Childhood Obesity among American Indians and Alaska Natives: Positive

Communication Strategies

California Medical Association Foundation Webinar

October 30, 2012Kelly Moore MD FAAP

Associate Professor University of Colorado Denver

Colorado School of Public HealthCenters for American Indian and Alaska Native Health

Disclosure Statement

We have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this activity.

We do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.

Webinar ObjectivesUsing a case presentation format, participants will be

able to:

Identify how culture and ethnicity can influence patient decision making related to childhood overweight and obesity within the American Indian Community.

Describe effective patient/provider communication techniques to help families understand behaviors they can take to help their child reach a healthy weight, particularly focusing on increasing healthy food choices.

Determine how and when to access support in their communication, particularly involving nutritionists and dietitians.  

Background

Prior to 1970s underweight & dietary deficiencies were major health issues

1969 National Conference on Nutrition, Growth and Development of North American Indian ChildrenSuboptimal nutrition and low weight-for-

height were commonAll surveys reported growth rates well below

the national referenceReferences: Moore et al. Nutrition, growth and development of North American Indian Children. Washington, DC: U.S. Dept of HEW, 1972; Am J Clin Nutri 1981;34(2):266-77; Carlile et al. Contemporary nutritional status of North American Indian children . In Moore, Silverberg, Read eds. Washington, DC. U.S. Dept of HEW, 1972; J Am Dietetic Assoc 1998;98(2):170-6; Prev Med 2003;37:S3-S12.

Background By late 1970s public health efforts

drastically reduced prevalence of underweight and growth retardation in American Indian children

Efforts included food assistance programs, improved health care, and prevention and treatment of infectious and chronic diseases

Transition 1960’s

Average AI preschool child had lower wt/ht than average US preschool child 1/3 Navajo preschoolers wt/ht <3rd % Apache preschoolers 40% ht <10%, 18% wt <10%

1970’s Improved health and food availability

1980’s 11.2% 0-4 yr AI children BMI>95%

2000 31.2% obesity AI preschoolers (12.8% non Hispanic white preschoolers) Higher rates of weight gain <2 yrs

Schell LM, Gallo MV, Overweight and Obesity Among Native American Infants, Children and Youth. Am J Human Biology 2012;24 (304-313).

Change in obesity prevalence during 1998—2003 and 2003—2008 among children aged 2 - 4 years, by race/ethnicityPediatric Nutrition Surveillance System, United States, 1998--2008

Overweight and Obesity in High School StudentsYouth Risk Behavior Survey 2001-2009

Overweight Obese0

5

10

15

20

25

White Black HispanicAI/AN

Everett Jones S, Anderson K, Lowry R, Conner H. Risks to health among American Indian/Alaska Native high school students in the United States. Prev Chronic Dis 2011;8(4):A76. http://www.cdc.gov/pcd/issues/2011/jul/10_0193.htm. Accessed 7/30/12.

Recognized Obesity Risk Factors

Poverty Substandard housing Food insecurity Single parent households Geographic isolation Lack of access to health care

Unique Contributing Factors to Obesity

Lack of access to health care providers with specific cultural knowledge and skills

Forced cultural change and displacement leading to cultural disintegration Historical transitions in location Transitions in food sources Other community and individual stressors—social

injustice, trauma, racism

References: Pediatrics. 2008;121(5):e1241-e1249. Joe JR, Young RS, eds. Diabetes as a Disease of Civilization: The Impact of Culture Change on Indigenous Peoples. New York, NY: Mouton de Gruyter; 1994. Am J Public Health. 2005;95:851-859. Lancet. 1994;343 (8893):324–327. Am J Prev Med. 1998;14(4):245–258. Int J Obes Relat Metab Disord. 2002;26(8):1075 –1082. Psychiatry Res. 2006;142(1):31–37.

“Growing up in such conditions could teach the child of parents with lower SES that the world is a hostile, depressing, and alienating place, and the child could also learn that smoking and consumption of larger amounts of alcohol and food help reduce the resulting distress.”

Redford Williams, JAMA 1998;21:1746

Additional Cultural Considerations with American Indians

Child Rearing Anglo-American: parent-focused responsibility Native American: community-focused child

rearing - children are to be shared; discipline and nurturing responsibility of all

Education Anglo-American: formal education stressed,

individual achievement is stressed Native American: education occurs in all facets of

life, individuals should learn from one another

Pediatrics Vol. 91 (5) Supp, May 1993 pp. 1063-1070

Overweight Sensitivity“Do no harm”

· Obesity· Ideal Weight· Personal

Improvement· Focus on Weight· Diets or “Bad

Foods”· Exercise

· Overweight· Healthier Weight· Family

Improvement· Focus on Lifestyle· Healthier Food

Choices· Play or Activity

ABCs of Counseling & Motivating Overweight Children & Families Ask Open-Ended Questions

How concerned are you about your child’s weight? Why? What are some of the things you might like to change?

Body Language Put patient at ease. Use eye contact. Convey respect. Counsel in a private setting.

Care and Empathy Do not criticize. Acknowledge patient’s feelings. Answer questions without signs of judgment.

· 2 - 5 Years Old¾ Communicate with Parent

¾ Child in Room

· 6 - 12 Years Old ¾ Communicate with Parent or Both¾ The First Encounter Consider Taking Parent

to Your Office to Discuss in Private First

· Over 12 Years Old ¾ Communicate with Teen or Both¾ The First Encounter Consider Having Parent

Leave Exam Room First

Who do you communicate with?

4 Key Messages

Readiness to Change Tool

“Get More

Energy!”

Poster

Albuquerque, New Mexico – July 2005 Everyone appeared to have general

awareness of the connection between healthy eating and diabetes

Challenges to Healthy Living Time Fast food Work Cost of healthy foods Grocery store marketing of unhealthy

foods Pow Wows/Traditional Gatherings Television Depression

American Indian Family Focus Groups

“Parents are role models. You’ve got to do it yourself.”

American Indian Family Focus Groups - Poster Reaction

“I’ve seen it a thousand times.” “Yeah the same messages over and over again.”

Didn’t like: “Energy”, “Cut Back” Colors Ruler

Suggested: Family photos Reflect pride and community

Encouraging a Healthy Weight for Your Child - Overall they liked this handout for the research, resources and suggestions.

Body Image: Learning to Like What You See - The least liked of all the articles, perceived as judgmental and negative.

Eating and Exercise: What Works for You - Overall reaction was positive and they thought that this handout would grab their attention. They all wanted to keep a copy.

American Indian Family Focus Groups – Tip Sheet Reaction

American Indian Family Focus GroupsCommunication Techniques Reaction

Parents tended to want physicians to ask permission when it involved their child

Wanted a physician to address the issue of diabetes if their children were found to be at risk

Understood readiness to change and valued exploring ambivalence but didn’t like the ruler

Wanted to spend more time with their physicians in discussion

“I think it helps to have a dialogue, to make it more personalized.”

Education Strategies There is general awareness about healthy

living and diabetes Some educational materials need to be

culturally adapted with depression addressed Communication techniques were well

received, but wanted more time with providers Messages need to include pride, family,

community & traditional ways of living

Environmental Strategies Grocery store advertising, pricing and point of

decision labeling School, community & work site interventions Community changes and policy

American Indian Family Focus Groups – Conclusions

Acknowledgements

American Indian Family Focus Group Participants Scott Gee MD Sandra G Hassink MD Association of American Indian Physicians Envision New Mexico Kaiser Permanente