Systematic Assessment and Treatment of Childhood Obesity

Annette Frain, RD, LDNBen Hooker, MS, MD, MPH, FAAP

Disclosures

Annette FrainThis speaker is employed by Triad Adult and

Pediatric Medicine, Inc and has no other financial sources to disclose.

Ben HookerThis speaker is employed by Triad Adult and

Pediatric Medicine, Inc and has no other financial sources to disclose.

How bad is the problem? (1)

Since 1980, obesity among children and adolescents has almost tripled.

9.5% of children 0 to 2 years are OBESE(≥95% Weight : Length ratio)

14.8% of 2 to 19 year olds are OVERWEIGHT

16.9% of 2 to 19 year olds are OBESE

(2)

Public Health (3)

Number of the heaviest (BMI > 97%) children is increasing, even if overall percentage has stabilized.

North Carolina will spend over $11 billion dollars annually by 2018 on health care costs attributable to obesity.

Allowing this problem to continue to grow at its current pace will have dire economic, social, and public health consequences, including lower life expectancy in the 21st century.

Health Disparity1 of 7 low-income, preschool-aged children is

obese.

The rate of obese and overweight HISPANIC and AFRICAN-AMERICAN children ages 2-19 is 38.2% and 35.9%, respectively, while their CAUCASIAN counterparts are at 29.3%.

Childhood obesity rates of AFRICAN AMERICANS and HISPANICS increased by 120% between 1986-1998, but among non-Hispanic whites it grew by only 50%.

Health Risks: NOW (4)

Obese children are more likely to have:

1. High blood pressure and high cholesterol (risk factors for cardiovascular disease). In one study, 70% of obese children had at least one CVD risk factor, and 39% had two or more.

2. Increased risk of impaired glucose tolerance, insulin resistance and type 2 diabetes.

Health Risks: NOW3. Breathing problems, such as sleep

apnea, and asthma.

4. Joint problems and musculoskeletal discomfort.

5. Fatty liver disease, gallstones, and gastro-esophageal reflux.

6. Greater risk of social and psychological problems.

Health Risks: LATER (4)

1. Obese children are more likely to become obese adults.

2. If children are overweight, obesity in adulthood is likely to be more severe.

3. Adult obesity is associated with a number of serious health conditions including heart disease, diabetes, and some cancers.

Obesity Management StrategyObesity management is like management of any

other CHRONIC DISEASE:

Requires patient-centered and well-coordinated care (MD/PNP, RD, Behavioral Health, Nursing, Exercise), preferably within the context of a Patient Centered Medical Home.

Obese children seen by general pediatricians can be effectively managed using standardized practices:a. Evidence-based messagesb. Motivational interviewing techniques

Obesity Management System (5)

SORT: Identify all practice methods currently used to manage obesity in the practice. Evaluate practices for effectiveness and discontinue duplicate practices.

SET IN ORDER: Order practices into a logical practice protocol for assessing, risk stratifying, and step-wise management of obesity.

Obesity Management System

SHINE: Improve each step already in place to achieve the desired goal.

STANDARDIZING: Make execution of each step consistent across the practice. Make standard the evidence-based messages used, intervals between visits, documentation, referrals, etc.

Obesity Management System

SUSTAIN: Ongoing system assessment in the form of continuous PDSA cycles. Patient input is critical to ensure the program is and remains patient-centered.

Obesity Management (6)

At every PE appointment for children ≥2 years:

1. HEIGHT, WEIGHT, and BMI:a. Accurately MEASURE height and weight,

manual BPb. CALCULATE BMI and plot according to

percentile by age and gender

c. CDC child and teen BMI calculator (7)

2. HISTORY and PHYSICAL EXAM

3. LABS

Risk Stratification

Once appropriate data is in hand, it is possible to assign a risk category to the patient.

This RISK CATEGORY determines treatment.

Determining Risk Category (7)

Start with BMI definition (by age and gender):

<5th% Underweight

5th% to <85th% Healthy weight

85th% to 94th% Overweight

95th% to 98th% Obese

≥99th% Obese (increased risk)

(8)

(9)

Truth? Or, just an excuse?

“I’m not fat! My mom says I’m big-boned!”

“I'm not fat, I just haven't grown into my body yet!”

“I'm not fat, I'm buff!”

(9)

Personal Risk Factors

Elevated BP for age and genderEthnicity (AA, NA, Hispanic, PI)PubertyMedications (steroids, anti-psychotics,

AED)Acanthosis nigricansLGA or SGA at birthDisabilities

Family Risk Factors

Type 2 DMHypertensionHigh cholesterolGestational diabetes in motherFirst degree relative with early death from

cardiac disease or stroke

Lab Screening (11)

1. FH of dyslipidemia or premature CVD or dyslipidemia (male first degree relative ≤55 yrs, female first degree relative ≤65 yrs).

2. Patients for whom FH is not known or those with other CVD risks: overweight, obese, HTN, cigarette smoking, or diabetes.

3. Screen with FASTING lipid profile.

Lab Screening (10)

Per the provided algorithm:<10 yrs BMI ≥ 85th%, no risk factors

OR≥10 yrsBMI 85th to 94th%, no risk factorsConsider fasting lipids.

≥10 yrsBMI 85th to 94th%, ≥2 risk factorsOR

≥10 yrsBMI ≥ 95th%, Do fasting lipids every 6 months, plus fasting

glucose, LFT.

However… (12)

Recent research:FH is not sensitive or specific in identifying those children who may need medication.

Proposing UNIVERSAL screening:First at 9 to 11 years old, thenRepeat at 16 to 19 years old

However… (13)

FASTING is currently still recommended, but:

Study from UNC (fasting v. NON-FASTING):Total Cholesterol and HDL were same,LDL varied slightly,TG varied the most.

It may be as effective to draw lipids at the same visit that prompts the decision to do so.

Risk Stratification

1. Defined by BMI as overweight, obese, or obese (increased risk),

2. Identified risk factors by PE and history,

3. Collected blood for appropriate labs.

We are ready to get started on treatment, BUT…

(14)

Are they ready? (15)

TRANSTHEORETICAL MODEL (TTM) OF CHANGE identifies 5 stages of change:

1. PRE-CONTEMPLATION:No intent to change in the next 6 months.“Unmotivated”

2. CONTEMPLATION:Intend to change in the next 6 months.“Ambivalent”

Stages of Change

3. PREPARATION:Intends to take steps within 1 month.“Active”, but in EARLY change.

4. ACTION:Has made obvious lifestyle changes.More tempted to relapse.

5. MAINTENANCE:Working to prevent relapse, consolidate

gains.Less tempted to relapse.

(16)

Readiness to Change

Information alone does not motivate change.

A unilateral agenda is unlikely to work.

When you find a “ready patient”…TOGETHER you work to find what motivates

them to make lifestyle changes.

MOTIVATIONAL INTERVIEWING:To move a family that is not ready to change closer to making changes.

To create a shared agenda to change lifestyle for the family that is ready to change.

Motivational Interviewing

Child is the focus, but family is also engaged.

Foster a co-operative relationship.

Incremental changes add up over time to produce a healthier lifestyle.

(17)

(10)

Prevention (10)

HEALTHY WEIGHT (BMI < 85th%)OVERWEIGHT (BMI 85-94th%), no risk

factors

Reinforce healthy behaviors,Address questions and concerns,Correct any misconceptions,Follow on a yearly basis to reassess BMI and

risk factors.

Step 1 TreatmentOVERWEIGHT (BMI 85-94th%) WITH risk

factorsOBESE (BMI ≥ 95th%)

Treatment starts with the coordinated efforts of the PCP and RD.

Meet with PCP or RD once every 1 to 3 months.

Review previous visit and identify ways to make progress.

Step 1 Treatment

Evidence-based messages about healthier eating and physical activity are the content of patient-provider dialogue.

Information is important to advance the patients understanding of the problem of obesity, but is not sufficient to motivate the patient to change.

Eat Smart, Move More NC's Seven Target Behaviors (18)

1. Promote breastfeeding2. Increased physical activity3. More fruits and vegetables4. No sugar-sweetened beverages5. Reduce screen time6. More meals at home7. Smaller portions of food and drinks

Step 1 Treatment

Managed by PCP +/- RD

Visits every 1-3 months

If RD involved, the two clinicians must communicate regularly.

BEHAVIORAL HEALTH CLINICIAN may also become involved, if appropriate.

GOAL: Slow velocity of weight gain, then BMI decreases as patient grows in height.

“Warm Hand-Off’

PCP assesses the family’s “readiness to change,” finds they are ready to make lifestyle changes.

PCP calls the RD in to give more detailed nutrition counsel. Calling the RD in on the spot increases the impact of counseling and improves the chances that the family will follow-up.

Continued contact between PCP and RD ensures consistent messages and helps the patient and family continues to perceive this as an important issue.

IF,

Patient does not stabilize or improve after 3 to 6 months of Step 1 treatment

OR

Patient > 6 years old with BMI >99th percentile at initial assessment

THEN

STEP 2 treatment

Step 2 TreatmentOVERWEIGHT WITH RISK FACTORS (no

improvement after 3-6 months)OBESE (no improvement after 3-6 months)EXTREMELY OBESE (BMI >99th%) and >6

YEARS OLD

Designated Provider (DP) with an interest in obesity

DP coordinates care with RD.DP or RD sees these patients once per month.

Step 2 TreatmentDP starts with a comprehensive history and physical

exam to collect data to RISK STRATIFY the patient.

Also, perform detailed screening for Psychosocial factors that may make change difficult.

May be appropriate to involve the BEHAVIORAL HEALTH CLINICIAN.

Entire family is still the target.

Step 2 TreatmentGOAL: Weight maintenance, allowing BMI

to decrease as the patient grows.

IF

Patient fails to improve or stabilize over 3 to 6 months

THEN

STEP 3 treatment

Step 3 Treatment

OVERWEIGHT WITH RISK FACTORS (no improvement after 3-6 months of Step 1 or 3-6 months of Step 2 treatment)

OBESE (no improvement after 3-6 months of Step 1 or 3-6 months of Step 2 treatment)

EXTREMELY OBESE and >6 YEARS OLD (with no improvement after 3-6 months of Step 2 treatment)

Step 3 Treatment

Most intense phaseOften carried out at a tertiary care center.

Weekly visits for 8 to 12 weeks,

Seen by the DP, RD, and BEHAVIORAL HEALTH CLINICIAN at every visit.

GOAL: Weight maintenance or gradual weight loss.

“Given what we knowabout the health benefits

of physical activity,it should be mandatory

to get a doctor’s permissionNOT to exercise.”

—Author Unknown

ExercisePhysical activity is FUN!!!

Each family defines fun differentlyBe aware of parents limitations

Have a sensitivity to the environmentSafety of the neighborhoodAccess to exercise resources

Generally, we encourage limited screen time (<2 hours per day), but “active videogames” can be a compromise

Medications

1. Hypertension2. Dyslipidemia3. Metabolic syndrome

(18)

(20)

Table 8-5. Anti-hypertensive Medications with Pediatric Dosing (20)

Angiotensin-converting enzyme (ACE) inhibitors

Drug Initial Dose Interval EvidenceFDAMaximum Dose

Benazepril 0.2 mg/kg/day up to 10 mg/day Daily RCT YES0.6 mg/kg/day up to 40 mg/day

Captopril 0.3-0.5 mg/kg/dose (>12 mos) TID RCT NO6 mg/kg/day Case series

Fosinopril 5-10 mg/day Daily RCT YES(Children >50 kg) 40 mg/day

Lisinopril 0.07 mg/kg/day up to 5 mg/day Daily RCT YES0.6 mg/kg/day up to 40 mg/day

Quinapril 5-10 mg/day Daily RCT80 mg/day

(20)

(21)