Transcript Center for Pediatric Medicine 2009 Grocery Store Survey

Pediatric Obesity
Kerry K. Sease, MD, MPH
Medical Director, New Impact
Program Director, Pediatric Residency Program
Greenville Hospital System University Medical Center
Objectives
• Define overweight and obesity
• Recognize co-morbid complications of
overweight and obesity
• Employ motivational interviewing
techniques for counseling
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.
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:
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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.
What we know
• Higher prevalence of intermediate metabolic
consequences and risk factors for adverse health outcomes
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insulin resistance
elevated blood lipids
increased blood pressure
impaired glucose tolerance
What we know
Severe childhood overweight/obesity
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pseudotumor cerebri
slipped capital femoral epiphysis
tibia vara
steatohepatitis
cholelithiasis
sleep apnea
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**Increased risk of injury and prolonged recovery time
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
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BMI
BMI
BMI
BMI
< 5% = underweight
5-84% = healthy weight
85 - 94% = overweight
> 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.
A Staged Approach Overview
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Stage 1 - Prevention Plus
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Stage 2 - Structured Weight Management
– Family visits with physician or health professional
– Frequency individualized to family needs and risk factors
– 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
A Staged Approach Overview
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Stage 1 and 2 Behavioral Recommendations
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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
A Staged Approach Overview
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Stage 3 - Comprehensive, Multidisciplinary Intervention
– Multidisciplinary team with experience in childhood obesity
– Frequency often weekly group sessions for 8-12 weeks with
follow up
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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)
Modifiable risk factors
(Childhood Obesity Action Network, NICHQ, 2007)
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
Ability to Counsel
Poor
Fair
Average
Good
Excellent
FM (n = 74)
Peds (n = 213)
11%
30%
44%
15%
0%
6%
17%
47%
27%
3%
11%
48%
36%
9%
0%
23%
33%
35%
Efficacy of Counseling
Poor
Fair
Average
Good
Excellent
0.5%
Provider Perceived Barriers to
Effective Treatment
(Health Care Systems Work Group of the South Carolina Coalition for Obesity Prevention Efforts (SCCOPE), 2007)
Weight Management Counseling
• Sensitive with nonjudgmental tone toward both the
child and the parents
– family-based management strategy cannot be overemphasized
– 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
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
Patient-Centered Communication
Empathize/Elicit - Provide - Elicit
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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?
Nutrition
• The path to optimal nutrition......
– Nutrition basics
• Stoplight diet
• Healthy plate model
Physical Activity
Age
Minimum
Activity
Comments
Infants
No
requirements
Toddler
1.5 hrs
30 minutes planned
physical activity AND 60
minutes unstructured
activity (free play)
Preschool
2 hrs
60 minutes planned
physical activity AND 60
minutes unstructured
activity (free play)
School Age
1 hr or more
Break up into segments of
Physical Activity should
encourage motor
development
15 minutes or more
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
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
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
Advocacy
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Educate Your Patients
Encourage Healthy Activities
Create a Healthy Office Environment
Promote a Healthy Community
Chronic Care Model
Environment
Medical System
Family
Information Systems
School
Decision Support
Worksite
Family/Patient
Self-Management
Delivery System Design
Community
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)
(The Economist – December 2003)