Dr.ElizabethDetmer,C.Psych.SickkidsTeamObesityManagementProgram(STOMP)

TheHospitalforSickChildren

Dr.AnnickBuchholz,C.Psych.CentreforHealthyActiveLiving(CHAL);

PediatricResearchonEatingDisordersandObesity(PREDO)Unit

Outline1. Reviewwhychildrenandteens/familiesarereluctanttotalkaboutweight,bodyimage,ea<ng,&exercise.

2. Learnhowfamiliesandchildrenwouldlikehealthcareproviders(HCP)toapproachandworkonweightissues.3. ReviewfundamentalsofMo<va<onalInterviewingandprac<cespecifictechniques.

“I’ve always known, even in kindergarten, that something was wrong with me . . that I was bigger . . . and that it was my own fault.”

“I’ve always felt - even in kindergarten - that something was wrong with me . . that I was bigger . . . and that it was my own fault.”

16 year old STOMP Patient

KidsarePrejudicedAgainstHeavierPeopleatAge4

Heavier Alfie was less likely to do well in school, to be happy with the way he looks, or to get invited to parties They rated heavier Alfie as more likely to be naughty and as having fewer friends that Thomas to play with

Hill(2013).EuropeanCongressonObesity(ECO).

TeasingandBullyinginAdolescenceAdolescentreportsofwhypeersareteased/bullied,and

observedfrequency(N=1555)

Yaleruddcenter.org(2014);Puhletal.,JSchoolHealth(2011)

AWeightObsessedWorld

SocietalPressures

•  InWesternSocietythemediaisapowerfulinLluenceandpressureonyouthtoday

• Bodyimagemessagesareeverpresentandtypicallystate:•  Thinwomenarebeautiful,successfulandhappy

•  Muscular,leanmenarehandsomeandsuccessful

Grabe et al. Psychological Bulletin (2003)

MixedMessagesintheMediaAroundBodyImageandFood

• 47%ofoverweightgirlsand34%ofoverweightboysreportbeingteasedabouttheirweightbytheirparents

• 72%ofoverweightadultsreportedtheyhadexperiencedweightbiasfromfamilymembersaschildren

PuhlRMetal.,JSchHealth(2011);PuhlRMetal.,PsychBull(2007)

WeightBiasatHome

CultureofValuingThinnessWeightBias

HighBodySelf-ConciousnessLowBodyEsteem

HighWeightPreoccupa<on

Die<ngPrac<ceWeightLossStrategies

Increasedoverea<ngEmo<onalea<ngBingeEa<ng

Shame,guilt,anger,sadnessIncreasedweightover<me

TheNegativeSpiral

WeightBias

BodyImage

•  Themostimportantself--esteemdomaininboysandgirls,andmenandwomen.

Harter,1999;A`e&Brooks-Gunn,1989;S<ce&Shaw,2002;Neumark-Sztainer,etal.,2006

•  Strongpsychologicalcorrelateofdisordered

ea<ngandobesity.

AChild’s‘Best’BMIMayNeverBeHisorHer‘Ideal’BMI

Key Principles

NeuroendocrineControlofEnergyBalance

Science. Feb 7, 2003

WhoisHealthier?

HealthatEverySize:HAES®

HealthManagement

Aaron12yo,BMI22kg/m2

Plays3hoursofvideogamesanight,isbeingbulliedatschool,

andhasfewfriends.Skipsbreakfast.Sleeps8hoursanight.Liveswithhismomandhasno

contactwithhisdad.

Jeff12yo,BMI22kg/m2

Excelsinschool,hasmanyfriends.Ac<vewithschoolsportsteams.Hassuppor<veparents.Sleeps10hoursanight.Hasnobiochemicalorclinicalevidenceofweightrelatedhealthcomplica<ons.

•  Sizeacceptance•  Recognizes<gmaandbiases•  Understandandvalidatebodyimageconcerns•  No-die<ngapproach•  Focusonhealthbehaviours,notweight

HealthAtEverySizeFramework

ExplainBeneLitsofHealthBehaviours•  ThefirstgoalistoSTABILIZEBMI

• Changesinhealthbehaviourscanresultinsubstan<alhealthbenefitsincludingimprovementsin:

o  Lipidprofileo  Bloodglucosecontrolo  Bloodpressurecontrolo  Fitnesso  Sleepo  Bodyimage

o  Self-esteemo  Coping

DiscussingWeightwithYouth

• Approachwithsensi<vity“Howdoyoufeelaboutyourhealth,body?”

•  Speaktotheirmo<va<ons“Doyoufeelthatyourweightisinterfering?”

• Promote/ProtectBodyEsteem“AtCHAL,wethinkthatallbodyshapesandsizesareaorac<veandcanbehealthy;weareheretohelpyouachieveyourbestphysicalandmentalhealth”

BodyEsteemActivities• Educateaboutmediaanddiscussionaboutbeauty

• Addresssocialanxietyandbodyesteem• Stopweighingyourself-esteem• Tellyourchildthathe/sheisbeau<fulopen

Takinguponesideofaninternalargument,

elicitstheothersideoftheargument

Bem’sselfperceptiontheory• Webecomegraduallymorecommittedtothatwhichwevoice.

• Elicitingcounter-changeargumentsdecreasesthelikelihoodofchange.

Confrontation&defensiveness•  Levelofclientdefensivenessisstronglyinfluencedbytheinterviewer

•  Acounselor’sconfronta<onelicitsdefensiveness

• Clientdefensivenesspredictslackofbehaviorchange

Whatisthebestwaytohelppeoplelookatthreateninginforma5onand

letitchangethem?

•  Empathetic counseling technique to elicit

‘change talk’

•  Core principles: •  Expressing empathy •  Developing discrepancy •  Rolling with resistance •  Supporting self efficacy

EvidenceforMI–Resnicowetal.,2015

•  MIdeliveredbyPrimaryCareProviders&RegisteredDie<<anstoparentsofoverweightchildren(2-8years)over2years

•  Compared•  Group1:Usualcare•  Group2:4PCPMIsessionstoparents•  Group3:4PCPMIsessions+6RDsessionstoparents

•  Group3experiencedsta<s<callysignificantreduc<onsinBMIpercen<les

EvidenceforMI–Pakpouretal.,2015

•  MIdeliveredbytrainedinterven<onists(e.g.RegisteredDie<<ans,ExerciseSpecialists)toadolescents(14–18years)over12months

•  Compared:•  Group1:UsualCare•  Group2:Six40minutesMIsessionwithadolescentonly•  Group3:Six40minuteMIsessionswithadolescentplusone60minuteMIsessiontoparents

•  Group3showedexperiencedsignificantlyimprovedhealthbehaviorsandgreaterweightloss(BMIzscores)

EightTasksinLearningMotivationalInterviewing

1 OverallSpiritofMo<va<onalInterviewing

2 OARS–ClientCenteredCounselingSkills

3 RecognizingChangeandSustainTalk

4 Elici<ngandStrengtheningChangeTalk

5 RollingwithSustainTalkandResistance

6 DevelopingaChangePlan

7 Consolida<ngCommitment

8 Transi<onandBlending

Motivational Interviewing Training New Trainers, September, 2014

Practice&coaching•  Masteryofacomplexskilltakesprac<ce.•  Withoutreliablefeedbackoneisunlikelytolearnitwell.•  Acoach/teachermustbeabletoobserve.Thetenniscoachhastowatchyouprac<ce;thepianoteachermustlistentoyouplay.

OverallspiritofMI

GoodMI•  Talklessthanyourclientdoes•  Addressfeelingbeforefixing•  ReLlecttwiceforeachquestionyouask•  Whenyoudoaskquestions,askmostlyopenquestions•  Avoidgettingaheadofyourclient’slevelofreadiness•  Rollwithresistanceversusconfront•  Elicitchangetalkversusinform/advise•  AfLirmeffortandcommitment•  Giveuptheexpertrole

FundamentalsofMI-OARS•  Openendedques<ons•  Affirma<ons•  Reflec<ons•  Summarystatements

Openendedquestions:•  Cannotbeansweredwithayesornoorveryshortphrase

•  Examples:“Whatstrategieshaveworkedforyouinthepast?”“Whatkindsofhealthychangeswouldyouliketofocusonthisweek?”

AfLirmations:•  Statementsthatrecognizetheclient’semotionsandstrengths

•  Examples:“DealingwithweightissuesisdifLicult,”“Youhaveworkedsohard.”

ReLlections:•  Letthepatientknownotonlythatyouarelisteningbutthatyouarehearingwhattheyaresaying

•  Example:“So,yousayyourchildrenwon'teatvegetables,andtheyareexpensive,butyoufeelyoucanpreparethemforyourself.”

SummaryStatements•  Collectingmaterialthathasbeenofferedbythepatientintoaconclusivestatement

•  Example:“You'veexpressedconcernaboutyourweight,hypertension,andfamilyhealthhabits.”

FundamentalsofMIAskpermissionto-

•  Approachadifficulttopic•  Giveadvice

Whengivingop<ons/advice-

•  Provideatleast2op<ons•  Undersell–“Thismightwork,Idon’tknow”

ExamplesofhowtoapproachdifLiculttopics

•  Would it be alright if we discussed your (child’s) weight?

•  Are you concerned about your (child’s) health/weight?

•  Can I share some information with you about cholesterol levels and why that information can be important?

Givechoices

SedentaryBehaviour

MentalHealth/BodyImage

PhysicalAc?vity

Sleep

Ea?ngBehaviours

SedentaryBehaviourSleep

Topicofyourchoice

Rollingwithresistance•  Reflect the resistant statement:

You don’t like this idea. •  Reflect the tone of what you are hearing:

You seem to feel hopeless. You’re not happy about . . .

•  Reflect ambivalence: On the one hand you want . . . and on the other you don’t think you can . . .

•  Acknowledge the resistance process: I’ve gotten us off track here.

•  Support choice/control: It’s up to you. You are in charge here.

Rollingwithresistance-Exercise•  Writedown1-3resistantorsustaintalkstatementsyouhaveheardfrompa<entsandfamilies•  Examples:Ireallyhatevegetables,Ican’texercisebecausemyjointshurt.

•  Taketurnsreadingthesestatementstotherestofyourtable.•  Collec<velyasatablegiverepliesthatdodgeand/orrollwiththeresistance.Youcanusereflec<ons,reframesorstatementsthatemphasizethatthepa<enthascontrol.

•  Writedowntheresponsesyoulikethebest.•  Con<nuearoundthetableun<ltheworkshopfacilitatorscall<me.

•  Decideasatablewhichareyourfavoritesandsharewiththelargergroup.

Ultimategoal–increasechangeandcommitmenttalk

Typesofchangetalk•  Desire–Whydoyouwanttomakethischange?•  Ability–Howmightyyoubeabletodoit?•  Reasons–Whatisonegoodreasonformakingthechange?•  Need–Howimportantisitandwhy(0-10)?

•  Commitment–Whatdoyouintendtodo?•  Ac<va<on–Whatareyoureadyandwillingtodo?•  TakingSteps–Whathaveyoualreadydone?

RespondingtochangetalkElaborate

Askforelabora<onoranexample(itwhatways,how,etc.)Affirma?on

Offeraffirma<on(agree,encourage,praisesupport)Reflect

Reflectwhatthepersonhassaid

Remember–it’saboutthinkingaheadtoavoidtheroadblocks

Bestresponsetoincreasechangetalk“Ireallydon’twanttochangethewayIeatbutIknowthatIshould.I’vetriedbeforeandit’sreallyhard.”

A.  Youreallydon’twanttochangeyourea<ng.B.  It’spreoycleartoyouthatyououghttomakeachangein

yourea<ng.C.  You’renotsureifyoucanchangeyourea<ng.

Bestresponsetoincreasechangetalk“Familymealssoundgreatintheorybutwearetoobusytomakethemwork.Thekids’schedulesareallovertheplaceanditisimpossibleforustositdownatthesame<me.”

A.  Becauseofyourfamily’sbusyschedule,youfeellikefamilymealsareimpossible.

B.  It’sveryhardtofinda<methateveryonecansitdowntogether.

C.  Youliketheideaoffamilymeals.

Bestresponsetoincreasechangetalk“Ihavetobehonest.Ihavenotdonethebreakfastthingatall.Idon’treallyhaveanexcuse.I’vedoneokaywithea<ngaliolebitatlunchandusingtheplatemethodatdinnerbutIjustdon’tlikeea<ngbreakfast.”A.  It’sreallyhardtoeatbreakfast.B.  You’refeelinggoodabout2outof3ofyourgoals.C.  Youyoureallydon’tlikeea<ngbreakfastandyoudon’t

knowhowyouwillworkitintoyourday.

5questionstoincreasechangetalk

•  Whywouldyouwanttomakethischange?•  Ifyoudiddecidetomakethischange,howmightyougoaboutitinordertosucceed?

•  Whatarethethreebestreasonsforyoutodoit?•  Howimportantwouldyousayitisforyoutomakethischange,onascalefrom0to10,where0isnotatallimportant,and10isextremelyimportant?

•  Whyareyouat___insteadof___[alowernumber]?

Follow-upto5questions•  Aperyouhavelistenedcarefullytotheanswerstotheseques<ons:

Givebackashortsummaryoftheperson’smo<va<onsforchange.

•  Thenask:Sowhatdoyouthinkyou’lldo?

Listenwithinteresttotheanswer.

Roleplay

Resources

AcknowledgementsDr.JillHamiltonDr.CatherineBirkenDr.AleneToulanyDr.AndreaReginaPree<Grewal,NPDanielleBerard,NPAndreaLeyser,RNMelanieGelfand,MSWAlisaBar-Dayan,RDAlissaSteinberg,RDKelseyGallagher,RDAllisonLougheed,B.S.SejalPatel,PT

Ea<ngDisordersProgram,especially:Dr.WendySpe7gue Dr.JuliePerkinsDr.MarkNorris Dr.ClareRoscoeDr.StephenFeder Dr.MeganHarrisonDr.JuliePerkins Dr.NicoleObeid

CentreforHealthyAc<veLiving,especially:Dr.AnnickBuchholz Dr.LaurieClark FaImaKazoun,ResearchAssociate Dr.StasiaHadjiyannakisCharmaineMohipp,ResearchAssociate

CHEO’sCentreforHealthyAc<veLivingandObesityResearchGroup,especially:Dr.GaryGoldfield

PREDO:NicoleHammond,ResearchCoordinator

PediatricResearchonEatingDisordersandObesity(PREDO)

Thankyou!