers priorities and one of the reasons for this is that it is one of the most common chronic diseases in childhood, 1:4 school aged children have overweight or obesity and all as you can see from the slide here, it looks like the prevalence is actually beginning to plateau out a little bit which is great, means that some of the changes that we have been making have started to make a difference, but I would like to just point out that it still is 1:4 children with weight issues or above a healthy weight and not only that the worrying trend is that the prevalence of obesity and particularly severe obesity is actually continuing to increase. So, lots of work being done, more work needs to be done and just also be aware that there are some pockets of children that have even higher risk and higher prevalence of obesity than the general population, those being from a lower socioeconomic background and also those from certain ethnic backgrounds, particularly from the Middle East. Just to address some of the questions that were asked in the last webinar and also just to cover that one of the issues that we talked about in the previous one is that there was a problem with recognising children with overweight or obesity above a health weight and particularly, parents that have weight issues themselves. So, one of the questions that was asked was the heritability of obesity is said to be about 40 to 80%. What are the relatively common conditions we should be thinking about in general practice? So, at the end of the day, childhood obesity is somewhat different from adult obesity. Many adults with obesity have underlying medical conditions that have either caused the obesity or significantly contributed to the obesity; this is much less so the case in childhood and ultimately it is only relatively about 5% of children that have a pure genetic disorder that has a propensity for obesity or a pure medical condition that has caused their obesity. So, it is basically remembering that the environment is the main problem and that is what we need to address and as I said then, the epigenetic changes if you like, is like the gun but it is the environment that is like the trigger that actually sparks off the excessive weight gain.
So, that sort of leads into that we covered excess weight gain or having a weight stasis above the healthy weight can affect any system in the body. As far as GPs, you know what excessive adipose tissue problems can occur and it is the same in children, diabetes, benign intracranial hypertension is something that we are seeing even more of in our clinic, problems with fatty liver disease etc. One of the potential differences I think in childhood obesity and adult obesity is that the children do not always present because of concerns about obesity but more because there are problems with bullying or teasing at school, so parents are worried about that. Sometimes there might be low self-esteem. There might be school avoidance because of issues around that and so the reason for presentation in most of the children you see that have weight above the healthy range will be for something totally different but actually might be exacerbated because of the weight, such as a chest or asthma problem. So, in recognition that childhood obesity is a significant issue, there has been a lot of work particularly in New South Wales and as I said, it is our Premier’s priority, it is one of 12, it is the only childhood priority and the NSW Ministry of Health have been working in a number of areas including the clinical side across all spectrums; primary, secondary and tertiary care levels, they are also working with schools, they are working in preschool and childhood settings and they are working in the food and built environment. One of the questions from the last webinar is; is there anything schools currently do or can do? Yes, there are lots of things that schools can do. Many of the schools follow the traffic light system for healthier canteens, many of them do crunch and sip to encourage children to drink water and have fruit and vegetables. Not all schools do it but there are a large percentage and personally I would like to see the schools doing a lot more about physical activity and interaction for that, as we know that physical activity is actually good for a number of things. So, the fact that NSW Health and the Ministry of Health have been working in multiple areas just highlights that obesity is a complex condition, it is multifactorial and there is not one single solution; it has to be a suite of solutions and that is what we have been working towards. In fact, we have been working with the Ministry of Health on a regular basis to help develop a number of resources and things that we will talk about later.
So, I suppose this is one of those things where as general practitioners, where there are
limits as to what we can do but there are also things that we can do. As Shirley has pointed out, there is a very large ecological component to obesity and especially how we manage it at a systems-base level. So, we have to look at it as a whole of system area and the things that we can do as general practitioners are interesting because we can use this as one of the tools to become engaged at community levels but there is of course still the patient we have to see in front of us. So, one of the interesting things is the NSW Health have been engaging much more closely with general practice in trying to address this issue and there are some very strong reasons for it. If we follow the model of general practice, where general practice is continuous, comprehensive, family based, community based, seeing patients for their life time in the context of the social media with their whole family, these all provide a great starting point. So, there is often that background knowledge which assists in knowing how to address each patient or each child and their family because addressing the issue of child weight is not just an issue of dealing with the child but it is actually addressing the whole environment. The continuity of care is a vital part because any program, no matter how good it is, is a time limited program and so whatever else happens needs to continue on beyond the length of that program and we know that put to children and in fact we know that 86% of the population have at least one contact with a general practitioner each year. So, this is part of the work of general practice which is managing these complex and chronic conditions and that interplay with different conditions.
What we also covered in the first webinar was how to raise the issue because we all know obesity is a very sensitive issue and it is often difficult for people to broach it. Although we use the medical term obesity and overweight, the NSW Health have been doing a lot of work around what sort of language to use because at the end of the day it is about communication, it is about using sensitive language, language that is not stigmatising and so helps to engage and progress discussions around weight. So, what we encourage people to do is to talk about things in terms of below a healthy weight, a healthy weight, above a healthy weight or well above a healthy weight when you are speaking with families in particular, because people often find using the word obesity a bit more offensive. So, we like to use that language, we like to do the heights and weights to make is normalised, to put it on a BMI chart and then show the chart as an introduction for the parents to say, look you know, I can see your child is above the healthy weight, is that something that you have thought about before or if not maybe that is something we can discuss. I know you have not come this time to discuss that but maybe we could make an appointment to discuss in detail another time. So, around that sort of thing, one of the other questions that we got last time was; what about children under the age of 2, how is a healthy weight determined in this age group and at what point is intervention required for this age group? So, again I would say you are looking at weight for age and again once you are above the 97th centile you really are beginning to get into that above a healthy weight category. We do not work with BMI in the same way in the under 2’s and I think that overall the focus again should be not necessarily obesity per se but looking at healthy feeding practices with the parents and teaching them. What we normally do is get the families to talk to the early childhood nurses and go over exactly what they are feeding the children, how much milk they are giving them, by the age of 3 they really should not be having a night time bottle and that sort of thing, so it is again being sensitive, not blaming the parents because many parents who may be first time parents, are working within the knowledge that they have but it is just teaching or helping them to develop strategies for healthy eating. Two other last questions on that were; how can an overweight GP discuss a child’s weight and if the mum is overweight then she will be protective and her guard will be up? Well, the first thing I would say, even if you have an excess weight issue yourself as a GP it should not deter you from bringing it up. It is like if you have hypertension it is not going to stop you talking about hypertension in your patients. I would just say, sometimes when I am talking to families, I am talking about good sleeping practices for example and I say to them, you know I am actually not the best at that, I don’t always get to bed you know at the right time and so whenever I am talking to people about that it is a reminder for myself that I need to make some changes to have a healthier lifestyle. Again, even if your parent has weight issues, it is talking in general terms of health not weight per se and doing these things for the whole family to get healthier. So, take home messages from the last time was basically make it routine so it is not strange for height and weight to be done when children come to see you, using sensitive non-stigmatising language so that they are more open and more likely to engage, use BMI charts to show families the BMI status of the child is so you can leap into talking about it and talking in terms of health and as family-wide practices for healthy habits around nutrition and activity.
So, this next section of the webinar is about assessing and managing children who are above the healthy weight with a particular focus on the resources which are available through NSW Health and a lot of these are available online and particularly how we can actually use this in general practice. So, one of the key things first of all is that assessment and that is part of what we will talk about which is what tools are available, how we can use those and in fact not even necessarily just as general practitioners but how our practice team can use it, so whether that be the practice nurse or the medical assistant, the dietitian within the practice and how this can all be done in using the same language and with consistency.
So, the first thing is to talk about this approach. The AAAA’s approach is very much in alignment with simple approach that we have for managing adult obesity but also in fact for managing most other conditions where we are discussing issues with patients. So the AAAA’s being of course, ask and assess, advise, assist and arrange. This flow chart is available and is downloadable from the pro.healthykids.NSW.gov.au website and it is a very logical way and a very streamlined process which will be able to be followed by any member in the practice team. So it provides a good workflow.
I would just like to add there that this flow chart or pathway came after a lot of Discussion with a number of people from a number of health disciplines to sort of agree on what we felt would be the best as a generic health pathway. So a lot of work went into that and hopefully it makes sense to everybody.
So, certainly to follow on from that, at our practice this is the sort of chart or pathway that gets put in at a few different levels, there is actually a copy at the front desk, there is also a copy at the nurses station and of course the doctors have it available to them. Part of the idea is that everyone is able to be on that same page and so the whole practice team has an awareness of the sort of workflow that we are going to follow. So it is a logical arrangement, going through a process. As with any practice, it is something which a practice is free to customise if need be but it also aligns very well with the resources available at the pro.healthykids.NSW.gov.au website. So the website has been designed in a manner that makes is accessible and usable as a tool again by any person in the practice. So, this is what the website looks like at the NSW Health end and I don’t know whether anyone has had a chance to look at it or use it yet. However, to give you an example about how this works at our practice level, this is something which scales very well to the iPads and in our tablets. So it scales very well to tablets and in our practice the practice nurse is able to use this on a tablet to talk to patients, children and their families as needed about the process that we go through. It is set out in a similar sort of manner; assess, advise, assist and arrange. This website is free and open to anyone and that actually means that we can allow other practitioners whether they be health practitioners or in fact we can allow our patients access to it as well, but there is still some very useful Q&As, some very useful video resources and a very handy lot of downloadable resources on it. So we will be talking about how some of these resources fit into our day to day workflow. The clinical resources there that these sort of points or have these aims in mind so firstly it is about engaging families and raising that issue. This is something which can cause a lot of angst amongst health professionals. Issues which Shirley has raised in some of the previous questions; how do we raise this, what if we have some push back, could there be some friction, could there be issues if say the doctor him or herself is not within a healthy weight range and what if the family are sensitive about that issue how can we address these? On the website there are quite a few Q&As especially in the advise section which talk about how these issues could be dealt with. The clinical resources also explain in a very neutral manner about how overweight and obesity is set, setting expectations and framing the issue as a health problem and it assists the patient to set goals and of course guide both the patient and family as well as the doctors in terms of setting and guiding their ongoing management. So there was a question earlier on about the BMI charts and so the BMI charts are available either as a downloadable sheet on this website or actually within the website itself, if you were to click on the assess button you would be able to either download that BMI chart or go to the Healthier BMI calculator, which then plots a patient’s or a child’s weight on this chart. So in this example you can see a girl’s 2-18 BMI chart showing what the percentile band that persons BMI falls within. So, are they within the healthy 5 to 85% band or are they above. Bearing in mind of course as we all know, that the BMI is not a 20-25 normal weight for children and that BMI range is going to change according to the age of the child. So by plotting along this chart you can do two things, one of them is actually demonstrate to a patient and their family, and it is actually more the family a lot of the time, where they stand on the chart and I find one very useful way of using this chart is actually after plotting it is just turning the screen around to a patient or if I am using a tablet to actually show the tablet to the patient and say, well this is where you stand, this is the red zone, this is the orange zone, this is the green zone and this is where you are. Then perhaps let the patient and their family come to some sort of thought about raising the question and to ask the next question where to from here?
The other elements of this website are the conversation starters. So the conversation starters can be found in this advise part and it raises a few, well it has a few, commonly asked questions, so FAQs and the FAQs are often those ones which have actually been raised already by some other participants in this webinar, such as how and why raise this question?, what do I do if I am not within a healthy weight range myself?, how do I do this if I am not confident?, how do I do this if there is some push back from the family? So part of where we as general practitioners have a little bit more of an advantage is often having that familiarity with patients, familiarity with their family and knowing where to push and knowing how hard to push sometimes and knowing when to do it because sometimes it is a case of finding the right time and as Shirley says, sometimes it is best not to deal with it at that point but perhaps to say, let’s come back to that question after.
So, this is where I think there has been a few discussion points raised and there have been some questions raised by participants in previous webinars. This is about that approach to assessment and management, so if you like, this is actually going right back to the first of the AAAA’s which is the ask and assess part. There were some questions here from the audience in the last webinar and I am going to raise some of those and I think that Shirley and I will probably both try to answer them.
One of the questions was; how do you treat younger children, especially those under 2 years of age?
So, as I said previously, what we prefer to do is to more redirect to the early childhood Nurse because hopefully these parents have had some connection with the childhood nurse in the earlier days when they were establishing feeding and get some advice from the nurse about healthier feeding practices. It is not good to be having a huge amount of milk in the 1 to 2 year olds for example, you want to have the child starting to have the same sort of food as the parents and developing good eating habits like sitting at the table with the family with the screen off. So, again the emphasis is not necessarily on the weight per se but on more healthy practices that need to be established at an early age because it is often if you can get those healthier eating habits started at an early age they are more likely to persist in the rest of the childhood and into adulthood.
The next question which always comes up is; can we use a GP management plan and I am assuming this refers to the team care arrangements as well, to refer obese or children above or well above a healthy weight range to dietitians/exercise physiologists/other services? This one is always a complicated question. Probably the best way to look at this is to actually go back to the Medicare descriptors of where a GP management plan and team care arrangements can be used, which is basically that they are available for use where there is a chronic complex condition and the definition of complex condition is almost circular because it is always a case of a complex condition is defined as any condition which is going to last more than six months and requires the care of a multidisciplinary team. We are sort of stuck on this one, given that obesity has not and is not currently recognised as a disease as such in Australia. So, if obesity is the only problem that someone suffers from, then it would probably be difficult to justify using a team care arrangement and management plan for that patient. However, if obesity were a component of or a comorbid factor, then there might be the capacity to use it. So, an example might be a child with obstructive sleep apnoea who also has obesity. In which case, then I think it is likely that a GP management plan and team care arrangement could be used in that case. However, if you had a well child who had no other complications then it is probably unlikely obesity could be used. Other situations where it might be able to be used would be where there might be psychological factors, bullying at school, school refusal, other complex issues which were to come into it. The problem is that Medicare and the department does not give us very much guidance on this and tends to actually say it is up to the judgement of each practitioner to do so. However, there is a foot note somewhere in the very, very fine print of Medicare descriptors saying the obesity itself is not generally recognised as a disease state for which management plans and team care arrangements can be used. So, does it help us, I am not sure but this is where it stands and we have to work within the rules.
So, one of the other questions was; do you ever use medications in kids for treating the obesity? The short answer is very rarely, there are very few that are actually registered to be used in children with obesity, which is zero. Orlistat is sometimes used in adolescents above the age of 12 but the side effects are usually very poorly tolerated and so they tend to not be adherent to taking it. Occasionally we will use metformin and I think that will be something we can talk about a little bit later. In other ones, we use metformin obviously if they have developed type 2 diabetes but we will also use it in certain situations of insulin resistance but for me, usually, I go with lifestyle change first even if they have quite marked insulin resistance and if that starts to fail then I might consider adding in metformin, particularly if they have very severe obesity or a very strong family genetic history of type 2 diabetes for example.
One of the other questions was; should we be looking at weight loss in overweight kids or maintenance of weight that they can grow into as they get taller? I would say, yes. In children that have overweight or just above the healthy weight range certainly you would not really be looking at weight loss. The only time that we would say looking at weight loss is when they have a weight range of well above the healthy weight range or if they have complications secondary to their obesity. So, for the majority of patients that you see, it would be looking at either slowing down the rate of weight gain or being weight maintenance and allowing that growth to occur to grow into it. Obviously the older the child is where they have less capacity or time to actually grow into their weight, ie, they are adolescents and they have almost reached their adult height, that might be a different scenario. Really, on the whole, if they are just in the overweight or above the healthy weight categories rather than well above, you would be just looking at weight maintenance.
Another thing that we were asked was; when do you check thyroid function tests and look for a medical reason. Usually, I have to say, hypothyroidism is an uncommon cause of obesity in general in children. Most parents think it is the underlying cause though and quite often I add in TSH levels whilst I am doing other bloods just to be able to show the parents that this is normal. You would certainly want to check thyroid function if there is a tailing off, crossing centiles of height gain to suggest that there might be a thyroid problem. If they have a goitre, obviously you would want to check that too. If there is short stature, the you are much more likely to want to look for a medical reason and other medical ones are if they have suggestions of Cushing’s disease or very violaceous striae, hypertension, they might be conditions and when you are examining them the thought might go through that they might actually have some underlying things.
I have a couple of other questions now which was; could you repeat the age of which they should not be having a night time bottle? Really, I would say that if you have a child at the age of 2 to 3, they really should not be having night time bottles anymore and it is not actually just for weight, it is actually also for dental care. If you go to sleep with a bottle in your mouth you are much more likely to have dental caries which is often a comorbidity that gets forgotten about.
There is another one of; what work up do you do at the first encounter and subsequently looking for any genetic and medical things? Again in paediatrics we are very reluctant actually to do any investigations really at the end of the day and there has to be a good reason. So, the reasons that we would do investigations would be if they have severe obesity or weight status well above the healthy weight range, an older adolescent with obesity or severe obesity, if there is a very strong family background or from an ethnic background that have a higher risk of cardiometabolic issues and when you examine the child or from history there is suggestion of complications from their excess weight gain. So, I would do bloods in that situation and the bloods I would do are fasting and I would particularly look for iron studies because they often have iron deficiency anaemia associated, I would do vitamin D and vitamin B12 because vitamin D is often low and vitamin B12 can also be low and it just acts as a baseline if are going to start metformin. Metformin can interfere with vitamin B12 metabolism and reduce it even further. I also do liver function tests to see if there might be some fatty liver. I usually do a lipid work up as well. I personally when I was at the Children’s Hospital Westmead we do fasting insulin and glucose and as I said I often just, particularly on the first occasion, I will chuck in thyroid function just more to show the parents that in fact there is not an underactive thyroid problem. So that is my usual sort of screen. I don’t do liver ultrasounds up front, I will only do them if they particularly raised liver function tests 2 to 3 above the normal range or there is persistence of raised ALT despite some weight loss. You have to remember that raised AST and ALT is not always purely indicative of fatty liver.
So, probably this is a good time to go back to the website and so this is actually a poster or a resource which is available under the advise tab of the pro.healthykids.NSW.gov.au website and it is actually a pretty good summary which when we are in our general practice, when we are back in our practices, one of the team can run this through with the patient. So, it is worth going through a few of the points here because this is really about how to normalise eating and healthy behaviour.
Some of the key messages on the diagram and this can be downloaded and given to patients as a handout. Eat together as a family at least once a day and that is the Be Healthy Together, that central message there. Drink water instead of soft drink, juice or cordial. Eat at least five serves of vegetables and two serves of fruit per day. There is a slight variation there for those who are slightly younger but that is available on this slide or rather on this resource when you download it. Starting each day with a health breakfast and there have been some interesting studies that show that a healthy breakfast does have an impact on performance at school, so that is another useful angle for the parents, say that their child is going to do better at school. Know your portion serve size, now that is an interesting one because I think that some of us as doctors are not so good at that, especially when we go to some of these medical conferences and stuff. Some of that information will be available further on when we look at the healthy shopping video, but choose healthier snacks and fewer treat foods and limit screen time. Now this is actually a very interesting one because while we do talk now about less than an hour a day for 2 to 5 years olds and two hours a day for children 6 years and older, it is actually becoming increasingly problematic because schools are expecting so much screen time and so sometimes we do have to talk about that in terms of recreational screen time as well. Certainly it is a message that we have to temper and we have to try to get out there. The one hour of healthy activity a day and of course getting enough sleep is another important part. So, these provide a good sort of basis which can be used to allow the health providers to assist families to set goals for themselves. So, a family can actually set a smart goal on this and these are actually quite eminently suitable for setting smart goals, so we will reduce our soft drink intake by this much by this point in time and we will do whatever measurements to go and check that, or we will attempt to have dinner together five nights out of seven because of whatever reason. So, these are the sorts of changes which can involve the whole family and can help us to create a more sustainable change.
Just to say that I know we have had some comments from colleagues about the fact that this resource is in English and do we have the same on in other languages. We don’t at the moment but we did through the working party that we have and meet regularly with a number of health professionals from different disciplines across different areas LHDs. Oh, we do have the translated versions now, sorry. The main message is through the pictures and it could be universal for anyone to look at these pictures and as I said, we have a lot of toing and froing and discussions and we also sent off to experts within the eating disorder world to make sure that these messages were healthy messages for all. And just to say, to add on, there are actually smarter goals that you can have and the E stands for emotion and the R is for reward because E most of the time we do things because of an emotional reason or logical reason, so again maybe to tack into the reason to make some changes is to say, well just think how much more energetic you would feel if you maybe lost a little bit of weight or you did these things rather than spending all your time or more time watching TV for example and to get behaviour recurrence you have to reward yourself. So, again, the reward has to be not around food and screen time ideally, although sometimes it might be that we suggest to families that the child can chose a sort of reward with discussion with the family and that might be actually going out for a picnic with the family and that means family interaction and doing everything together. So, as I said, a lot of work went into developing this and at the end of the day it is a great visual that you do not necessarily need to read the text but get the messages from the pictures.
Just one last one, someone gave a question; is there a reference for using metformin for kids to lose weight and what is the dose and duration of use generally. So, just in comment, is to highlight; as I am sure you know, metformin is not a weight loss drug per se, it is an insulin sensitising agent that sometimes helps when you have put in place lifestyle interventions to get some additional weight loss. We do the same as I think you do in adults in that because of the GI side effects we like to start at a small dose and it is the same dose as the adults, 500 mg. I start off with that and I work up to 1 g after a couple of weeks if there is no side effect and then eventually after another two to four weeks lead up to 2 g and use the slow-release preparation because I find that this gives you less side effects. I do find sometimes that when the metformin starts it does kick start a little bit of weight loss and the other thing that I am not sure whether you get the feedback from adults, but we often get feedback from parents that the mood of the child improves greatly. It seems to be that insulin resistance makes you even more moody as a teenager and if you treat the insulin resistance they become much nicer teenagers, so there you go, that might be a positive. As I said, metformin is almost like a not last resort but it I don’t start it readily, I like to try the lifestyle interventions first.
KEAN -SENG LIM:
Yes, that is a great reward actually if you get less moody adolescents in your household.
Oh absolutely, anything to point towards a positive outcome for everyone. It has to be a win-win for everyone.
Oh yes. On that same page, where this is found in the website there is also some further resources which can be used by the practice in terms of motivational interviewing and a module to work through on healthy weight and how to manage it.
So, moving on through the website, the next tab is on the assist part. So, the assist part provides some videos which can actually be downloaded and the video, even though it is here for practitioners, is actually set up in such a way that it can be used by families and patients themselves and of course, it is freely available on YouTube and you can link to it on your practice websites and Facebook sites as well. So, it has been produced in order to be easy and in order to allow a patient to use it and to have this in mind when they are going through a supermarket. So it is literally aisle by aisle tour of the supermarket saying do this, maybe that is not such a great idea, if that particular food is going to be in your basket consider doing something else instead and other ways of trying to manage the total calorie intake and try another healthy intake. So, other resources are ready to be downloaded from this section which is printouts which can be given to patients or emailed to patients as well as other referral forms for secondary and tertiary services if we need to refer further on.
That probably brings us to the arrange part. With the arrange part of this, I am going to pass onto Shirley who can tell you a lot more about what other services are available.
So, I think just realising that many of the people who have signed into webinar are actually from New South Wales but from those who are not from New South Wales, many of the states are actually doing a number of things to address childhood obesity. This slide I am going to talk specifically about and the next few slides that Kim is going to do, is specifically what is happening in New South Wales and we are looking at a number of new services being developed within LHGs to help support families of children above a healthy weight. So, on the website we have referral forms and also on the Children’s Hospital at Westmead there is also an electronic form that people can click onto, put in the details and obviously the form gets electronically sent to the relevant people. So if you are not from New South Wales I am afraid I don’t actually know specifically what is happening in your state but I suspect there is a similar service that you can log into but we certainly encourage you to have a look at that to do your electronic referrals.
So, one of the big resources, especially since we are talking about childhood obesity, is the Go For Fun Program. The Go For Fun Program for anyone who hasn’t used it yet, is a very interesting program that we have been using quite extensively in our practice and helps to provide extra bandwidth in managing patients because managing weight in both adults and children is a very time consuming process. It is something which even though it may not be classified as chronic disease, has to be managed using the same chronic disease model. So, basically if we don’t manage it, it will recur. There will be relapses, there will be remissions and so we have got to go through the same processes. Go For Fun is a free community based child obesity treatment program. It is quite structured. There is a once a week session which is delivered during the school term but over a school term and the child will go into the program, sometimes with their siblings, always with a carer or family member and while the child is involved in activities and some educational themes, the parents are involved in further education as well, so it actually educates both the children and their parents. So, here is the eligibility criteria which is that unfortunately it is only in New South Wales. Unfortunately it is only for 7 to 13 years and in general the programs are done in such a way that they will group children of a similar age together, so you won’t get 7 years old in the same program as a 13 year old generally, although if the program is there, there will be separate groups of 7 years old, separate groups for other older children. So the program outcomes are listed on this slide here but the bottom line is that there have been significant improvements with this and there are interestingly now some of those other components that Shirley talked about, such as those reward systems which are used in this. So where a family is able to make changes to their lifestyle overall, the family actually has some reward and there is excellent feedback for this. Now some of the other points are that 74% of the programs have been delivered in the socioeconomically disadvantaged community, 28% of families have been from rural or regional communities and there is a specific aboriginal Go For Fun pilot from this year. So, it is something that anyone can refer to and they can refer form this website and to let you all know, there is even prepopulated templates available in Medical Director and Best Practice, to make it easier to refer patients to this service. So, if you look under the supply templates in either of those programs, you will find you will be able to have a sheet like you see on the screen here, download it and get ready for you to fax off for patients.
The other service which I think also answers one of the questions raised here about any Telehealth resources, is actually the Get Healthy Service. The Get Healthy Service is actually more for adults but well, 16 and over, and the service requirements and the service facilities are listed here on this slide in bullet form, so probably again there is no need to go through each of these in detail. However, a few points to pick up, there have been significant improvements, while there is mention here of Get Healthy in Pregnancy, the Get Healthy coaching service is opposed to Go For Fun which is a group program, Get Healthy is an individual telephone coaching service. With this individual service you can specific on the referral form whether the patient is referred for a specific reason. So, for example, diabetes, hypertension, gestational diabetes, prediabetes, whether there is any other specific issues, fatty liver disease and alcohol actually are on the list as well and this assists the telephone counsellors to be able to tailor the program more specifically for those who are there. Now there is this question about what do we do with 15 and 16 year olds and the answer is, very good question. That might come down to a question which is a much broader question, which is what do we do with adolescents overall, because that is a different group which may require a slightly different approach. But we will leave that to some of the scenarios which are coming up because we do have scenarios where we discuss about what to do with adolescents because it is true, different age groups do require different approaches, the drivers and the levers for each group are different. So, we might move on now to the scenarios as I realise that we have been talking a lot and we are going to miss out on scenarios unless we move onto that.
The first one here is some of those issues on managing motivation and expectations. So, Shirley shall we both talk on these ones. I will let you start off first.
So, you might get the situation where the family believes that either they are doing everything or there is nothing additional that they can do. Again I think there is always something that can be done and just trying to tap into one area, even if it is just asking them, well are you drinking water as your main drink? You know, having just half a glass of orange juice every day. Are you going for a 10 or 15 minute walk every day just to get moving? Are you sitting together as a family for your evening meal? You will probably find that there will be something that you can focus on for a health weight, that there will be something there that they can actually do. Even if at that point in time they still think there is nothing, I think Kim has already said, you know you can give them the resource and say, okay maybe at this point in time we can’t think of anything but take this away with you and have a think about it and then we can talk about it the next time you come back.
It is one of those things where again it does take a lot of time and can be very time consuming. What is interesting is that it is not always necessary to target the child with Go For Fun because it is frequently still going to be an issue with the family as well, so the issue of overweight is likely to be an issue. In our practice in Mt Druitt where we have weighed 87% of all our patients and of that 87% of patients we have weighed the level of overweight and obesity is between 80 to 90% depending on the age group and particular decile. So, we can still use the Get Healthy program to assist for that and certainly that Eat for a Healthy Weight is actually a very useful resource because it is almost like a menu, you can say to the family, pick which one of these do you want to start with first and let’s review the situation after that. I think that sort of brings us to the second point which is; what should I do if a patient’s family said they have tried everything without success and one of them is actually going through that Eat for a Healthy Weight and it provides a very good scaffold in terms of how do we use the Eat for a Healthy Weight as a scaffold in our day to day practice, which is that is literally can be bullet points and say have we tried this, what is entered here, what has been done here, what can we do to improve that there and there are of course the other resources which is where we can refer to other services as necessary.
Yeah and I think sometimes what I like to say is; you may not think you have had success in trying these things but actually what the study shows is that if you have had no intervention or tried nothing then the weight gain would probably have been even more. So think in terms that in fact you have probably made a difference you just don’t realise it. Even if you don’t see a difference, and again this is not to focus on the weight per se, but if the child has become more active they are more likely to be healthier and have less complications from the excess weight gain. So, I think to convey messages of positiveness and that you know it is great that you have tried some things, it may not have made as big a difference in the weight gain but they may have become a bit fitter or they are managing to concentrate more or sleep better and often I think sleep is that forgotten cousin. You might not have made changes around the sleep that you could maybe focus on. So, I think there is always something that you can work on around that. So, I would say that if you had not done anything the weight gain would potentially have been actually greater and so you have made some difference, you just don’t know it yet so just keep going.
There is a good point there that unfortunately one of the traps I fall into in my practice Shirley is that I often tell patients, well you haven’t lost weight yet, oh no you have put it on again and that can be a big issue because it is really a great demotivator if I keep saying the same thing, so at some point we have to find something positive to work with. So, the next slide is really about the issue of managing belief. So how do we manage different beliefs within the family. This can be a very tricky issue, certainly we find that and maybe given that we are running low on time we might try to deal with all of these in one sort of big block.
So, I mean, again I think for me I find it is a bit like the customer is always right, in the sense that I like to aim for the positive and say; look you know you are who you are because of the knowledge that you have had or the resources that you have had, you have been doing your best and I am here to help you do even better and make some changes around some of the things that might be stopping you making some changes. They might be around their beliefs and the only thing you can do is use food or use screen time for rewards and get them to think outside the box, that actually at the end of the day you can use stickers, you can use time, children want to spend time with their parents and often we don’t spend enough time. So, it is just little things like that that you can delve into a little bit and again it doesn’t actually have to take too much time to find out, asking them what do you think might make the changes, what do you think is stopping you from making changes. Also one of the main ones we have is that it is cultural to be big and that is the desirable trade. Well again it is like; well I understand that and that is fine and maybe we are not looking at major weight loss but just to take the edge off some of the complications that might be happening because of that excess weight gain. It is not to say this is right, this is wrong, it is let’s work within what you know, what you believe, what we know as health professionals and what we can do to optimise the health for everybody. At the end of the day it is about health, not specifically weight per se, but optimising health so you can do what you want to do in your life.
And so it comes back to the principles of motivational interviewing which is how do we define what is meaningful for any family, for any child, for any parent and then we work with what we have. So, I think a lot of these questions in this slide have been covered in this and the previous discussion, so we probably should move onto this interesting and challenging issue which is managing adolescents. We know that adolescents have different drivers, so for example, one thing we found in our Salsa Program which is the students Lifestyle Activist Program, which is a child obesity program in schools, is that the people adolescents listen to the most are not their parents, not their teachers but actually more their peers. So one of the approaches we have to do is find how do we approach adolescents, how do we try to get that change. Sometimes it is about trying to find the right peer group, sometimes it is about trying to work out what is important to the adolescent and what are the drivers for them.
Yeah, I would totally agree. I mean I think the way we often work and it seems to be working well for adolescents is, that it is still family wide changes but is actually focusing on the adolescent and aiming to get them engaged and give them some accountability and choice and responsibility, so that the adolescent makes the decision about what changes they want to make and the parents support that decision and we have found that actually works really really well.
So, some of the questions that have come up here about real talking about weight causing eating disorder, Shirley have you ever found that.
No we have never found that I have to say. You know, there is no evidence to say that doing weight management in a supervised way triggers an eating disorder. We aim for teaching or giving strategies around healthy weight loss if that is needed and it is basically looking at healthy lifestyle practices that can be sustained. It is not about being on strict diets and depriving yourself of foods and things, it is about having a healthy attitude towards what you are eating and your activity. As I said, even in children that we have seen quite marked weight loss, as soon as they stop seeing us quite so regularly, the weight starts to go back on again, so we have no concerns about good advice around weight management triggering an eating disorder.
And I think that really comes back to where we consider weight issues as chronic illness and that is whether it is or isn’t classified as one it is all about the follow up, it is the fact that if you stop taking your antihypertensives often the blood pressure will go back up, the same with weight. Stop doing the right thing then there will be relapses but just like all that relapses, well we are trying to be there to try to comfort the remissions. So, this is probably as we are now running very short in time, where we need to talk about what is coming up next.
So, the next webinar is for the Go For Fun Program much more specifically and that is on 18 October, same time same place with Dr Georgia Regus and Shae Salle and again you can register through the RACGP website for this seminar. So again another very interesting and useful seminar coming up.
There is also the option to have more webinars next year, so any feedback. There are two more webinars planned for early next year but any suggestions that you would like us to cover please send them in and we would be very keen to see what would be of interest to you, to all of the general practitioners and colleagues and I am going to say to our extended practice teams as we work more and more in a team based environment.
The GP 17 active learning module. So on Wednesday 25 October, between those hours. They will be the active learning module which will be run and I think Shirley will be there. So we will all be there to talk further about this issue and so anyone who is going to be there, again you can register through the website which is on the screen in front of you.
Now that brings us to the formal end of what we are talking about and we are open to any questions which might arise.
There have been some questions in particular about parents who are separated and involving child protection services and that is a topic close to my heart, having written a paper on it, but I think that is the sort of topic that actually has to be discussed in much greater detail and we don’t quite have the time at the moment. I think we will either reply by email or maybe cover it in some of the other webinars. I think one is; how do you approach parents who believe the issues are solely genetic or being big boned and the weight of their baby is appropriate. I have to say I tend to say to everybody, look we all have a genetic propensity to put on weight, some more than others, so we have all got to work at it. Most of us do have to work at it. There is no real such thing as big boned and really at the end of the day, again we are looking at being healthy. It is about being healthy, having energy, feeling good about yourself, being able to do things and when you have excess weight gain that often restricts what you can do. So it is really looking about health and talking about how to optimise what you want to do in life.
At what point does the child need intervention like medication and surgery? So, as I said, medication we use very very rarely at the moment in children. We will use metformin for those that have marked insulin resistance and often you have marked acanthosis nigricans which again you will see in adults and if there is a strong family history and they are an adolescent and they are in the severe obesity or well above the healthy weight range and they have complication secondary to their obesity, I would consider metformin as an insulin sensitising agent in conjunction with lifestyle interventions, they have to have lifestyle interventions.
Surgery is unfortunately another topic that we could talk all night on. I think there are some children again, they need to be post-pubertal having reached their maximum adult height, so usually around the age of 15 to 16, you might consider surgery in those again well above the healthy weight range or severe obesity, strong family history of type 2 diabetes and obesity-related issues and have obesity complications. Now unfortunately at the moment in New South Wales anyway there is no real public money available for adolescents with severe obesity for bariatric surgery. They are usually lower down on the list, it is usually adults with multiple complications that get bariatric surgery ahead of an adolescent and that again is another topic itself that could be discussed. For most adolescents, if they are going to go for bariatric surgery if it often done in the private sector. The only thing is that really the adolescents that probably need it more are the adolescents from the lower socioeconomic sector and cannot actually afford the bariatric surgery. So, as I said, it is a controversial topic but there are some working groups, particularly in New South Wales, that are looking at how we can provide services including bariatric surgery for those adolescents that specifically need it.
That brings us to the end of this evening’s webinar. Thank you again Shirley and Kim Seng for joining us. If you feel you have not had any of your questions answered please feel free to send us through an email and we will be happy to get back to you. Just before we go, I would just like to remind you that this is a QA and CPD activity so if you can please complete the evaluation that will come up at the end of this session we would really appreciate it. We hope you found tonight’s session really useful.
Thank you for joining us.