Transcript PPT - American Academy of Pediatrics

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Pediatric Obesity in
Primary Care
Sandra G. Hassink, MD, FAAP
Director, Nemours Obesity Initiative
Alfred I. duPont Hospital for Children
Wilmington, DE
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Objectives
 Increase awareness on childhood obesity among
pediatricians so they can work with their patients
and parents to identify at-risk patients and take
preventive or corrective action.
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Childhood Obesity
 Epidemic – Widespread in population (adults and
children)
 Progressive – Childhood obesity becomes adult
obesity
 Alters Development – Physically, emotionally,
psychosocially
 Chronic disease – Lifelong morbidity accelerates
“adult” disease into childhood
 Increases morbidity/mortality – First generation to
have shorter lifespan than parents
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Obesity and Normal Development
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Deconditioned
Derailed from normal activity
Depressed, teased and bullied
Disease burden
Decreased quality of life
Diminished educational and job opportunities
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Trends in Obesity Among Children
and Adolescents: United States, 1963–2008
Note: Obesity is defined as body mass index (BMI) greater than or equal to sex- and age-specific 95th percentile from the 2000 CDC
Growth Charts.
CDC/NCHS, National Health Examination Surveys II (ages 6–11), III (ages 12–17), and National Health and Nutrition Examination
Surveys (NHANES) 1999–2000, 2001–2003, 2003–2004, 2005–2006, and 2007–2008.
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Prevalence of Obesity* and Overweight†
Among Children Aged 2–5 Years, by Race and Ethnicity
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Prevalence of Obesity in Infancy
 Birth to 1 year
• 11.1% of children 0–11 months were >95% weight/length.
 1 to 2 years
• 17.0% of children 12–23 months were >95% weight/length.
 2 to 3 years
• 12.9% of children 24–35 months had a BMI >95%.
 3 to 4 years
• 15.2% of children 36–47 months had a BMI >95%.
Centers for Disease Control and Prevention. 2009 Pediatric Surveillance. National Summary of Trends in Growth Indicators by Age. Children Aged <5 Years.
Available at http://www.cdc.gov/pednss/pednss_tables/pdf/national_table20.pdf.
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Obesity Trajectory
 Phase I – Steady increase in childhood obesity
 Phase II – Emergence of serious obesity related
comorbidities
 Phase III – Medical complications lead to life
threatening disease—death in middle age
 Phase IV – Acceleration of obesity epidemic by
transgenerational transmission
Ludwig DS. Childhood obesity—the shape of things to come. N Engl J Med. 2007;357(23):2325-2327.
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Age-adjusted Percentage of U.S. Adults
Who Were Obese or Who Had Diagnosed Diabetes
CDC’s Division of Diabetes Translation. National Diabetes Surveillance System. Available at http://www.cdc.gov/diabetes/statistics.
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Expert Committee Recommendations
June 2007
 Purpose: Update pediatric obesity prevention and
treatment recommendations.
 Focus
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Pediatric practice change
“Universal prevention”
Parents/families as partners in lifestyle change
Obesity in the context of the Chronic Disease model
Connections to the community
 Medical Home
Assessment of Child and Adolescent Overweight and Obesity. Pediatrics. 2007;120(Supplement 4):163-288.
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Expert Committee Recommendations
 Assessment – BMI/nutrition/activity/readiness to
change
 Evidence based/evidence informed/expert opinion on
high risk behavior for obesity
 Stepwise approach to prevention and treatment
 Addressed obesity management in primary and
tertiary care
 Multidisciplinary approach
 Family centered/parenting/motivational interviewing
Assessment of Child and Adolescent Overweight and Obesity. Pediatrics. 2007;120(Supplement 4):163-288.
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Expert Committee Recommendations
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Assessment
Prevention
Prevention Plus
Structured Weight Management
Comprehensive Multidisciplinary Protocol
Tertiary Care Protocol
Assessment of Child and Adolescent Overweight and Obesity. Pediatrics. 2007;120(Supplement 4):163-288.
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Universal Assessment of Obesity Risk: Steps to Prevention and Treatment
American Academy of Pediatrics. Pediatric Obesity Clinical Decision Support Chart.
Elk Grove Village, IL: American Academy of Pediatrics; 2008.
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Recommendations with Consistent Evidence
 Multiple studies show consistent association
between recommended behavior and either obesity
risk or energy balance.
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Limit consumption of sugar sweetened beverages.
Limit TV (0 hours <2 years, <2 hours >2 years old).
Remove TV from primary sleeping area.
Eat breakfast daily.
Limit eating out.
Encourage family meals.
Limit portion size.
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Recommendations with Mixed Evidence
 Some studies demonstrated evidence for weight or
energy balance benefit but others did not or the
studies were too few or too small.
– 5 or more fruits and vegetable servings/day (9 age
appropriate servings recommended)
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Recommendations Where Evidence Suggests
 Studies have not examined association with weight
or energy balance, or the studies were too few or too
small, but expert committee thinks it could support
healthy weight and would not be harmful
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Eat a diet rich in calcium.
Eat a diet high in fiber.
Eat a diet with balanced macronutrients (food groups).
Breastfeeding
Promote moderate-vigorous activity 60 minutes a day.
Limit consumption of energy dense foods.
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Assessment of Obesity
 Calculate, chart, and classify BMI for all children 2–18
years of age at least yearly.
 Assess dietary patterns.
 Assess activity/inactivity.
 Assess readiness for change.
 Assess obesity related comorbidities.
 Assess ongoing progress.
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BMI – Calculate, Chart, Classify
• BMI is a screening measure, determines further
evaluation
• 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 DS, Mei Z, Srinivasan SR, et al. Cardiovascular Risk Factors and Excess Adiposity Among Overweight Children and Adolescents: The Bogalusa Heart Study.
J Pediatr. 2007;150(1):12-17.
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Prevention
 All children are considered “at risk for obesity.”
 Message at well visits
– Simple
– Consistent
– Cumulative prevention
 “Gateway message” to nutrition, activity, and high
risk behavior
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BMI 99th Percentile Cut-Points (kg/m2)
American Academy of Pediatrics. Pediatric Obesity Clinical Decision Support Chart. Elk Grove Village, IL: American Academy of Pediatrics; 2008.
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Weight Loss Targets
American Academy of Pediatrics. Pediatric Obesity Clinical Decision Support Chart. Elk Grove Village, IL: American Academy of Pediatrics; 2008.
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BMI
 Children with a BMI >99% have a greater rate of
cardiovascular risk factors.
 Children (age 12) with a BMI >99% followed into
adulthood (age 27).
• 100% BMI >30
• 90% with BMI >35
• 65% with BMI >40
Freedman DS, Mei Z, Srinivasan SR, et al. Cardiovascular Risk Factors and Excess Adiposity Among Overweight Children and Adolescents: The Bogalusa Heart Study.
J Pediatr. 2007;150(1):12-17.
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Prevention of BMI 5%–84%
 Promote breastfeeding.
 Diet and physical activity
• 5 or more servings of fruits and vegetables per day
• 2 or fewer hours of screen time per day, and no television
in the room where the child sleeps
• 1 hour or more of daily physical activity
• No sugar-sweetened beverages
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Prevention BMI 5%–84%
 Portions
– Age appropriate
– “Parents provide, child decides”
– 10–15 minute increments of exercise
 Structure
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Breakfast
Family dinners, no TV
Limit fast food
Outdoor time
 Balance
– Food groups
– Limit refined sugar
– Screen time alternatives
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Prevention
Minimum Once a 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/activity behaviors
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Universal Assessment of Obesity Risk: Steps to Prevention and Treatment
American Academy of Pediatrics. Pediatric Obesity Clinical Decision Support Chart.
Elk Grove Village, IL: American Academy of Pediatrics; 2008.
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Prevention Plus BMI >85%
 Build on prevention.
 Eating behaviors
– Family meals should happen at least 5 to 6 times per
week.
– Allow the child to self-regulate his or her meals and
avoid overly restrictive behaviors—“Parents provide,
child decides.”
– Structure activity.
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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 to 6 months; if no
improvement go to Stage 2.
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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)
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Dietary Assessment
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Consumption of sugar sweetened beverages
Daily breakfast
Eating out
Family meals
Portion size
5 or more servings of fruits and vegetables
Calcium
Fiber
Balanced macronutrients (food groups)
Energy dense foods
Readiness to change
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Assess Physical Activity/Inactivity
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Screen time
TV in room
Daily activity
Self-efficacy and readiness to change
Physical (built) environment
Social/community support for activity
Barriers to physical activity
Assess patient’s and family’s activity and exercise
habits.
 Assess outdoor activity.
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Physical Activity/Inactivity
 Advise 60 minutes of at least moderate physical
activity per day and 20 minutes of vigorous activity
3 times a week.
– Refer to community activity programs.
– Encourage development of family activities.
– Consider pedometer use.
 Decrease level of sedentary behavior.
 Limit screen time to <2 hours per day.
 No TV/computer in bedroom.
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Structured Weight Management
 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 minutes a day
– Screen time of 1 hour or less a day
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Structured Weight Management
 Increased monitoring (eg, 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.
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Structured Weight Management
 Weight maintenance that
– Decreases 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/week in older overweight/obese
children and adolescents
 If no improvement in BMI/weight after 3 to 6
months, patient should be advanced to Stage 3.
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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.
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Review of Systems
Obesity Assessment: Findings on Review of Systems and Possible Etiologies
American Academy of Pediatrics. Pediatric Obesity Clinical Decision Support Chart. Elk Grove Village, IL: American Academy of Pediatrics; 2008.
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Severe Obesity Related Emergencies
 Hyperglycemic
hyperosmolar state
 DKA
 Pulmonary emboli
 Cardiomyopathy of
obesity
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Comorbidities Requiring Immediate
Attention
 Pseudotumor cerebri
 Slipped capital femoral
epiphysis
 Blount’s disease
 Sleep apnea
 Asthma
 Nonalcoholic
hepatosteatosis
 Cholelithiasis
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Chronic Obesity Related Comorbid
Conditions
 Insulin resistance
(metabolic syndrome)
 Type II diabetes
 Polycystic ovary syndrome
 Hypertension
 Hyperlipidemia
 Psychological
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Physical Examination
Obesity Assessment: Physical Examination Findings and Possible Etiologies
American Academy of Pediatrics. Pediatric Obesity Clinical Decision Support Chart. Elk Grove Village, IL: American Academy of Pediatrics; 2008.
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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.
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Medical Screening by BMI Category
American Academy of Pediatrics. Pediatric Obesity Clinical Decision Support Chart. Elk Grove Village, IL: American Academy of Pediatrics; 2008.
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Comprehensive Multidisciplinary
Protocol
 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
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Comprehensive Multidisciplinary
Protocol
 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 is
<85th percentile and should not exceed 1 lb/month in
children aged 2–5 years, or 2 lb/week in older obese
children and adolescents
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Tertiary Care Protocol
 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
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Partnership with Families
 Families have a critical role in influencing a child’s
health.
 Effective interaction with families is the cornerstone
of lifestyle change.
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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.
 Motivational interviewing
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