Transcript Weight Management for Pediatric Patients Seen

Weight Management for Pediatric
Patients: Expert Committee
Recommendations
Sandra G Hassink, MD, FAAP
Director Weight Management Clinic
A I DuPont Hospital for Children
Wilmington, DE
Case - An 8 year old boy
An 8 year old boy comes to your
office after an absence of 2 years.
Mother reports that he has gained 30
lbs since you last saw him
Now what?
Expert Committee Recommendations
June 2007 (Published Pediatrics Supplement
December 2007)
Assessment
Prevention
Prevention Plus
Structured Weight Management
Comprehensive Multidisciplinary
Protocol
Tertiary Care Protocol
Assessment of Obesity
Calculate, chart and classify BMI for
all children 2-18 yrs at least yearly
Assess dietary patterns
Assess Activity/Inactivity
Assess Readiness for Change
Assess obesity related comorbidities
Assess ongoing progress
BMI- Calculate, Chart, Classify
BMI based on age and gender and is
a population based reference
Underweight BMI<5%
“Normal weight” BMI 5%-84%
Overweight BMI > 85%-94% (IOM
classification)
Obese BMI 95%-99% (IOM
classification)
Morbid (severe) obesity BMI>99%
» Freedman et al J Pediatr 2007 ;150;1217
Case an 8 year old boy
Weight 71 kg (156.2 lbs)
Height 150 cm (4’11”)
BMI 31.5
BMI
BMI 31.5 for an 8 year old boy is >99%
Children with BMI > 99% greater rate of
cardiovascular risk factors
Children (age 12) with BMI>99% followed
into adulthood (age 27)
100% BMI>30
90% with BMI>35
65% with BMI>40
Freedman et al. Cardiovascular Risk Factors and Excess
Adiposity Among Overweight Children and Adolescents: The Bogalusa
Heart Study. Journal of Pediatrics. 2007; 15: 12-7
Continuous Assessment
Calculate, chart and classify BMI for
all children 2-18 yrs at least yearly
Prevention BMI 5%-84% - Diet
Promote breastfeeding
Diet and physical activity:
5 Five or more servings of fruits
and vegetables per day
2 Two or fewer hours of screen
time per day, and no television in
the room where the child sleeps
1 One hour or more of daily
physical activity
0 No sugar-sweetened beverages
Prevention BMI 5%-84% - Diet
Portions
Age appropriate
“Parent’s provide child decides”
Structure
Breakfast
Family dinners, no TV
Limit fast food
Balance
Food groups
Limit refined sugar
Prevention Dietary Patterns
minimum once /year at well visits
Self-efficacy and readiness to
change
Small incremental steps for change
Family support
Positive
Self monitoring
Setbacks are normal, trouble shoot,
support return to plan
Identify high risk nutritional
behaviors
Prevention
All children 2-19 yrs BMI >5%<84%
Eating Behaviors
Eating breakfast daily.
Limiting eating out at restaurants,
particularly fast food restaurants.
Encouraging family meals in
which parents and children eat
together.
Limiting portion size.
Prevention Plus
BMI >85%
Build on Prevention
Eating behaviors:
Family meals should happen at
least 5-6 times per week
Allowing the child to selfregulate his or her meals and
avoiding overly restrictive
behaviors “Parents provide
child decides”
Prevention Plus
BMI >85%
Within this category, the goal
should be weight maintenance
with growth that results in a
decreasing BMI as age
increases.
Monthly follow-up for 3-6
months, if no improvement go to
Stage 2.
Assess Dietary Patterns
Additional practices to be considered
for evaluation during the qualitative
dietary assessment include:
Excessive consumption of foods that
are high in energy density
Meal frequency and snacking patterns
(including quality)
Case - 8 year old boy
Assess dietary patterns
Breakfast at home (cereal with 2% milk)
Breakfast at school Surprise to Mom
(french toast, chocolate milk)
School lunch (extra money for ice cream,
sometimes trades food)
Snack at home (Juice and potato chips)
Dinner (2/7 nights order out), 2nds at home
Beverages at home, soda, gator aid, juice
5 glasses/day
Assess Physical Activity/Inactivity
Self-efficacy and readiness to change
Physical (Built) Environment
Social/community support for activity
Barriers to physical activity
Assess patient and family’s activity and
exercise habits
Assess outdoor activity
Physical Activity/Inactivity
Advise 60 minutes of at least moderate
physical activity per day and 20 minutes
vigorous activity 3x/week
Refer to community activity programs
Encourage development of family activities
Consider pedometer use
Decrease level of sedentary behavior
Limit screen time <2 hrs/day
No TV/computer in bedroom
Case 8 year old boy Activity/Inactivity
Physical education 1x/week
Recess daily but “stands around”
No after school outdoor time
Screen time 4 hours/day
TV in bedroom
Structured Weight Management
Stage 2
Dietary and physical activity
behaviors;
Development of a plan for utilization
of a balanced macronutrient diet
emphasizing low amounts of
energy-dense foods
Increased structured daily meals
and snacks
Supervised active play of at least
60 per day
Screen time of 1 hour or less per
day
Structured Weight Management
Stage 2
Increased monitoring (e.g., screen time,
physical activity, dietary intake, restaurant
logs) by provider, patient and/or family
This approach may be amenable to group
visits with patient/parent component,
nutrition and structured activity
Structured Weight Management
Stage 2
Weight maintenance that
Decreasing BMI as age and height
increases;
Weight loss should not exceed
1 lb/month in children aged 2-11 years,
Or an average of 2 lb/wk in older
overweight/obese children and
adolescents.
If no improvement in BMI/weight after 3-6
months, patient should be advanced to
Stage 3
Comprehensive Multidisciplinary
Protocol Stage 3
Multidisciplinary obesity care team
Physician, nurse, dietician, exercise trainer,
social worker, psychologist.
Eating and activity goals are the same as in
Stage 2
Activities within this category should also
include:
Structured behavioral modification
program, including food and activity
monitoring and development of shortterm diet and physical activity goals
Comprehensive Multidisciplinary
Protocol Stage 3
Behavior modification
Involvement of primary
caregivers/families in children under age
12 years
Training of primary caregivers/families for
all children
Goal
Weight maintenance or gradual weight
loss until BMI less than 85th percentile
and should not exceed 1 lb/month in
children aged 2-5 years, or 2 lbs/wk in
older obese children and adolescents.
Tertiary Care Protocol
Stage 4
Referral to pediatric tertiary weight
management center with access to a
multidisciplinary team with expertise in
childhood obesity and which operates
under a designed protocol.
Continued diet and activity counseling and
the consideration of such additions as meal
replacement, very-low-calorie diet, medication,
and surgery.
Family History
Focused family history
Obesity, type 2 diabetes, cardiovascular disease
(particularly hypertension), and early deaths
from heart disease or stroke
Family history may be the touch point for
emphasizing family involvement
Our 8 year old has a father with
hypertension, obesity and sleep apnea and
a maternal grandmother with diabetes.
Review of Systems
Severe Obesity Related
Emergencies
Hyperglycemic
Hyperosmolar
state
DKA
Pulmonary emboli
Cardiomyopathy
of obesity
Co-morbidity's Requiring
Immediate Attention
Pseudotumor
Cerebri
Slipped Capital
Femoral Epiphysis
Blount’s Disease
Sleep Apnea
Asthma
Non alcoholic
hepatosteatosis
Cholelithiasis
Chronic-Obesity Related Co Morbid
Conditions
Insulin Resistance
(Metabolic Syndrome)
Type II Diabetes
Polycystic Ovary
Syndrome
Hypertension
Hyperlipidemia
Psychological
Case of an 8 year old boy:
Review of systems
Medical
Snoring with pauses, daytime tiredness
? Sleep apnea
Gold standard: Nighttime polysomnography
Psychosocial
Poor school performance over past year
? Sleep apnea
ADD
? Teasing, low self esteem
Physical Examination
Copyright AAP 2008
Case of an 8 year old boy
Physical examination
Blood pressure 118/78 (>905<95%)
Pre hypertension
Skin – Mild acanthosis nigricans
Family history of diabetes
Insulin resistance
Pharynx – Enlarged tonsils
Overlap upper airway obstruction from
enlarged tonsils
Laboratory Evaluation
BMI >85% <94%
Fasting lipid profile, AST, ALT q 2 years
BMI >95%
Fasting lipid profile, AST, ALT q 2 years,
fasting glucose
Laboratory evaluation as always
depends on clinical assessment
Partnership with Families
Families have a critical role in
influencing a child’s health
» Cohen RY et al Health Educ Q 1989;16;245253
Effective interaction with families is
the cornerstone of lifestyle change
Communication
Positive discussion of what healthy lifestyle
changes families can make (evidence
base)
Allow for personal family choices
Have families set specific achievable goals
and follow up with these on revisits
Be aware of cultural norms, significance of
meals and eating for family/community,
beliefs about special foods, and feelings
about body size.
Modeling in the office
Waiting room
Books, posters, videos promoting
healthy lifestyle
Staff role models
Drinking water, healthy snacks, physical
activity
Consistent messages, involvement
with community
Lifestyle Change
Listen
Ask
Provide
Assess
Partner
Revisit
Reassess
Interactions around Lifestyle
Change
Four essential skills
Asking
Informing
Advising
Listening
Three styles of communication
Following – information gathering
Guiding- clarification of values, confidence,
importance
Directing – post decisional planning
» Rollnick S et al BMJ 2005;331;961-963
Stages of Change
Pre-contemplation: Resistant to Change
Contemplation: Aware That a Problem Exists
but Ambivalent Toward Change
Preparation: Intend to Take Action in Near
Future
Action: Involved in Change
Maintenance: Involved in Sustaining Change
and Working to Prevent Relapse
Relapse: A Return to the Problem Behavior
Adapted From Prochaska and DiClemente, 1986.
Stages of Change
Stages of change vary between
individuals
Stages of change vary with time and
circumstance in the same individual
Assessing readiness to change can
help direct the conversation toward
what is possible at that particular visit
Ingredients of Readiness to Change
Importance (Why should I change?)
(Interest)
Confidence (How will I do it?)
(self-efficacy)
Rollnick S, Mason P, Butler C. Health Behavior Change: A Guide for
Practitioners New York: Churchill Livingstone; 2001.
Precontemplation /Resistance
Identify roadblocks, triggers, fears,
barriers etc.
Don’t try to push patient into action.
Don’t give up or become apathetic or sarcastic.
Acknowledge that now may not be the best time.
Assure patient that you are there to help when the
time is right.
Ask permission to provide information.
Follow-up at next visit.
Case - 8 year old boy
Assess dietary patterns
Breakfast at home (cereal with 2% milk)
Breakfast at school Surprise to Mom
(french toast, chocolate milk)
School lunch (extra money for ice cream,
sometimes trades food)
Snack at home (Juice and potato chips)
Dinner (2/7 nights order out), 2nds at home
Beverages at home, soda, gator aid, juice
5 glasses/day
Case - 8 year old boy
Breakfast at home (cereal with
2% milk)
Breakfast at school Surprise to
Mom (french toast, chocolate
milk)
Mother not happy with his double
breakfast, decided right away to
stop school breakfast.
Case - 8 year old boy
Beverages at home, soda,
gator aid, juice
5 glasses/day
After discussion about
acanthosis, family history of
diabetes and obesity, mother
thought she could stop buying
soda and sugared beverages,
even though her son would
initially be “unhappy”
Case 8 year old boy Activity/Inactivity
Physical education 1x/week
Recess daily but “stands around”
No after school outdoor time
Screen time 4 hours/day
TV in bedroom
Case 8 year old boy Activity/Inactivity
Screen time 4 hours/day
All physical activity changes seemed
hard to mother and son
They decided to “look into” the local
Boys and Girls Club to see if he could go
there after school.
You ask them to keep track of his
screen time and see them in one
month.