obesity in children and adolescents · 2014. 7. 29. · 1 obesity in children and adolescents:...

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Obesity in Children and Adolescents:

Review of Recent Clinic Practice Recommendations and Introduction of the New SCMA Childhood

Obesity Taskforce Toolkit

2014 Annual Meeting, Myrtle Beach SC

Janice D. Key, MD Kerry K. Sease, MD James Simmons, MD

Educational Objectives

•!Review recent clinical practice recommendations for diagnosis, treatment and prevention of overweight and obesity in children and adolescents •!Develop a plan for use of the new

SCMA toolkit in clinical practice THE SPEAKERS HAVE NO CONFLICTS TO DISCLOSE



SCMA toolkit in clinical practice

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Obesity Trends* Among U.S. Adults BRFSS, 2002

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No Data <10% 10%–14 15%–19% 20%–24% 25%–29% !30%

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No Data <10% 10%–14 15%–19% 20%–24% 25%–29% !30%

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No Data <10% 10%–14 15%–19% 20%–24% 25%–29% !30%

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Prevalence of obesity (body mass index >95th percentile) among children and adolescents 2 to 19 years of age in the United States between 1971 to 1974 and 2009 to 2010 shows a recent

plateau from 2003 to 2004 on.

Lakshman R et al. Circulation. 2012;126:1770-1779

Copyright © American Heart Association, Inc. All rights reserved.

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Change in the distribution of weight among adults in SC (During the past 40 years, obesity has gone from being rare

to the “normal” condition)

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<15% 15-85% 85%-95% >95%

1970 2010




Weight status cannot be determined without assessing BMI

1966

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http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/english_bmi_calculator/bmi_calculator.html

CDC BMI Calculator:

“Body Mass Index (BMI) is a number calculated from a person's weight and height. BMI provides a reliable indicator of body fatness for most people and is used to screen for weight categories that may lead to health problems.” CDC

BODY MASS INDEX (BMI): What is it and how does it work?

•! Quetelet Index initially created by Adolphe Quetelet (1796-1874) •! Dr. Ancel Keys (the Mediterranean Diet) proposed use of BMI in 1970’s •! 1985 NIH Consensus Development Panel promoted use in practice Dr. Ancel Keys

Caveats about BMI •! Assumes proportion of

muscle, fat, bone, fluid so does not actually measure obesity = excess fat

•! Cannot be used in children less than 2 years old

•! Height and weight measurements must be accurate

BMI video located on the Lean Team website: http://academicdepartments.musc.edu/lean_team/physicians/bmicheck.html

Definition of Overweight and Obesity in Children and Adolescents

•! % Based on BMI distribution in 1970’s •! Risk categories based on adult morbidity •! Overweight = BMI > 85% - 94% •! Obese = BMI > 95% or •! Obese = BMI > 30

Pediatrics 2007 120, (suppl 4)

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Body proportion changes during childhood and adolescence

1. Normal BMI for children varies by age and gender

2. BMI normative data not available for children < 2 years old

3. Adiposity rebound is important

4. BMI > 30.0 is obesity regardless of percentile

Adiposity rebound = age at which BMI first increases Adiposity rebound <5 associated with >3 BMI units increase by age 18-21

Rolland-Cachera et al American Journal of Clinical Nutrition 1984 Taylor et al Current Opinion in Clinical Nutrition & Metabolic Care 2005

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Obesity Prevention / Treatment in Well Child Care

•! Assessment of BMI at least annually •! Promotion of healthy life style •! 5-2-1-0 Plan •! Stage I – IV Treatment Plan

Staying Healthy: Weight Fruit Vegetables Whole grain Calcium Physical activity

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5-2-1-None •! > 5 fruits/vegetables •! < 2 hours of screen time •! > 1 hour of physical

activity •! No sugar sweetened drinks

http://www.choosemyplate.gov/

Additional Screening for an Obese Child •! Insulin Resistance – random/fasting insulin •! Diabetes – random / fasting BS, hgb a1c •! Hyperlipidemia – random / fasting cholesterol /

lipid panel •! Hypertension - accurate blood pressure •! Obstructive sleep apnea - sleep study •! NAFLD – Liver function tests •! Hypothyroidism - only if short, sudden onset, or

additional symptoms

Expert Committee Recommendations of the Assessment, Prevention and Treatment of Childhood and Adolescent Obesity 2007

STAGE 1: 5-2-1-0 and lifestyle counseling (breakfast, limit eating out, family meals 5-6/week). Allow child to self regulate. Monthly FU. Goal of weight maintenance with growth.

STAGE 2: Diet plan limiting energy dense foods, structured meals and snacks, supervised active play 1 h/d and screen time < 1 h/d. Goal of weight maintenance to decrease BMI or lose < 1 lb/m.

STAGE 3: Multidisciplinary team with structured behavioral modification program about food and activity. Goal weight loss 1 lb/month age 2-5y or up to 2 lb/week > 5 years

STAGE 4: Referral to pediatric tertiary weight management center (MUSC Heart Health)

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•! 9X risk of hypertension •! Early onset puberty in girls* •! 25% impaired glucose tolerance** •! 4% type 2 diabetes mellitus** •! 80% adult obesity,

1/4 of whom will have metabolic syndrome*** * Pediatrics 108(2):347,2001

** NEJM 346(11):802,2002

***JAMA 287(3):356,2002

Consequences of obesity in children and adolescents

METABOLIC SYNDROME IN CHILDREN AND ADOLESCENTS*

> Of the following: •! Elevated fasting triglycerides •! Low HDL cholesterol •! Elevated fasting glucose •! Increased waist circumference •! Elevated systolic BP

Among 1960 children > 12 years old in NHANES: 2/3 had one finding of metabolic syndrome 1/10 had metabolic syndrome (1/3 of those with BMI > 85%) (Circulation 2004;110:2494-2497)

* No standard definition of pediatric metabolic syndrome

Short et al. Vascular health in children and adolescents: effect of obesity and diabetes. Vascular Health and Risk Management 2009:5 973-990

Developmental pattern in childhood

Change with age in adulthood

Effect of obesity

Effect of type 2 diabetes

Endothelial function

No change or reduced; limited age and developmental stage-related norms

Reduced, preserved in exercisers

Reduced in children and adults

Reduced in adults, no data in children

Arterial compliance

Increased; limited age and developmental stage-related norms

Reduced, preserved in exercisers

Reduced in most studies of children and adults; recent conflicting data in children

Reduced in adults, no change in children

Intima-media thickness

No change or increased slightly

Increased Increased in most studies (both children and adults)

Increased in adults and adolescents

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•!Review recent clinical practice recommendations for diagnosis, treatment and prevention of overweight and obesity in children, adolescents and adults •!Develop a plan for use of the new


2014 SC AAP CATCH Meeting

SCMA TASK FORCE ON CHILDHOOD OBESITY

Created as a committee of SCMA in 2011

•! Established following presentation about childhood obesity at SCMA Board of Trustees retreat Fall 2011

•! Vince Degenhart, MD former Chair •! Janice Key, MD and Mike Finch, MD Co-Chairs

•! Invitations extended to leaders from relevant state agencies and experts in children’s health, obesity, nutrition, health care delivery

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•! Developed in collaboration

with SCMA, Dr. James Simmons, ESMMSC, MUSC Boeing Center, BCBSSC, DHEC

•! Pilot testing completed •! Contents include:

–! 5-2-1-0 age-appropriate questionnaires

–! 5-2-1-0 Handouts –! Prescription pads for

nutrition and exercise

Pediatric Obesity Toolkit 5-2-1-NONE RECOMMENDATIONS

Physician behavior rarely (? never) changes with CME or journal articles or clinical practice guidelines

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Group Baseline After 1st AD visit Final Control 3% 1% Toolkit only 11% 4% Academic Detailing 0% 0% 45%

Academic detailing improves communication of BMI assessment in pediatric practices*

* Funded by Select Health

6 pediatric practices (2 in each condition) Data from 1269 well child patient visits

547 baseline, 182 after AD visit, 535 final 3-17 years old; 49% female; 52% white, 37% AA 49% Medicaid, 48% private insurance

Focus groups found only AD implemented systemic changes

Fruits and vegetables

Meal habits

Screen time

Physical activity

Change talk

Beverages

Motivational Interviewing •! Defined in 1983 by Miller

& Rollnick in treatment of adults with substance abuse

•! Patient-centered, only the patient can make a change

•! Starts with patient’s Stage of Change (Prochaska and DiClemente), moving from Pre-contemplation to action and maintenance www.motivationalinterview.org

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1.! Express empathy Acceptance facilitates change Skillful reflective listening in fundamental Ambivalence is normal

2.! Develop discrepancy The patient should present the argument for change Change motivated by a perceived discrepancy between current behavior and goals

3.! Roll with resistance Avoid arguing!!!! Do not directly oppose resistance New perspectives invited but not imposed Patient is the primary source of answers and solutions

4.! Support self-efficacy Patient’s belief in possibility of change is important Patient, not the doctor, is responsible for carrying out change Doctor’s belief in patient’s ability to change becomes self fulfilling

Underlying Principles of Motivational Interviewing

Primary Techniques of Motivational Interviewing

•! Open-ended questions vs close-ended •! Reflective listening •! Affirmations •! Summary statements •! Evocation of change talk vs importance and

ability rulers

Using the Toolkit Questionnaire: !! Have patients/parents fill

it out during triage/while waiting

!! Use for all patients not only those who are overweight/obese

!! Review during interview !! Base MI on “change

talk” selected by patient !! Focus on only one thing

at a time !! Use handout for that one

item !! FU in 1 month !! Celebrate success

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Example: “Based on your answers, is there ONE thing you would like to help your child change now” Eat more fruits and vegetables (Preparation stage of change) MI: Good choice! You can do it! Fruits & vegetables are … Have you tried: The 3 bite rule Low fat salad dressing dip Fruit smoothie Don’t give up; it takes 7-10 times to get a kid to like a new food

Example: Nothing checked MI: What do you think about this new questionnaire? Have you ever thought about making any of these changes to keep your child healthy? I know you are concerned about the diabetes that runs in your family. Getting a healthy dinner together every night can be really hard; I have trouble with it myself!




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OBESITY IS A RECENT HUMAN PHENOMENON; TODAY, NORMAL HUMAN BEVAVIOR RESULTS IN

UNHEALTHY WEIGHT GAIN

THEREFORE EFFECTIVE INTERVENTION

MUST ADDRESS THE OBESOGENIC ENVIRONMENT

“The solution is simple. With more than half of Americans living with at least one chronic

disease, we should be investing more in community-based prevention.” Risa Lavizzzo-Mourey, Robert Wood Johnson Foundation,

“We must focus on prevention disease if we want our nation to thrive” The Atlantic, June-2012

“Strengthen schools as the heart of health.” Institute of Medicine; Accelerating Progress in Obesity Prevention: Solving

the Weight of the Nation May 2012

THEN vs NOW

1950s NOW

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20 year change in average caloric intake

Children 11-18 eat fast food 2X/week*

Fast food meal 187 cal > home meal**

Fast food restaurants more common in low SES predominantly AA neighborhoods***

*Paeratakul J Am Diet Assoc 2003;103:1330 **Bowman Pediatrics 2004;113(1):112 ***Block Am J Preventative Med 2004;27:211

Post & Courier Sept 25, 2011

MUSC

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THEN vs NOW

1950s NOW

Television "!5 h / day = 5X Higher risk obesity "!25% of children watch > 4 h / day "!TV in bedroom associated with obesity "!Limiting “Media Time” lowered BMI*

*Robinson JAMA 1999; 282:1561

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THEN vs NOW

1950s NOW

THEN vs NOW

1950s NOW

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Decreased Physical Education and Physical Activity in Schools

•! Increased emphasis on academic achievement and testing

•! PE & PA enhances learning, academic achievement, and positive behaviors*

*Shepard Pediatric Exercise Science 1997;9:113 Calas Pediatric Exercise Science 1994;6:406 Dwyer Pediatric Exercise Science 2001;13:225

THEN vs NOW

1950s NOW

HIGH FRUCTOSE CORN SYRUP

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Although they have the same chemical composition, fructose has a more open structure than glucose and therefore causes more gycoslylation of proteins than does glucose. Gylcation (non-enzymic glycosylation) inactivates glutathione reudctase Blakytny & Harding, Biochem J 1992 288 303-307

Glycation = Non-enzymatic binding of sugars to protein

Representative images of a mesenteric venule from 1 animal for each experiment.

Mattioli L F et al. JPEN J Parenter Enteral Nutr 2011;35:223-228

Copyright © by The American Society for Parenteral and Enteral Nutrition

“…intragastic fructose, but not dextrose, elicits considerable intestinal inflammation…”

Public Health Approach for Obesity Prevention: IOM Accelerating Progress in Obesity Prevention 2012

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MUSC Boeing Center for Children’s Wellness Docs-Adopt/School Wellness Initiative,2012-2013

Charleston County School District Since 2007

Charleston County Medical Society Physicians Adopting Schools: 80 Schools Adopted: 66

Dorchester 2 School District Since 2012 Dorchester County Medical Society Physicians Adopting Schools: 16 Schools Adopted: 15

Berkeley County School District Since 2012 Physicians Adopting Schools: 2 Schools Adopted: 2

www.musc.edu/leanteam

Dr. Bill Lomax, Adopting Doc for Alston Middle School

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Examples of Policy and Environmental Changes

Docs-Adopt School Wellness Initiative Preliminary Outcomes

•! Increased score over time (p<0.022) •! Reduction in variance in Title 1 schools (p<0.039) •! Increased scores with physician adoption (p<0.05) •! Increased scores associated with healthier BMI (p<0.05) •! Increased student attendance (p<0.0005) •! Decreased office referrals (p<0.0006)

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Thank you

obesity in children and adolescents · 2014. 7. 29. · 1 obesity in children and adolescents:...

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