pediatric obesity elizabeth h. kwon md, mph. obesity defined according to the ama’s expert...

Pediatric ObesityPediatric Obesity

Elizabeth H. Kwon MD, Elizabeth H. Kwon MD, MPHMPH

OBESITY DEFINEDOBESITY DEFINED According to the AMA’s Expert Committee on the Prevention, According to the AMA’s Expert Committee on the Prevention,

Assessment, and Treatment of Child and Adolescent Assessment, and Treatment of Child and Adolescent Overweight and Obesity in 2005 (Co-funded by Health Overweight and Obesity in 2005 (Co-funded by Health Resources and Services Administration (HRSA) and the Resources and Services Administration (HRSA) and the Centers for Disease Control and Prevention (CDC))Centers for Disease Control and Prevention (CDC))

OverweightOverweight BMI for age 85%ile to 94%ileBMI for age 85%ile to 94%ile

ObeseObese BMI for age >=95%ileBMI for age >=95%ile

Causes of Pediatric Causes of Pediatric ObesityObesity

Caloric Intake has IncreasedCaloric Intake has Increased Less supervised family mealsLess supervised family meals More eating out/ Fast food/ RestaurantsMore eating out/ Fast food/ Restaurants

Portions sizes are much largerPortions sizes are much larger Fried foods/ Trans fatsFried foods/ Trans fats

High Calorie BeveragesHigh Calorie Beverages Increased availability of calorically dense, Increased availability of calorically dense,

ready-to-eat foodready-to-eat food More chips, cakes, cookies, donuts, crackers, More chips, cakes, cookies, donuts, crackers,

candy…candy… Pop tarts, Easy Mac, Canned Ravioli, frozen Pop tarts, Easy Mac, Canned Ravioli, frozen

pizzas…pizzas…(From Cochran, W., Pediatric Obesity: A Huge Problem in the USA)(From Cochran, W., Pediatric Obesity: A Huge Problem in the USA)

Causes of Pediatric Causes of Pediatric ObesityObesity Less Physical ActivityLess Physical Activity

More sedentary activities like video games, TV and More sedentary activities like video games, TV and computercomputer less time to run around less time to run around

TV/Computer --Average 2.5 hours/day with 20% >5 hours day TV/Computer --Average 2.5 hours/day with 20% >5 hours day Studies show higher BMI’s, obesity and cholesterol with more Studies show higher BMI’s, obesity and cholesterol with more

TVTV 40% of low-income children 1-5y.o had a TV in their room40% of low-income children 1-5y.o had a TV in their room

Schools have less or no gym time – in order to Schools have less or no gym time – in order to achieve “No Child Left Behind” goalsachieve “No Child Left Behind” goals

More kids in after school programs without much More kids in after school programs without much physical activitiesphysical activities

““More dangerous world”—keeps children inside more More dangerous world”—keeps children inside more than previous decadesthan previous decades

(From Cochran, W., Pediatric Obesity: A Huge Problem in the USA)(From Cochran, W., Pediatric Obesity: A Huge Problem in the USA)

Causes of Pediatric Causes of Pediatric ObesityObesity

GeneticsGenetics One parent obeseOne parent obese3x risk3x risk Two parents obeseTwo parents obese10x risk10x risk( Hassink, A Parent’s Guide to Childhood Obesity 2006)( Hassink, A Parent’s Guide to Childhood Obesity 2006)

EnvironmentalEnvironmental Energy imbalance Energy imbalance

(Energy In>Energy Used (Energy In>Energy Used Energy Energy Stored at Fat)Stored at Fat)


Increasing Percent of Increasing Percent of Obese Children and Obese Children and

Adolescents 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

From Comorbidities of Pediatric Obesity—William Cochran, MDFrom Comorbidities of Pediatric Obesity—William Cochran, MD

12. 5 Million US Children are 12. 5 Million US Children are Overweight today…Overweight today…

Racial Disparities in Racial Disparities in Overweight/Obesity Overweight/Obesity

PrevalencePrevalence The NHANES in 1988-1994 The NHANES in 1988-1994 versus the NHANES in 2002 versus the NHANES in 2002 showed overweight prevalence showed overweight prevalence in non-Hispanic Black (20.5%) in non-Hispanic Black (20.5%) and Mexican-American (22.2%) and Mexican-American (22.2%) increased at a faster rate than increased at a faster rate than in Whites.in Whites.

Childhood Obesity has Childhood Obesity has Medical ConsequencesMedical Consequences

Diabetes Mellitus Diabetes Mellitus type IItype II

PsychosocialPsychosocial HypertensionHypertension HyperlipidemiaHyperlipidemia AsthmaAsthma Sleep ApneaSleep Apnea ArthritisArthritis SCFESCFE Blount’s DiseaseBlount’s Disease

SteatohepatitisSteatohepatitis GallstonesGallstones PancreatitisPancreatitis Metabolic SyndromeMetabolic Syndrome Polycystic Ovarian Polycystic Ovarian

SyndromeSyndrome Skin InfectionsSkin Infections Back PainBack Pain Pseudotumor Pseudotumor

CerebriCerebri

Prevalence of Diabetes in Prevalence of Diabetes in US US

1990 versus 20011990 versus 2001

From : Narayan et al. 2003, Sinha et. Al 2002, Weiss et al, 2003From : Narayan et al. 2003, Sinha et. Al 2002, Weiss et al, 2003

Life years lost from Life years lost from DiabetesDiabetes in the US in the USfrom Narayan et al., 2003from Narayan et al., 2003 If diagnosed at age If diagnosed at age

10 years10 years

White White male: male: 16.5 yrs16.5 yrs female: 18.0 yrsfemale: 18.0 yrs

Hispanic Hispanic male: male: 19.0 yrs19.0 yrs female: 16.0 yrsfemale: 16.0 yrs

Black Black male: male: 22.0 yrs22.0 yrs female: 23.0 yrsfemale: 23.0 yrs

If diagnosed at age 40 If diagnosed at age 40 yearsyears

White White male: 1.01 yrsmale: 1.01 yrs female: female: 13.5 13.5

yrsyrs Hispanic Hispanic

male: male: 11.5 11.5 yrsyrs

female: female: 12.4 12.4 yrs yrs

Black Black male: male: 13.0 13.0

yrsyrs female: female: 17.0 17.0

yrsyrs

HypertensionHypertension

60% of Children with persistently 60% of Children with persistently elevated blood pressure had weight elevated blood pressure had weight >120% Ideal Body Weight >120% Ideal Body Weight (Lauer J (Lauer J Pediatrics 1975;86:697-706.)Pediatrics 1975;86:697-706.)

Overweight adolescents have 8.5 x Overweight adolescents have 8.5 x increased risk of hypertension as increased risk of hypertension as adults adults (Srinivasan Metab 1996;45:235-240)(Srinivasan Metab 1996;45:235-240)

HyperlipidemiaHyperlipidemia

Obesity in adolescence is associated withObesity in adolescence is associated with 2.4 times more likely to have 2.4 times more likely to have

cholesterol >240mg/dlcholesterol >240mg/dl 3 times more likely to have 3 times more likely to have

LDL>160mg/dlLDL>160mg/dl 8 times more likely to have HDL<35 8 times more likely to have HDL<35

mg/dl by the time they are adults aged mg/dl by the time they are adults aged 27-31 y.o.27-31 y.o.

(From Srinivasan Metab 1996;45:235-240)(From Srinivasan Metab 1996;45:235-240)

SteatohepatitisSteatohepatitis

Affects 20-25% of Obese Children Affects 20-25% of Obese Children (Tazewa (Tazewa

Acta Paeditr-1997; 86:238-241) Acta Paeditr-1997; 86:238-241) while 83% of while 83% of Children with Steatohepatitis are ObeseChildren with Steatohepatitis are Obese (Comorbidities of Pediatric Obesity, William Cochran MD)(Comorbidities of Pediatric Obesity, William Cochran MD)

Can progress to fibrosis or frank Can progress to fibrosis or frank cirrhosis. cirrhosis. Obesity and type 2 diabetes are the strongest Obesity and type 2 diabetes are the strongest

predictors for fibrosis progressionpredictors for fibrosis progression (Angulo P. (Angulo P. Keach JC, Batts KP, Lindor KD, Hepatology 1999; 30(6) 1356-Keach JC, Batts KP, Lindor KD, Hepatology 1999; 30(6) 1356-62.)62.)

CholelithiasisCholelithiasis

Is caused by obesity in 8-33% of Is caused by obesity in 8-33% of childhood caseschildhood cases(Friesen Clin Pediatr 1989 7:294)(Friesen Clin Pediatr 1989 7:294)

Is associated with obesity in 50% of Is associated with obesity in 50% of adolescent cases adolescent cases (Crichlow Dig Dis. 1972; 17:68-(Crichlow Dig Dis. 1972; 17:68-72)72)

May be associated with weight lossMay be associated with weight loss (Crichlow Dig Dis. 1972, 17:68-72).(Crichlow Dig Dis. 1972, 17:68-72).

SCFE and Blount’sSCFE and Blount’s

50-75% of 50-75% of SCFE SCFE patients are patients are obeseobese

(Wilcox , J Pediatric (Wilcox , J Pediatric Orthopedics 1988:8: 196-Orthopedics 1988:8: 196-200)200)

2/3 of 2/3 of Blount’s Blount’s Disease Disease patients are patients are obeseobese

(Dietz, J Pediatrics 1982: (Dietz, J Pediatrics 1982: 101: 735-737)101: 735-737)

Obstructive Sleep ApneaObstructive Sleep Apnea 40% of severely obese children had 40% of severely obese children had

central hypoventilation central hypoventilation (Silvesti, Pediatric (Silvesti, Pediatric Pulmonology 1993; 16:124-139)Pulmonology 1993; 16:124-139)

Abnormal sleep patterns were found in Abnormal sleep patterns were found in 94% of obese children in one study94% of obese children in one study

OSA leads to decreases in learning, OSA leads to decreases in learning, attention span and memoryattention span and memory (Rhodes, J Pediatrics 1995;127:741-744; Greengerg GD, Watson RK, Deptula (Rhodes, J Pediatrics 1995;127:741-744; Greengerg GD, Watson RK, Deptula

D., Sleep 1987; 10(3):254-62.)D., Sleep 1987; 10(3):254-62.)

And increases in pulmonary hypertension, And increases in pulmonary hypertension, systemic hypertension and right heart systemic hypertension and right heart failurefailure

(Tal A, Lieberman A, Margulis G, Sofer S., Pediatric Pulmonology (Tal A, Lieberman A, Margulis G, Sofer S., Pediatric Pulmonology 1988;4(3):139-43; Marcus CL, Greene MG, Carroll JL., American J 1988;4(3):139-43; Marcus CL, Greene MG, Carroll JL., American J Respiratory Critical Care Medicine 1998; 157 (4 PT1): 1098-103; Massumi Respiratory Critical Care Medicine 1998; 157 (4 PT1): 1098-103; Massumi RA, Sarin RK, Pooya M, Reichelderfer, Dis Chest 1969; 55(2): 110-4.)RA, Sarin RK, Pooya M, Reichelderfer, Dis Chest 1969; 55(2): 110-4.)

Pseudotumor CerebriPseudotumor Cerebri

30-80% of children with 30-80% of children with pseudotumor cerebri have pseudotumor cerebri have obesityobesity (Scott, American J Ophthalmology 1997; 124: 253-255)(Scott, American J Ophthalmology 1997; 124: 253-255)

Increased Intracranial Pressure Increased Intracranial Pressure can lead to visual impairment or can lead to visual impairment or blindnessblindness (Comorbidities of Pediatric Obesity, William Cochran)(Comorbidities of Pediatric Obesity, William Cochran)

Physical ExamPhysical Exam

HypertensionHypertension Acanthosis NigricansAcanthosis Nigricans PapilledemaPapilledema ThyroidThyroid HepatomegalyHepatomegaly Bowed legs/Osgood Sclatter’sBowed legs/Osgood Sclatter’s DepressionDepression Short StatureShort Stature

Laboratory TestsLaboratory Tests BMI 85-94%ile with no other risk-->Fasting lipid BMI 85-94%ile with no other risk-->Fasting lipid

profileprofile

BMI 85-94%ile with risk factors (BMI 85-94%ile with risk factors (family history of family history of obesity, family history of obesity-related diseases, obesity, family history of obesity-related diseases, elevated lipid levels, elevated blood pressure, elevated lipid levels, elevated blood pressure, smokingsmoking) ) Fasting lipid profile, LFT’s, fasting Fasting lipid profile, LFT’s, fasting glucoseglucose

BMI >=95%ileBMI >=95%ile Fasting lipid profile, LFT’s, Fasting lipid profile, LFT’s, fasting glucosefasting glucose

Repeat tests every 2 years after age 10.Repeat tests every 2 years after age 10.

Other possible suggested tests by endocrinologists:Other possible suggested tests by endocrinologists: Fasting InsulinFasting Insulin HbA1CHbA1C Thyroid function testsThyroid function tests

Obese Children are Likely Obese Children are Likely to Become Obese Adultsto Become Obese Adults

0

10

20

30

40

50

60

70

80

Preschool School-age Adolescent

Percent of Obese Children Becoming Obese Adults

From Pediatric Obesity: A Huge Problem in the USA—William Cochran MDFrom Pediatric Obesity: A Huge Problem in the USA—William Cochran MD

Obesity Increases Obesity Increases MortalityMortality

“Because of the increasing rates of obesity,

unhealthy eating habits, and physical inactivity,

we may see the first generation that will be less healthy and have a shorter life expectancy than their parents”

--Richard H. Carmona, MD, MPH, FACS, Surgeon General

U.S. Dept of Health and Human Services, 2004

Psychosocial Impact of Psychosocial Impact of Childhood ObesityChildhood Obesity

Increased rates of DepressionIncreased rates of Depression Poorer Self-Esteem—may last til adulthoodPoorer Self-Esteem—may last til adulthood 10-11 year olds prefer friends with handicaps 10-11 year olds prefer friends with handicaps

than obese than obese (Richardson, 1961)(Richardson, 1961)

6-10 year olds associate obesity with laziness 6-10 year olds associate obesity with laziness (Staffieri,1967)(Staffieri,1967)

Obese Females have lower college acceptance Obese Females have lower college acceptance rates than non-obese females rates than non-obese females (Canning, 1966)(Canning, 1966)

Obese Adolescent Females as young adults had Obese Adolescent Females as young adults had less education, less income, higher poverty less education, less income, higher poverty rates and decreased rate of marriage versus rates and decreased rate of marriage versus non-obese females non-obese females (National Longitudinal Survey of Youth, (National Longitudinal Survey of Youth, 1993)1993)

Economic Consequences of Economic Consequences of ObesityObesity

In 2002, the estimated cost of obesity In 2002, the estimated cost of obesity in the US was $117 billion dollars.in the US was $117 billion dollars.

Hospital Costs associated with Hospital Costs associated with pediatric obesity are rising:pediatric obesity are rising:

In 1979: $35 millionIn 1979: $35 millionIn 1999: $127 millionIn 1999: $127 million

From Pediattric Obesity: A Huge Problem in the USA—William From Pediattric Obesity: A Huge Problem in the USA—William Cochran, MDCochran, MD

What can we do about What can we do about Childhood Obesity?Childhood Obesity?

PREVENTIONPREVENTION

IS KEY SINCE IS KEY SINCE TREATMENT IS SO TREATMENT IS SO

MUCH MORE MUCH MORE DIFFICULTDIFFICULT

Prevention of Childhood Prevention of Childhood ObesityObesity Advise Pregnant Women to gain the Advise Pregnant Women to gain the

recommended amount of weight during recommended amount of weight during pregnancypregnancy LGA, SGA and infants of diabetic mothers have LGA, SGA and infants of diabetic mothers have

increased rates of obesity increased rates of obesity (Hediger M.. , Pediatrics 104, p. 33, 1999)(Hediger M.. , Pediatrics 104, p. 33, 1999)

Encourage BreastfeedingEncourage Breastfeeding 8 out of 11 studies noted a lower rate of obesity in 8 out of 11 studies noted a lower rate of obesity in

children if breastfed vs. formula fed (children if breastfed vs. formula fed (Dewey 2003)Dewey 2003)

Longitudinal study of breastfed vs. formula fed infantsLongitudinal study of breastfed vs. formula fed infants (Bergmann 2003)(Bergmann 2003)

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 Childhood Prevention of Childhood ObesityObesity CALCULATE AND PLOT BMI on ALL CALCULATE AND PLOT BMI on ALL

CHILDREN OVER 2 YEARS OLD at all WELL CHILDREN OVER 2 YEARS OLD at all WELL CHILD EXAMS.CHILD EXAMS.

PLOT WEIGHT-FOR-LENGTHS ON ALL PLOT WEIGHT-FOR-LENGTHS ON ALL CHILDREN UNDER 2 YEARS OLD!CHILDREN UNDER 2 YEARS OLD!

If there was an infectious disease that had…If there was an infectious disease that had… double - tripled in prevalence,double - tripled in prevalence, was afflicting 25-30% of children of all ages, was afflicting 25-30% of children of all ages, had life life-long, potentially life threatening had life life-long, potentially life threatening

impact… impact…

Would we be acting?Would we be acting? Would we take 10 sec to plot a point?Would we take 10 sec to plot a point?

(From Krebs, N., Hassink S., Obeesity Basics 101: Role of the Pediatrician)(From Krebs, N., Hassink S., Obeesity Basics 101: Role of the Pediatrician)

Prevention of Childhood Prevention of Childhood ObesityObesity

Are MD’s Using the BMI Charts? Are MD’s Using the BMI Charts? 31 % of pediatricians: “Never”31 % of pediatricians: “Never” 11% : “Always”11% : “Always” According to a 2006 AAP Periodic Survey, only a According to a 2006 AAP Periodic Survey, only a

little more than half the pediatricians assessed a little more than half the pediatricians assessed a BMI.BMI.

Use of BMI by MD’s was associated with:Use of BMI by MD’s was associated with: Greater assessment of “fatness”Greater assessment of “fatness” Greater concern about co-morbiditiesGreater concern about co-morbidities

““Visual diagnosis” subject to under-Visual diagnosis” subject to under-diagnosis of obesitydiagnosis of obesity

(Perrin et al, J Peds 2004, and(Perrin et al, J Peds 2004, and Krebs, N., Hassink S., Obeesity Basics 101: Role of the Pediatrician)Krebs, N., Hassink S., Obeesity Basics 101: Role of the Pediatrician)

Can you see risk? 4 year old girl Is her BMI-for-age a) 5th to <85th

percentile: “normal”?

b) >85th to <95th percentile: “overweight”?

c) >95th percentile: “obese” ?

(Photo from UC Berkeley Longitudinal Study, 1973)

(Slide Courtesy Krebs, N., Hassink S., Obeesity Basics (Slide Courtesy Krebs, N., Hassink S., Obeesity Basics

101: Role of the Pediatrician)101: Role of the Pediatrician)

Measurements:

Age=4 y

Height=99.2 cm (39.2 in)

Weight=17.55 kg (38.6 lb)

Plotted BMI-for-Age

Girls: 2 to 20 years

BMI

BMI=17.8

85-95th percentile

Answer: b)“overweight”

(Slide Courtesy Krebs, N., Hassink S., Obeesity (Slide Courtesy Krebs, N., Hassink S., Obeesity Basics 101: Role of the Pediatrician)Basics 101: Role of the Pediatrician)

Can you see risk?3 year old boy

Is his BMI-for-age :

a) 5th to <85th percentile: “normal”

b) >85th to <95th percentile: “overweight”?

c) >95th percentile: “obese”?

(Slide Courtesy Krebs, N., Hassink S., Obeesity Basics 101: Role of (Slide Courtesy Krebs, N., Hassink S., Obeesity Basics 101: Role of the Pediatrician)the Pediatrician)Photo from UC Berkeley Longitudinal Study, 1973 CDC

Measurements:

Age = 3 y 3 wks

Height = 100.8 cm (39.7 in)

Weight = 18.6 kg (41 lb)

Plotted BMI-for-Age

Boys: 2 to 20 years

BMI BMI

BMI BMI

BMI=18.3

Answer: BMI-for-age ~ 95th percentile“obese”

(Slide Courtesy Krebs, N., Hassink S., Obeesity (Slide Courtesy Krebs, N., Hassink S., Obeesity Basics 101: Role of the Pediatrician)Basics 101: Role of the Pediatrician)

Slide Courtesy Krebs, N., Hassink S., Obeesity Basics 101: Role of the Pediatrician)Slide Courtesy Krebs, N., Hassink S., Obeesity Basics 101: Role of the Pediatrician)

Referral

Boys: 2 to 20 years

BMI BMI

BMI BMI

BMI>95% strongly correlates with body fat Slide Courtesy Krebs, N., Hassink S., Obeesity Basics 101: Role of the Pediatrician)Slide Courtesy Krebs, N., Hassink S., Obeesity Basics 101: Role of the Pediatrician)

3 yr old boy

Early Identification – Early Identification – BMI vs Visual DiagnosisBMI vs Visual Diagnosis

(Slide Courtesy Krebs, N., Hassink S., Obeesity Basics 101: Role of the Pediatrician)(Slide Courtesy Krebs, N., Hassink S., Obeesity Basics 101: Role of the Pediatrician)

95th % >> 95th%85-95th %

Nutrition AdviceNutrition Advice ALL children should be counseled (not just ALL children should be counseled (not just

those with BMI’s>85%ile)those with BMI’s>85%ile) Beverages Guidelines—Beverages Guidelines—

Lowfat Milk (3 dairy servings/day)Lowfat Milk (3 dairy servings/day) Juice/juice drinks (120calories/8oz.)Juice/juice drinks (120calories/8oz.)

Ages 1-6 Ages 1-6 4-6 oz/day 4-6 oz/day Ages 7-18Ages 7-188-12 oz/day8-12 oz/day Don’t buy it for the house—>just drink it when Don’t buy it for the house—>just drink it when

out/school/afterschoolout/school/afterschool No Soda/Iced Tea/ Lemonade/Gatorade unless No Soda/Iced Tea/ Lemonade/Gatorade unless

it’s dietit’s diet Lots of WaterLots of Water

Make it inviting and convenient -> put bottles in the Make it inviting and convenient -> put bottles in the fridge, fun sippy cups with iced water, pitchers of fridge, fun sippy cups with iced water, pitchers of water with lemon wedges etc.water with lemon wedges etc.

Nutrition AdviceNutrition Advice 5 Fruits and Vegetables per day5 Fruits and Vegetables per day

Draw out a plate with 2/3 plate with fruit Draw out a plate with 2/3 plate with fruit vegetables, and 1/3 carbs and meat…vegetables, and 1/3 carbs and meat…

Whole Grains and High Fiber foods Whole Grains and High Fiber foods (Fiber=Age+5)(Fiber=Age+5)

Use Canola/Vegetable oils not butterUse Canola/Vegetable oils not butter Limit Fried FoodsLimit Fried Foods No Trans FatsNo Trans Fats Keep track of what child eats at school, Keep track of what child eats at school,

afterschool, daycare etc.afterschool, daycare etc. Do not use food as a rewardDo not use food as a reward Do not skip mealsDo not skip meals

ff

NUTRITION ADVICENUTRITION ADVICE Pediatric Annals March 2010 Pediatric Annals March 2010

Nutrition AdviceNutrition Advice Give appropriate portions for age: Allow child Give appropriate portions for age: Allow child

to decide on how much he/she wants (within to decide on how much he/she wants (within reason) reason) Studies showed children consumed 25% less of an Studies showed children consumed 25% less of an

entrée when allowed to serve themselves rather entrée when allowed to serve themselves rather than being served a large portion than being served a large portion (Fisher et al., AJCN, 2003)(Fisher et al., AJCN, 2003)

Don’t force a child to clean the plateDon’t force a child to clean the plate Try to eat at home rather than outTry to eat at home rather than out Eat food at the table (not in front of the TV)Eat food at the table (not in front of the TV)

Eating in front of the TV is associated with:Eating in front of the TV is associated with: higher intake of fat and salthigher intake of fat and salt Lower intake of fruits/ vegetablesLower intake of fruits/ vegetables Eating without awarenessEating without awarenessencourages overeating encourages overeating

60-80% of commercials during children’s shows 60-80% of commercials during children’s shows relate to foodrelate to food

Eat slowly/Stop when fullEat slowly/Stop when full Read LabelsRead Labels

Nutrition GuidelinesNutrition Guidelines

frrom Pediatric Annals March 2010frrom Pediatric Annals March 2010

Encourage Physical ActivityEncourage Physical Activity COUNSEL COUNSEL ALLALL CHILDREN at WELL CHILD CHILDREN at WELL CHILD

CHECKS (not just those with BMI>85%ile)CHECKS (not just those with BMI>85%ile) Limit screen time with TV and video games Limit screen time with TV and video games

to less than 2 hrs/dayto less than 2 hrs/day Make it active by running/dancing during Make it active by running/dancing during

commercials or requiring running/ dancing for the commercials or requiring running/ dancing for the first 30 minutes to be able to watch the next 1-1/2 first 30 minutes to be able to watch the next 1-1/2 hours.hours.

Don’t use the remote controlDon’t use the remote control

Encourage 60 minutes/day of activityEncourage 60 minutes/day of activity Encourage organized sportsEncourage organized sports Encourage outdoor timeEncourage outdoor time Parents have to support the child’s activity--Parents have to support the child’s activity--

Otherwise it will not likely happen. Otherwise it will not likely happen. Plan family field trips on weekendsPlan family field trips on weekends

(Slide Courtesy of Krebs, N., Hassink S., Obeesity Basics 101: Role of the Pediatrician)(Slide Courtesy of Krebs, N., Hassink S., Obeesity Basics 101: Role of the Pediatrician)

(Slide Courtesy Krebs, N., Hassink S., Obeesity Basics 101: Role of the Pediatrician)(Slide Courtesy Krebs, N., Hassink S., Obeesity Basics 101: Role of the Pediatrician)

Treatment of ObesityTreatment of Obesity ““The new recommendations detail The new recommendations detail

treatment strategies organized in a treatment strategies organized in a stepwise protocol format. By stepwise protocol format. By facilitating a more aggressive facilitating a more aggressive approach to weight management in approach to weight management in the primary care setting (eg. More the primary care setting (eg. More frequent follow-up visits, more frequent follow-up visits, more timely and appropriate referrals to timely and appropriate referrals to nutritionists and exercise nutritionists and exercise specialists), the greater the specialists), the greater the likelihood of success.”likelihood of success.”

----Contemporary PediatricsContemporary Pediatrics Volume 25, no. 4 Volume 25, no. 4

Stage 1:Prevention Plus Stage 1:Prevention Plus ProtocolProtocol The Committee recommends a staged approach The Committee recommends a staged approach

based on age and progress on decreasing BMI as based on age and progress on decreasing BMI as follows:follows:

The MD should recommend:The MD should recommend: >=5 servings of fruits and vegetables /day>=5 servings of fruits and vegetables /day <2 hours of screen time/day and no tv or computers <2 hours of screen time/day and no tv or computers

in the child’s sleeping areain the child’s sleeping area >1 hours of physical activity/day>1 hours of physical activity/day No sugar-sweetened beveragesNo sugar-sweetened beverages Eat breakfast every dayEat breakfast every day Limit fast foodLimit fast food

GOALGOAL weight maintenance weight maintenance decrease BMIdecrease BMI Follow patients as often as monthly for 3-6 monthsFollow patients as often as monthly for 3-6 months If there is no progressIf there is no progress GO TO STAGE 2 GO TO STAGE 2

Stage 2: Structured weight Stage 2: Structured weight management protocolmanagement protocol

Physicians should:Physicians should: Develop a plan for an organized diet with Develop a plan for an organized diet with

structured daily meals and snacks with structured daily meals and snacks with nutritionist advicenutritionist advice

Recommend that the child have active play for at Recommend that the child have active play for at least 1 hour a day and least 1 hour a day and further restrict screen time further restrict screen time to one hour or less per dayto one hour or less per day

Suggest improved monitoring of exercise, screen Suggest improved monitoring of exercise, screen time or diet by patient and/or familytime or diet by patient and/or family

GOALGOAL maintain weight or lose weight maintain weight or lose weight

(no more than 1 lb./month in children aged 2 to 11 (no more than 1 lb./month in children aged 2 to 11 OR 2 lbs./week in those aged 12 and older)OR 2 lbs./week in those aged 12 and older)

Follow patients as often as monthly for 3-6 monthsFollow patients as often as monthly for 3-6 months If there is no progressIf there is no progress GO TO STAGE 3 GO TO STAGE 3

Stage 3: Comprehensive Stage 3: Comprehensive multidisciplinary protocolmultidisciplinary protocol

REFER to a multidisciplinary team for more REFER to a multidisciplinary team for more aggressive and coordinated management aggressive and coordinated management including evaluation by a including evaluation by a psychologistpsychologist with with consideration given to consideration given to behavior modificationbehavior modification and and motivational counselingmotivational counseling

Stage 3 interventions include the same Stage 3 interventions include the same eating and activity goals as stage 2 plus eating and activity goals as stage 2 plus psychological counseling that may involve psychological counseling that may involve the entire familythe entire family

GOALGOAL weight maintenance or loss (no more weight maintenance or loss (no more than 1 lb./month ages 2-5, or 2 lbs./week than 1 lb./month ages 2-5, or 2 lbs./week ages 6 and up )til BMI<85%ile ages 6 and up )til BMI<85%ile

Follow up may be provided weeklyFollow up may be provided weekly

Stage 4: Tertiary Care Stage 4: Tertiary Care ProtocolProtocol For patients with BMI>95%ile with For patients with BMI>95%ile with

comorbidities or who have not responded to comorbidities or who have not responded to Stage 1-3 strategies Stage 1-3 strategies

OROR For patients with BMI>99%ile with no For patients with BMI>99%ile with no

improvement after 6-12 months of a Stage 3 improvement after 6-12 months of a Stage 3 regimenregimen

MUST be referred to a tertiary weight MUST be referred to a tertiary weight management center that usually include management center that usually include dietary and activity counseling, low-calorie dietary and activity counseling, low-calorie diets and sometimes even medications and diets and sometimes even medications and surgery.surgery.

From Contemporary Pediatrics Volume 25, No. 4 April 2008

An obesity action plan for An obesity action plan for childrenchildren

From Contemporary pediatrics Volume 25, no. 4 April 2008

Treatment of ObesityTreatment of Obesity Important to communicate effectively Important to communicate effectively

with patient and familywith patient and family Try to assess a typical day—to better Try to assess a typical day—to better

identify ways to change diet and activityidentify ways to change diet and activity Try to be sensitive and not use words Try to be sensitive and not use words

that may offend (“obese”, “fat”). Try to that may offend (“obese”, “fat”). Try to avoid being judgmental and stigmatizing.avoid being judgmental and stigmatizing. ““Are you concerned about your child’s Are you concerned about your child’s

weight?”weight?” ““I’m concerned that your child’s weight is I’m concerned that your child’s weight is

getting ahead of his height”getting ahead of his height” (older child) “Is your weight ever a problem (older child) “Is your weight ever a problem

for you?”for you?”

Motivational Motivational InterviewingInterviewing

““Recent studies have demonstrated the Recent studies have demonstrated the efficacy of motivational interviewing in efficacy of motivational interviewing in helping patients change their health helping patients change their health behaviors.”behaviors.” ““MI is a patient-centered method for MI is a patient-centered method for

enhancing intrinsic motivation to change by enhancing intrinsic motivation to change by exploring and resolving ambivilance.” exploring and resolving ambivilance.”

““MI is patient centered, not doctor MI is patient centered, not doctor centered.”centered.”

““The physician listens to the patient’s The physician listens to the patient’s perspective on how the problem affects perspective on how the problem affects daily life and seeks to understand the daily life and seeks to understand the patient’s point of view without judging or patient’s point of view without judging or criticizing the behavior.”criticizing the behavior.”from Pediatric Annals March 2010from Pediatric Annals March 2010

3 Communcation Styles of 3 Communcation Styles of Motivational InterviewingMotivational Interviewing

Following (history taking)Following (history taking) Open-ended questionsOpen-ended questions Reflective listeningReflective listening Agenda settingAgenda setting Asking permissionAsking permission

DirectingDirecting Commonly used by physicians—clinicians tells Commonly used by physicians—clinicians tells

patients what to do and how to do itpatients what to do and how to do it GuidingGuiding

The physician helps the patient find his/her way The physician helps the patient find his/her way and acts more like a tutor.and acts more like a tutor.

The patient is encouraged to explore his/her The patient is encouraged to explore his/her own motivation and goals. The patient makes own motivation and goals. The patient makes the case for changethe case for change

Four Guiding Principles of Four Guiding Principles of Motivational InterviewingMotivational Interviewing

Resist arguing and trying to persuade your Resist arguing and trying to persuade your patient to change behaviorpatient to change behavior Otherwise patient will become defensiveOtherwise patient will become defensive

Understand your patient’s motivationUnderstand your patient’s motivation Ask them why they might want to change and might Ask them why they might want to change and might

do itdo it Listen to your patientListen to your patient

For exampleFor example Your patientYour patient may have the answers may have the answers as to how to defeat the barriers to exercise in his as to how to defeat the barriers to exercise in his daily life.daily life.

Empower your patientEmpower your patient A physician’s belief in the patient’s ability to change A physician’s belief in the patient’s ability to change

can be all a patient needs to succeed.can be all a patient needs to succeed.frrom Pediatric Annals March 2010frrom Pediatric Annals March 2010

frrom Pediatric Annals March 2010frrom Pediatric Annals March 2010

Motivational Counseling Script (cont’d)Motivational Counseling Script (cont’d)

Treatment of ObesityTreatment of Obesity Negotiate for Negotiate for family family change—otherwise, it change—otherwise, it

will be almost impossible for the patient to will be almost impossible for the patient to change.change. Try to get all family members to come to at Try to get all family members to come to at

least one visit so everyone is on the same page. least one visit so everyone is on the same page. The family’s kitchen and habits have to change.The family’s kitchen and habits have to change.

Food diariesFood diaries Activity logsActivity logs Pedometers. Pedometers. Handouts Handouts

on food nutritional content/ portion sizeson food nutritional content/ portion sizes on healthy recipes snackson healthy recipes snacks on exercise ideason exercise ideas reviewing eating habits, activity goalsreviewing eating habits, activity goals

Treatment of ObesityTreatment of Obesity

BUT BUT TREATMENTTREATMENT IS VERY IS VERY DIFFICULTDIFFICULT

Thus, Thus, PREVENTIONPREVENTION OF PEDIATRIC OF PEDIATRIC OBESITY IS THE MOST EFFECTIVE OBESITY IS THE MOST EFFECTIVE WAY TO COMBAT CHILDHOOD WAY TO COMBAT CHILDHOOD OBESITY.OBESITY.

IT IS VITAL that pediatricians help IT IS VITAL that pediatricians help develop, encourage healthy eating develop, encourage healthy eating and activity habits.and activity habits.

BARRIERS TO THERAPY BARRIERS TO THERAPY OF PEDIATRIC OBESITYOF 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 17% of pediatricians felt physicians did not need to counsel parents of obese childrenneed to counsel parents of obese children

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

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

(Slide Courttesy of Cochran, W., Pediatric Obesity: A Huge Problem in the USA)(Slide Courttesy of Cochran, W., Pediatric Obesity: A Huge Problem in the USA)

BARRIERS TO THERAPY BARRIERS TO THERAPY OF PEDIATRIC OBESITY 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

Slide Courtesy of Cochran, W., Pediatric Obesity: A Huge Problem in the USA)Slide Courtesy of Cochran, W., Pediatric Obesity: A Huge Problem in the USA)

PREVENTION: SCHOOLPREVENTION: SCHOOL

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

incorporated into regular school incorporated into regular school curriculum.curriculum.

Encourage children to walk or bike to Encourage children to walk or bike to school safely.school safely.


PREVENTION: PREVENTION: COMMUNITYCOMMUNITY

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: PREVENTION: INSURANCE AND INSURANCE AND

GOVERNMENTGOVERNMENT Acknowledge obesity as a medical Acknowledge obesity as a medical condition for which one can be condition for which one can be reimbursed.reimbursed.

Provide reimbursement for anticipatory Provide reimbursement for anticipatory guidance for nutrition and physical guidance for nutrition and physical activityactivity


LET’S MOVE CampaignLET’S MOVE Campaign

The White House Obesity Initiative and Your Family

What is the White House Obesity Initiative? The First Lady’s national campaign against childhood

obesity called “Let’s Move” is a comprehensive and coordinated initiative with many partners. The focus is to prevent childhood obesity.

The campaign has four pillars: healthy schools, access to affordable and healthy food, raising children’s physical activity levels, and empowering families to make healthy choices. The American Academy of Pediatrics (AAP) is proud to join the

White House in this initiative

White House Obesity Initiative FAQ for Families

Why do parents need to know their child’s BMI? Parents need to know their child’s BMI

because prevention is the best medicine. By plotting BMI and monitoring physical

activity and nutrition throughout childhood, parents and pediatricians can keep an eye out for children at-risk of becoming overweight and take action early to prevent future obesity.

By catching at-risk children early, families in partnership with their pediatrician can explore ways to make changes to live healthier active lives.

From the House Obesity Initiative FAQ for Families

How do I talk with my children about making healthy active changes? Talk with your children about the

importance of the whole family being healthy. Get together with your family and decide ways your family can make healthier choices.

Talk with the whole family and decide what changes to make together. Remember to make it fun to try new things together.

What can families do to lead healthier lives?

Healthy active living can be fun and family-oriented. Make healthy choices together – grow a garden, play outdoor games, cook as a family. Have fun! As parents, it’s important to set a good example.

There are a lot of things families can do to be healthier and it can be overwhelming trying to decide where to start. From the House Obesity Initiative FAQ for Families

5-2-1-0- RX5-2-1-0- RX But it is important to remember that

small changes can make a big difference. The AAP recommends starting with one

of these behaviors:5 – Eat 5 fruits and vegetables a day.2 – Limit screen time (TV, computer, video games) to 2 hours each day.

Children younger than 2 should have no screen time at all.

1 – Strive for 1 hour of physical activity a day.0 – Limit sugar-sweetened drinks.


5-2-1-0 Rx. For Healthy 5-2-1-0 Rx. For Healthy Active LivingActive Living

5-2-1-0 Rx. Cont’d5-2-1-0 Rx. Cont’d To start, families can pick one of these

behaviors and set specific goals to improve their health.

In addition to 5, 2, 1, 0, goals, families can make small changes in their family routines to help everyone lead healthier active lives. Science suggests these activities can help prevent obesity: · Eating breakfast every day; · Eating low-fat dairy products like yogurt, milk, and

cheese; · Regularly eating meals together as a family; · Limiting fast food, take-out food, and eating out at

restaurants; · Preparing foods at home as a family; · Eating a diet rich in calcium; and · Eating a high fiber diet.


How do we start to make changes to our family’s

routine? You can start in small steps. Small changes can make a big difference in your child’s health.

First Lady Michelle Obama gives a few concrete examples of doing just that – putting water in your child’s lunch box, providing a fruit serving at breakfast, and curbing fast food consumption.

TheAAP’s healthy active living prescription available at www.aap.org/obesity/whitehouse is designed to help you and your pediatrician identify some areas where you might want to begin. Small changes you make every day can make a big difference in your family’s health in the long run!


How can our communities support healthy active

children? The environments our children live in have a

profound impact on the foods they eat and the amount of activity they get.

Some communities lack full-service grocery stores, but have an abundance of fast food restaurants. In turn, families may fall back on these fast food options because healthy, fresh foods are not available nearby.

Working with community leaders to encourage the creation of healthy, fresh food options can make a difference in the choices available for families.


How can our communities support healthy active

children? (cont’d) Communities can also ensure that

children have a safe place to play. Community centers, green space, parks

– these all provide an opportunity for kids to be active.

Encourage your community to have fun and safe places for children to play – inside and outside – so they have options for fun and safe activities.


How can pediatricians and parents partner on healthy

active living? Your pediatrician can partner with you on a

prescription for healthy active living that is right for your family.

He or she knows your family and understands the nutritional and physical activity needs for your child.

Your pediatrician is also familiar with your community and may be able to help you find needed resources to support your healthy active lifestyle goals.

Together, you and your pediatrician can help your family get started on the path to leading healthier lives.


EAT WELL PLAY HARDEAT WELL PLAY HARDor else……or else……

Relevant WEBSITESRelevant WEBSITES www.www.aapaap.org/obesity/whitehouse/index.html.org/obesity/whitehouse/index.html

Let’s move campaign by First Lady Michele Let’s move campaign by First Lady Michele Obama endorsed by the AAPObama endorsed by the AAP

www.nichq.org/NICHQ/Programs/ConferencesAndTraining/ ChildhoodObesity/ActionNetwork/htm Pediatrician can join the Childhood Obesity Pediatrician can join the Childhood Obesity

Action NetworkAction Network http://www.verbnow.com

CDC site for 9-13 year olds to promote physical CDC site for 9-13 year olds to promote physical activityactivity

www.aap.org/obesity/index.html/index.html American Academy of Pediatrics web site American Academy of Pediatrics web site

regarding obesityregarding obesity http://www.bam.gov

Site to answer kids questionsSite to answer kids questions

Relevant WEBSITESRelevant WEBSITES 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/ 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.trowbridge-associates.com

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

Pediatric food pyramidPediatric food pyramid(From Cochran, W., Pediatric Obesity: A Huge Problem in the USA)(From Cochran, W., Pediatric Obesity: A Huge Problem in the USA)

pediatric obesity elizabeth h. kwon md, mph. obesity defined according to the ama’s expert...

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