OFFICE-BASED MANAGMENT OF PEDIATRIC OBESITY

William J. Klish, M.D.Professor of Pediatrics

Baylor College of Medicine

Most logical approach to controlling the obesity epidemic

Prevention

However for the average practicing pediatrician treatment and prevention must go together

Treatment Options available to the Pediatrician

• Weight Loss Drugs

• Bariatric Surgery

• Behavior Modification

OBESITY TREATMENT

Generic Name Trade Name

Dexfenfluramine* Redux

Diethylpropion Tenuate

Fenfluramine* Podimin

Mazindol Sanorex, Mazanor

Phendimetrazine Bontul, Plagine, Prelu-2,X-Trozine

lonamin, Adipex-2

Phentermine* Fastin, Oby-trim

Sibutramine Meridia

*Recalled by the FDA

Lipase InhibitorOrlistat Xenacal

Appetite Suppressants

Treatment of Adolescent Obesity with Orlistat

• 1 year double-blind placebo controlled study

• 29 patients of a total of 150 studied by us

• Orlistat group lost 2.8 kg

• Placebo group lost 1.5 kg

• Major side effect: oil leakage

Treatment of Adolescent Obesity with Sibutramine

• 1 year double-blind placebo controlled study

• 82 adolescents (13-17 yrs of age)• Sibutramine group had 6.8% reduction in BMI

Placebo group had 5.4% reduction in BMI• Drug reduced in 23 subjects and discontinued in 10 due to side effects.• Side effects included increase blood pressure and increased pulse rate.

Berkowitz et al, JAMA 2003;Apr 9:289(14)

SURGICAL THERAPY

• Only Recommended in Selected Adult Patients

BMI > 40 or with Co-morbid Conditions

• Very Little Experience in Children National Collaborative Study is on-

going

Roux-en-Y GBP

Current Status of Medical and Surgical Therapy for Obesity

Gastroenterology Vol.120, No.3

Restrictive bariatric procedures

Adjustable gastric banding

Current Status of Medical and Surgical Therapy for Obesity

Gastroenterology Vol.120, No.3

Restrictive bariatric procedures

ONLY ACCEPTED WEIGHT LOSS THERAPY FOR CHILDREN

• Diet

• Exercise

• Behavior Modification

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Behavioral treatment is more effective in children than in adults

Epstein, et.al., JAMA, 1995

Kids are not just “little” adults!

Medical Treatment of Obesity

Success limited !!

A WEIGH OF LIFE

Total number of patients 468

Number completing info packet 83 (18%)

Number completing interview only 53 (11%)

Number starting program 332 (71%)

Number finishing program 92 (20%)

OUTCOME(ONE YEAR STUDY)

A WEIGH OF LIFE

Change in % IBW (all completers) -23.5+16.1

(average sessions - 18.3)

Success rate for completers 98%

Change in % IBW (all starters) -11.2+16

(average sessions - 9.34)

OUTCOME(ONE YEAR STUDY)

OFFICE BASED PRIMARY PREVENTION PROGRAM

• If BMI is normal

• Patient and parents should be congratulated!

RecommendationsPatients should get Ht and Wt measured and

BMI calculated at least yearly

• If patient is crossing BMI percentiles

• The parents should be warned about the potential for obesity.

• Family given obesity prevention self-help instructions

Recommendations

PRIMARY PREVENTION OF CHILDHOOD OBESITY

SUGGESTIONS TO INCREASE PHYSICAL ACTIVITY

1. Limit television, computer time and video games to approximately 2 hours per day.

2. Plan family activities for the weekend. These activities can include bike riding, hiking, trips to the zoo, museum or library, and house or yard projects.

3. Walk the dog. 4. Take family walks. Walk with friends instead of talking with

them on the telephone. 5. Play outdoors every day. If it is raining or snowing, dress

appropriately and still go outside to play in the snow or puddles. 6. Define indoor areas for physical play such as ‘Nerf’ balls, bouncy

balls or scooter toys.

 

PRIMARY PREVENTION OF CHILDHOOD OBESITY

TIPS TO MODIFY EATING BEHAVIOR

1. Families should eat together at the dinner table. The family table encourages discussion, problem solving and interaction which diverts attention from eating thereby slowing the process and allowing for satiety to develop more naturally.

2. Establish routine daily family meal and snack times. 3. Television should be turned off during meals. Television tends to

stimulate children to eat more. 4. Slow down eating. Meals should last at least 20 to 30 minutes to

allow enough time for the normal sensations of fullness and satiety to be felt.

5. Prepare plates in the kitchen rather than allow self serve. 6. Eat regularly, 3 meals a day with 1 snack a day for children. This

prevents excessive hunger and overeating.

PRIMARY PREVENTION OF CHILDHOOD OBESITY

SIMPLE DIETARY MODIFICATIONS

1. Choose sugar-free beverages or low fat milk only. 4. Review school lunch menus to identify healthy . Avoid all juices, regular sodas, and other sugary menu items. drinks such as fruit punch, lemonade and sports . Pack a lunch with 2 oz. of lean meat or low fat drinks. Limit daily intake to 4-8 ounces cheese on two slices of bread with fruit, . Avoid whole, 2 percent and chocolate milk salad, or vegetables and low fat milk. (including low fat and fat free) . Choose skim, ½ or 1 percent milk. Limit to 16- 5. Cooking tips: 24 ounces per day . Use cooking spray to ‘grease’ pan for frying . Choose water (try with a wedge of lemon) . Use whole grain breads, cereals and pastas. . Choose unsweetened iced or herbal tea . Salad should contain only vegetables not (try decaffeinated) cheese, eggs, meat or bacon bits. Toss the . Choose diet sodas (try decaffeinated) salad before serving to decrease dressing . Choose sugar free drink mixes such as Crystal use. Light or sugar free Kool-Aid . Choose sugar free flavored waters

• If BMI is > 85th percentile

• Patients and their parents should be told they are overweight

• Risk of co-morbidities should be discussed

• Family provided with self help instructions

• Follow up appointment in 1 month

Recommendations

Dear Parent, Your child has been identified as being overweight or obese. As you know, childhood obesity rates have reached epidemic proportions. A recent study showed that 37% of Houston area school children are overweight or obese. We are concerned because the health consequences of being overweight are very serious and can cause many associated diseases. The most severe and life threatening obesity related diseases seen in children include sleep apnea (sudden cessation of breathing while asleep), diabetes and liver disease caused by fat accumulation in the liver. These diseases were very rare in children until recently but now because of the obesity epidemic doctors are diagnosing them routinely in overweight children. Children can also develop problems with both the hip and knee joints that can lead to permanent disability when obesity puts increased weight on their legs. Other chronic diseases associated with obesity in children include high blood pressure, gall bladder disease, high blood cholesterol, and polycystic ovary disease in girls. Many children who are overweight develop poor self-esteem or become depressed because they don’t like to be overweight. We think it is very important that all parents help their children achieve a normal weight to prevent the diseases of obesity and allow their children to lead a normal and productive life. The time for you to get started on this is NOW. Ask us to help.

• If BMI is > 95th percentile

• Patients and their parents should be told they are obese

• Risk of co-morbidities should be discussed and the

• Patients screened with fasting serum glucose, insulin, ALT, lipid panel

• Family provided with self help instructions

• Follow up appointment in 1month

• Referred to specialists if labs abnormal

• Refer to obesity treatment program if compliant

Recommendations

RECOMENDATIONS

ex: Parks and Recreation Programs

School Based Programs

Child Oriented Weight Loss Programs

Become aware of referral options

OUTCOMES DATA IS NEEDED!

% Compliant with Entire Protocol

17%

69%

0%

20%

40%

60%

80%

100%

1

TCPA

RPCG

% Compliant with Entire Protocol

2%

58%69% 67%

0%

20%

40%

60%

80%

100%

1

TCPA Sick

TCPA Well

RPCG Sick

RPCG Well

Visits with BMI%ile Plotted by Clinic

2%

58%

94%100%

0%

20%

40%

60%

80%

100%

1

TCPA Sick TCPA Well RPCG Sick RPCG Well

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