Sammi: Good evening everybody and welcome to this evening’s Engaging with Adolescents in discussions about healthy weight and lifestyle behaviours. My name is Samantha and I will be your host for this evening. Before we get started I would like to make an 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 and present.
Alrighty, so I would like to introduce our presenters for this evening. So we are joined by our presenter, Dr Kathryn Williams and our facilitator, Dr Tim Senior. Dr Kathryn Williams is an endocrinologist, Conjoint Senior Lecturer at the University of Sydney and the Clinical Lead and Manager for the Nepean Family Metabolic Heath Service. This service is one of the only interdisciplinary lifespan obesity clinics in Australia and aims to deliver state of the art family based solutions for its patients. It maintains a strong focus on research and education and is working towards helping to reduce the burden of obesity and obesity stigma within the community. And our facilitator, Dr Tim Senior. Tim is a GP at Thurawal Aboriginal Corporation in South Western Sydney. Tim is also an RACGP medical advisor for the National Faculty of Aboriginal and Torres Strait Islander Health and a Senior Lecturer in General Practice and Indigenous Health at UWS. So, welcome Kathryn and Tim and thanks for joining us this evening.
Tim: Thank you very much, Sammi.
Sammi: No problem and I will hand over to Tim now and he will take us through our learning outcomes for this evening.
Tim: Absolutely. Thank you very much. Good evening, everyone. I hope you are having a good evening and in the east of the country, staying warm. So these are our learning outcomes and this is what we hope to achieve by the end of this session. So at the end of this activity, you should be able to assess adolescent growth using the appropriate growth charts, interpret and discuss weight status with adolescent patients using appropriate and non-stigmatising language, provide appropriate advice to adolescents about healthy behaviours and refer appropriate adolescents and their families to existing services. We will be revisiting these at the end to make sure that we have covered them all. And the first thing that we are going to before we actually get stuck into any knowledge, is just do a little poll just to see how you currently feel about it. So we are going to launch a poll. We are going to ask you before, how confident do you feel having conversations about weight management and healthy lifestyle behaviours with your adolescent patients. So, just be honest and rate yourselves as to how confident how you are feeling about doing this.
Sammi: That is great. And we have got 60% of people voted already Tim so I will wait until we get to 80% before we close that off. So keep clicking away.
Tim: Keep clicking and do not miss out.
Sammi: 69, 71. 73. Alright let us close that off there and I will pop those results up so you can all see.
Tim: So that is the results. So we have most people in the fairly confident to a bit confident and not confident which I think is very good, and probably what we would expect people attending a webinar on this area wanting to increase their confidence.
Kathryn: Yes, no, I think that is a really nice spread and hopefully we can increase some of those, a bit confident, not confident by the end of the webinar, Tim.
Tim: Absolutely, that would be great. And so the next slide. This just shows us that the, it is actually a real priority in New South Wales, coming directly from the Premier. So the Premier has a priority to reduce childhood obesity by 5% by 2025. And in order to do this, New South Wales Health has put significant investment into a range of programs into the community, in schools, childcare centres, social marketing campaigns. So there is a sort of a group of knowledge out there among people and hopefully healthier environments and hopefully and helping people make choices about their food. One of the things we will be talking about, is there is a routine advice and clinical engagement strategy that involves the whole health system, including us as GPs. And New South Wales Health are hoping to do more to make sure that children’s growth is routinely measured in the New South Wales health system. But another thing that they have done is fund webinars such as this, so that more of the New South Wales health system including GPs are on the same page about adolescent overweight and obesity. And so included in this is referral to treatment programs but also back to ourselves as GPs. And obviously we all know that we have got an important part to plat in the health system as being the first port of call for the vast majority of people in New South Wales and other states seeing us. Is there anything you would add on that, Kathryn?
Kathryn: No, I think you covered that very well, Tim.
Tim: That is very kind, thank you. The next slide. This I find really interesting because this is the prevalence at different ages showing the percentage of population who are above a healthy weight. And you can see there are two big life stages on prevalence where there is a big increase, and so one of those is at the nought to three age group. There is a big increase in prevalence. And the other is over late teens to early adulthood, in that 16 to 21 to 30 age group. And so, it would seem that that is a really good time that we are seeing people and able to engage with children, adolescents and their parents and carers, to actually prevent hopefully that big increase in prevalence that we see around that.
Kathryn: This is really what I see in the clinics, even in the adult clinic when I am talking to patients and taking their weight history. We see those that have been overweight and obese from a very young age, and then there is a huge cohort that have gained weight from 16 up. And I guess some of the factors there, they all say that they get a job and they have access to money and then they can buy their own discretionary foods. They are getting out of the home more. They are much more socially active. And they are drinking a bit of alcohol and the physical activity really drops off. So it is a major danger time, and I guess it is the real problem because overweight and obesity in this group is a real risk factor for overweight and obesity in adulthood and more severe forms of obesity where we are seeing those real complications. And complications then really impact on our ability to treat overweight and obesity later on. So it is really important to intervene early.
Kathryn: Okay, so Tim, many people are aware of the medical complications associated with obesity, and just to go through a few of those, obviously we have got the substantial increase in cardiovascular disease, type 2 diabetes which actually really probably a very nasty disease, much more nasty than type 1 diabetes when it is of young onset, and overall mortality by the time they reach middle age. There is higher rates of asthma, sleep disorders, breathing and also bone and joint complications among others. But we are not really selling is the psychosocial implications of obesity which are often overlooked. And they are probably the most important in this age group. They can be hidden but are very, very significant. The problem is that these become more and more ingrained into adulthood and they actually become more or less very, you know, near impossible to tackle in adulthood. And they can have a major effect. And also have implications for the future generations.
So what we are seeing in adolescents with overweight and obesity are higher rates of depression, anxiety and eating disorders. And it is the chicken or egg as to which one precedes which but they definitely feed each other. We also see lower self-esteem and body image. And weight is actually one of the most common reasons for being bullied at school. Now you would know that stigma probably comes from other children, but surprisingly, their peers are not the only ones delivering the stigma. Teachers and educators, parents and healthcare providers all contribute. Children with overweight and obesity have social exclusion and weaker friendship groups and this can lead to poorer quality adult relationships, reduced academic achievement which coupled with obesity stigma can actually lead to lesser employment outcomes. So it is actually really, really important and sets that child up for some significant things in the future. So a summary is that we have got to have a key focus on interventions for mental health in particular if they are present. We need to involve as part of our strategies, psychological and social supports, and this is for and from families, not just the index case. And it is a real argument for early diagnosis and effective actions to address these issues, as the complications are actually already present, even if the patient does not have diabetes, they may well have significant mental health.
So that is the first point to address, the complications. But before we can start managing overweight and obesity, I think we need to start discussing some more peripheral issues, but very important issues. So if we can move to the next slide.
Tim: So yes, so this slide and I think that previous slide shows how important it is for GPs to be involved, because those are just the sort of issues we are actually used to dealing with. This slide shows the Healthy Kids for Professionals website, and this is a screen shot from that. The pro.healthykids.NSW.gov.au, is the website that you are able to visit and you will see that referred to a few times during the webinar. It is a free resource developed to support ourselves and other health professionals, specifically for assessing and managing children who are above a healthy weight. You will all recognise those four A’s. Sometimes we call them the five A’s. But that approach that we take to encouraging people and enabling people to change behaviour. Assess, Advise, Assist and Arrange. And you will have seen that referred to in, across many different areas. Now, when you are on the website, if you click on that resources button at the top right, then there are all sorts of resources there that are available to you. So BMI charts, 8 for a healthy weight, which is a resource that you will be able to download as a handout from here as well. The guides to measuring height and length. Healthy habits eating fact sheets. And some of the centile charts can all be found on that website if you click resources. There are also some videos, FAQs, other online learning and both on the College website and I think on this website, some previous College webinars that cover a range of topics that are related to this as well. Anything you would add, Kathryn?
Kathryn: Yes, no I was introduced to the four A’s approach very recently. I think it is a great framework. I guess, in practice it is going to be a much more dynamic process and I just wanted to emphasise that that assessment has to be ongoing and is probably involved at every step. So, I think I jumped ahead before, but now I would like to discuss some peripheral issues before we start talking about overweight and obesity management in adolescents.
So if we can move to the next slide. The first one is on obesity stigma, otherwise known as weight bias. So I think we have a little bit of sound here to play for us.
Sammi: Yes we have got a little audio clip that we will play for you now. Bear with us.
Audio female: Oh no, not watching the telly again!
Audio male: No, this is educational. It is all about obesity and how bad it is for you. Tell you what, I would not like to catch it.
Audio female: You do not catch obesity, Norm.
Audio male: Hm? How do you get it, then?
Audio female: By eating too much. By eating the wrong things or by not doing any exercise.
Audio male: Mm. What is obesity exactly?
Audio female: It is getting fat, Norm.
Audio male: Oh.
Audio presenter: When you eat more than you need, the excess is turned into fat. To avoid obesity, cut down the amount you eat. Chose a balanced diet and include some regular exercise as part of your lifestyle. Obesity reduces your chance of a long and healthy life. So, watch what you eat and exercise regularly.
Audio male: I have just got big stomach bones.
Kathryn: So Tim that is the Life.Be.In.It. campaign. I think we are all familiar with it from our childhood. I do not think this campaign would happen today. What do you think?
Tim: No I suspect it would not. This is from before my time in Australia and so watching this video and hearing the audio was quite surprising now, and we certainly hear that fat shaming that people understand what that is, and I would think, my understanding is that certainly doctors have had quite a role in that in the past in using language that does stigmatise people who are above a healthy weight.
Kathryn: Yes, I think this today would seem an extreme example, but it was actually a population health campaign about 10 years ago and well accepted. And I think it is sort of true to a stereotype that we all kind of recognise to a lesser extent today. I think we still internalise this, where the patient with obesity may be less intelligent, lazy, disorganised, misguided, and these approaches tend to shame and blame the individual, and also I guess I would add, that eating less and moving more is not the full story and we will talk about that in a minute. But there is very good evidence Tim, that health care providers do not like treating obesity. They feel under-prepared to do so and they have got little hope that their patients will actually make any changes. And this is probably detectable in their communications. And the communication changes might be quite subtle. So for example, you might smile and make eye contact with a patient who is thinner when you walk in the room, whereas if you have a patient who is a bit heavier in your room, you might avoid eye contact. And this daily sort of subtle messaging could actually have a big impact on that patient. What we also see is this stigma has direct and observable consequences for the quality and the nature of the services that are provided to those with obesity. And that leads to yet another pathway, where a weight stigma can contribute to poorer health outcomes. I have a conversation regularly with my patients, they actually refuse to have some testing done because they are constantly sort of told how, that they cannot have that test because they are overweight or obese, or they should just lose weight, without any sort of assistance or help as to how to do so. And that leads to avoidance behaviour, and people leave medical conditions for a lot longer than they should. Also the doctor will tend to just focus on the obesity and they may not investigate the symptom that actually could be a much more serious problem. And we have good evidence actually that weight loss attempts are less successful when patients perceive that their primary care doctors judge them on the basis of their weight. So it is a very important issue.
Moving on to the next issue, associated with weight stigma, it is really important to get our language right. If we move on to the next slide. Now, we need to be very aware that patients are affected by the language that we use. And it is very important to avoid stigmatising language such as using the word “fat”, “obese”, “overweight” or “chubby.” And I experienced this myself with our service, which was called originally the Nepean Family Obesity Service. And what I found was that a significant minority were finding that name was very disturbing, particularly when they were going with their referral forms to get their testing done and, so what we did was we changed our name to the Metabolic Health Service because I just do not want any barriers to treatment. I think it is important to remember that when we are treating our patients. It is also important to remember to use first person language. How many times have you called a patient a diabetic, or an obese person? It is actually not okay. We should not be defining patients by their disease. So it is the patient with obesity. So, what the RACGP and Ministry of Health have worked with, children and their families on what language might be acceptable to them when we are engaging them about weight issues. And they have come up with this framework, where if the patient is between the 85th and 95th centile, then they are above a healthy weight, and if they are greater than the 95th centile, they are well above a healthy weight. Now it is important to realise that this is a guide, it is not a label for children. It is used to assist us in our conversations when we are talking about overweight and obesity, and to minimise that problem with weight stigma and weight bias.
So the next issue to talk about is obesity as a disease. Now this is a very complicated slide but it is just to illustrate a point. So there are many advocates now pushing for obesity to be recognised as a disease so that there is a greater recognition of the complex drivers behind the state of energy excess that leads to weight gain. So the first part of the slide talks about a genetic study. And this was presented at a recent obesity conference I went to. And it is essentially a cohort of over 1,000 people who are very phenotypically thin and healthy. And what they did, is they contrasted their genetic architecture to those with severe early onset obesity, and they found that thinness, like obesity, is actually an inheritable trait with clear genetic components. And they concluded that it was easy to rush to judgement and criticise people for their weight, but the science shows that things are far more complex. We have far less control over our weight than we may wish to think. So if you are thin, you may just be lucky because your genetic signature makes you that way. Now these genes are often involved in neurons that are involved in drivers for eating. For eating certain types of food, including our energy dense foods and for physical activity and or propensity towards sedentary type and many other things. There is also clear differences in energy handling. These can be from differences in the fat and muscle distribution and the way it handles energy, or differences even in the autonomic nervous system and the way the sympathetic and parasympathetic nervous systems can buffer change in any energy intake or physical activity. What is also clear is that our physiology fights to maintain our weight and will vigorously aim to regain weight that it has lost. And it is interesting that there is not a converse measure, so if we gain weight we do not vigorously try to lose weight to get to the set point. So the set point is gradually pushed up over time. And these fundamental differences in us all operator among others related to the environment. We know for example in Western Sydney where there is lower socioeconomic status that obesity rates are much higher. And also complex psychosocial and medical stressors that can be part of our patients’ lives.
Now the second part of the slide just actually represents the foresight diagram which was developed in the year 2007. And it is a diagram that sums up all the factors that contribute to obesity and their interdependent relationships and I think you would agree that is quite a busy slide. In fact, there is over 180 contributors that have been described as contributors to obesity and it well and truly justifies the term of obesity being described as the canary in the coal mine. So you are not really treating obesity, you need to treat those potentially 180 drivers for obesity. So it is very important to individualise your approach with patients. So the overall message I would like everyone to take home is that contributors to obesity are often multiple, and aiming for a simple eat less and move more approach is unlikely to achieve success. I really want you to check your assumptions in at the door and count yourself lucky if you do not struggle with weight. Although I think most of us do. And be humble and curious when assessing those that are above a healthy weight.
Now the third point is that when we are dealing specifically with adolescents, it is important that we reframe out expectations. Now adolescent brain development is a very interesting time and what we can see here from the graph, we have adolescents moving into young adult on the horizontal axis and then we have the weights on the vertical axis. And what we are seeing is, that the emotional brain develops quite early but in fact the prefrontal executive control which is so important for being able to enact healthy behaviour changes, takes a very long time to develop and is not fully developed until young adulthood. So what we are seeing is that this psychosocial development is very important for mature adulthood, but it has a real negative impact on chronic disease management and weight. And I think we should think of type 1 diabetes as an example that we are all familiar with. Most patients will have a significant deterioration in their glucose levels with type diabetes as they travel into adolescence. And sometimes we are after just simple harm minimisation until that individual is ready to engage again. And that is what we have to remember when we are treating our young adolescent patients. So the tasks in young adolescents are all about achieving independence and increasing autonomy and moving away from eating with the family. They are about a strong identification with a peer group and their opinions and behaviours, and associated with that comes risk taking behaviours.
Other negative things that can impact on weight in adolescence are you know, loss of discretionary time through study and employment. They have problems with their sleep through delayed sleep onset, bright evening lights, energy drinks, small screens and social media. And this all leads to less and disrupted sleep which is associated with increased adiposity and metabolic derangement, and of course anxiety and irritability. So we must change, for a change in health behaviours, or even body acceptance, could be considered a win. We may not always get weight reduction and that is an important thing to remember when we are treating this group of patients.
Tim: So I guess the next question arising from all of that, is how do we start to have conversations with adolescents, given all that genetic and developmental background. And I think it is worth just asking the participants to share with us through their question box, what approaches they are taking at the moment and I will invite Kathryn to share with us her approach and comment on some of the approaches we are putting through. So feel free to put through the way you would approach talking to adolescents who are above a healthy weight into the chat box. I have gone quiet, which I assume means you are all busy typing.
So someone has commented, using the HEADSS approach. So I hope you are all familiar with the HEADSS approach, this is a really helpful way of talking to young adults about their entire, about all the things that are going on for them in their life. HEADSS assessment asks about exercise and who cooks food in the house. Focus on wellbeing and not on the weight.
Kathryn: Fantastic. We are getting some really good answers here, Tim.
Tim: We are. Discuss what is important to them at present. Absolutely. That is good. So I think those are all familiar Kathryn as the sort of approach that you would recommend.
Kathryn: Yes, look I think we have got a very well educated audience here and possibly experienced with their own adolescents. But I think the main things to focus on are obviously rapport. Do not try to achieve the world in 20 minutes, this is a marathon not a sprint. And recognise that conversations can be all or nothing and you have just got to wait for that time where there might be some verbal diarrhoea and sometimes it can really be quite impressive how much you find out. But it might not be in your first consultation. Be very comfortable with vague. You will not always get the feedback that you want after having the discussion and while you have got some agreement on some points you will not always get that real consensus that you might get from an adult.
Communication is really important. You must be authentic. Be yourself and be humble. Do not use and authoritarian approach. You are not an expert in their life. And be curious and ask and question your assumptions. You have got to use negotiation for your developmental goals. Do not come from a point of power or authority because it will be met with resistance and it may lead to maladaptive behaviours and you also risk being seen as a co-conspirator with parents and other authority figures.
Tim: I think that is really important because it is so easy to slip into doing that without thinking, and I think that is really, really important to consider.
Kathryn: Absolutely. And I guess being problem solvers together, Tim, so that is important. And now the golden rule, do you ever sort of talk to your patients about their metabolic health in the future? Tim, I say…
Tim: Sorry, I was just muted. That is a really good question. Sort of looking at some of the answers in terms of asking people if they think about a healthy lifestyle and discussing what is important to them at present and I would imagine for many adolescents the future is a long way off and they can feel pretty invincible at that age.
Kathryn: It generally rarely gets many interactions so it is important as one of our contributors said, to focus on their wellbeing rather than possible health outcomes in 20 years’ time. So remember, their drivers are about becoming independent from their parents, being part of their peer group, romantic partners, trying new experiences, getting an education, finding a job and working out where they fit in the world.
Now there is also some gender differences, Tim that we need to be aware of. So in males, generally they can be more caught up more with strength, this is definitely stereotyping but it tends to work out a lot of the time, and physical fitness. Now, in high school, they are starting to flail a little. In primary school they may have been quite good at sports because they were bigger, but in high school that becomes less of an advantage. Females are often concerned about their body weight and peer opinions. And actually very few boys will present for their weight, so it is important to grab opportunities when they arrive. Now it is important to normalise psychological distress and offer support when it is needed. And I think really important is celebrating small wins and acknowledging that the treatment course may not always produce the desired result and you should, when people are not meeting goals, frame them as challenges rather than failures.
So, moving on to the next slide, I think the next thing to do is to realise that not all adolescents are the same and we basically sort of group them into three categories here. So starting with the 13 to 14 year old, these adolescents are just leaving childhood. So, the parents and families still shape largely what is being done. And they just want to be kids. They are more open to trying new things such as sporting activities, but they are quite concrete so you have to give them good rules or boundaries. They actually take knowledge from teachers, coaches and mentors as trusted adult sources. So you have got a fair bit of traction here. And they are quite reliant on their family, so it is very important to bring the family into the plan.
Now when we move into the 15 to 16 year olds, this is where things can get a little more complicated. So often from year 8 onward they are having increased pressure and expectations placed upon them. There is a lot more anxiety. They may be developing some sleep issues, particularly with small devices. And they are very body conscious and material and physical pressures are very much present. So they are experiencing this uncertainty and anxiety and it is easy for them to retreat or hide and not participate. They are actually happy to try things, but they may benefit from things like compulsory participation for everyone to try and get out and about. And they do tend to quit organised sport without an alternative. Now at this time they are less trusting of adult sources, so it may be a good idea to sort of try and find good web resources for them, or what I have found very successful is involving some sort of Allied Health member in the team, and personal trainers and other sort of physical activity experts can be very valuable in this age group, particularly with the boys.
Moving on to the next age range, is the 16 to 17 year olds. And this is where you might be able to start re-engaging. But it is important to start to listen to what is important with the adolescent at this stage. So they are forming a sense of self and future horizons and they are looking at life beyond school. Eating is actually a key social connector and they are out quite a bit socially. Now time management and best use of time is going to be a very big challenge and should be worked through with them. They have got a lot of focus and motivation, based on what fits in. So again, that time management is really important. Now the stigma as a GP and wellbeing officers and parents is that you are sources of relevant information or experience again so that trust may be starting to rebuild.
So moving on to the next slide now. So, Tim how do we provide some brief advice to our patients do you think at this stage?
Tim: Yes, I think it is a really crucial question because we cannot just dump everything we know on someone, someone made the important point about understanding who is cooking in the family and I think often finding the particular priorities and using that to give some really practical, detailed advice. And I know that this is one of the handouts, one of the resources on the website, the 8 for a healthy weight, which I think goes through eight particular pieces of advice that are quite specific and could be useful to using in giving people something constructive to do.
Kathryn: So, that is right. I mean, I think I would use this almost as a prompter for conversations. So, you know, some of the stuff, your advice is going to be very specific to the patient, but for example looking at the drinks thing, they might be drinking a lot of soft drinks or something like that and you might use that as a goal. So trying to replace some of those sugared, sweetened beverages with water or low fat options. Also when you are looking at eating, a lot of adolescents do not actually eat very many fruit and vegetables. It is something I have observed. They are very carbohydrate heavy and simple carbohydrate heavy and their meals are often not very regular so breakfast will often be skipped and it might just be as simple as recommending that they have some breakfast. When you are looking at physical activity, you have really got to sort of make it work in with their day, unless they are very keen you are not always going to get very much traction if you are recommending formal sporting and gym activities. So I do not know whether you or the audience have any other sort of suggestions?
Tim: We can certainly invite people to put in their particular healthy behaviours that they might recommend to people if they have got any particular things that they find useful.
Sammi: While people are tying, we might keep moving through the slides just to make sure that we do not run out of time at the end.
Kathryn: Yes, like take your dog for a walk, it is very therapeutic.
Tim: Absolutely. So, I think in terms of setting goals, there are some really important things. One of the things I find useful is just asking people, what do you want to achieve? And it can be really inspiring to see what it is that young people want to do. And often those are not health related goals, they are something that they want to do with their life that good health will allow them to do, or be more likely to allow them to do. They have to be realistic, sometimes that can be difficult to determine, like whether someone is likely to be an astronaut in six months is perhaps not a goal that is going to be achievable. It is really useful if they are quantifiable goals. So, so rather than saying lose some weight, being able to say lose 5 kg or lose 2 kg or not increase weight. Something that is actually quantifiable and is easier to measure. Find work at this place is a quantifiable thing, even if it is not a number.
Many young people like to be engaged in monitoring themselves and using phone apps and there are plenty of phone apps about and it is an evolving situation at the moment where there is not that much evidence around which apps are demonstrated to work but it is certainly a way. Often a young person may know about apps that other people are using that they could tell you about. And of course as GPs it is always really important to review people regularly and check their progress and expect times where they will fall back or move forward, and doing that over a period of time, and setting goals that are achievable in a particular amount of time, so that it is not sort of drifting over a number of years. And I see that we have got some other suggestions come in, about role models and people around them who are able to help. Self-care, so have a bubble bath. Walk to school if you can. Ensuring that their mental health is in a good state for making changes to their behaviour. And involving friends and group activities.
Kathryn: So, I mean it is very important talking about involving friends and sometimes that can definitely be an easy thing to do. We have not really talked about parents yet and I guess while they are less pivotal than when we are dealing with children, they are still very important. It is important to bring them into the conversation. There are a lot of positives. They do provide supportive environments. They can provide encouragement and praise the effort of the person. They can support realistic goals and be a real advocate for change and they can model the desired behaviour and this can be actually probably most important for an adolescent is seeing a parent modelling a behaviour that is healthy. There are a lot of negatives and you do have to be careful of these traps. So they may have a long history of weight loss failure themselves and they may not have a lot of faith in what is going on. Now, chaotic parenting styles are very common in our clinic, and it can be very anxiety-provoking and also very difficult to establish routines in the child or adolescent if the parents are chaotic. They may also be unwilling or unable to model behaviour and this might be because there is a lot of stress in the family, for example there may be a sibling with severe behavioural problems or autism or they may be unwilling to model them and that might be in the parent that you are actually not meeting, and that can make it even more difficult. But, so parents need to be involved and supportive, however adolescents really need to be treated as individual patients by health professionals. Are there any traps Tim in involving parents do you think?
Tim: Yes, certainly. I have met families where the parents are not particularly supportive and that can be difficult and so I think understanding the circumstances of the family and the relationships in there is really important. I have also found that it is really helpful to be explicit with people, saying from an adolescent’s point of view, all you see is adults telling you what to do. So your parents tell you what to do, your teachers will tell you what to do and I am the doctor, I am going to tell you what to do. And actually we are going to try and let you have some control over making decisions around this. So, parents and family are really positive and supportive but as we were talking about, those developmental stages earlier on, it is also a time where these young people are wanting to become more independent and gain more control over their life. And so actually finding ways of saying, yes, this is one of the ways we can do that can be really helpful.
Kathryn: Yes, so I guess on that note, it is important to observe as well as listen to what is being said and body language particularly in the family dynamic can be very instructive and it is quite easy to recognise dysfunctional relationships over any period of time. And so I guess that might be a time to consider family counselling. Is that something you have ever done, Tim, or?
Tim: It is and it is not so much around the weight issues then about around the communication issues in the family. And it can be a difficult thing because often in those sorts of situations parents come in and they say, well the problem is with the child and so introducing the idea that the problem is also with the relationships between people in the family. And we all have things that we can do to change. We have also had some really interesting comments come in that when the parents are also above a healthy weight, that can be hard to manage. There is also an opportunity there I think Kathryn, where if the young person, the adolescent is keen to change, they can actually be sometimes the catalyst for change in the whole family as well.
Kathryn: Yes, absolutely. And I think as the GP it is your opportunity to potentially try and engage the parents in their own health behaviours. So that is one of the things that we do in our clinic, is when we are running the group sessions for parents, we will actually get them to look at their own health and examine you know, things that they could do to improve their own health. And there is other sort of support, state-wide programs that we will talk about later that could be potentially harnessed. So, yes, just to sort of help the parents get on track, improve the organisation in the household and get everyone healthier.
Tim: Yes. And someone has written re-emphasising the challenge to manage when there is other co-existing mental health issues such as depression and probably goes for other comorbidities as well, but certainly depression can suck the motivation out of people to make any changes at all, whether that is in the adolescent themselves or if it is in other family members. So I think that is really important for us as GPs to recognise. And also another really important point about community culture where particular cultures that the child and family may be immersed in or part of, have different expectations around size. So it may actually become quite attractive, men are seen as attractive if they are particularly big, and certainly that is, we cannot just assume that that is neutral, that there may be other unspoken community culture pressures on people regarding their size.
Kathryn: That is true and you can get the grandparents and others weighing in there as well.
Tim: Absolutely. Thank you very much. I think, we are going to talk about following progress next, I think.
Kathryn: Yes. So, following progress is as you have said Tim before, regular follow up, constant assessment and reassessment and always checking your assumptions. Really celebrate successes. Formulate new plans if the current ones are not working, but be careful what you define as not working and reframe what is not working as a challenge rather than a failure. Consider other team members and resources and what you can draw on to strengthen the package that you are providing. And always considering the possible referral to secondary or tertiary weight management services if things are not going as you would expect.
Tim: Absolutely. And some of the successes to celebrate can be really small. Fantastic, you have not gained weight over the three months, that is really, that is a real success. And that what we might view as failure is often, that is normal. People do not just have routine progress.
I have got a question just before we move on to the case study. How do you get young people back if they are not sick?
Kathryn: Well, I think you are engaging them in healthy behaviours aren’t you? So I guess it is talking about fitness and wellness, so we are not really focussing on sickness at all. And we are not really even focussing on weight. We are trying to improve their health and wellness. So, yes it is a good question but I think if you schedule regular appointments, you have a plan with them, you have listened to them and you have engaged them, it should not be a problem to get them back.
Tim: Yes. And sometimes using that goal, the goals that they have identified themselves, like I want to do this course in TAFE, I want to do that. Seeing people regularly with a view to achieving that goal can actually be a really useful one. And if rapport has been gained early on, for some of the families that I have met, you are the only person who has actually said, yes you are important, we are going to see what we can do to help you here. And so that can be really important.
Tim: Let us move onto the case study which hopefully should illustrate a lot of the points that we have been making and that everyone here has been making. So of course, because we are in general practice we are running late after a busy overbooked morning and we have got 20 minutes until we need to attend our important practice meeting that is going to increase our pay perhaps. So there are aspects of this that may not be particularly realistic. You have got one more patient to see. This patient is known to another GP in the practice, but has not been seen for three years. Her name is Anastasia. She is a 16 year old girl who attends with her mother who is concerned about her daughter’s extreme fatigue and poor memory. Anastasia’s mother would like you to exclude a problem with Anastasia’s thyroid. She has read on the internet that it is a common complication or a common cause of fatigue. So you all have thoughts running through your mind at the moment. When you see them, Anastasia and her mother are seen to be arguing in the consultation. Anastasia’s mother will often answer questions directed at Anastasia, and you find it difficult to ascertain a comprehensive history because of this.
So as you are asking questions, you establish that Anastasia has no specific symptoms or signs of or particular risk factors for thyroid disease. Anastasia is well above a healthy weight and has been noted to have obesity, or severe obesity in documentation of your clinical notes dating back to 2014. So you do a routine clinical examination and you measure her height and weight and her weight is 135.5 kg and her height is 170 cm. And some already are sending through some, one of the differential diagnoses and wondering about I assume PSES is polycystic ovarian syndrome. So there is a multiple choice question set here. What should you do now? And more than one answer or none of these answers may be correct. So let us know whether, which of these you would do. A, tell Anastasia and her mother that she does not have thyroid disease. B, show Anastasia and her mother where her BMI is on a BMI growth chart. C, inform Anastasia and her mother that her symptoms are due to her weight and that she should see a dietician to lose weight. D, exclude thyroid disease by checking TSH. E, inform Anastasia and her mother that fatigue and poor memory can be caused by many things, including being above a healthy weight and that you would like to reschedule an appointment to discuss this further. Or F, seek permission to see Anastasia alone in consultation.
So lots of answers coming through. Lots of Ds, Es and Fs. D-Es. A few Bs in there as well. And an E. Sammi, shall we see what the answers might be?
Kathryn: So you know, I think case by case and these answers are not necessarily definitely right every time, but I was pleased to see some of the audience agree with us, Tim.
Tim: It is always good to see that.
Kathryn: So, Tim do we tell Anastasia and her mother that she does not have thyroid disease?
Tim: I do not really see how we can if it would be a possibility.
Kathryn: That is right. So I think you cannot rule it out without a blood test really. But it is also important to acknowledge the family’s concern. This is what they have presented with. If you do not answer that question, they may actually go away dissatisfied and not come back and see you. It is also potentially a good chance to measure some other pathology for example, metabolic profiling and if she has got some menstrual dysfunction potentially investigating that. So that is not a bad thing to do. So we have said that showing Anastasia and her mother where her BMI is on a growth chart is important and I think this is right, I think this opportunity has been missed multiple times in Anastasia’s development. She has obviously been you know, she has had obesity or severe obesity for most of her life and it does not seem that we have engaged her in that conversation.
So, do we inform Anastasia and her mother that her symptoms are due to weight and that she should see a dietician to lose weight? What do you think about that, Tim?
Tim: I am on mute. I think that is a very simplistic solution to what would be a complex problem. We have not ascertained exactly what is going on here, and so just saying right go and see a dietician I think is probably a little too early. We do not know what the problem is yet.
Kathryn: Yes, I agree. I think it is palming it off and it is not really recognising the primary problem. So we should exclude thyroid disease by checking TSH. I think we have said that. I think it is, yes, it is important to inform Anastasia and her mother that fatigue and poor memory can be caused by many things including being above a healthy weight. So it is linking the problem that we are concerned with to what they presented with and that you would like to reschedule the appointment because you are in a rush. You have got to get out there and talk about your pay. You cannot do this quickly. It also potentially gives them some opportunity to prepare themselves, because they would not have been going to that consultation thinking that they were going to talk about weight issues. Now we are seeking permission to see Anastasia on her own in consultation. This is probably important to anyone 12 and up, and particularly in this situation where you are having getting a history from Anastasia herself. Now importantly confidentiality can actually be maintained provided there is no risk to self-harm, there is no risk of harm to others or there is no risk of that person being harmed. And you can seek permission to discuss aspects of your consultation with parents later. And getting that parental buy-in will be important if Anastasia allows it. So Tim we are just going to look at the BMI chart.
Tim: Yes. So we will move through the next two slides fairly quickly I think. But this is one of the charts that is available in the resources section of the website. It can be really helpful. That red dot that you can see I think is where Anastasia is, and so that can be really helpful to show to her parents.
Kathryn: Yes. And moving to the next slide. So, at the next appointment you start your assessment. What do you need to know? I think a lot of our audience have already put some points forward, but as we are moving more quickly, we will just run through it. So pattern of weight gain is very important as we talked about, whether it is from the very beginning or an adolescent acceleration. And also whether they have actually had any weight loss attempts at all and what the success was like with those. You need to know what their usual intake is, what is their pattern of eating. A lot of people will not necessarily eat during the day, particularly if they are concerned about what other people are seeing them eat, or they might be having a lot of boredom eating at night. They could have quite disordered eating and in fact be exhibiting bulimia type behaviours. We need to know the triggers for eating, is it anxiety or stress. Their actual knowledge around food and who is providing the food and whether there is actually food insecurity in the house. Physical activity and barriers to physical activity and also sedentary and screen time are important. And obviously their interest in physical activity.
Next thing is to look at sleep. Very important and also do they have any sleep disordered breathing? Or is there any risk of sleep disordered breathing? And excessive daytime sleepiness would be important to assess.
Next is the family stressors. Essential, put in the centre here. So family routines as well, are they a very disordered family or do they have good routines? Is there financial security? Is obesity in other family members or household members? School performance. Absolutely key. Whether they are attending school, what their perceptions of school are. Their social support, whether there is any bullying. Or if there is learning or behaviour requirements or support. So things like ADHD and other things can be quite common in some of the patients we see in our service.
Medical and psychological complications and risk of medical and psychological complications, and it might be through family history and other things. And obviously secondary causes of obesity are important to exclude. They are very, very rare but if you do see someone of very high, tall or short stature, severe appetite reporting or learning problems or any sort of unusual physical features, or obesity that is very severe from a young age, you just need to think of this. And very, very importantly, is what matters to them and why. And this is what you need to address first.
Okay, so if we look at Anastasia she has had weight gain from four years and she was 110 kg at 13 years. She is actually cycling between dieting and feeding ad libitum. She has got a very high simple carbohydrate intake and she hates fruit and vegetables. She often misses breakfast and she eats when bored at night. She prepares her own meals as her mother does not want to cook. She has got no physical activity. It is a 45 minute bus ride to and from school. Significant screen time with a TV in her room. She enjoys going to the motorway races and she enjoys cake decorating. She has actually been a prize winner. She actually interestingly goes on regular cruises with her mother and during these cruises, the sleepiness and her health behaviours generally improve. Now she has had extreme fatigue for three to six months and occasional napping in the afternoon. She does snore and her father has sleep apnoea. She is sleeping up to 15 hours a day on the weekend. Her mother has reduced hours at work due to back pain. She is an RN. She also has two preschool cousins living with the family because their parents are not available at the moment. Her brother was recently crushed by an excavator. She feels unsupported to make healthy changes in her home. Her mother has obesity. Her father also has overweight. She is in year 10. She tells me school is boring but on fleshing that out further, school is actually stressful. She is quite absent a lot of the time and she is unwilling to ask for help at school.
Now from a medical point of view, she has intermittent abdominal pain after an appendectomy which was complicated by a stump abscess in 2014. She says she is not sure at times if she is hungry or if she has got an upset stomach. She has got GORD symptoms. She has got borderline hypertension. She has got hyperlipidaemia, with an LDL of 5. She has got menorrhagia controlled on the combined oral contraceptive pill after having menarche at age 12. She has got chronic back pain which has led her to present to the Emergency Department on several occasions. Impaired glucose tolerance. Cortisol excess has been excluded and she does not smoke or drink alcohol and she has no family history of metabolic cancers or liver disease, thank goodness. And importantly for her, she actually wants to be a child care worker. She really cannot stand school and she would like to embark on an apprenticeship. So a lot of stuff.
This is a real patient and some of the stuff we did with her, is we did involve the welfare counsellor or school to talk about how she was going at school and potentially to explore this option of an apprenticeship. She saw a clinical psychologist to help deal with stress and anxiety. We worked with her on planning and food preparation. She actually enjoys cooking. We knew that cooking had to be toddler friendly because she has got the young people at home and she also likes childcare. We really tried to sneak in the fruit and vegetables and work on her selective fruit preferences and we had to make sure that all our suggestions were economical given the food insecurity at home.
Time management was important to work on with Anastasia and we also supported the family to implement structure and improve the environment. We got a sleep study organised and we started some Metformin and we were considering the possibility of whether she might have some gastrointestinal pathology.
So moving to the next slide. It is just this slide, we will discuss places of referral for general practitioners shortly, but this is just a slide to highlight that the Ministry of Health and Royal Australian College of General Practitioners has a framework based on BMI to help to guide you as to when you might escalate therapy. And it is pointing out that a BMI more than 99th centile, they do actually recommend referral to a specialist service or paediatrician such as in the case of Anastasia.
So moving to the next slide which is actually talking about the referrals, sorry I just need to take a sip of water. So what we have here, you know from left to right, we have some state-based programs which are actually very high quality. We use the Go4Fun program quite a bit. It is for seven to 13 year olds, so just at the lower end of adolescents but it is a really great 10 week program that involves both parents and the patient in healthy lifestyle behaviours. Tim, I will get you to tell us about the Get Healthy information and coaching service.
Tim: Yes, so that is for older people and it is a free six month telephone coaching service with qualified health coaches for people 16 years and older. I had a little bit to do with this, because me and a colleague, they have a specific Aboriginal health line and so we were talking to some of the staff on there and so that can be a really, a really useful service as well that is free and it is an extra option for referral for us with our late teenage and adult patients as well.
The other thing worth mentioning is that for, we can use GP management plan and team care arrangements for some or perhaps all of these patients. You have to satisfy yourself that it is tipping over into the definition of a chronic disease and Medicare are very vague about whether it is eligible or not, but if we can satisfy ourselves that the majority of our peers would agree with whether we think it is a chronic disease and eligible for a chronic disease management plan and team care arrangement, then it is billable and I would suggest, particularly someone like Anastasia where their on, if they are needing medication and they are needing regular follow up and there are potential health consequences, then they would qualify for a GP management plan team care arrangement.
Kathryn: Yes and then we have got obviously local or community services. You can contact your PHN or your council and find out what is available in your local area. There is also at the far end, the secondary and cursory services. And we will talk a little bit more about where you can access those on the next slide.
So Tim this is a good resource slide where you can get information about secondary and tertiary services.
Tim: Yes, absolutely. It is also worth, so that is on the website we have already talked about. Many of the health pathways websites in your areas as well will have the local services in your area. Someone has also asked about services available in ACT. I think they have their own arrangements, but they do have arrangements I think.
Kathryn: Yes, and there is lots of information on all these programs on the Healthy Kids website.
Tim: So this is how we might define success for Anastasia, and again, are there any particular answers here that would strike you as being successful? In the interests of time I might suggest that any of A, B, C or D would actually be considered successful in Anastasia.
Kathryn: Yes. I think it is important to note that obesity is a chronic relapsing condition or disease with complex drivers and thus complex solutions and adolescence is a really difficult time for engagement and motivating changes so we have got to reframe our expectations.
Tim: Absolutely. And the next slide is really interesting in showing what actually happened with Anastasia.
Kathryn: Yes. So I think from the beginning in 2015 this was when she presented to hospital on one occasion and what is most striking is I suppose is this massive weight gain. So there was a real missed opportunity in 2015. Oh, they are really rushing ahead. Then in 2017, she was referred to the Kids Fit for Future Clinic at our service and you can see that initial interventions were successful. But then there was a period of weight regain and what is really impressive is the steepness of that weight regain. It can be very fast and it is really important to jump on when it occurs. So she was actually then referred to the adult healthy weight clinic at that point just to see if there was any other interventions that could be offered to Anastasia at that point. She had some success although there was a period of stagnation and then there was some weight regain. So at that point, we talked about where we could go with her therapy and she was offered some liraglutide which did have some effect. But also at that point, she actually stopped school and started childcare study apprenticeship and was really loving that, and so I suppose I recently had a discussion, so sorry then the next step was that she started having a very low energy diet as an 18-year-old. Now I think the most lovely thing is I was chatting to the dietician just yesterday about how she is going and she is actually submitting food diaries for analysis and sort of really engaging in physical activity and loving what she is doing. And you know, the things that we are discussing now is sort of how she can increase her calcium intake and modify her saturated fats on a reduced energy diet, which just would not have been heard of when we first met her because of the degree of social dysfunction and the impact that the school environment was having on her ability to engage. So in fact all of her excessive daytime sleepiness has now gone. She only had mild sleep apnoea in the end and that was largely just this real dissatisfaction with what was going on in her school life. So I guess the take home points are that success can take many forms and may not look like what you expect. Sometimes a shift in readiness to change can come from an unexpected source such as actually you know, leaving school potentially for an apprenticeship. I am not advocating for that, but in this case it is what needed to happen. The impact of school or family stressors really should not be underestimated and I guess it highlights the tertiary referral services can offer advanced management for those with a BMI greater than 99th centile. So in actual fact, Anastasia is quite keen in the future to consider bariatric surgery and I think this may be a reasonable option for her because she certainly is well above a healthy weight, will struggle with her weight and has got quite a few adverse metabolic features that may cause problems for her in the future. So that is an ongoing discussion with her. Not a suitable option for everyone but certainly maybe in this case it might be something that comes up in the future.
Tim: Excellent. This is a question people worry about. Will talking about weight cause of eating disorder? And I expect the short answer is no.
Kathryn: Yes. So I guess this is a big concern. I think the main point is first, that eating disorders are quite uncommon and overweight and obesity is very, very common really. Now there is an observed association between eating disorders and dieting at all body weights, and those with overweight and obesity are certainly at higher risk for eating disorder behaviours. They often do not eat at school because they are being bullied. There are mental health concerns. But was reassuring, the bests evidence we probably have, was a systemic review published in Obesity Reviews earlier this year that actually showed a reduction in the prevalence of eating disorders, eating disorder risk behaviours, emotional binge eating with the structured professionally run obesity treatment programs. What we see is that nutrition knowledge, accessibility to nutritious foods and self-esteem and self-efficacy are all protective and they are all taught in these programs. And the other thing that was reassuring was that the duration that people are engaged in these programs actually reduced their risks of eating disorders. So I think we can be fairly reassured that in these professional structured interventions, we are not going to increase the risk of eating disorders.
So practice points, very quickly. So, today we have learnt that we need to measure weight and height to inform your assessment. Do not miss that opportunity. Plot them on the growth charts and serial measurements over time are needed for growth assessment. If an adolescent is crossing the centiles or presents with morbidity secondary to their overweight or an unrelated health issue, then have a non-judgemental conversation with the patient around lifestyle behaviours after you have performed a thorough assessment. Provide the brief intervention and then help to develop strategies with the adolescent and their family. And if needed, refer to appropriate local community based programs or indeed the secondary or tertiary clinics that are available.
And we are looking at practice point two. Find out what is important to adolescents and set realistic goals. Take the time to adequately assess their personal situation, use feeling well and being fit as an engagement language, and golden rule, avoid talking too much about future health issues.
Tim: So there is a list here of previous webinars that we have done that look at similar issues. Those are available on our website and I think on the Pro-healthy kids website as well. So if we move through those slides, I think people get the slides as well afterwards. We can actually look back at our learning outcomes to see whether we have achieved that in our quick skip through adolescent obesity. So by now, we should be able to assess adolescent growth using the appropriate growth charts, interpret and discuss weight status with adolescent patients using appropriate and non-stigmatising language. Provide appropriate advice to adolescents about healthy behaviours and refer appropriate adolescents and their family to existing services.
We have run slightly over time. Thank you very much for your engagement in answering all the questions. We do hope it was helpful. Normally if you have questions that are ongoing, if you send them through to us we will do our best to answer them and we leave you there will be an evaluation questionnaire for you to fill out.
Thank you very much Kathryn, for being such a great source of information. Thank you to Sammi for making it all run so smoothly.
Sammi: That is great. Thank you so much Kathryn and Tim and thank you everyone online for joining us this evening and again apologies that we did run a couple of minutes over time there. But thank you for joining us and we hope you enjoy the rest of your evening.