Can I prevent an obese child from becoming an obese adult?

Dr. Geert ‘t Jong, Pediatrician

60th Annual Scientific Assembly

Conflicts of interests

No conflicts

Objectives

Understanding the gravity of the issues of obesity in childhood and adolescence

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Learning about strategies around weight management and fitness approaches

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Discussing the pitfalls of too much focus on weight loss

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Obesity is a big issue

• The prevalence of obesity in Canadian children has risen dramatically from the late 1970s, more than doubling among both boys and girls

• Recent estimates (2009- 2011) indicate 32% of children 5-17 years areoverweight (20%) or obese (12%); obesity prevalence is almost twice as high in boys (15% vs 8%)

• Childhood obesity is associated with increased risk of cardiovascular disease, diabetes and other chronic conditions in adolescence and later in life

• Excess weight in children often persists into adulthood

Contributing factors

Genetics

Metabolism—how your body changes food and oxygen into energy it can use.

Community and neighborhood design and safety.

Short sleep duration.

Eating and physical activity behaviors.

Environment

Assessing Social Contagion in Body Mass Index, Overweight, and Obesity Using a Natural Experiment. Datar A, Nicosia N; JAMA Pediatr. 2018 Mar 1;172(3):239-246

Using data from military service members assigned to installations around the country, this study found that exposure to counties with higher rates of obesity (relative to counties with lower obesity rates) was associated with higher mean BMI and greater odds of obesity in parents and higher BMI z scores and greater odds of overweight/obesity in children. Associations were stronger among families who had resided longer in a given location and with off-installation residence.

Putting Preventioninto Practice

Canadian Task Force on Preventive Health CareGroupe d’étude canadien sur les soins de santé préventifs

Recommendations for growth monitoring, prevention and management of overweight and obesity in children and youth in primary health care 2015

Canadian Task Force on Preventive Health CareMarch 201

Growth Monitoring

Recommendation: For children and youth 0-17 years of age we recommend growth monitoring at all appropriate primary care visits using the WHO Growth Charts for Canada

• Strong recommendation; very low quality evidence

Basis of the recommendation:• Growth monitoring is a long-standing, feasible, low- cost

intervention unlikely to result in harms, and likely to be valued by parents and clinicians in identifying children and youth at risk of developing weight-related health conditions

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Obesity Prevention

Recommendation: We recommend that primary care practitioners not routinely offer structured interventions aimed at preventing overweight and obesity in healthy weight children and youth 0-17 years of age.

• Weak recommendation; very low quality evidence

Basis of the recommendation• The lack of evidence for clinically important benefits

of current interventions to prevent overweight and/or obesity in the target population, the lack of evidence that any benefits are sustained in the long-term, and the lack of evidence for the use of such interventions in primary care settings

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Obesity Management

Recommendation 1: For children and youth aged 2 to 17 years who are overweight or obese, we recommend that primary care practitioners offer or refer to structured behavioural interventions aimed at healthy weight management.

• Weak recommendation, moderate quality evidence

Basis of the recommendation• The modest, short-term benefits of weight management

interventions and the lack of identified harms• The recommendation is weak because of the lack of data

that such weight loss is sustained or has health benefits over time

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Obesity Management

Recommendation 2: For children and youth aged 2 to 11 years who are overweight or obese, we recommend that primary care practitioners not offer Orlistat aimed at healthy weight management.

• Strong recommendation, very low quality evidence

Basis of the recommendation• The lack of studies examining pharmacologic

interventions and effectiveness as a treatment in this population

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Obesity Management

Recommendation 3: For children and youth aged 12 to 17 years who are overweight or obese, we recommend that primary care practitioners not routinely offer Orlistat aimed at healthy weight management.

• Weak recommendation, moderate quality evidence

Basis of the recommendation• The lack of trials that examine pharmacologic interventions

versus control with no behavioural intervention• Pharmacologic + behavioural interventions and trials were not

more effective than the behavioural interventions on their own• The potential for harm associated with Orlistat treatment (e.g.,

GI disturbances)

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Obesity Management

Recommendation 4: For children and youth aged 2 to 17 years who are overweight or obese, we recommend that primary care practitioners not routinely refer for surgical interventions.

• Strong recommendation, very low quality evidence

Basis of the recommendation• The absence of RCTs comparing with usual care

showing that this intervention is effective, the potential for harm and the irreversibility of the procedure

• Primary care practitioners do not normally refer directly to a clinic for bariatric surgery.

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The relation between family meals and health of infants and toddlers• Descriptive data showed that mothers offer food at

a structured mealtime, but that eating together as a family was not always upheld. The frequency of family meals was positively associated with more nutrient-dense food intake and a more balanced diet. Different advantages (e.g., social importance, practical considerations) and obstacles (e.g., planning, possible mess) of the family meal were mentioned by parents. Further, having structured mealtimes and family meals was associated with more food enjoyment and less fussy and emotional eating.

Treatment of adolescent obesity

The broad principles of treatment include

• management of obesity-associated complications;

• a developmentally appropriate approach;

• long-term behaviour modification (dietary change, increased physical activity, decreased sedentary behaviours and improved sleep patterns);

• long-term weight maintenance strategies;

Adolescent obesity management strategies are more reliant on active participation than those for childhood obesity and should recognize the emerging autonomy of the patient. The challenges in adolescent obesity relate primarily to the often competing demands of developing autonomy and not yet having attained neurocognitive maturity.

Links between the organization of the family home environment and child obesityBates CR et al. Obes Rev. 2018 May;19(5):716-727

• Prior research on household organization has examined an array of constructs, including family routines, limit setting, household chaos, crowding and the broad home environment.

• This study systematically reviews literature on organization within the family home environment and weight among children ages 2-12.

• Overall, 84% of studies provided evidence for relations between at least one indicator of organization within the family home environment and child weight.

• Studies provided compelling evidence across several constructs, suggesting that the relevance of household organization to child weight extends beyond a single indicator.

• Elvsaas IKØ, et al. J Obes. 2017;2017:5021902

Multicomponent Lifestyle Interventions for Treating Overweight and Obesity in Children and Adolescents: A Systematic Review and Meta-Analysis.

Multicomponent lifestyle interventions have a moderate effect on change in BMI and BMI Z score after 6, 12, and 24 months compared with standard, minimal, and no treatment.

Weight management programs

We interviewed 8 Canadian and 8 US programsGoal: understand the development, evolution, benefits, challenges and future directions of pediatric weight management programs from the perspectives of program team membersIdentified: • perceived need and gaps in services; • limitations of body mass index (BMI); • weight bias and stigma; • comprehensive family-centered care; • access, partnerships and resources.

Weight management programs

A theme of “health and wellness, not weight” emerged.

weight bias and stigma

Bias / stigma was described as occurring at the level of the individual, within the family, the healthcare system and society.

defining success in pediatric weight management programs from the perspectives of team members working within these programs.

Canadian sites: family centered or tailored to the individual’s goals.

Both Canadian and US sites described using a summary of measures and the value of “softer data”. Difficulties in defining success were attributed to limited available outcome measures and limiting conceptualizations of success.

What not to do:

Stigmatize children and adolescents with obesity

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Focus on calories or weight; physical and mental fitness is more important

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Focus on the individual patient

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Conclusions

Many interventions tried:

- Multidisciplinary approach is pivotal

- Family-oriented in children, more towards autonomy in adolescence with support

- Is a medical approach really necessary/working?

What can you do as a busy family physician?

- Find programs / partners in the community

- Focus on behavioral intervention and family oriented care.