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Evidence-based Recommendations for Managing Obesity in Children

Bethany:
 
Welcome to this evening’s Evidence-based Recommendations for Managing Obesity in Children webinar. My name is Beth, your host this evening. And we are joined tonight by our presenters, Stavroula Zandes, Dr Kean-Seng Lim and Tracey Clifton.
 
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. We pay our respects to Elders past and present.
 
I would like to introduce our presenters for this evening. Stavroula Zandes has a background in psychology and counselling and has worked with Quit Victoria and the Cancer Council of Victoria for 20 years in tobacco control. During this time, her roles included training a range of health and community professionals including hospital staff and allied healthcare professionals to support their clients to quit. She has counselled smokers on the Quitline and as a Quit educator has also run group sessions for smokers. In 2013, Stav founded Health and Wellbeing Training Consultants, a unique training and education business focussing on health and wellbeing and specialising in behaviour change and communication skills such as motivational interviewing. In 2016, Stav started working with the Cancer Council and Victoria’s Live Lighter program, as one of their principal trainers. As part of her role, she developed the content for the training on how to engage in the weight loss conversation with patients and in collaboration with the Live Lighter manager, has since then tweaked the training to suit the needs of the participants attending.
 
Dr Lim is a general practitioner and GP principal in a small group practice in Mt Druitt. He is the immediate past President of AMA New South Wales, the immediate past Deputy Chair of AMA Council of General Practice and a Wentworth’s Clinical Council member. In 2015, he was awarded the RACGP General Practitioner of the Year Award. He has previously served on the RACGP Faculty Board and Western Sydney PHN Board. Among other things, he has been a clinical lead with the National E-Health Transition Authority and is one of the developers of the schools based obesity prevention and lifestyle education program called Students as Lifestyle Activists, with which he remains heavily involved. He was previously involved in developing the Healthcare Homes training material as well as being engaged in PHN training. He currently serves on several advisory groups including the QIPIP data governance group, Health Direct clinical advisory group and ADHA Health working group. He has been heavily engaged in the Western Sydney PCMH implementation project and as a member of the Wentworth’s Clinical Leaders group. He is also the co-founder of the Care Monitor, a patient-provider partnership shared care digital platform.
 
Tracey Clifton is a State Project Officer at the Ministry of Health and has supported the state-wide delivery of Go4Fun for almost two years. Her background is as a dietician and she has worked in a number of settings including private practice, research at the George Institute and as a community dietician in the Hunter New England LHD, and as a health coach on the Get Healthy Service. I am now going to pass you over to Kean-Seng who will take us through our learning outcomes.
 
 
Kean-Seng:
 
Thank you very much. And so as with all of these things, we have to start off by well, looking at what we are supposed to be doing by the end of it. So by the end of this online QI and CPD activity, we should be able to become aware of current evidence-based recommendations in managing childhood obesity, and utilise evidence-based programs to support children above a healthy weight. So, now let us move on to our first poll question, which is this one. How often do you see children who are above a healthy weight in your practice? So I will leave you to answer those questions, and in a moment I am going to hand across to Stav who will take us through the discussion.
 
 
Bethany:
 
Perfect. So we have had over 74% of you who have voted and I will share the results with you. So as you can see, 2% rarely, 52% said sometimes, 45% very often, and 1% said always. So we will now move over to you, Stav.
 
 
Stavroula:
 
Great, thanks everyone for sharing that information. So let us keep reflecting on your practice, and what is the first thing that you do when a child above a healthy weight presents at your clinic? And how do you know if a child is above a healthy weight? So, type in your answers and your reflections in the Q and A box, and then we will draw those out and have a little bit of a conversation around this. What is the first thing you do when a child above a healthy weight presents at your clinic? How do you know if a child is above a healthy weight? What if the family does not raise the issue with you, that their child may possibly have an issue with their weight? So we have a couple of responses there I think. So let us have a look. Excellent. So, we ask the parent, the carer what they think. Excellent. We do an examination. We gather their history. We have a conversation about this. We measure weight and height. Excellent and we plot this on the chart. Great. Are there any other thoughts and reflections? BMI. Excellent. Food and activity history. Yes, so we start to gather some additional information about the family. You know, what is their food and activity history? What are their thoughts about the height and weight and BMI? We use the BMI chart. We ask the parents what they think. Absolutely. And this is really important when we are having this conversation. It is important because we know from the research that we cannot tell and identify a child’s weight status just by looking at them. And it is important therefore that we do these growth assessments, that we measure a child’s height and weight and we plot this against the age specific and gender chart in order to determine if that child is above a healthy weight. This then also provides us with an opportunity to engage in conversation, to raise the issue with the parent, with the carer, that their child may have a weight issue and to have that conversation about what the parent thinks, which is exactly what you guys have highlighted tonight. So thank you for sharing. Let mum and dad see the chart. I never say, I let them say, absolutely. So visuals are very powerful and when I take you through the four A’s, we will talk more about how you can actually engage in the conversation by really allowing the chart to do the work for you. And also reflecting on that whole of family approach.
 
Okay, so let us keep moving. And if you go onto the next poll. This time we would like you to reflect on what percentage of children you do see, do you actually undertake a growth assessment? So you do take their height and weight. What percentage of children you see. While we are doing that, someone has also put into the Q and A that it is also a great ice-breaker. Absolutely, using those BMI charts. So from the poll, we can see that 25% of you have said, yes, you do undertake a growth assessment in terms of the children you do see, 50%, and we have also got a portion that said 75% and 100%. So a real mixed bag. The most important thing is that you are doing some form of a growth assessment which is fantastic and we are hoping that by the end of this webinar, you do a lot more and you do feel a lot more comfortable and confident to be able to engage and have that conversation.
 
I have got some data from within New South Wales Health Services where 59% of children had their growth assessed in 2019 to 2020, and this was in comparison to 53% in 2018 to 2019. So those of you who are doing more than 50% are doing a great job, and those of you who are doing a little bit less, that is okay, that is what this webinar is all about, about how we can engage in conversation and do this as part of routine care. So what can we do? We can follow the weight management recommendations and the recommendations are that we offer brief intervention by following the four A’s. So my next question to you is, are you familiar with the four A’s? Do you use the four A’s in practice? Do you engage in conversation by using this as a structure to help you raise the issue about the child’s weight? So type into the Q and A, into the box there, about what the four A’s are, have you heard of them, are you aware of them, do you currently use them in practice? What do you think about the four A’s? And then I will just briefly touch on each of the A’s before we move on.
 
Okay, let us have a look. Yes, good, I did not know about them but it looks a bit like what I do anyway. Absolutely, and you will find that a lot of you are doing this quite intuitively. And what we are doing with the four A’s is actually providing you with the structure where you think, oh yes, I am doing this. I can refine it but I can also do this quite quickly. And this is what I love about the four A’s, where you can engage in conversation with as little as three to five minutes. So we are not asking you to spend a lot of time here initially, but just to initially plant the seed and engage in that conversation. I am more of a nudger. Absolutely. I am aware of them. I use them in adults often for weight loss and smoking cessation. I do not tend to use them in kids. That is no problem. What you will find with the four A’s or the five A’s is that you can pretty much use them for any type of behaviour change to really help you engage in conversation, alcohol management, fantastic. Cannot see the question or the answer sheet. I am not sure what that one is in reference to. But we have a yes, that you are using the four A’s which is wonderful. Any other thoughts?
 
Okay, so for those of you who may not be familiar with the four A’s, let me take you through them. And they are pretty self-explanatory, so you will say oh yes, I already do that in practice. So, the first one is quite obvious. This is where we do an assessment. So we are pretty much assessing the child’s growth and development. We measure their height and weight and then we plot that on the BMI specific chart. Of course, we do this by gaining consent from the family and from the child if that is appropriate. And of course we do this quite sensitively. So you are using your own clinical judgment.
 
The next A is where we start to advise the parent or the carer about the results. So we highlight that little Johnny is above a healthy weight. We have plotted this on the growth chart and then we have that conversation with the parent about reflecting on some positive lifestyle choices which very much moves into assistance, but what I also encourage you to do, is to check in with the parent and ask them whether they have seen this chart before. Has any other clinician possibly raised the issue that little Johnny might be above a healthy weight. So we are just touching base. We are asking the parent to reflect on what we are presenting and we are asking them to think about little Johnny’s height and weight and their growth assessment.
 
We then move into assistance, where we start to arrange some ongoing support or possibly we make a referral. We discuss some positive lifestyle changes. But the most important point here is that we focus on key messages that are very simple and small steps. So, we do not wish to overwhelm the patient with large steps, we want to focus on something that is small and simple like possibly reflecting on how much water little Johnny drinks and could we replace their soft drink with water. Maybe we ask them to reflect on the amount of screen time. Are they having breakfast every day? So little changes that could be maintained and sustained over time. And this is in collaboration with the family. So we are setting small goals with the family to ensure that this can be maintained over time and we are asking them to think about some of these positive changes that they think could be possible to implement throughout the whole family. So we are not just picking on little Johnny. We are asking the whole family to reflect on, could you possibly drink a little bit more water, or maybe get to bed a little earlier, or maybe could you go out for a walk, or walk to school a lot more often.
 
And then the final A is to arrange a follow up or provide some ongoing support or assistance. This might be a referral to the Go4Fun program which we will be highlighting tonight, or it might be to some other family focussed interventions or the health coaching service, or it might be to an obesity specialist depending on the child. And obviously you will be tailoring and interacting accordingly. But the most important thing about the four A’s and about this conversation is that it is not a one-off conversation. So it is important that you are constantly engaging in checking in with the family, with the carer, because we know that behaviour change takes time and that you may need to have a number of conversations before you start to see some small changes happening within the family dynamic and within the family unit. But it is what we call brief intervention, and you can move quite quickly through the four A’s quite quickly and I can imagine that a lot of you are using these quite intuitively anyway. So they are the four A’s for you.
 
And while we are thinking about that, I might just have a look at the Q and As. Perfect. Once off. Assess the child in the family context. Absolutely. So some of you may be using the five A’s, you know the first A is asking, we have dropped that off in this instance, because basically what you are doing is assessing the child’s growth and development. Are there any questions about the four A’s or about providing brief intervention before we move on?
 
Okay. So that is the four A’s for you. Let us move on.
 
 
Kean-Seng:
 
Great, thanks Stav. So, the next question is, I think it is actually supposed to be a poll question here but it is aright if it is not, because if it is not a poll question, let us start typing answers to this one in the Q and As. So, this is the discussion here which we are going to talk about, and before I read it out, I am actually going to expand on the topic a little bit. What we often do as general practitioners and the way we are trained, is often to work as a good general practitioner in the context of what we do within the scope, the boundaries of our rooms, and within that one to one doctor-patient or doctor-patient-family relationship. However what is interesting is that we are now moving into a different sort of world. And it is not a different world in that it is itself different, but it is very much about how we are going to think of not just what we do as individual practitioners but what we do in a practice as part of a micro-system. And so, whether we are solo practitioners, whether we are small group or large group practices, what we do for our patient population is part of how we can establish how successful we have been.
 
So this is a question here which I am going to ask everyone. So what the barriers and enablers to arranging support for children who are above a healthy weight, and support for their families? Because there are things here which happen both ways and one of the things which is quite interesting because I am going to go just a little step back to the previous poll question, which asked what percentage of children are being weighed at your practices, and it ranged from probably one person who said zero percent through to 15 people who said 100%. So we had a really good range there. But what is interesting is that that is actually a really interesting metric which we can use to work out how successful we are in a practice, which is how many of our patients have actually been measured? Or if we flip it around, how many patients have not? So what is the percentage in our practices? So anyway, let us have a look at this.
 
So some of the barriers out there are which have been brought up. Parents not realising their child is overweight. And then of course having this shocking realisation. Which is quite interesting because again it comes under this perception, now nationally we are looking around 24%, 23 or 24% of children who are overweight or obese. Now, it actually depends on what area you are in. So where I am in Western Sydney, that number is actually closer to about a third. And we do not know what the numbers are across all the schools, but certainly we do know in our high schools in our area, it is about 35% to 40%. So, it is quite different according to where you work. And so what is interesting about that realisation issue, about children or other adults not realising their children are overweight or above a healthy weight is that it comes on to what we see around us. And so a lot of that can be normalised. If we start to see everyone around us being above a healthy weight, then that tends to change the frame of normality and so that is a very interesting one. The other things there which we are seeing here are barriers which are coming up and I would love to see some enablers as well, but let us keep talking about the barriers, is that limited scope for the team. And this is really an interesting one, because again this comes back to that whole concept that as general practitioners, we are not working on our own. So it actually is not a general practitioner and the patient and family in the room by themselves, it is actually the general practitioner, the whole practice team as well as the broader team within the community, and how we can engage them.
 
So, these are certainly some of the other issues, other ones there which is that some parents do not perceive it as a problem and they think their child will just lose weight when they get older and that is another common thing. I think I will go along with that one and say there are also some parents who actually think it is quite normal for their child to look a bit chubby and if they are not, then they are not doing the right thing. And that can be prevalent in certain groups. So again, another barrier that has come up is some of the children are not those we are seeing, so adolescents, we often do not see as often and that is a well-known thing. Cultural issues. Grandparents, that is a very interesting one. Grandparents are very influential and especially grandparents and their daughter in laws are one of those issues. But again, what happens in the community. So if the parents themselves are above a healthy weight, peers and all of these other factors. Let us see, time is coming up as a factor here which is, do we have time to look at our own data? So Michelle has asked us that question. Do we have a dietician on site? Do we have access to all these other support services?
 
So let us move on to the next question, and actually then try to address some of those barriers there. Sorry, some of those enablers. So the next question on this one is, what are the effective interventions? So part of the discussion now, and this is where I am going to move the discussion on, and again I would be very keen to see some of this discussion happen in the Q and A, and so when we talk about those options, some of those options are really the flip side to the barriers. So for example, one of the barriers which is coming up quite clearly is the lack of access to the support that we need as part of that broader health care neighbourhood, and that means we are thinking dieticians, we are thinking obesity support services, we are thinking obesity specialists, paediatricians perhaps. But that is one level. So are there any other effective interventions that anyone has come across? So is there anything anyone would like to raise? So when we think about effective interventions, bear in mind that not all of them are referred interventions, but if we want to group them overall, you have things which are family focussed, so things which are effective are things which, considering we are talking here about children, we know that this is a group who are generally not going to the shop and purchasing their own food. So this is part of the question here. Who are we trying to address and what is the best way to address that? With adolescents and secondary school kids it is actually a slightly different story, because they are going to shops and buying food. They are stopping in at places on their way home from school and they are sometimes in a situation where the fast food shops are actually cheaper than buying healthy food, depending on where they are. And if you are in western Sydney again, we can talk about food deserts, we can talk about proportion of junk food shops to the proportion of healthy food shops and so forth.
 
So these are all other types of barriers. And so of course, when we turn that around, it is how we can think about what the enablers are. So here we go, we have got some other people saying, some of the enablers are that at an individual practice system level, is we make time to analyse our own data. So I think that is really about the population level health, trying to assess, trying to identify who amongst our practice, might actually be benefitting from further intervention. Enablers as well are online and local support. So someone has mentioned Go4Fun which is of course a very good one which we will talk further about. Having a good relationship with your usual healthcare professional is also seen as important. And one of the important things we have got here is good access. So access is seen as an important thing. Other things which are coming through, changes in behaviour. So, behavioural change.
 
Again, I am going to talk about how when we talk about behavioural change, and Julie has really raised this one here, it is about educating parents and this is talking about cooking, preparing healthy meals. Of course one of the biggest barriers to that one is time. So how are we going to get around that barrier of time? And I would be keen to hear what everyone thinks on that one, because yes, giving parents flyers about healthy food options, online, reviewing patients and children ourselves regularly which is what we do as general practitioners. So it is good to see what others have found successful and I would be really keen to hear what you have all found successful, because I think a lot of this is coming through here, which is that there are those of us who are making really strong use of those referral services such as Go4Fun, but also making really good use of the doctor patient relationship. And this is about that enabling and trying to really harness the strength of that, the power of that continuity of care. Kate has talked here about sharing personal experiences and sharing personal experiences can actually be a very powerful tool because one of the problems is that, I am going to share my personal experience which is that we have got a really, really great dietician that works with us, and half our patients do not want to see her because they say she is so skinny, what does she know about losing weight? So, this is the you know, some of us would say, she is so skinny so she probably does know something about this, but nonetheless, one of the things is sometimes sharing those experiences and exposing our vulnerabilities can actually be a powerful tool as well. So I think it is all part of how we identify with our patients and how we engage, and I think the thing coming through here is that there is no single best option. There are multiple options, and this is part of where we as what we do, select different options and tailor it. Personalise those choices for our patients. But it is good to see all of these options coming through. So they range from, for some patients we give them a flyer, for others we are going to give them a hyperlink. For some we are going to put their name on a text list and message them something. For others it is going to be about perhaps say talking to them, about well, healthy recipes, what they can do in whatever time. And of course, for others it is about changing the frame of normality and saying well, what you see as normal may not actually be normal. Stav, any questions we need to ask we well then?
 
 
Stavroula:
 
I was going to ask you about some of your experiences. What interventions have you found are successful in your practice? How do you engage in the conversation?
 
 
Kean-Seng:
 
Oh, so I think, you know what, I think I actually use a combination of pretty much all of these things which all of our audience are putting into the chat. One thing which I actually really like to do, is that every month we actually put a table saying what percentage of all patients in our practice have had a weight and height and BMI done within the last 12 months? And then we use it along the lines of what percentage of active patients? And so, we are not at 100%. So whoever is at 100%, they are doing a fantastic job, because the best we ever get up to is usually about 92% or 93% or so. But I will also say that number drops and with children, we are lucky to get about 75%. And there are multiple reasons why that is the case. And it is probably partly because we define our child cohort up to the age of 15, and we do miss out on a lot once they hit that age of nine, 10 and above. So, this is a really interesting question, but that is at a system level. The other thing of course is we actually then have little contests if you like, and contests with our practice nurses and our practice staff, saying who has engaged parents in this discussion and handed out flyers on Go4Fun? So we actually do use Go4Fun quite actively, but we also do hand out other information. Our practice website is another thing out there, and I must say one which I am really enjoying is I am challenging all of our patients to give us healthy recipes which they have got to bring in to us and say, this is my example of a healthy recipe, and you know there are some huge benefits with this, because it gives me an opportunity to have that discussion about what constitutes a healthy recipe and two, it gives me lunch for a day as well. So, I have an ulterior motive for many things. And so, I consider it efficiency myself, but anyway I will put that one aside and I will hand this on to, and I will let this one move on, and I will say that our next step is going to be creating Youtube channel for all these healthy recipes and we are going to put that up on our practice website. So watch this space.
 
So I will hand over now to I think, Tracey for this next part.
 
 
Stavroula:
 
Thanks, Kean-Seng. Before we move on, can I also just check in with the participants and just to remind them, and really reflect on why is it important that we intervene early? You know, what do they think about that? Why is it important that we intervene early? So if you can put that into the Q and A, because we need to have that why, as practitioners, as helpers, as supporters. You know, why is it that I am engaging in conversation about this now, or as soon as we can? And I think it is important to remind the participants that you actually can make a difference. So, do we have any thoughts about that, about the importance of intervening early? Good, so we have got that from Kate. Children who are overweight are far more likely to become overweight adults. And I think that is really important to remind ourselves that weight gain is difficult to reverse, and it is important that we do intervene early, so we do prevent you know, chronic ill health that is related to obesity, whether it is type 2 diabetes or cardiovascular problems, or joint problems. And I always reflect on a time when I was doing some training with a clinician and she was telling us that she will never forget the time when a young family came in and their child was struggling to walk from the desk to the play area or to the playground. They were struggling with joint problems. And I think it is important that we remind ourselves of the impact that we can have by having that conversation to support behaviour change. And that by intervening early, we can actually set up these young people, these children, these families, these adolescents with some positive lifestyle changes that can impact them in a positive way moving forward into adulthood. Okay. And we have got some other great points there. It is predisposing to metabolic syndrome later on. Absolutely, very important to intervene ASAP. Important to get those dots on the graph as evidence for parents to see, absolutely. And like some of you highlighted, for some of the parents and the carers that you might be working with, it might come as a big shock, and saying I wanted to ask you that question. When you are working with families who are not aware that their child is well above a healthy weight and it is a shock, how do you manage all those emotions in a very gentle and sensitive way?
 
 
Kean-Seng:
 
Yes, you are right. It is an interesting one because the risk of course of challenging someone’s mind or frame of mind, is that the automatic response is to shut down and not engage further. So, yes if I say you know, your child is overweight, that is going to, well run the risk that my patient is going to say they are not overweight. So end of story, end of conversation. So I think a lot of our audience have actually come across that and I can see that in the chat box, that has come up before and it is very much about that gentle approach and so, very frequently, we let the numbers do the talking. And so where people have talked about having those dots on the graph and saying this is what it is, and so it is a case of normalising weighing children, normalising this whole question about who are we, normalising this whole thing about just checking. So we check everyone’s blood pressure, we check everyone’s weight. We check the parents, we check the children. That is one. The second thing of course, is most parents are quite keen to see whether their children are developing normally and are good weight, so often it is not that hard, not so much to say let us check children’s weight, it is often better to say, well let us see how little Johnny, how Adam, Ahmed, how everyone is going. And let us see. And then you plot it on the graph. And then you let the numbers do the talking. And then you say right, this is where it is. What do you think? What do you see there? And they will say, oh, that is a little bit above that. And I will say yes, that is normal range and so this is a bit above a healthy weight range. Or if we use the other terminology, someone can be above a healthy weight range or well above a healthy weight range.
 
Michelle has actually pointed out, and Cassandra has also pointed out some of the other complications. And that is interesting because in an area like where we are, which is actually Western Sydney again, we have got 48% of adults whose screening blood tests would put them into a pre-diabetic range, and I suspect where Michelle is it is going to be very similar as well because I think Michelle is probably still in Alice Springs at the moment, now. So this is another thing which is that you say, well this is a risk. This is what is happening in our community. This is what is happening in the family and so forth. But it is very much about finding this, and Michael Fasher did talk about this as well, the nudge factor, let us say, so what do you think? Put it back and say, what do you think? What would you like to do next? And then depending on what the response is, we can say these are the options. Let us talk about what it might be. So others have said, yes, never use the word overweight or obese or worst of all, fat, as it ends in disaster. And that is straight from the Go4Fun, in fact that is straight out of the Healthy Kids for Professionals website playbook which is absolutely, I cannot agree more with you on that one, Kate. I think that is very much a case of you know, what do you think? Well above a healthy weight, well above a healthy weight. We can use these variations on it. But yes, we certainly want to make sure that we maintain that relationship, because I think as everyone has pointed out, this is not a one-off intervention. This is not a case where we are going to say, alright here is a referral, off you go, and everything is going to be fixed. It is going to keep coming back and it is like a chronic illness. We will do it and we will have to keep doing it.
 
 
Stavroula:
 
That is great, thanks Kean. I really love how you really encourage the parents to reflect on their thoughts and how they are feeling and what they are thinking, and this really provides them and empowers them to make the decisions that are right for them and their family. So thank you.
 
 
Kean-Seng:
 
Okay. So, I think Tracey, are you doing this next poll question or not?
 
 
Tracey:
 
Yes. Thanks Kean-Seng and thanks, Stav. Yes, so both of you have mentioned Go4Fun. So just before I sort of go into it a bit more and tell you guys a bit more about the program, I have just got a polling question here. So, were you aware of the Go4Fun program prior to today? And if yes, do you refer children and families to Go4Fun?
 
 
Bethany:
 
Perfect. So again we do have a bit of a mixed bag, so 23% that said yes, I was aware and referring. 32, yes I was aware but not referring. And 45% said no I was not aware. And I will just share those results with you.
 
 
Tracey:
 
Thank you, Beth. So that is quite interesting that a lot of you, the majority, or half of you almost were not aware, because doctors are actually one of our highest referrers into Go4Fun, followed closely by paediatricians and oral health staff. So hopefully after today’s webinar, hopefully knowing a bit more about the program, I guess and the importance of I guess referring children above a healthy weight to the program, hopefully that will encourage you to refer future children.
 
Okay. So what is Go4Fun? So, Go4Fun is a free, evidence based healthy lifestyle program for children seven to 13 who are over a healthy weight. The program is definitely family-focused and it is definitely not just focussing on the child themselves. It is New South Wales Health funded and delivered by trained health and community health professionals. So they are in good hands. We have dieticians and exercise physiologists that deliver the program. The program really focusses on improving the dietary habits, fitness levels and behaviour change rather than I guess focusing on weight. So, once the family start making changes to their diet and exercise, they definitely see changes in their weight as well and Kean-Seng will talk a bit more about the outcomes and results later on.
 
So Go4Fun is run across New South Wales, across 15 LHDs. So each term, the program is run in different locations. So you can definitely check this out on our website, it is definitely not something you need to know each time you refer a family to the program. So once you make the referral, the Go4Fun team will contact the family and then they will discuss the most appropriate program for the family based on their location as well. So it is run in line with the school terms and generally after school hours. So obviously as it is a family based family, both the child and parent needs to be in attendance. And just in relation to I guess a bit of a COVID update as well, so we generally do run face to face programs throughout the year, but it has been put on hold until I guess term two this year. So we still have the Go4Fun online version which I will talk to you guys a bit more about in a minute. So that is still available to families. So you can definitely still refer families to the program and then the Go4Fun team will discuss with the family if they would like to start the online version now or they can be put on a wait list for the face to face program as well. And just to really highlight I guess the eligibility criteria as well. So Go4Fun is only currently run in New South Wales, it is only for New South Wales residents. The child must be between the age of seven and 13 and be above a healthy weight. And like I said, a parent or carer must be in attendance as well.
 
Okay. So moving onto the development of Go4Fun. So the program was actually developed in the UK back in the year 2000 by leading childhood obesity experts including dieticians, paediatricians and even psychologists. So it was a clinical treatment program in the UK and it was known as MEND. But then in 2011, it was redeveloped for the New South Wales community and that is when it started running in New South Wales. The program has also been culturally adapted to support Aboriginal and Torres Strait Islander children and families since 2017. So this is known as the Aboriginal Go4Fun. So this program follows a bit of a co-delivery model, so local health districts establish a formal partnership with local Aboriginal organisations to deliver the program and then the model I guess draws on the strengths of both the parties to deliver the program in an effective and engaging way for the families as well.
 
And as well, Go4Fun online that was created in 2018 for families, particularly those in rural and remote areas, and those that cannot attend face-to-face program, or families that live in areas where the program was not delivered or easily accessible for them. The program is run over 10 weeks. It just can be completed in convenient time, convenient to the families, in the comfort of their own home. It consists of online modules, weekly phone coaching, a closed Facebook group for families to interact with other families and share ideas. They get weekly SMS and email reminders and they get physical resources sent to them to support them with their behaviour change as well.
 
And we know in terms of referring families to Go4Fun is only 10 weeks, it is only a short term intervention, so we are actually working on developing a Go4Fun graduates program. So this is in order to help continue supporting families in the long term. So we are still in development at the moment. It was planned to be piloted earlier this year with our face to face program, but due to COVID, has been put on hold. So basically, Go4Fun graduates consists of an additional three terms of support on a bit of a tapered approach. So I guess the families would complete the 10 week face to face program and then it is followed by another term of fortnightly coaching calls and access to online modules and then the last two terms they will have access to what we call a hotline service. So families will only need to sort of call in to speak to a health coach as required. So hopefully I guess at that point, at the new point, they are sort of more about maintaining their lifestyle changes at that point. So we can definitely see in the past 10 years, almost 10 years now, the program has definitely evolved and it continues to meet the needs of the community, particularly of those at-risk populations.
 
And I will pass it back to Dr Lim to talk a little bit more about the benefits and the outcomes of the program.
 
 
Kean-Seng:
 
Thanks very much, Tracey. So I am actually going to start with a little bit of a story, because one is that I noticed that Gordon has written in the chat box a question about family. And it actually does remind me of well, a story. And so, I had, one of the early ones who were referred to Go4Fun was actually this family. So, this is a family from Samoa, and they actually came in because they were concerned their child was underweight. And so, I first saw the child when he was around about six months old. They were concerned the child was underweight. He was not. He was actually above a healthy weight range. In fact, by the time he was 12 months, he was well above a healthy weight range, and as the years went on he got a bit more above that. But none the less, anyway, part of this discussion started at that point in saying, your child is doing fine but of course there was still the perception that they had that their child should actually be bigger. Now, it took quite a while and it was not until this child was diagnosed with obstructive sleep apnoea and was well above a healthy weight that there was a need to then try and actually intervene more strongly, and also that the family was ready to have that intervention. And unfortunately at this point, the child was actually under seven and so was not eligible for Go4Fun. But at another level, because of the severity, we were able to utilise a lot of referred services, which included using some of the paediatric services as well as the dieticians and exercise physiologists within our practice. And so we were able to establish a relationship as things go and as it always goes, this child did well and then we had this fluctuating course where there was weight gain, weight loss, weight gain, weight loss. And so we did not really start to get on top of things until we actually did refer them to Go4Fun. So the question is, why? What did work with Go4Fun? So, part of this issue, and what worked with Go4Fun was the fact that Go4Fun was not just addressing a child’s problems, it was actually addressing the whole family and so when this child was going to Go4Fun and doing whatever he was doing with the other children, the family were also getting engaged, or rather the parents were getting engaged as part of the carers group. And the strategies and the little games and things they did also set family level targets which they are able to use. So targets such as, how much weight as a family are we going to lose? How much exercise are we as a family going to be doing over this next week? What are we going to be doing in the way of vegetables or fruit over this next week? So it is about setting little goals which they would all address as a whole family unit. And so the benefit of this one was that over the period of time they were going to Go4Fun, the whole family lost weight. And the whole family did better. And then after that, they managed to maintain that. And yes there were relapses, because that is the nature of this condition. There were relapses. But we were able to re-engage and further down the track, re-enrol and re-refer into Go4Fun again and we have managed to keep this going until now the family, and now this child is about 16 years old, and the family of course have all grown up with this, and there have been other children in the family, and he whole family now have a much stronger awareness of what they need to do, and of doing it. So it is an example of where the Go4Fun program made a big difference to not just the person who has been referred, but to the whole family unit. And how in fact the success factors were not just what happens with the child, but with the whole family because this is what helped to maintain that weight loss, and also with that recognition that there were going to be relapses but we were always able to re-engage and that they could continue to have support from our practice team which included in our practice a dietician, the general practitioners in our practice team, the nurses in our practice and so forth. So there was always that strong support and not just single support, but multiple levels of support. So, this is just one of the examples of that.
 
So in terms of Gordon’s question here about the mother blaming the Maori heritage and the child being aware they are overweight but is too embarrassed to engage. We do find that especially once we reach that adolescent age there becomes that level of self-consciousness. And it is really a no-blame game. This is not a case where anyone is right or wrong. We are not there to say, we are not there to be the foot police to say this is bad, do not do that. There is no such thing as good or bad. It is actually about referring that question back, so what would my approach be? My approach would often be just simply, okay, this is where you are. What would you like to do? And then okay, and then often they will say well, they will come up with suggestions. They will invite suggestions and then they will say okay, what is it that you would like to start with, what are well without using the words barriers, but exploring that, what are the barriers to why that is not happening now? What are the reasons why you might do this? What could you do instead? So if someone says, well I probably should not have my Coke every day, well say okay. That is probably not a bad place to start. So what else could you do instead? So that is the sort of thing.
 
So it is an interesting question which Kate has put up there, which is how does this sit with the development of eating disorders? And it is a very interesting question, because this comes up a lot and I am actually going to pass that one back to Stav who is a far more experienced person in that than I am. So, Stav, can I get you to respond to that one?
 
 
Stavroula:
 
Yes, absolutely. I think you have really nailed it Kate by reflecting on the terminology that we use. So, if we are reflecting on that a child is above a healthy weight or well above a healthy weight, and are not using terminology such as fat, or you are obese and that kind of shaming, body shaming or guilting young people, then the evidence tells us that if we present the information in a very respectful and non-judgmental way, then they are less likely to then develop an eating disorder. Now having said that, I encourage you to use your clinical judgement. If you are working with a young person who you feel is very sensitive or might be anxious about their body image or their self-esteem, then possibly you may not have conversation about their weight, but may reflect on some healthy lifestyle choices or you may reflect on, tell me about your eating patterns and what are they like? Or tell me about your moods and do you ever link your emotional sort of moods to food? And start to have a conversation other than weight, by reflecting on how they are feeling, how they think about food. Is food form of nourishment, is it a form of punishment? And in this way we are approaching the conversation in a very sensitive and non-judgemental way. And then in that way, we are well, kind of keeping it safe. And sometimes I say to clinicians, if you do not want to go there, then do not go there. You know, trust your gut and reflect and engage in that conversation in a different way. But as long as you are using terminology that is very respectful and you are presenting the information, and as Kean-Seng suggested, ask the young person, what is it that you think? Or how do you feel about this? And if they are embarrassed, then can you have a conversation alone? I mean if they are a young person, an adolescent, maybe you can have a conversation without mum and dad, you know bickering in the background or saying things like, well you know, you are the one that buys the soft drinks, or you are the one that chucks a tantrum in the supermarket and wants the potato chips. Can you have that conversation with the young person alone? Just to gauge their thoughts, their feelings, and as Kean-Seng highlighted, reflecting on what is it that you want to do? How do you wish to move forward and what do you think makes it hard for you to reduce your Coca-Cola intake? What makes it hard to stop drinking Red Bull first thing in the morning? And really start to reflect on some of those barriers, and what makes it challenging to make some change. And then asking the young person again, you know, what could you do? How could you overcome that challenge of drinking Red Bull first thing in the morning? So they are some of my thoughts. But as long as we keep to the sensitive language, neutral language, we find that we are able to engage in conversation in a very respectful and healthy way, because we are not focusing on weight. We are focussing on positive behaviour change, positive lifestyle choices that will carry us all the way through into adulthood. And often you find working with a young person, I always remind myself that the one thing that a young person wants is independence. They do not want to be dependent on parents. And so I often say to them, when you make a choice to not drink Coca-Cola, you have just shown your independence. Because that is your decision. That is your choice and has nothing to do with your parents. If you make the decision to get on your bike and go for a quick bike ride you know, in the park or around the block, that is your decision, and that is a sign of independence. And I find that by focussing on independence and those little choices that they can make without their parents, if that starts to build their self-esteem and their self-confidence that they can start making positive lifestyle changes, that can affect them in the long term in terms of their overall health and wellbeing. Kean-Seng, your thoughts?
 
 
Kean-Seng:
 
Yes, no actually I love all of that and I will just go a little bit further on from that one with some very important things. So Kate, I note you talk here about weight loss targets and I totally agree. Sometimes it is actually best not to focus on that and in fact what do they do in Go4Fun and what do we do? And the answer is well, you do not have to look at the outcome measure, you can look at the process measures. And the process measures might be that thing about what you eat, what you do, or what you do not eat and what you do not do. And so, it is about setting those achievable goals and those achievable targets, but sometimes it actually is not about talking about weight, it is about talking about healthy lifestyle. And when in fact when we do the SALSA program, Students As Lifestyle Activists, it is actually not about weight. It is actually about lifestyle. And it is about improvement in health overall.
 
Just another tool which I will share, and I do not know if anyone is familiar with the PAM scores? Patient Activation Measures. But anyone who does, there is a very sort of little tool you can use called confidence scaling. So what you do, is you say to a person whether this be parent or child, or whoever, on a scale of one to 10, how confident are you that you think you could do this? And they will say, well most people will not say 10 out of 10, but most people will not say one out of 10. They will say something in between, three out of 10, four out of 10. And you say, that is fantastic. You know, you do not do what we do because we are Asian parents. And Asian parents say, four out of 10, why is it not 10 out of 10? But no, this is what we do not do here, because we are not Asian parents, we are doctors and so as doctors, what we say is, that is fantastic. It is four out of 10. So, tell me why is it not three out of 10? And so at that point, the patient will say, well okay it is not three out of 10 because I actually do have an understanding of this and I do like to do it, but I do find it hard to do this. And I will say, well that is really fantastic. So how would you, what do you think it would take you to move from four out of 10 to five out of 10, or six out of 10? So it is another way of just introducing that question. So, this is just another useful little tool which we use which is confidence scoring or confidence scaling. You do the same thing with important scaling or important scoring which is you know, on a scale of one to 10. How important is this to you? Why is it, if it is four out of 10, why is it not three out of 10? And what would it take to move to five out of 10 and so forth? So that is just another little tool I will share.
 
But I do note some interesting questions here about data and things. So probably we should actually go through that one, which is that the benefits or rather, the first hour, as we have alluded to in Go4Fun, the whole family receives nutrition as well as exercise education. And the topics include things such as the five food groups, label reading and different types of fats and sugars. And that is the first hour. In the second hour, the children will often play games-based activities. So they are physical activities. And the parents then participate in behavioural change discussion. So a lot of it is very much about what has been raised here, which is about behavioural change. And oftentimes in fact, an interestingly enough as someone has pointed out, I do not think we should ever expect kids to lose weight. It is actually quite right. Often it is not setting a weight target, it is about saying, well let us try not to have it going up at the same rate. But oftentimes it is not even about focussing on the weight at all. It is actually about the lifestyle and the behavioural changes. So that is a lot of what Go4Fun is doing. So, at the end of it, it is equivalent at the end of the 10 sessions to about 20 hours of free education. And so the other discussions are about family routines, how to be active as a family, how to eat together. These are some of the things that patients have found to be useful. And often they will do things, such as they will pick a family level target such as, we as a family are going to walk four days out of seven in this next week.
 
So the outcomes. So over 15 thousand children have participated in Go4Fun. This is where I am going to read my notes here to give you all of the data. And on average, children who have completed the program achieve statistically significant outcomes, and these are, reduction in BMI by about 0.5 kg per square metre, sorry, per metre square, reduction in waist circumference of about 1.2 cm. 68% of participants increase the number of days meeting physical activity guidelines. 57% increase their vegetable intake. 44% of participants increase their water intake. 43% of participants reduced their sugar sweetened beverages and 42% of participants also reduced take away foods. So, that is the sort of data we are looking at there.
 
And I think that, yes, some of the other things coming through the chat box I totally agree with, which is that we do have to understand the way that advertisers get to us. And it is a little bit of an arms race, because the advertisers are really very, very cleaver. They do all sorts of things to get to us. Part of what we have got to do is try to get around that, and that is behavioural change and that is actually to realise that it is not just us. We are not the only ones as GPs playing this game. We have around us schools, we have Go4Fun, we have other services we can use.
 
So I am going to move onto the next slide, which is how do we refer to Go4Fun? So, when we refer to Go4Fun, there are multiple ways, but this is interesting because this is part of where we have to think about what is going to work within our practice workflow. So, do we do it ourselves when we are seeing a patient? Do we in fact make it as a list which then gets done by the whole practice at the end, or do we use other referral forms? So, let us go through this quickly. So I know, because we are starting to run a bit short on time here because we have had such an engaging discussion. So, if you use Best Practice, you go into the word processor, and in the word processor, you can pick the template for Go4Fun referral and that will pre-populate the information about the patient and that can be faxed or emailed directly through Best Practice through to Go4Fun. In Medical Director, you go through the letter writer again, and again, you find the supply templates and you can do the same thing, print it out and fax it off. Now, you can also do the same in Communicare which is another software package used by some. And you can also go through the Go4Fun website itself, which will ask you to register and go in through that, and of course go in first of all as a health professional. Now the Go4Fun website is an interesting one because you can register either a patient individually or you can do bulk referrals, which actually introduces some very interesting workflows. So I mentioned about competitions within our practice to identify well, one of the ways to do that is after patients have been identified and put on this list, you can have someone, whether it be the practice nurse or someone else who can then go in and just do a bulk registration, and that can be a really good way to actually manage that workflow in a much more efficient manner.
 
So, the other thing is then, what happens? So let us talk about how Go4Fun interacts with the whole continuity of care and how this interfaces with what we do. So if everyone has looked at the NHMRC guidelines and obesity management, even though we are not going to use the word “obesity” here, the guidelines would say when you initiate some sort of intervention, you have to do regular follow up reviews. And that is part of what Go4Fun is to encourage. So even though we are referring a patient for this and they are going every week for these services, there is a feedback loop. Whereas health professionals with the family’s consent, Go4Fun will send letters back to the referrer, and so that when someone asks, can patients refer themselves, the answer is yes, but is it better to get a GP referral? In my mind, yes. Because this is part of how we maintain the continuity. But if this happens and a referral is made through the usual practice, the usual practice and practitioners will then receive a report back on progress throughout the program, and of course at the end of the program itself. And this is part of how, and these are the points, which is when the referral is received, when the participant commences the program and of course, after the program is finished.
 
So I am now going to move on to the next slide, mindful of our time, which is of course, the poll question. So, how likely are you now to refer eligible children to Go4Fun? So knowing what you know now and having seen what you have seen and having heard Tracey and Stav and everyone’s experiences. So I will give it a minute for this one. And then of course after that, we will be moving on to very open questions from anyone who might like to ask, although I will just note that questions are still tending to come through the Q and A box. And someone has also mentioned the Think, Eat and Move program as well, which is also important. I think it is also important to realise that there are programs within schools and these are often quite useful.
 
So Bethany how are we going with the poll?
 
 
Bethany:
 
Great, thank you. So I am just going to end this poll and share the results with you all. So for the majority, we have got 45% who said very likely, and 29% who said most likely. So 9% it was not applicable to them, so obviously they are in different states. But yes, we have got very good results from that.
 
 
Kean-Seng:
 
Fantastic, thanks very much, Bethany. So I think at this point now, that brings us to the end of the formal, concludes the formal part of this presentation, so I am going to hand back to well, everyone else, so Bethany, Stav, Tracey, and open it up to anyone if there are any questions.
 
 
Bethany:
 
So Tracey, this might be a good one for you. How many kids or families have actually completed the Go4Fun program?
 
 
Tracey:
 
Yes, so like Kean said, over 15 thousand families have participated in the program in the last sort of yes, nine to 10 years.
 
 
Bethany:
 
Awesome. And we have a comment here, I love the line, let the child’s weight, sorry, let the child’s height catch up with their weight.
 
 
Kean-Seng:
 
That is a good line.
 
 
Bethany:
 
And we have another comment, I think the battle of losing weight needs a lot more than what we as doctors can do and offer. Stopping smoking did not happen until government rules about advertisement and sales et cetera got changed. We need the schools to offer healthy lunches and healthy food to become more affordable as it is a social problem, not just an individual one. It is hard to watch patients try and fail at losing weight and feeling a failure as parents that know what to do but cannot due to money problems. Does anyone have any comments?
 
 
Kean-Seng:
 
I think that is a great one, because it is an absolute recognition of the fact that health problems are not just medical problems alone. And the solution is not purely a medical solution. In fact, there is actually a risk in making it a medical solution. So, when we do think about it, and I do not know where you are, but I know my area best, Mt Druitt, western Sydney, I can talk to you about green space ratios. I can talk to you about ratios of tree canopy cover. We can talk about how, not how in fact the level of obesity within a community is actually directly correlates with the amount or negatively or inversely correlates with the tree canopy cover within that region. So it is useable green space. There are also relationships between the percentage of junk food shops, or sorry, fast food shops and healthy food shops over the 1.6 km radius of a person’s house. So there are some really interesting statistics and so if we really look at it, we need to work with everyone. We need to work with local councils, we need to work with jurisdictions, we need to look at advertising. Dare we say it, we probably should think about a tax on sugary sweetened beverages. And yes, it is schools. And so this is where we have to consider everything right across the board. So there is the question of what is the success rate? And I think we can share, there was some of these slides before, but we did find that on various measures, so that the increased physical activity, increased vegetable eating, reducing consumption of sugary, sweetened beverages, it was on average somewhere between 55% to 68% or so of graduates of the programs had improved levels of all of these. So, I will say it because I again I can only give you some of the statistics from the SALSA program which we run, which is adolescent and secondary schools, these results are actually better than what we achieve in secondary schools. So, this is actually pretty good.
 
There is a really interesting question about individual issue responsibility. Why is obesity not 100%? I am actually going to pass to Stav on that one, because it is a really good question which has so many elements to it.
 
 
Stavroula:
 
Absolutely. Just first I want to reinforce that it is a comprehensive approach and that we are living in an obesogenic environment. So I often say to clients, you know we are all a work in progress, and this is not focussing on weight, but making those positive lifestyle choices because we are bombarded with TV advertising and junk food is so much more heavily discounted and so on, and then the children with those temper tantrums in the supermarket. So I often say we are all a work in progress. We are living in an obesogenic environment. Tobacco control took you know, over 20 or 30 years, and even in engaging in the smoking cessation conversation, when I first started working with the Cancer Council of Victoria in tobacco control, you know clinicians did not want to have that conversation. They did not want to ask whether their patients smoked, but their patient just had a heart attack. And now we are having that sort of same, sometimes we have that same push back from clinicians that I do not want to raise the issue, it is too sensitive, you know, we have normalised it, we are you know all above a healthy weight so why are we even going there? But I think it takes time and the main point that I want to reinforce is that it is important that we are all singing the same song. That we are always engaging in that conversation in a respectful and supportive way, and not underestimate the difference that you can make just by planting the seed, and by checking in next time, in three months’ time or in six months’ time and asking your patients to reflect on that conversation can be really empowering because it highlights that your patient, that you care about your patients. And I often think about my GP who does the four A’s or the five A’s and when I was you know living healthily and then I sort of fell off the rails a little bit, she had some data she could draw on, and she said to me, remember that time when you were eating well, when you were managing your stress in a much more productive way. And let us go back that, and what has happened since then. And that can be a very empowering conversation to have. But it is a comprehensive approach. Do as much as you can you know, in that brief way, but do engage in that conversation and do let your patients know that you are there to support them when they are ready to have that conversation if there is that initial push back when you first have that conversation.
 
 
Bethany:
 
Perfect. Unfortunately that is all the time we have tonight. So thank you to everyone for typing your answers or typing in your questions. It has been wonderful to see so many comments and questions come through that chat box. And I just wanted to say a big thank you to our presenters, Stav, Tracey and Kean-Seng. Thank you so much for this evening, it has been such a wonderful discussion. And that brings us to the end of this webinar. I hope you all enjoy the rest of your evening. Have a great night.
 
 
Kean-Seng:
 
Thanks very much for joining us.
 
 
Stavroula:
 
Thanks everyone.
 
 
Tracey:
 
Thank you.
 
 
Stavroula:
 
Thanks for joining us.

Other RACGP online events

Originally recorded:

2 December 2020

Childhood overweight and obesity is a major issue in Australia, with one in four children above a health weight or well above a healthy weight. Multicomponent interventions that promote healthy eating, physical activity and behaviour modifications are more effective than single interventions. The Go4Fun program is a free evidence-based program for children aged 7-13 years who are above a healthy weight and their families. The 10 week program involves weekly two hour sessions. The first hour the whole family learns about healthy eating and in the second hour, the children participate in games-based physical activity, whilst the parents have a discussion around behaviour change.

Learning outcomes

  1. Be aware of the current evidence-based recommendations in managing childhood obesity
  2. Utilise evidence-based programs to support children above a healthy weight
This event attracts 2 CPD points

This event attracts 2 CPD points

Presenters

Stavroula Zandes
Director of Health & Wellbeing Training Consultants

Tracey Clifton
State Project Officer - Go4Fun, NSW Office of Preventative Health

Dr Kean-Seng Lim

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