The Elephant in the Room: Consequences of Unhealthy Lifestyle Choices on Pediatric Health

1. Unhealthy life-style choices: The Elephant in the Room! Lynn Clark, MS, RN-BC, CPNP-PC Lynn.clark@childrens.com Britney Cox, MS, RN-BC, CPNP-PC Britney.cox@childens.com Pain Management Nurse Practitioners Children’s Medical Center Dallas Although the world is full of suffering, It is also full of the overcoming of it. -Helen Keller

2. Conflict of Interest Disclosure • Conflicts of Interest for ALL listed contributors. • Clark, L: None • Cox, B: None A conflict of interest is a particular financial or non-financial circumstance that might compromise, or appear to compromise, professional judgment. Anything that fits this should be included. Examples are owning stock in a company whose product is being evaluated, being a consultant or employee of a company whose product is being evaluated, etc. • Taken in part from “On Being a Scientist: Responsible Conduct in Research”. National Academies Press. 1995.

3. Objectives Participants will be able to: • Describe consequences of obesity and sedentary life-style on the health of pediatric patients • Learn 3 challenges for pediatric patients that impact the ability to make healthy life-styles choices • List 3 pain conditions (co-morbidities) that are frequently related to obesity and sedentary life-style • Describe an intervention that is helpful to address the elephant in the room in relation to managing pain

4. Background on Obesity • Center for Disease Control Comparing children of the same age and sex • Overweight: BMI >85th - 95th percentile • Obese: a BMI at or above the 95th percentile • 17% (12.5 M)of US Children are obese • 33% (72 M) of US Adults are obese

5. Do you know your BMI? BMI= pounds/(inches2) * 703 160/(662) *703 160/4356*703= 25.82185

6. Epidemiology

7. Trends

8. Rates

9. Culture Crisis • Obese children are more likely to become obese adults. • Adult obesity is associated with a number of serious health conditions including heart disease, diabetes, and some cancers. • If children are overweight, obesity in adulthood is likely to be more severe.

10. Nutrition Culture/ Practices • School influence • Sugary drinks & less healthy food • Advertising • Day cares not regulated like public schools • Lack of daily, quality physical activity in school • < 4 % of elementary schools have PE • Increasing portion sizes • Lack of breastfeeding support • TV and media • 2-4 hours daily

11. Culture/ Practices Perceptions: • 67% of obese children were perceived as overweight by their mothers • 14% of overweight boys and 29% of overweight girls perceived themselves as overweight • Ethnic minority women have a great acceptance of body image than white women. Education: • Mothers with HS or less education were less likely to identify children as overweight

12. Times have changed Poor Role Modeling: • 9 out of 10 kids are driven to school (compared to 50% a generation ago) • Home cooked meals are rare and fast-food and eating out are the norm. • Foods are more dense in calories Lack of Limit setting: • Fewer hours of sleep = higher likelihood for obesity • Screen Time • Limited adult exercise

13. Familial Influence Study by Whitaker et al. (4432 families with 7078 kids) Incidence of childhood obesity: • 2 normal weight parents = 2.3 % • 2 overweight (but not obese) = 4.9% • 2 obese parents = 21.7% • 2 severely obese parents= 35.3% Association of child BMI has a stronger link to maternal BMI

14. Socioeconomical

15. Sedentary Lifestyle

16. Dietary Risk Factors • Skip breakfast or lower energy meal • Eat lunch at school • Ate supper while watching TV > 5 days/wk • Separated/ divorce parents • Eating alone • High energy meal at dinner • Clean plate club • Snacking and watching TV (sedentary)

17. Physical consequences include: Cardiovascular disease (70 % had 1 symptom & 39% had 2 or>) • Hypertension • high cholesterol/ triglycerides Endocrine • Hyperinsulinism • type 2 diabetes Neurologic • pseudo tumor cerebrii • Migraine/ Headaches • MS Respiratory • Asthma • OSA GU • Polycystic ovarian syndrome Gastrointestinal • Fatty liver disease • Gallstones • Gastro-esophageal reflux • Encopresis • Constipation • IBS • FAP • Low Vitamin D Musculoskeletal • Tibia vara (Blount’s) • Slipped capital femoral epiphysis (SCFE) • Musculoskeletal problems • Back pain • Chronic pain

18. Psychological Consequences • Children < 15 yo–Victim of Bullying • Overweight = 26% more likely • Obese = 85% more likely • Aggression, withdrawn friendships, rumors, lies, name calling, teasing, hitting and kicking • Children > 15 yo who are obese are more likely to be a perpetrator of bullying • School based friendship clusters

19. Psychological Consequence • Psychological crisis • Depression • Lower Self-esteem • Appearance • Widespread bias • Anxiety • Stress • Socially withdrawn

20. Psychological Consequence • Poor quality of life

21. Why… Obesity and pain? • Stress on joints • Inflamatory process

22. Chronic Pain • Affects 25-37% of children and adolescents • Combination of pain and obesity • decreased QOL and functioning • BMI should be a routine screen for patients with chronic pain

23. Pain Amplification • Adults: • 30% were overweight • 47% were obese • Pain Amplification symptoms are increased with sedentary life-style • Treatment includes exercise • Kinesophobia • Obesity contributes to the continued presence and increase in severity of symptoms

24. Headache • Increased BMI = increase frequency & disability related to HA • Patients who lost wt had decrease in headache frequency • Overweight females are 4x more likely to develop headaches than normal-weight girls

25. Chronic Back Pain • BMI > 30 = increase risk of LBP • Mechanical stress • CVD which decrease blood flow to the lumbar spine • Wt loss may or may not address pain • Children > 95% BMI are more likely to have LBP and pain in at least 1 joint.

26. Lower extremity pain (knees, ankles, hips) • Mechanical issues • Overweight patients are at 2.2x higher risk for development of osteoarthritis • 69% of knee replacement surgeries in adult women are related to obesity

27. Why is there an elephant in the room? • Emotional • Political • Controversial • Perception is skewed / cultural barriers • Lack of community education and support • Fear by provider of an emotional reaction • Fear of promoting disordered eating behaviors

28. Addressing the elephant… • Addressing the vital statistics • Discuss BMI with the patient and family • State why we assess the whole patient and their behaviors • Nutritional, dietary behavioral and activity assessment • Diagnose the patient appropriately • Build trust to achieve outcomes

30. Promote positive change in your practice • Communication and building trust • Collaborative process SMART goals • Set 1-2 nutrition goals • Set 1 physical activity goals

31. Education • Hot Cheetos • Creative BASIC Handouts • Engaging the family • Address negative behaviors • Giving permission • Limit setting

32. CDC-Division of Nutrition, Physical Activity, and Obesity • http://www.cdc.gov/nccdphp/dnpao/index.html

33. Follow up • Follow up phone call at one month • Follow up appt at 2 months • Reassess and reevaluate goals • Global impression of change • Affect on pain • New goals • Discuss as a life style change

34. Outcomes • Compliance with set goals • Functionality • Perception of improvement • Global impression of change

35. Acheivements Participants will be able to: • Describe consequences of obesity and sedentary life-style on the health of pediatric patients • Learn 3 challenges for pediatric patients that impact the ability to make healthy life-styles choices • List 3 pain conditions (co-morbidities) that are frequently related to obesity and sedentary life-style • Describe an intervention that is helpful to address the elephant in the room in relation to managing pain

36. Take home points • Recognize the epidemic • Address the elephant in the room • Listen • Ask • Act • Be SMART • Praise and reassess • Multimodal treatment is the Key!