Howe - PEDIATRIC OBESITY

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  • CV risk: htn, elevated trigs, elevated ldl, elevated insulin
  • BMI has been shown to be a reliable predictor of risk of continuing overweight in children and shown to be predictive of obesity by age 12 years
  • Provide handout on specifics of diets
  • Assumes that people generally desire to be well and want this for their children as well
  • BSM= taught skills needed to lose weight: identify high risk situations for over-eating, preplanning for stressful situations SFM= taught skills to help with maintenance of social skills, build healthy friendships, deal with teasing
  • BSM= taught skills needed to lose weight: identify high risk situations for over-eating, preplanning for stressful situations SFM= taught skills to help with maintenance of social skills, build healthy friendships, deal with teasing
  • Ie. meditation (no peds data), relaxation and imagery, hypnosis, yoga (has been shown effective in peds obesity programs), muscle relaxation, biofeedback (small studies have shown benefit), cognitive behavior therapy, spirituality (no peds data)
  • APPLE: activity coordinators made exercise at recess more fun and active, bought exercise equipment, provided before and after school activities to increase exercise, educated in science class about sugary drinks, increasing fruits and veggies and fast food. Despite having 4 year data, activity coordinator was present for only 2 years
  • Recommended screening for specific categories according to AMA: 85-94% BMI: overweight with no risk factors, fasting lipids 85-94% BMI : overweight with risk factors: fasting lipids, AST, ALT, fasting glucose >95% BMI: obese: fasting lipids, AST, ALT, fasting glucose, BUN/Creatinine
  • Howe - PEDIATRIC OBESITY

    1. 2. Introduction <ul><li>The Problem </li></ul><ul><li>Pediatric overweight and pediatric obesity defined </li></ul><ul><li>Successful treatment strategies </li></ul><ul><li>Implement into your daily practice </li></ul>
    2. 3. The Scope of the Problem <ul><li>In 30 years, obesity rates have DOUBLED for preschool age children and adolescents </li></ul><ul><li>TRIPLED for children aged 6 to 11 years </li></ul><ul><li>Obese children under 10 have at least 1 cardiovascular risk factor already </li></ul><ul><li>Overweight children have 70% chance of being an overweight or obese adult </li></ul><ul><li>Increases to 80% if one parent is overweight </li></ul>
    3. 4. Goals of Treatment <ul><li>Reduce energy intake while maintaining optimal nutrition to support growth and development </li></ul><ul><li>Increase energy expenditure while reducing sedentary behaviors </li></ul><ul><li>Facilitate a supportive family environment with ‘buy in’ from the adults </li></ul>
    4. 5. Sobering fact <ul><li>Only 21% of 64 preventitive obesity programs for children reviewed resulted in even short-term weight loss </li></ul><ul><li>Those that do represent change often show small changes </li></ul>Stice E, Shaw H, Marti N. A meta-analytic review of obesity prevention programs for children and adolescents: the skinny on interventiosns that work. Psychol Bull 2006;132(5):667-91.
    5. 6. Definitions <ul><li>Underweight: BMI <5 th percentile </li></ul><ul><li>Normal: 5 th to <85 th percentile </li></ul><ul><li>Overweight: 85 th to <95 th percentile </li></ul><ul><li>Obese: >95 th percentile or BMI >30 </li></ul>American Medical Association. Expert Committee Recommendations on the Assessment, Prevention, and Treatment of Child and Adolescent Overweight and Obesity. Jan 25, 2007.
    6. 8. Treatment Strategies <ul><li>Therapeutic use of nutrition </li></ul><ul><li>Motivational interviewing </li></ul><ul><li>Mind-body connection </li></ul><ul><li>Exercise counselling </li></ul><ul><li>Close partnership between patient and physician </li></ul>
    7. 9. Treatment Strategies Therapeutic use of nutrition <ul><li>Anti-inflammatory diet </li></ul><ul><ul><li>Phytochemicals found in foods lead to reduced levels of inflammatory states in the body </li></ul></ul><ul><ul><li>Antioxidant properties are cardioprotective </li></ul></ul><ul><li>Omega-3 fatty acids </li></ul><ul><ul><li>Most pediatric diets are insufficient </li></ul></ul><ul><ul><li>May consider supplementing if high number of cardiac risk factors </li></ul></ul>
    8. 10. Treatment Strategies Therapeutic use of nutrition <ul><li>5-2-1-0 project </li></ul><ul><li>5 or more servings of fruits and vegetables </li></ul><ul><li>2 or fewer screen hours </li></ul><ul><li>1 or more hours of physical activity </li></ul><ul><li>Zero sugar-sweetened beverages </li></ul>
    9. 11. Treatment Strategies Motivational interviewing <ul><li>Directive style of counseling </li></ul><ul><li>Focus is on patient’s own perceptions and motivations </li></ul><ul><li>Seeks to resolve ambivalence </li></ul><ul><li>Strengthen’s patients reasons for positive behavior change </li></ul><ul><li>Triggers change in a way consistent with patient’s goals and values </li></ul>
    10. 12. Treatment Strategies Motivational interviewing <ul><li>Treatment of 7-12 year olds for childhood overweight using three treatment arms </li></ul><ul><ul><li>Behavioral skills maintenance (BSM) </li></ul></ul><ul><ul><li>Social facilitation maintenance (SFM) </li></ul></ul><ul><ul><li>Control </li></ul></ul><ul><li>Each family was instructed on dietary recommendations, exercise goals, behavior change (ie. less screen time) </li></ul><ul><li>The first two groups received extended maintenance therapy for 2 years </li></ul>
    11. 13. Treatment Strategies The studies that WORKED <ul><li>During management phase, more counseling resulted in higher weight loss </li></ul><ul><li>At 2 years, the BSM and SFM patients maintained their weight better but only modestly compared to controls </li></ul><ul><li>Bottom line: </li></ul><ul><ul><li>Regular monitoring with counseling appears to help in the weight loss effort but effects tend to wane over time </li></ul></ul>Wilfley, et al. Efficacy of Maintenance Treatment Approaches for Childhood Overweight: A Randomized Controlled Trial. JAMA. 2007;298(14):1661-1673.
    12. 14. Treatment Strategies Mind-body connection <ul><li>Engages power of thoughts and emotions to positively influence physical health </li></ul><ul><li>May help children feel a sense of control over their illness </li></ul><ul><li>Indirectly has been shown to help obesity by improving the co-morbidities: stress, depression, anxiety, low self-esteem, coping </li></ul>
    13. 15. Treatment Strategies Exercise counseling <ul><li>The APPLE project </li></ul><ul><li>School based initiative in New Zealand </li></ul><ul><li>Intervention: school-based activity coordinators acted to increase exercise before/during/after school, actively improve diets </li></ul><ul><li>Measurements of BMI annually x 4 years </li></ul><ul><li>Intervention group: improvement in BMI and sustained BMI change compared with control </li></ul>Taylor RW, et al. Two-year follow-up of an obesity prevention initiative in children: the APPLE project. Am J Clin Nutr 2008;88:1371-7.
    14. 16. Treatment Strategies Exercise counseling <ul><li>The APPLE project </li></ul><ul><li>Very cool side effect: </li></ul><ul><li>Intervention schools decided to remove fried foods and sugary drink options from cafeteria </li></ul><ul><li>One school created an edible garden </li></ul><ul><li>Parental involvement in sports remained strong in follow-up phase </li></ul>Taylor RW, et al. Two-year follow-up of an obesity prevention initiative in children: the APPLE project. Am J Clin Nutr 2008;88:1371-7.
    15. 17. Treatment Strategies Close partnership between patient and physician <ul><li>What is the ‘job’ of the physician? </li></ul><ul><li>Beginning at age 3, yearly BMI measurements should be taken </li></ul><ul><li>Educate parents and patients about BMI as a screening tool </li></ul><ul><li>Identify cardiac risk factors if present </li></ul><ul><li>Referral to nutritional counseling </li></ul><ul><li>Get involved with local schools! </li></ul>
    16. 18. Implementation into Daily Practice <ul><li>Monitor BMI at least once annually between 2-20 years of age </li></ul><ul><li>Adopt motivational interviewing style </li></ul><ul><li>Consider monitoring for cardiovascular risk factors in obese children ‘ </li></ul><ul><li>Get involved with local communities to help affect change </li></ul>

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