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Management of child and adolescent obesity . Barwon Division 9 th November 2008. Speaker: Dr Colin Bell, Program Director, Good for Kids. Good for Life. Acknowledgement. Louise A Baur Discipline of Paediatrics & Child Health, Univ. Sydney; NSW Centre for Overweight & Obesity

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management of child and adolescent obesity

Management of child and adolescent obesity

Barwon Division

9th November 2008

Speaker: Dr Colin Bell, Program Director, Good for Kids. Good for Life

acknowledgement

Acknowledgement

Louise A Baur

Discipline of Paediatrics & Child Health, Univ. Sydney;

NSW Centre for Overweight & Obesity

The Children’s Hospital at Westmead

Email: louiseb3@chw.edu.au

obesity
Obesity
  • One of today’s most blatantly visible – yet most neglected – public health problems
  • The public health equivalent of climate change
  • The Millennium Disease

WHO; www.who.int/nut/obs.htm; Laing & Rayner, Obesity Reviews 2007; www.iotf.org

slide4
ObesityOne of the most common chronic diseases in childhood and adolescence1:4 school-aged children are overweight or obese
slide6
YesBut in even higher numbers than for the general populationAnd NOT for the problem of overweight or obesity
slide7

In Australia, of every 200 children presenting to their GP, 60 are overweight or obese (23 obese) – and 1 is offered weight management intervention

BEACH data set, Annual national random survey of 1000 GP surgeries

2002-2006, Children aged 2- 17 years, Self-reported heights & weights

Cretikos M et al, Medical Care, 2008, in press.

what gps say are the barriers to management of paediatric obesity in general practice
What GPs say are the barriers to management of paediatric obesity in general practice
  • Lack of time
  • Lack of reimbursement
  • Lack of parent / patient motivation
  • Lack of effective interventions
  • Lack of support services
  • Complex, difficult problem
  • Inadequate training
  • Parent / child sensitivity

Results of focus groups held with NSW GPs.

King L et al. British Journal of General Practice. 2007; 57:124-129.

case 1 katie 6 years of age
Case 1: Katie – 6 years of age
  • Chinese ethnic origin; only child of busy parents (father has two jobs; mother works as a cleaner)
  • Mother brings her to you with an intercurrent illness (URTI) which is simply managed
  • But you note incidentally that Katie looks quite plump for her age
slide11
How do you confirm your impression

that Katie is overweight?

slide12
How do you confirm your impression

that Katie is overweight?

Measure height & weight

Calculate BMI

Plot on BMI for age chart

slide13

Clinical example of Katie

Girl aged 6 years

Weight 33 kg

Height 120 cm

BMI 22.9 kg/m2

Overweight or obese?

Normal weight?

Unsure?

slide14

Katie

Girl aged 6 years

Weight 33 kg

Height 120 cm

BMI 22.9 kg/m2

(>>97th centile for age;

obese range)

slide15
You’ve confirmed your clinical impression

that Katie’s BMI is in the obese range

Would you raise this issue

with Katie’s mother?

If so: why?

If not: why not?

factors to consider
Factors to consider
  • Health risks for Katie
    • Severity of obesity
    • Associated co-morbidities
    • Family history of obesity, diabetes and related disorders
  • Approach to raising the issue
    • Avoid stigmatising
    • Avoid blaming
    • Solution-focussed
    • Supportive
slide17
What would you ask about

in the family history?

Are there high-risk ethnic groups?

high risk family history ethnicity
High risk family history & ethnicity
  • Enquire re F/H of obesity and type 2 diabetes:
    • Obesity, type 2 diabetes, premature heart disease, obstructive sleep apnoea, hypertension, dyslipidaemia
  • Enquire re parental eating disorders & bariatric surgery
  • Ethnic groups at higher risk of diabetes etc
    • Indian sub-continent, Mediterranean/Middle-Eastern, Maori & Pacific Islander, Aboriginal & Torres Strait Islander, probably east Asian
katie s family history
Katie’s family history
  • Family history:
    • Obesity – maternal grandmother
    • Type 2 diabetes – maternal grandmother
  • Chinese ethnic origin
katie s medical assessment
Katie’s medical assessment
  • Mild teasing by classmate at school
  • No other co-morbidities suggested by history or physical examination
slide21
How would you raise this issue

with Katie’s mother?

little direct evidence to guide approach but the following may be useful
Little direct evidence to guide approach but the following may be useful
  • Regular assessment of growth and plotting of BMI allows the issue of growth and weight to be raised
  • Be non-judgmental and sensitive
  • Example of an introduction:
    • “I notice that Katie’s weight (or weight adjusted for height) is high for her age. Is that something you’ve been concerned about? ….. Would you like to discuss it at some stage?”
slide23
Katie’s mother is interested in talking further about this issue, as she knows that Katie has been teased about her weight.

Obesity is not the original reason

for today’s consultation ….

and your waiting room is crowded!

What would your next steps be?

next steps
Acknowledge the importance of dealing with the issue

Make another appointment – with Katie’s mother (+/- other carers) - to start discussions re weight management intervention

Do not include Katie in the weight management intervention – she’s only 6 years of age!

Next steps
slide25
Weight status of children in the Parents-only vs. Parents + Child treatments(Golan. Int J Pediatr Obes 2006)

Parents + child

Parents-only

65

Baseline

a

b

55

45

6 months

45.5

45.0

43

41.6

35

Overweight Percentage

12 months

32

31.8

25

*

15

BMI +0.32

**

BMI -1.09

5

BMI -1.28

Change within each group * p=0.003 ** p=0.001

Change between groups a p=0.02 b p<0.05

be developmentally sensitive
Be developmentally sensitive
  • For younger, pre-adolescent children: Focus on parents as the agents of change. Consider excluding the child from the consultations
  • For adolescents:

Include some adolescent-only sessions

slide27
Katie’s mother returns a week later when Katie is at school, in order to discuss strategies for weight management.

What approach would you use?

What strategies might you discuss?

the basics
The basics
  • Family focus
  • Developmentally appropriate approach
  • Long-term behaviour change
  • Both sides of the energy balance equation need to be addressed
  • Set small, achievable goals
  • Regular follow-up and support
the big five chw program
The Big Five (CHW Program)
  • Choose water as your main drink
  • Eat breakfast each day
  • Eat together once a day as a family without the TV being on
  • Spend at least 60 minutes outside every day (playing or being physically active)
  • Limit screen time to less than 2 hours per day (TV, electronic games, DVDs, computer, Ipod, MP3 or videos etc)
slide30
The first law of thermodynamics

Energy is conservedEnergy in = energy out

practical tips regarding food 1
Practical tips regarding food - 1
  • The person who buys the food and who cooks it needs to be engaged in the treatment approach
  • Regular meals – especially breakfast
  • Water as the main beverage
    • limit soft drinks, fruit juice, cordial
  • Eat together as a family
    • Make a ritual of meal-times
    • No TV or other distractions
practical tips regarding food 2
Practical tips regarding food - 2
  • Store healthy snacks – for morning & afternoon teas
  • One approach for the whole family
  • What foods are in the cupboards? These will invariably be eaten!
  • Check serve sizes – are these appropriate for a child?
tv viewing and a screen friendly lifestyle
TV viewing and a screen-friendlylifestyle
  • Look at TV, video game and computer usage - for the whole family
  • How many TVs are there in the house? Is there one in Katie’s bedroom? Who turns the TV on or off?
  • Explore alternatives
  • Parental overview vital
practical tips regarding activity 1
Practical tips regarding activity - 1
  • Family approach to television, video-games, computer use
    • Plan TV viewing with the TV Guide
    • Limit to <2 hours per day
    • No TV on during meals
  • Transport to/from school
    • Walking instead?
    • Dropping off at a distance from the school gate?
  • Use of the family car. Is it needed for short trips?
practical tips regarding activity 2
Practical tips regarding activity - 2
  • For most, organised activity is less important than increased opportunities for incidental activity
  • “Mucking around” outside is vital:
    • balls, skipping ropes, swings, trampolines …
    • backyards?, parks?, other playgrounds?
  • Whole-family opportunities for physical activity?
  • Role-modelling of parents
different exercise programs epstein 1996

15

10

Calisthenics

Gym-aerobics

5

Lifestyle

0

-5

% Change in Overweight

-10

-15

-20

-25

0

5

10

Time (y)

Different “exercise” programs (Epstein, 1996)
targeting sedentary behaviour epstein 1996

0

-5

Exercise

% change in overweight

-10

Combined

Sedentary

-15

-20

0

4

12

0

14

Time (months)

Targeting sedentary behaviour (Epstein, 1996)
what happened with katie
What happened with Katie?
  • Mother identified the following as issues she’d like to change:
    • Soft drink intake (evening meal and afternoon tea in particular)
    • TV viewing (accompanies mother while she does her cleaning jobs – mother turns on TV to act as child-minder for Katie; TV on while eating at home)
    • School lunch “treats”
what happened with katie39
What happened with Katie?
  • Strategies
    • Only water offered at meal-times
    • TV viewing – colouring in equipment, books and games brought so that Katie is occupied while mother works; some extra support for child-minding from neighbour; TV turned off when the family eats
    • Katie booked in to After School Care three days a week
    • School lunch box – no more packets of crisps!
slide40

Katie’s anthropometry

6 months later

Weight unchanged

Height 123 cm (  3 cm)

What has happened to BMI?

slide41

Katie’s anthropometry

6 months later

Weight unchanged

Height 123 cm (  3 cm)

BMI 21.8 kg/m2

slide42
In what circumstances would you

organise further investigations?

If so – what ones?

further investigations when
Further investigations – when?
  • Age: adolescents > younger children
  • Severe obesity (esp. central obesity)
  • High risk family history:
    • 1st and 2nd degree relatives with heart disease, type 2 diabetes (incl. GDM), dyslipidaemia, sleep apnoea etc
  • High risk ethnic group:
    • Indian sub-continent, Mediterranean & Middle-Eastern, Maori & Pacific Islander, Aboriginal & Torres Strait Islander, probably east Asian
  • Clinical suggestion of co-morbidities
further investigations what ones
Further investigations – what ones?
  • Initial fasting blood tests (others dependent upon results*):
      • Glucose
      • LFTs (ALT, AST)
      • Lipids (TG, HDL cholesterol, LDL cholesterol)
      • Insulin
      • ?TSH???
  • Consider referral for sleep assessment
  • Other investigations that MAY be warranted: OGTT, liver ultrasound
when to refer on
When to refer on?
  • Will depend upon your expertise and the resources available
  • Paediatrician referral:
    • Severe obesity
    • Presence of co-morbidities
    • Strong family history of co-morbidities
  • Mental health unit referral:
    • Significant psychosocial distress
when to refer on47
When to refer on?
  • To other health professionals eg
    • Dietitian
    • Nurse (Early Childhood nurse, community nurse)
    • Clinical psychologist
    • Physiotherapist
    • Exercise scientist etc
  • Ideally for all patients, but hampered by cost & availability
slide48
How often should the

patient/parent be seen in follow-up?

frequency of follow up
Frequency of follow-up?
  • Frequent follow-up is important in the first few weeks and months in order to aid behaviour change
  • CHW practice:
    • 3 fortnightly consultations,
    • Then progressively less frequent thereafter
  • Consider shared care with other health professionals
good for kids
Good for Kids
  • To mainstream healthy eating and physical activity for children (up to 15 yrs) and their families in the Hunter New England region
    • ↓ sweetened drink consumption ↑ non-sweetened drinks
    • ↓ energy dense foods ↑ fruit and vegetables
    • ↑ physical activity (sport, play, leisure)
    • ↓ time spent in small screen recreation (TV, video games)
three key messages reinforced in all settings
Three key messages – reinforced in all settings
  • Step 1: Get active, get out and play
    • Kids need at least one hour a day of physical activity
    • Kids should not spend more than 2 hours a day watching TV/computer games
  • Step 2: Drink H20- think water first
    • Kids should drink water instead of juice or soft drinks
  • Step 3: Eat more fruit and vegies
    • Kids should also limit less healthy snack foods
a role for general practice
A role for General Practice
  • Find opportunities to reinforce program messages – build on brand and message recognition
  • Participate in Medicare Healthy Kids Check
  • 97% parents agreed ‘I would feel comfortable with a GP measuring my child’s height and weight, and discussing their weight status with me (letting me know whether he/she is underweight, healthy weight, or above healthy weight)’
building on the healthy kids check
Building on the Healthy Kids Check
  • Assess
    • 4 year old weight status
    • Other ages opportunistically
  • Advise
    • Drink H20, think water first
    • Get active, get out and play
    • Eat more fruit and veges
  • Manage/refer
    • those who are above a healthy weight eg HIKUPs
healthy kids check
Healthy Kids Check
  • Height and weight are mandatory.
    • Opportunity to assess BMI and introduce it as a tool to monitor growth over time
  • Brief prevention messages at a time when life long behaviours are being defined
    • Use resources to reinforce program messages, relevant for all kids/families
  • Messages for whole family not just the 4 year old
  • Option to manage/refer children ‘above healthy weight’
  • Financial incentive for General Practice
resources to help with advice
Resources to help with advice
  • Get Set for Life (Commonwealth parent resource)
  • Good for Kids posters, general program brochures
  • G4K Healthy Families checklist
    • Can use at 4 year old check and opportunistically with other ages
    • 15 child and family behaviours – encourage small changes for whole family
healthy kids check overview
Healthy Kids Check overview
  • Weigh & measure child along with other components of check
  • Calculate BMI and plot on BMI chart
  • Show parent chart –’raise the issue’
  • Offer ‘brief advice’ – use handouts (including Healthy Families checklist if not done prior)
  • Provide parent with materials to reinforce
  • If child ‘above healthy weight’ encourage parent to make another appointment to manage weight status or consider referral
further resources
BMI for age charts: www.cdc.gov/growthcharts/

NHMRC Clinical Practice Guidelines for the Management of O&O: http://www.obesityguidelines.gov.au

CHW Fact Sheets: http://www.chw.edu.au/parents/factsheets/

Further Resources