Dr. Huang is a pediatric gastroenterologist at the University of California, San Diego, who has developed a Web-based curriculum on the topic of pediatric obesity, which has become a national epidemic. As many dentists seek to discover new practice strategies to combat the current economic downturn, and given the strong interaction between oral health, diet, and nutrition, the following article suggests that dentists can help address the issue of obesity and also add value to their practices by providing parents and children with nutrition counseling, measuring Body Mass Index (BMI), and providing resources for improving diet and health.
CHILDHOOD OBESITY - THE REASON FOR HOPE
Approximately one in three children is affected by overweight and obesity, and childhood obesity is accordingly one of the nation's most important health issues. Obese youth are at risk for hypertension, type 2 diabetes, liver disease, obstructive sleep apnea, and a lower quality of life. A recent CDC report estimates yearly health costs related to obesity at $147 billion. Childhood obesity is a significant predictor of adult obesity, and life expectancy can be reduced by as much as 20 years among obese youth who remain obese into adulthood. As a result, we are faced now with the reality that youth today may actually have a lower life expectancy than prior generations.
THE ROLE OF ORAL HEALTH PROVIDERS
Dentists have a tremendous amount of contact with youth, with the greatest contact among children six to 18 years of age. With this access comes the ability to influence families' awareness of obesity as a health concern and to offer families guidance on pursuing healthful dietary habits and
regular physical activity. However, oral healthcare visits represent a yet untapped opportunity to address and discuss weight-related issues with youth and their families.
Although a direct link between obesity and poor oral health has yet to be demonstrated, obesity has been shown to be associated with periodontitis and early loss of teeth. Obesity and oral health issues often coincide in similar populations and both diseases have common modifiable risk factors, including diet and physical activity. Therefore, there are shared reasons for both oral health and medical personnel to intervene on this important public health issue.
Both the American Academy of Pediatrics (AAP) and the American Academy of Pediatric Dentistry (AAPD) advocate increased clinician involvement in recognizing children at risk for obesity-related morbidities and counseling patients on how to live healthier lifestyles. Identified barriers to clinician involvement include insufficient clinician confidence, knowledge and counseling skills, as well as lack of time and resources. However, no standardized mechanism currently exists to train clinicians on how to incorporate weight status screening techniques into their practices, how to effectively counsel patients on healthy weight and lifestyles, and how to advocate for necessary policy and environmental changes to promote a healthy lifestyle.
OVERVIEW AND PURPOSE
The HOPE project is a Web-based, multidisciplinary, healthy living and counseling curriculum that educates clinicians and clinicians-in-training on how to recognize children at risk for obesity and its co-morbidities and how to promote healthy dietary choices and increase physical activity among children and their families. The curriculum instructs clinicians about the health consequences of childhood obesity, screening techniques to identify children and families at risk, the current evidence for health intervention recommendations, and reviews the theoretical rationale and art of constructive weight counseling for behavioral change. An interactive practicum has been incorporated into the curriculum, which allows trainees to practice counseling skills and use role-plays based on sample patient output. In addition, cultural competency is a major focus of the curriculum and HOPE provides important insight regarding how to approach weight management in a culturally sensitive manner among communities of color, which are disproportionately affected by the pediatric obesity epidemic. The Web-based HOPE curriculum has been distributed to both medical and dental training programs throughout the United States, and has been made available to currently practicing physicians and dentists for continuing education credits as of winter 2009.
CURRICULUM FORMAT, MODULES, AND RATIONALE
The HOPE curriculum addresses the prevention, assessment, and management of pediatric obesity via seven main modules. Module materials have relevance to clinical practice as a whole, independent of dental or medical specialty. An important goal of the HOPE
project is to highlight and outline the collaborative framework within which each specialty can contribute to the public health effort of reducing pediatric obesity and to improved communications between specialties. Relevance to each specialty has been highlighted in each module, and the modules have been piloted to both pediatric medical and dental clinicians in training with positive reviews.
Epidemiology and Etiology of Pediatric Obesity. Cases of overweight and obesity among children and adolescents have significantly increased over the past three decades. Awareness of this public health issue and contributing factors is an important step toward prevention and treatment of this epidemic.
Review of the 2007 Expert Committee Obesity Guidelines. The 2007 AAP guidelines codify the recommendations on the prevention and treatment of
pediatric obesity from an Expert Committee representing 15 national healthcare organizations that serve children and/or have expertise in obesity and obesity-related conditions, including the American Medical Association, the Health Resources and Service Administration, and the Centers for Disease Control. Clinicians who treat children should be aware of these clinical guidelines for their practice of weight management.
Oral Health and Obesity. Similar to other medical professionals who serve children, oral health clinicians have daily access to children with weight issues. Given an already accepted role in discussing dietary issues, there is a notable role for dentists and other oral health practitioners in healthy weight management among children. Collaboration among healthcare providers will be essential if we are to reverse the growing epidemic of obesity among youth.
Behavioral Counseling for Effective Dietary and Physical Activity Change. Clinicians need to be proficient in effective behavioral counseling techniques and methodologies (such as motivational interviewing) to promote healthy weight in their patients. In addition, an advanced parenting module provides helpful tips that providers may recommend to parents who are dealing with an overweight child.
Cultural Sensitivity. Obesity occurs disproportionately among children and communities of color. Understanding and addressing the patterns and causes of prevailing disparities in childhood obesity is a prerequisite to effectively addressing them. Clinicians should be familiar with cultural issues when engaging in healthy weight management for children. Four separate video modules address issues of the Hispanic American, African American, Asian American/Pacific Islander, and Native American cultures.
Systems. Clinicians must be familiar with systems-based practice and quality improvement models in order to translate the Expert Committee obesity guidelines into practice. Well-constructed systems can provide necessary resources and allow providers to spend more time on obesity prevention and counseling, as well as improve physician and dentist self-efficacy for healthy weight management.
Advocacy. The etiology of the obesity epidemic is multi-factorial and includes societal, commercial, financial, and community factors. Similarly, effective weight management requires participation from not only the healthcare sector but also from schools, the local environment, and society at large. Clinicians must therefore learn how to become effective advocates for policy and environmental changes in their communities to combat the obesity epidemic.
Each curriculum module presents topics via a dual-screen format projecting a video file of the lecturer accompanied by a simultaneous, self-advancing PowerPoint slide set. In addition to the dual-panel presentation, a supplementary materials bar is displayed where participants can select reference materials to view at any point during the program. Supplementary HOPE program materials have been developed according to the needs identified in the focus group sessions and comprise reference materials such as key articles and clinical toolkits. Clinical toolkits adapted from materials currently available from public and professional sources provide participants with the necessary instruments to implement suggested guidelines in clinical practice and include clinical algorithms, clinical intake forms, poster displays, and patient information handouts. Lists of regional (i.e., according to geographic location within the United States) resources are available for clinicians to distribute to patients as needed; the HOPE team will update these resources quarterly in order to ensure their reliability and utility. Role-play scenarios have been developed for case-based learning. This format provides a multi-resource, Web-based format that will satisfy various learning styles.
The HOPE project provides a fully developed, multidisciplinary curriculum empowering dental clinicians to promote healthy lifestyles and healthy weight among youth. This standardized educational series, grounded in an understanding of relevant sciences, literature, and research methods, will unify the approach to weight management among not only oral health and medical practitioners but also future and current clinicians.
For more information, please contact the HOPE project team via email at email@example.com.