Pediatric Obesity

1. Pediatric Obesity Kerry K. Sease, MD, MPH Medical Director, New Impact Program Director, Pediatric Residency Program Greenville Hospital System University Medical Center

2. Objectives • Define overweight and obesity • Recognize co-morbid complications of overweight and obesity • Employ motivational interviewing techniques for counseling

3. The Obesity Burden • Childhood obesity has more than tripled in the past 30 years. • Children aged 6–11 years • 7% in 1980 to nearly 20% in 2008. • Adolescents aged 12–19 years • 5% to 18% over the same period. • 2008 - > 1/3 children and adolescents overweight or obese. Ogden CL, Carroll MD, Curtin LR, Lamb MM, Flegal KM. Prevalence of high body mass index in US children and adolescents, 2007–2008. Journal of the American Medical Association 2010;303(3):242–249. National Center for Health Statistics. Health, United States, 2010: With Special Features on Death and Dying. Hyattsville, MD; U.S. Department of Health and Human Services; 2011.

5. What the studies show • ~60% of overweight children with at least 1 cardiovascular risk factor • 10% BMI-for-age at or below the 85th percentile • 25% of overweight children had 2 or more risk factors • Psychosocial consequences of overweight are significant • Overweight in children linked to: • social discrimination • negative self-image in adolescence • parental neglect • behavioral and learning problems Freedman DS, Dietz WH, Srinivasan SR, et al. The relation of overweight to cardiovascular risk factors among Children and adolescents: the Bogalus heart study. Pediatrics. 1999;103(6):1175-82. Freedman DS, Kahn LK, Dietz WH, et al. Relationship of childhood obesity to coronary heart disease risk factors in adulthood: the Bogalusa heart study. Pediatrics. 2001;108(3): 712-718.

6. What we know • Higher prevalence of intermediate metabolic consequences and risk factors for adverse health outcomes • insulin resistance • elevated blood lipids • increased blood pressure • impaired glucose tolerance

7. What we know Severe childhood overweight/obesity • pseudotumor cerebri • slipped capital femoral epiphysis • tibia vara • steatohepatitis • cholelithiasis • sleep apnea

8. ** **Increased risk of injury and prolonged recovery time

9. Long Term Risks • Overweight adolescents have a 70% chance of becoming overweight or obese adults • 30% of boys and 40% of girls born in 2000 are at risk to develop Type 2 DM • Early recognition BMI (kg/m2) should be routine practice – prevention is key • BMI < 5% = underweight • BMI 5-84% = healthy weight • BMI 85 - 94% = overweight • BMI > 95% = obese US Department of Health and Human Services. (2001). The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity. (Rockville, MD) Vehkat Narayan,K. (2003) JAMA.290:1884-1890.

11. A Staged Approach - Overview Stage 1 - Prevention Plus Family visits with physician or health professional Frequency individualized to family needs and risk factors Stage 2 - Structured Weight Management Family visits with physician or health professional with training in childhood weight management. May include visits with a dietitian, exercise therapist or counselor May include self-monitoring, goal setting and rewards Frequency monthly or individualized to family needs and risk factors

12. A Staged Approach - Overview Stage 1 and 2 Behavioral Recommendations Decrease screen time to 2 or fewer hours a day. Minimize sugar-sweetened beverages. Consume at least 5 servings of fruits and vegetables daily. Be physically active 1 hour or more daily. Prepare more meals at home as a family. Consume a healthy breakfast daily. Involve the whole family in lifestyle changes

13. A Staged Approach - Overview Stage 3 - Comprehensive, Multidisciplinary Intervention Multidisciplinary team with experience in childhood obesity Frequency often weekly group sessions for 8-12 weeks with follow up Stage 4 - Tertiary Care Intervention (for select children only when provided by experienced programs with established clinical or research protocols) Medications - sibutramine, orlistat Very-low-calorie diets Weight control surgery - gastric bypass or banding/sleeve gastrectomy (Childhood Obesity Action Network, NICHQ, 2007)

14. Modifiable risk factors (Childhood Obesity Action Network, NICHQ, 2007)

15. Behavior Modification • Behavior modification means changing what you do • Physicians may need to consider changing their behaviors as well • % Obese Patients Receiving... • Weight Reduction Counseling 15%-36%  • Exercise Counseling 18%-33%   • Nutrition Counseling 23%-42%  • Blood Pressure Measurement 57%-68% Source: Rimm & Masters, 1979 Source: Stafford RS. Farhat JH. Misra B. Schoenfeld DA. National patterns of physician activities related to obesity management. Archives of Family Medicine. 9(7):631-8, 2000

17. Provider Perceived Barriers to Effective Treatment (Health Care Systems Work Group of the South Carolina Coalition for Obesity Prevention Efforts (SCCOPE), 2007)

18. Weight Management Counseling • Sensitive with nonjudgmental tone toward both the child and the parents • family-based management strategy cannot be over-emphasized • assess the family's therapeutic readiness • Assess parental perceptions about their child's weight • delay intensive therapy if not receptive • focus on parental counseling and education in hopes of improving motivation

19. Motivational Interviewing Patient Centered Blank Canvas Develop Discrepancy • How does current behavior conflict with core values? Minimize Unsolicited Advice Roll with Resistance Support Self-Efficacy Usual Suspects • Express Empathy • Good Nonverbal Listening skills • Problem solving partners

20. Patient-Centered Communication Empathize/Elicit - Provide - Elicit • Empathize/Elicit • Reflect • What is your understanding? • What have you heard about? • What do you want to know? • Provide • Advice or information • Choices or options • Elicit • What do you make of that? • Where does that leave you?

21. Nutrition • The path to optimal nutrition...... • Nutrition basics • Stoplight diet • Healthy plate model WHOA SLOW GO

22. Physical Activity

23. Benefits of Exercise A child who is active will: • have stronger muscles and bones • have a leaner body because exercise helps control body fat • be less likely to become overweight • decrease the risk of developing type 2 diabetes • possibly lower blood pressure and blood cholesterol levels • have a better outlook on life

24. Consistent Messaging 5 -2-1-0 5 servings fruits and vegetables 2 hours or less screen time 1 hour or more physical activity 0 sugary drinks

25. Resources Choose My Plate www.choosemyplate.gov Let’s Go! http://www.letsgo.org/ We Can www.nhlbi.nih.gov/health/public/heart/obesity/wecan Let’s Move www.letsmove.gov

26. Advocacy • Educate Your Patients • Encourage Healthy Activities • Create a Healthy Office Environment • Promote a Healthy Community

27. Chronic Care Model Environment Medical System Family/Patient Self-Management Family School Worksite Community Information Systems Decision Support Delivery System Design Self Management Support “The normal physician treats the problem; the good physician treats the person; the best physician treats the community.” Chinese proverb (Childhood Obesity Action Network, NICHQ, 2007)

28. (The Economist – December 2003)