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Erna Wong, MD Pediatrician

Erna Wong, MD Pediatrician

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Erna Wong, MD Pediatrician

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  1. Overweight ChildrenThe Role of Health Care in Prevention & Treatment November 30, 2005 Erna Wong, MD Pediatrician

  2. Today we will talk about... • The Epidemic of Overweight Children • Medical Office Visit Interventions • Weight Management Interventions • Environmental Changes and Physician Advocacy

  3. By the end of this lecture participants will be able to… • Describe 3 overweight prevention strategies. • Diagnose overweight and at risk for overweight using BMI % for age. • Describe the weight goals for overweight children. • Give Brief Focused Advice.

  4. About Kaiser Permanente (KP) • One of the nation’s oldest not-for-profit health care delivery systems and a leader in quality. • 8.2 million members nationwide; 6.2 million in California. • KP has made a deep and longstanding commitment to healthy eating and active living in our communities with intensive interventions since 2001.

  5. How serious is the problem of overweight children in California today? • Very Serious • Somewhat Serious • Not Serious • No Opinion 1,068 random sample CA residents, telephone survey 10-11/2003 http://calendow.org/caobesityattitudes/index.htm

  6. How many children are overweight? Since 1963, the number of overweight children in the U.S. has tripled! SOURCE: CDC/NCHS, NHES and NHANES

  7. Some children are more likely to be overweight. % Overweight Kids & Teens in 2000 • Teenagers • Black, Mexican American, American Indian, Alaskan Native • Children of overweight parents NHANES 1999-2000 JAMA 2002;288:1728-1732

  8. Do overweight children grow up to be overweight adults? • The older the overweight child is, the more likely he/she will continue to be overweight as an adult. • 8 out of 10 overweight teens will continue to be overweight as adults. Preventive Medicine 1993; Vol. 22:pp. 167-177 Arch Pediatr Adolesc Med Vol. 158 May 2004 pp. 449-452

  9. How many adults are overweight? “the average weight gain among subjects (20-40 years old) in the population is 1.8 to 2.0 pounds/year.” Science. 299:7;853-855 (2003)

  10. What health problems are related to being overweight? • Type 2 diabetes • Heart disease • Hypertension • Asthma • Slipped capital femoral epiphysis • Nonalcoholic steatohepatitis • Polycystic ovary syndrome • Sleep apnea • Depression and low self-esteem Pediatrics Vol. 112 No. 2 August 2003 pp. 424-430

  11. How many overweight children have metabolic syndrome? • Metabolic Syndrome(1) • Criteria: TG>=110 mg/dL, HDL-C<=40 mg/dL, Waist Circ. >=90%, FBS>=110 mg/dL, BP>= 90% (3 of 5 criteria needed) • A predictor of Type 2 diabetes and premature coronary artery disease. • Prevalence = 28.7% among overweight adolescence. • The prevalence of metabolic syndrome increased with the severity of overweight and reached 50% in severely overweight children. (2) 1. Arch Pediatr Adolesc Med Vol. 157, Aug 2003 pp. 821-827 2. N Engl J Med Vol. 350, June 2004 pp. 2362-2374

  12. The Epidemic of Overweight Children “I think we’re looking at a first generation of children who may live less long than their parents as a result of the consequences of overweight and type 2 diabetes.” Francine Ratner Kaufman, MD Head, Division of Endocrinology & Metabolism Children’s Hospital Los Angeles www.discoveryhealthCME.com, N Engl J Med Vol. 352(11) March 2005, pp. 1138-1145

  13. What are the costs of overweight and obesity? • Health care for obese adults costs 37% more than for people of normal weight, adding $732 to the annual medical bills of every American. • Treatment of illnesses related to obesity costs America $93 billion a year. Health Affairs May 14, 2003; W3:219-226 NIHCM Obesity in Young Children: Impact and Intervention Aug 2004

  14. BEHAVIOR ENVIRONMENT What are the causes of overweight and obesity? GENES METABOLISM CULTURE SES

  15. What are the genetics of overweight and obesity? • Twin analysis indicates a heritability of fat mass of 40–70% • Adopted children have BMIs that correlate to those of their biological parents Genetic Risk for Overweight • One obese parent (3X increase) • Two obese parents (13X increase) • Early puberty Behavioral Genetics, 1997, 27:325–351

  16. What behaviors are related to children becoming overweight? • Not enough physical activity. • Too much TV & video games. • Not enough milk, dairy, fruits and vegetables. • Too many sweetened drinks (e.g., soda, juice drinks, sports drinks) and too much fast food. • Skipping meals and breakfast. Position Paper - Prevention of Childhood Overweight What Should Be Done? Center for Weight and Health - U.C. Berkeley 10/02

  17. Why is physical activity important? • 3 out of 4 children in California fail to meet the minimum fitness standards in 5th, 7th and 9th grade. • Being in good shape… • reduces the risk of being overweight and heart disease • is related to better school performance California Department of Education 12/10/02 http://www.cde.ca.gov/news/releases2002/rel37.asp

  18. Why is TV harmful? • Children average 2-3 hours of TV viewing every day. • 30-50% of children have a TV in their bedroom. • TV viewing is associated with... • increased risk for being overweight • school problems • aggressive behavior & drug use Pediatrics Vol. 107 No. 2 February 2001 pp. 423-426

  19. Are dairy products important? • Milk consumption in the U.S. has declined over the last 40 years. • Milk and calcium consumption has declined significantly for adolescent girls. • Drinking milk may reduce the risk of… • becoming overweight • developing osteoporosis J Am Diet Assoc. 2003;103:1626-1631.

  20. Are eating fruits and vegetables important? • In California, of 7th, 9th and 11th graders surveyed less than half reported eating fruits or vegetables at least once per day in the past week. • Eating 5 servings of fruits and vegetables every day can help reduce the risk of overweight. Food Review. 2002;25:28-31.

  21. Why are sweetened drinks harmful? • Teenagers drink an average of 20 ounces of soda every day. • Drinking more than 12 ounces a day of sweetened drinks is associated with… • an increased risk of being overweight • drinking less milk • an increased risk of cavities J PEDIATRICS Vol. 142 June 2003, pp. 604-610 BMJ. May 22, 2004;328:1237

  22. What about eating out and fast food? • Eating out has increased from 16% to 27%. • Some fast food portion sizes have tripled from 1960 to 2000. • Fast food and eating out may be associated with an increased risk for overweight. • Int J Obes Relat Metab Disord. 2004;28:282-289.

  23. What are the risks of skipping breakfast? • Eating breakfast by teens has declined by 20% over the last 20 years. • 44% of teens said they skipped meals to lose weight. • Skipping breakfast is associated with… • eating more later in the day and • the risk of becoming overweight. J Am Diet Assoc. Vol. 101, 2001, pp. 798-802

  24. Small changes over time can make a big difference! 15 minutes of play instead of watching TV can prevent some weight problems.

  25. Fetus Fetus Preventing: Infants Infants • SGA • LGA Promoting: Toddlers Toddlers • Breastfeeding Diagnosing: Children Children • Early Adiposity Rebound Increasing: Adults Adults • Physical Activity Decreasing: Increasing: • TV Viewing • Physical Activity • Sweetened Decreasing: Beverage • Portion Size Consumption Encouraging: • Weight The Permanente Journal/ Summer 2003/ Volume 7 No. 3 pp. 6-7 Maintenance A Longitudinal Approach to Preventing Overweight

  26. Can overweight among children be prevented? • Breastfeed for the first year. • Wean from the bottle at 12 months of age. • Limit juice and other sweetened drinks to 4-6 ounces per day max. • Limit TV - none before 2 years, 1 hour or less over 2 years of age. • Avoid using food as a reward for good behavior. J Pediatr Vol. 141 No. 6 December 2002 pp. 764-769 JAMA Vol. 285 No. 19 May 2001 pp. 2461-2467

  27. Primary Care Interventions

  28. Kaiser Permanente’s Approach to Preventing Overweight

  29. First Steps. . . • Changing the Message • Active bodies are healthy bodies • Healthy bodies come in all shapes and sizes • Anticipatory guidance • Breastfeeding promotion • Improved nutrition • Increased physical activity • Identification, Risk Stratification, and Early Intervention • BMI • Targeted evaluation and education

  30. A Practical Approach to Overweight Children Well Child Care Visit • Calculate BMI and Plot BMI% for Age • Perform In-Depth Medical Assessment • Determine Weight Goals • Order Screening Lab Tests (if indicated) • Provide Brief Focused Advice • Arrange for Follow-Up Visit or Phone Call 1-4 Weeks Follow-Up Visit or Phone Call • Review Labs • Discuss Treatment Options and Referrals • Provide Brief Negotiation or Motivational Interviewing • Arrange for Follow-Up as Necessary Proposed Treatment Approach to Overweight Children, Kaiser Permanente, © 2004

  31. Primary Care Interventions • Diagnosis of overweight using body mass index (BMI)% for age at well child care visits 2 years and older • In-depth medical assessment • Appropriate weight goals • Counseling - motivational interviewing • Referral and follow-up Pediatrics Vol. 112 No. 2 August 2003 pp. 424-430

  32. BMI = 28 BMI Does Not Measure Body Fat How do you calculate body mass index (BMI)? BMI (English): [ weight (lb) / height (in) / height (in) ] x 703 BMI (metric): [weight (kg) / height (cm) / height (cm) ]x 10,000 BMI Conversion Tables: http://www.cdc.gov/ Web Calculator: http://www.cdc.gov/ Palm Calculator and Growth Chart: http://www.pdacortex.com/ BMI Calculator Wheel: http://www.trowbridge-associates.com/ $5 Pediatrics Vol. 112 No. 2 August 2003 pp. 424-430

  33. Why do we use BMI? • Consistent with adult standards and tracks childhood overweight into adulthood • BMI for age relates to health risks including cardiovascular disease, hypertension and type 2 diabetes • BMI measurement is recommended by the AAP at all well child care visits 2 years and older. Pediatrics Vol. 112 No. 2 August 2003 pp. 424-430

  34. How is overweight diagnosed? • Indicators of Nutritional Status • Overweight >= 95% for age • At Risk of Overweight 85-94% for age • Underweight < 5% for age • Early Adiposity Rebound • Definition: Adiposity rebound is the point when the BMI is the lowest for a child before it increases again • Experiencing early adiposity rebound (rebound before 5-6 years old) is a risk factor for subsequent adiposity in adulthood (1) and is associated with parental obesity (2) Early Adiposity Rebound (4Y) (1) Pediatrics Vol. 101 No. 3 March 1998 pp. 462 (2) Pediatrics Vol. 105 No. 5 May 2000 pp. 1115-1118

  35. Who should receive an in-depth medical assessment?

  36. In-Depth Medical Assessment History Developmental delay (Genetic disorders) Poor linear growth (Hypothyroidism, Cushing’s, Prader-Willi syndrome) Headaches (Pseudotumor cerebri) Nighttime breathing difficulty (Sleep apnea, hypoventilation syndrome) Daytime somnolence (Sleep apnea, hypoventilation syndrome) Abdominal pain (Gall bladder disease) Hip or knee pain (Slipped capital femoral epiphysis) Oligomenorrhea or amenorrhea (Polycystic ovary syndrome) Family History Obesity Hypertension NIDDM Dyslipidemia Cardiovascular disease Gall bladder disease Pediatrics 1998 102: e29 http://www.pediatrics.org/cgi/content/full/102/3/e29

  37. In-Depth Medical Assessment Physical examination Height, weight, Blood pressure and BMI Truncal obesity (Risk of cardiovascular disease; Cushing’s syndrome) Dysmorphic features (Genetic disorders, including Prader–Willi syndrome) Acanthosis nigricans (NIDDM, insulin resistance) Hirsutism (Polycystic ovary syndrome; Cushing’s syndrome) Violaceous striae (Cushing’s syndrome) Optic disks (Pseudotumor cerebri) Tonsils (Sleep apnea) Abdominal tenderness (Gall bladder disease) Undescended testicle (Prader-Willi syndrome) Limited hip range of motion (Slipped capital femoral epiphysis) Lower leg bowing (Blount’s disease)

  38. In-Depth Medical Assessment - Laboratory Evaluation • Fasting lipid profile and insulin? (1) • Screening for diabetes if (2)… • Age 10 or older with BMI >= 95% with 2 of the following: • Family History: type 2 diabetes in a 1st or 2nd degree relative • Ethnic Group: Native American, African American, Hispanic, Asian/Pacific Islander • Signs of Insulin Resistance: acanthosis nigricans, hypertension, dyslipidemia, polycystic ovary syndrome • Screening Tests for Diabetes and Diagnostic Criteria • Fasting (8 hour) plasma glucose = 126 mg/dl • Oral glucose tolerance test: 2-hour plasma glucose = 200 mg/dl • Casual (random) plasma glucose = 200 mg/dl WITH symptoms of diabetes • ALT (SGPT) (1) • Other tests based on history and physical (1) Circulation 2005;111:1999-2012 (2) Diabetes Care 2000a;23:381-9

  39. What are the recommended weight goals? Older Adolescents and Adults: 10% weight loss from baseline over 6 months

  40. What should my child weigh? • Tell the parent what the weight would be for the BMI 85%. • Tell the parent that for children the focus is on making improvements in family lifestyles such as making better food choices and being more active not on weight or weight loss. Your health professional will follow your child’s height, weight and BMI and let you know how your family is doing. Pediatrics 1998 102: e29 http://www.pediatrics.org/cgi/content/full/102/3/e29

  41. All Children Get up and play hard Cut back on TV and video games Eat 5 helpings of fruits and vegetables/day Cut down on sodas & juice drinks ADVISE Children at Risk or Overweight Screen with BMI starting at age 2 for all children Focus on key intervention ages IDENTIFY Families at Risk to Make Changes Ask permission to discuss weight Negotiate areas of improvement Assess readiness to change Explore ambivalence Offer health education materials, referral and follow-up MOTIVATE The Role of Nurses, Health Educators, Physicians, etc.

  42. Get More Energy! Poster 4 Key Messages Readiness to Change Tool

  43. Health Education Materials Physicians who had written nutrition brochures in their exam rooms were more likely to discuss nutrition. Preventive Medicine Vol. 38 No. 2 February 2004 pp. 198-202

  44. Effective Communication With Families

  45. Personal behavior change 31% No solution suggested 17% Make better options available for school lunch 9% Improve counseling by pediatricians 8% Extend PE requirements in schools 7% Improve nutrition education in schools 6% Add a “fat tax” to foods based on nutrient value 5% Solutions for childhood nutrition problems mentioned in CA newspaper articles, 7/98–8/00 (N=88)

  46. What are more sensitive ways to address overweight? • Obesity • Ideal Weight • Personal Improvement • Focus on Weight • Diets or “Bad Foods” • Exercise • Overweight • Healthier Weight • Family Improvement • Focus on Lifestyle • Healthier Food Choices • Play or Activity Effective Communication with Families, Kaiser Permanente, © 2004

  47. Family Changes-Acknowledge Parental Perceptions and Barriers • May not perceive their obese children as overweight • May define overweight as limited physical activity or being teased, not by growth charts • May attribute to being “big-boned” or “thick” • May believe that nature not nurture determines weight • May have trouble controlling children’s eating habits or use food to shape child’s behavior • May feel lack of control over child’s diet • May themselves be dealing with weight issue Effective Communication with Families, Kaiser Permanente, © 2004

  48. Family Changes-Parental Sensitivity • Parents should explain that children come in different shapes and sizes and that they love them whatever their size. • Parents should avoid saying “skinny,” “fat,” “obese” or teasing children about their weight. • Parents should address eating and activity as a family issue, not as the child’s “problem.” Encouraging a Healthy Weight for Your Child, Kaiser Permanente, © 2003

  49. Family Changes-Positive family attitudes • Having extra weight is no one’s fault. • There’s no such thing as good food or bad food. • Any activity is helpful, it doesn’t have to be “exercise.” • There is no ideal weight or body shape. • Body size is just one part of who a person is. Encouraging a Healthy Weight for Your Child, Kaiser Permanente, © 2003

  50. Family Changes-Parents Responsibilities • Purchase and offer healthy foods and portion sizes. • Limit fast food and eating out. • Set limits on TV and video games. Stick to them. • Let child choose things to work on. • Be a good role model with healthy eating and physical activity. • Regularly show affection. Encouraging a Healthy Weight for Your Child, Kaiser Permanente, © 2003