pediatric obesity: a huge problem in the usa william j. cochran, md department of pediatric gi &...

PEDIATRIC OBESITY: A HUGE PROBLEM IN THE USA

William J. Cochran, MDWilliam J. Cochran, MD

Department of Pediatric GI & Department of Pediatric GI & NutritionNutrition

Geisinger ClinicGeisinger Clinic

WHY WORRY ABOUT PEDIATRIC OBESITY? Pediatric obesity is of epidemic proportion.Pediatric obesity is of epidemic proportion. Pediatric obesity is the most common Pediatric obesity is the most common

chronic disease of childhood.chronic disease of childhood.

DEFINITION OF PEDIATRIC OBESITY Overweight / At risk of overweightOverweight / At risk of overweight

BMI 85-95%BMI 85-95% Obese / OverweightObese / Overweight

BMI >95%BMI >95%

OLDER DEFINITIONS OF OBESITY

Weight for height >95%Weight for height >95%

Actual weight >120% ideal body weightActual weight >120% ideal body weight

Super obese >140% of ideal body weightSuper obese >140% of ideal body weight

Percent of obese children and adolescents

0

2

4

6

8

10

12

14

16

1963-70 1971-74 1976-80 1988-94 1999-02

6-11 years12-19 years

INCIDENCE OF PEDIATRIC OBESITY IN PENNSYLVANIA

15

20

25

2000 2001 2002 2003

RACIAL DIFFERENCES IN PEDIATRIC OBESITY Non-Hispanic whiteNon-Hispanic white 12.3%12.3% African AmericanAfrican American 21.5%21.5% HispanicHispanic 21.8%21.8%

WHY WORRY ABOUT PEDIATRIC OBESITY? Is pediatric obesity a real problem or just a Is pediatric obesity a real problem or just a

cosmetic issue?cosmetic issue?

WHY WORRY ABOUT PEDIATRIC OBESITY? Adult obesity is clearly associated with numerous Adult obesity is clearly associated with numerous

health problems.health problems. Type II DMType II DM CADCAD HypertensionHypertension CancerCancer Joint diseaseJoint disease Gallbladder diseaseGallbladder disease Pulmonary diseasePulmonary disease

WHY WORRY ABOUT PEDIATRIC OBESITY?

Significant risk of childhood obesity to Significant risk of childhood obesity to persist into adulthood.persist into adulthood.

PERCENT OF OBESE CHILDREN BECOMING OBESE ADULTS

0

10

20

30

40

50

60

70

80

Preschool School-age Adolescent

WHY WORRY ABOUT PEDIATRIC OBESITY? Economic impactEconomic impact

The estimated cost of obesity in the US in 2002 The estimated cost of obesity in the US in 2002 was $117 billion.was $117 billion.

The hospital cost of pediatric obesity is also The hospital cost of pediatric obesity is also increasing.increasing. 1979: $35 million1979: $35 million 1999 $127 million1999 $127 million

IMPACT OF CHILDHOOD OBEISTY IN ADULTHOODChildhood obesity has significant adverse Childhood obesity has significant adverse

effects on health in adulthoodeffects on health in adulthood Hoffmans 1988: Dutch males, increased Hoffmans 1988: Dutch males, increased

mortality after 32 years in obese vs. lean mortality after 32 years in obese vs. lean adolescent males.adolescent males.

Mossberg 1989:Swedish study, increased Mossberg 1989:Swedish study, increased mortality after 40 years in obese vs nonobese mortality after 40 years in obese vs nonobese childrenchildren

IMPACT OF CHILDHOOD OBESITY IN ADULTHOOD Harvard Growth Study: Harvard Growth Study:

Two fold increased all cause mortality in obese Two fold increased all cause mortality in obese vs nonobese adolescents as adultsvs nonobese adolescents as adults

2 fold increase in CAD mortality2 fold increase in CAD mortality Increased risk of colon cancer in malesIncreased risk of colon cancer in males Increased risk of arthritis in femalesIncreased risk of arthritis in females The association of adverse effects on adult The association of adverse effects on adult

health may be independent of obesity in health may be independent of obesity in adulthoodadulthood

CHILDHOOD COMPLICATIONS OF CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITYPEDIATRIC OBESITY

PsychosocialPsychosocial Most common complication of pediatric obesityMost common complication of pediatric obesity Increased rates of depression Increased rates of depression Poor self esteemPoor self esteem

Obese adolescents negative self image may carry Obese adolescents negative self image may carry over into adulthoodover into adulthood

CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITY

Societal discriminationSocietal discrimination Obese females have lower acceptance rate at Obese females have lower acceptance rate at

colleges than non-obese femalescolleges than non-obese females National Longitudinal Survey of Youth: obese National Longitudinal Survey of Youth: obese

adolescent females as young adults had less adolescent females as young adults had less education, less income, higher poverty rate, education, less income, higher poverty rate, decreased rate of marriage vs nonose femalesdecreased rate of marriage vs nonose females


EndocrineEndocrine Non-insulin-dependent diabetes mellitusNon-insulin-dependent diabetes mellitus

Pinhas-Hamiel 1994Pinhas-Hamiel 1994• The incidence of NIDDM has increased 10 foldThe incidence of NIDDM has increased 10 fold

• 92% of these had a BMI >90%92% of these had a BMI >90%

Geisinger weight management programGeisinger weight management program• 60% have insulin resistance60% have insulin resistance

• 10% have fasting insulin level > 100 (Nl <17)10% have fasting insulin level > 100 (Nl <17)

• 1% have type II DM1% have type II DM


EndocrineEndocrine Increased linear growthIncreased linear growth Advanced bone ageAdvanced bone age Earlier onset of pubertyEarlier onset of puberty Acanthosis nigricansAcanthosis nigricans


HypertensionHypertension Primary hypertension uncommon in childhoodPrimary hypertension uncommon in childhood 60% of children diagnosed with hypertension 60% of children diagnosed with hypertension

are obeseare obese Use pediatric standarsUse pediatric standars Geisinger weight management program Geisinger weight management program

45% have hypertension45% have hypertension


HyperlipidemiaHyperlipidemia The atherosclerotic process begins in The atherosclerotic process begins in

childhood.childhood. Pediatric obesity is associated with increased Pediatric obesity is associated with increased

cholesterol, LDL-cholesterol, triglyceride levels cholesterol, LDL-cholesterol, triglyceride levels and lower levels of HDL-cholesteroland lower levels of HDL-cholesterol

Geisinger weight management programGeisinger weight management program 45% have hypercholesterolemia45% have hypercholesterolemia


Hepatic steatosisHepatic steatosis Hepatic steatosis present in 25-83% of obese Hepatic steatosis present in 25-83% of obese

childrenchildren 10-15% of obese children have elevated liver 10-15% of obese children have elevated liver

enzymes: steatohepatitis or non-alcoholic fatty enzymes: steatohepatitis or non-alcoholic fatty liver diseaseliver disease

Rashid: 83% of children with steatohepatitis Rashid: 83% of children with steatohepatitis were obese. 75% had fibrosis-cirrhosiswere obese. 75% had fibrosis-cirrhosis


OrthopedicOrthopedic Slipped capital femoral epiphysisSlipped capital femoral epiphysis

30-50% are obese30-50% are obese

Blount’s disease (Tibia vara)Blount’s disease (Tibia vara) 70% are obese70% are obese

NeurologicNeurologic Pseudotumor cerebriPseudotumor cerebri


RespiratoryRespiratory Sleep disorder in 1/3Sleep disorder in 1/3 Sleep apnea: 7% of obese, 1/3 if >150% & Sleep apnea: 7% of obese, 1/3 if >150% &

breathing difficultiesbreathing difficulties Hypoventilation syndromeHypoventilation syndrome

GastrointestinalGastrointestinal CholelithiasisCholelithiasis

50% of cases of cholecystitis in adolescents are obese50% of cases of cholecystitis in adolescents are obese

PEDIATRIC OBESITY PEDIATRIC OBESITY IS NOT JUST A IS NOT JUST A

COSMETIC PROBLEM!COSMETIC PROBLEM!

ETIOLOGY OF PEDIATRIC OBESITY

ETIOLOGY OF PEDIATRIC OBESITY Etiology is multifactorialEtiology is multifactorial

Interaction of genetics and environmentInteraction of genetics and environment Energy imbalanceEnergy imbalance

Energy In = Energy Used + Energy StoredEnergy In = Energy Used + Energy Stored For every extra 100 calories consumed per day For every extra 100 calories consumed per day

one will put on 10 pounds per yearone will put on 10 pounds per year

ETIOLOGY OF OBESITY

Caloric intake has increasedCaloric intake has increased Eating unsupervised, lack of family mealsEating unsupervised, lack of family meals Eating at multiple sitesEating at multiple sites Eating out / take out foodEating out / take out food BeveragesBeverages Calorically dense foodCalorically dense food

ETIOLOGY OF OBESITY

Physical activity has decreasedPhysical activity has decreased Schools with less physical educationSchools with less physical education After school programsAfter school programs Safety concernsSafety concerns Convenience activitiesConvenience activities Increased sedentary activities: TV, computer, Increased sedentary activities: TV, computer,

video gamesvideo games

ETIOLOGY OF OBESITY

Physical activityPhysical activity TV / video gamesTV / video games

More time spent watching TV less time for physical More time spent watching TV less time for physical activity: average 2.5 hours / day, 20%>5 hours / dayactivity: average 2.5 hours / day, 20%>5 hours / day

BMI and obesity associated with higher amount of BMI and obesity associated with higher amount of time spent watching TVtime spent watching TV

Higher cholesterol levels associated with greater Higher cholesterol levels associated with greater amount of time spent watching TVamount of time spent watching TV

40% of children 1-5 years have TV in their bedroom40% of children 1-5 years have TV in their bedroom

TREATMENT OF PEDIATRIC OBESITY Weight management programs are available Weight management programs are available

and can be effectiveand can be effective High rates of recurrenceHigh rates of recurrence Prevention is the keyPrevention is the key

PREVENTION: PRECONCEPTION Prevention starts prior to conceptionPrevention starts prior to conception

Obese adolescents have an 80% probability of Obese adolescents have an 80% probability of being obese as an adultbeing obese as an adult

Today's adolescents are tomorrows parentsToday's adolescents are tomorrows parents Parents act as role models for their childrenParents act as role models for their children The risk of obesity in a child born to obese The risk of obesity in a child born to obese

parents is significantly increasedparents is significantly increased Need to educate and intervene at this time to Need to educate and intervene at this time to

help prevent obesity is subsequent generationhelp prevent obesity is subsequent generation

PREVENTION: POST CONCEPTION Routine prenatal careRoutine prenatal care Advocate normal weight gain during the Advocate normal weight gain during the

pregnancypregnancy LGA infants and infants of diabetic mothers LGA infants and infants of diabetic mothers

have higher rates of subsequent obesityhave higher rates of subsequent obesity SGA infants also at higher riskSGA infants also at higher risk

Hediger ML et: Pediatrics104:e33, 1999Hediger ML et: Pediatrics104:e33, 1999

PREVENTION: POST CONCEPTION Promote breastfeedingPromote breastfeeding

Dewey 2003: 8 out of 11 studies noted a lower rate of Dewey 2003: 8 out of 11 studies noted a lower rate of obesity in children if breastfed vs. formula fed obesity in children if breastfed vs. formula fed

Bergmann 2003: Longitudinal study of breastfed vs. Bergmann 2003: Longitudinal study of breastfed vs. formula fed infantsformula fed infants BMI the same at birthBMI the same at birth BMI at 3 & 6 months > in formula fed vs. breastfed infantsBMI at 3 & 6 months > in formula fed vs. breastfed infants Rate of obesity at 6 years was tripled in formula fed vs. Rate of obesity at 6 years was tripled in formula fed vs.

breastfedbreastfed

PREVENTION OF PEDIATRIC OBESITY Measure and plot BMI Measure and plot BMI

Only done by 20% of primary care providersOnly done by 20% of primary care providers Identify those at riskIdentify those at risk Anticipatory guidanceAnticipatory guidance

NutritionNutrition Physical activityPhysical activity Healthy lifestylesHealthy lifestyles

IDENTIFY THOSE AT RISK

Increasing BMI %Increasing BMI % Family historyFamily history

Risk of obesity 9% if both parents are leanRisk of obesity 9% if both parents are lean Risk of obesity 60-80% if both parents are Risk of obesity 60-80% if both parents are

obeseobese Sibling over weightSibling over weight

High birth weightHigh birth weight

IDENTIFY THOSE AT RISK

Lower socioeconomic statusLower socioeconomic status Ethnicity: African-American, Hispanic, Ethnicity: African-American, Hispanic,

Native AmericanNative American Environmental / socialEnvironmental / social

Both parents workBoth parents work Little cognitive stimulationLittle cognitive stimulation Lack of safe play areasLack of safe play areas Family stressFamily stress

NUTRITION ANTICIPATORY GUIDANCE BeveragesBeverages

Encourage water intakeEncourage water intake Limit sweet beveragesLimit sweet beverages

Juice, juice drinks: 120 calories / 8 ozJuice, juice drinks: 120 calories / 8 oz• No nutritional need for any juice <6 months of ageNo nutritional need for any juice <6 months of age• 1-6 years: 4-6 oz1-6 years: 4-6 oz• 7-18 years: 8-12 oz7-18 years: 8-12 oz• Discourage free use of box drinksDiscourage free use of box drinks• Discourage continuous access to sippy cupsDiscourage continuous access to sippy cups

Soda: 150 calories / 12 ozSoda: 150 calories / 12 oz

NUTRITION ANTICIPATORY GUIDANCE Eat 5 fruits and vegetables a day Eat 5 fruits and vegetables a day Structured meal and snack timeStructured meal and snack time Do not use food as a rewardDo not use food as a reward Know what the child is eating outside the Know what the child is eating outside the

home: school meals, day care etc.home: school meals, day care etc.

NUTRITION ANTICIPATORY GUIDANCE Encourage child’s autonomy in self-regulation of food Encourage child’s autonomy in self-regulation of food

intake intake Parents provide, child decides! Parents provide, child decides! Do not use the clean the plate rule.Do not use the clean the plate rule.

Provide choiceProvide choice Educate parents regarding healthy nutritionEducate parents regarding healthy nutrition

Healthy snacksHealthy snacks Consider using pediatric food pyramidConsider using pediatric food pyramid Portion size: Intake of children >5 years is dependent on how Portion size: Intake of children >5 years is dependent on how

much they are providedmuch they are provided Do not skip mealsDo not skip meals

ACTIVITY ANTICIPATORY GUIDANCE Encourage active play for young childrenEncourage active play for young children Promote physical activityPromote physical activity

Ideal 30-60 minutes per dayIdeal 30-60 minutes per day Have several types of potential activitiesHave several types of potential activities Be physically active with othersBe physically active with others Think about activity opportunitiesThink about activity opportunities Encourage participation in organized sportsEncourage participation in organized sports

ACTIVITY ANTICIPATORY GUIDANCE Decrease sedentary activityDecrease sedentary activity

Limit TV, video games and computer to 1-2 Limit TV, video games and computer to 1-2 hours per dayhours per day > 2 hours a day associated with higher rates of > 2 hours a day associated with higher rates of

obesity and hyperlipidemiaobesity and hyperlipidemia

Do not have a TV in the child’s roomDo not have a TV in the child’s room Children with TVs in bedroom watch more TVChildren with TVs in bedroom watch more TV

ACTIVITY ANTICIPATORY GUIDANCE Decrease sedentary activityDecrease sedentary activity

Do not use the remoteDo not use the remote Exercise on commercialsExercise on commercials TV / computer is not a right it is a privilegeTV / computer is not a right it is a privilege

BEHAVIORAL ANTICIPATORY GUIDANCE Encourage parents to act as role modelsEncourage parents to act as role models

NutritionNutrition ActivityActivity

Promote parent child interactionPromote parent child interaction Have special “family time” that is Have special “family time” that is

physically activephysically active

BEHAVIORAL ANTICIPATORY GUIDANCE Limit eating outLimit eating out

More calorically dense foodMore calorically dense food Larger portion sizesLarger portion sizes Less intake of fruits and vegetablesLess intake of fruits and vegetables $0.51 of every nutrition dollar is spent outside $0.51 of every nutrition dollar is spent outside

the homethe home

BEHAVIORAL ANTICIPATORY GUIDANCE Eat as a familyEat as a family

Provides “quality time”Provides “quality time” Slows down the eating processSlows down the eating process Parents act as role modelParents act as role model Parents monitor intakeParents monitor intake Associated with lower fat intake and greater Associated with lower fat intake and greater

intake of fruits and vegetablesintake of fruits and vegetables

BEHAVIORAL ANTICIPATORY GUIDANCE Do not eat in front of the TVDo not eat in front of the TV

Associated with higher intake of fat and saltAssociated with higher intake of fat and salt Lower intake of fruits and vegetablesLower intake of fruits and vegetables Encourages over eatingEncourages over eating

60-80% of commercials on during children 60-80% of commercials on during children programs are related to foodprograms are related to food

Eating without awareness Eating without awareness

TREATMENT OF PEDIATRIC OBESITY

TREATMENT GOALS

Behavioral goalsBehavioral goals Promote life long healthy eating and activity Promote life long healthy eating and activity

behaviorsbehaviors Medical goalsMedical goals

Prevent complications of obesity in childhood Prevent complications of obesity in childhood and potentially adulthoodand potentially adulthood

Improve or resolve existing complications of Improve or resolve existing complications of obesity obesity

TREATMENT GOALS

Weight goalsWeight goals First step is to achieve weight maintenanceFirst step is to achieve weight maintenance 2-7 years of age2-7 years of age

BMI 85-95%BMI 85-95%• Weight maintenanceWeight maintenance

BMI >95%BMI >95%• No complications: weight maintenanceNo complications: weight maintenance

• Complications: weight lossComplications: weight loss

TREATMENT GOALS

Weight goalsWeight goals 7-18 years of age7-18 years of age

BMI 85-95%BMI 85-95%• No complications: weight maintenanceNo complications: weight maintenance

• Complications: weight lossComplications: weight loss

BMI >95%BMI >95%• Weight lossWeight loss

EVALUATION OF THE OBESE CHILD History and physical examinationHistory and physical examination Laboratory evaluationLaboratory evaluation

Liver panelLiver panel Fasting lipid panelFasting lipid panel Fasting glucose and insulin levelFasting glucose and insulin level Hgb A1CHgb A1C ? Thyroid studies? Thyroid studies


First step is to educate the patient and First step is to educate the patient and parents about obesityparents about obesity

Assess patient and the family’s readiness to Assess patient and the family’s readiness to make changemake change

Treatment needs to be individualized and Treatment needs to be individualized and family basedfamily based

Make only a few changes at a timeMake only a few changes at a time


For a child who will not be entering the For a child who will not be entering the formal obesity clinicformal obesity clinic Stage I: Limit TV, do not eat in front of the TV Stage I: Limit TV, do not eat in front of the TV

and decrease calories from beverages.and decrease calories from beverages. Stage II: Eat as a family, some increase in Stage II: Eat as a family, some increase in

physical activityphysical activity Stage III: Nutrition education and initial Stage III: Nutrition education and initial

implementation of hypocaloric dietimplementation of hypocaloric diet


Formal obesity clinicFormal obesity clinic Team approachTeam approach

PhysicianPhysician TherapistTherapist DieticianDietician Exercise therapistExercise therapist

Intensive programIntensive program 15 sessions: 10 therapist, 3 dietician, 2 exercise 15 sessions: 10 therapist, 3 dietician, 2 exercise

therapisttherapist


Formal obesity clinicFormal obesity clinic AdvantagesAdvantages

Appropriate timeAppropriate time Frequent visitsFrequent visits Utilize each team members expertiseUtilize each team members expertise Good outcomes if completedGood outcomes if completed

Weight Loss Pharmacotherapy

SibutramineSibutramine FDA approved 1997FDA approved 1997 Induces feeling of satietyInduces feeling of satiety

Increases 5HT & Norepi.Increases 5HT & Norepi. Caution with use in Caution with use in

combination with SSRI’scombination with SSRI’s Contraindicated with Contraindicated with

CAD,CVA or uncontrolled CAD,CVA or uncontrolled blood pressureblood pressure Need to monitor BPNeed to monitor BP

Once dailyOnce daily 8-10% weight loss8-10% weight loss

OrlistatOrlistat FDA approved 1999FDA approved 1999 FDA approved 12-18 year oldFDA approved 12-18 year old Reduces absorption of ~30% Reduces absorption of ~30%

dietary fatdietary fat 1/3 of fat passes undigested1/3 of fat passes undigested Facilitates weight lossFacilitates weight loss GI side effectsGI side effects

3 times daily with meals 3 times daily with meals containing fatcontaining fat

Vitamin supplementationVitamin supplementation 8-10% weight loss8-10% weight loss

BARIATRIC SURGERY

Little information on pediatric bariatric Little information on pediatric bariatric surgerysurgery

May be appropriate in individual casesMay be appropriate in individual cases Severe obesity, BMI > 40Severe obesity, BMI > 40 Significant co-morbiditiesSignificant co-morbidities Unresponsive to more conventional weight loss Unresponsive to more conventional weight loss

programprogram

BARIATRIC SURGERY

Preoperative evaluation in a pediatric Preoperative evaluation in a pediatric weight management programweight management program

Psych evaluationPsych evaluation DepressionDepression Ability to copeAbility to cope Support systemSupport system Willingness to complyWillingness to comply

BARIATRIC SURGERY

Pediatric cases should be done in a pediatric Pediatric cases should be done in a pediatric centercenter

Prospective multi-institutional study in Prospective multi-institutional study in progressprogress

Options:Options: Gastric bypassGastric bypass Lap bandLap band

CONCLUSIONS

Pediatric obesity is of epidemic proportionPediatric obesity is of epidemic proportion The etiology of pediatric obesity is The etiology of pediatric obesity is

multifactorialmultifactorial Pediatric obesity is associated with Pediatric obesity is associated with

complications in childhood as well as complications in childhood as well as adulthoodadulthood

CONCLUSIONS

Treatment of obesity is not idealTreatment of obesity is not ideal Prevention of obesity may be a more effective Prevention of obesity may be a more effective

means dealing with pediatric obesitymeans dealing with pediatric obesity In order to have any significant impact on In order to have any significant impact on

pediatric obesity a team approach is required: pediatric obesity a team approach is required: child, family/parents, community, health care child, family/parents, community, health care providers, insurance companies, governmentproviders, insurance companies, government

TREATMENT OF PEDIATRIC OBESITY Protein sparing modified fastProtein sparing modified fast Low carbohydrate dietLow carbohydrate diet

Restrictive Bariatric ProceduresRestrictive Bariatric Procedures

Mun EC, Blackburn GL, Matthews JB. Gastroenterology 2001:120:669-681

Adjustable Gastric Banding

Adjustable Gastric Banding

Gold Standar

d

Vertical BandedGastroplasty

Vertical BandedGastroplasty

Roux-en-Y Gastric Bypass

Roux-en-Y Gastric Bypass

WEB SITEES OF INTEREST

www.panaonline.orgwww.panaonline.org PA Department of Health effort to address PA Department of Health effort to address

obesity and its co-morbiditiesobesity and its co-morbidities http://www.trowbridge-associates.comhttp://www.trowbridge-associates.com

Pediatric BMI wheelsPediatric BMI wheels http://www.usda.gov/cnpp/kidspyrahttp://www.usda.gov/cnpp/kidspyra

Pediatric food pyramidPediatric food pyramid


http://www.bam.govhttp://www.bam.gov Site to answer kids questionsSite to answer kids questions

http://147.208.9.133/http://147.208.9.133/ A free dietary assessment tool to keep up to a A free dietary assessment tool to keep up to a

20-day food log20-day food log http://www.kidnetic.com/http://www.kidnetic.com/

An interacitve website for 9-13 year olds and An interacitve website for 9-13 year olds and families re healthy eating and activityfamilies re healthy eating and activity


http://www.verbnow.comhttp://www.verbnow.com CDC site for 9-13 year olds to promote CDC site for 9-13 year olds to promote

physical activityphysical activity www.aap.org/obesitywww.aap.org/obesity

American Academy of Pediatrics web site American Academy of Pediatrics web site regarding obesityregarding obesity

BARRIERS TO THERAPY OF PEDIATRIC OBESITY Lack of commitment of primary care Lack of commitment of primary care

physiciansphysicians Many physicians do not address obesityMany physicians do not address obesity Price 1989Price 1989

17% of pediatricians felt physicians did not need to 17% of pediatricians felt physicians did not need to counsel parents of obese childrencounsel parents of obese children

33% did not feel that normal weight is important to child 33% did not feel that normal weight is important to child healthhealth

22% felt competent in treating obesity22% felt competent in treating obesity 11% felt treatment of obesity was gratifying 11% felt treatment of obesity was gratifying

BARRIERS TO THERAPY OF PEDIATRIC OBESITY Time commitmentTime commitment Lack of reimbursementLack of reimbursement

Tershakovec 1999Tershakovec 1999 Median reimbursement rate 11%Median reimbursement rate 11%

Lack of standard treatment protocolLack of standard treatment protocol Social / environmental barriersSocial / environmental barriers

PREVENTION: SCHOOL

Promote physical activityPromote physical activity Provide nutritious mealsProvide nutritious meals Control vending machinesControl vending machines Have nutrition education incorporated into Have nutrition education incorporated into

regular school curriculum.regular school curriculum. Encourage children to walk or bike to Encourage children to walk or bike to

school safely.school safely.

PREVENTION: COMMUNITY

Have safe playgroundsHave safe playgrounds Provide safe places for bike riding and Provide safe places for bike riding and

walkingwalking Promote physical activity outside of schoolPromote physical activity outside of school

PREVENTION: INSURANCE AND GOVERNMENT Acknowledge obesity as a medical Acknowledge obesity as a medical

condition for which one can be reimbursed.condition for which one can be reimbursed. Provide reimbursement for anticipatory Provide reimbursement for anticipatory

guidance for nutrition and physical activityguidance for nutrition and physical activity

PREVENTION: PRIMARY CARE PROVIDER Be an advocateBe an advocate

pediatric obesity: a huge problem in the usa william j. cochran, md department of pediatric gi &...

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