A TV IN EVERY ROOM A Practical Approach to the Management of Childhood Overweight and Obesity - PowerPoint PPT Presentation

Loading...

PPT – A TV IN EVERY ROOM A Practical Approach to the Management of Childhood Overweight and Obesity PowerPoint presentation | free to view - id: 1d401-Y2U3M



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

A TV IN EVERY ROOM A Practical Approach to the Management of Childhood Overweight and Obesity

Description:

Recognize importance of BMI calculation. Recognize 4 stages of weight management ... BMI gives more accurate assessment of adiposity/concern for co morbidities ' ... – PowerPoint PPT presentation

Number of Views:258
Avg rating:3.0/5.0
Slides: 89
Provided by: HSC65
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: A TV IN EVERY ROOM A Practical Approach to the Management of Childhood Overweight and Obesity


1
A TV IN EVERY ROOM A Practical Approach to the
Management of Childhood Overweight and Obesity
Susan Bryce Cluett, CRNP VCNP Conference March
2009 sbc2n_at_virginia.edu
2
(No Transcript)
3
Program Objectives
  • Recognize importance of BMI calculation
  • Recognize 4 stages of weight management
  • Guidelines to manage children in the Prevention,
    Prevention Plus stages
  • Know when to refer

4
How is obesity defined in childhood
BMI
Obese
BMI is a screening tool Measure of
adiposity Childhood BMI tracks into adulthood
Overweight
Underweight
Normal BMI
5
WEIGHT DEFINITIONS- CDC
  • Based on (BMI) age and sex
  • Children
  • Normal weight - 5-84
  • Overweight
  • BMI ? 85th percentile, age and sex.
  • Obese BMI ? 95th percentile for age and sex.
  • Morbidly obese, 99th percentile

6
So….Are we using BMI?
  • 31 PCPs Never use it
  • 11- always
  • BMI gives more accurate assessment of
    adiposity/concern for co morbidities
  • Eyeballing results in under diagnosis
  • Perrein et al. 2004

7
  • What is the scope of the issue?

8
Obesity Trends Among U.S. Adults BRFSS, 1990,
1998, 2006
(BMI ?30, or about 30 lbs. overweight for 54
person)
1998
1990
2006
CDC-2007
9
Overweight Prevalence in U.S. children 12-19
years of age 1999-2000
Data from Centers for Disease Control
10
Comparison of National and Local Obesity
Prevalence
CDC 1999-2002, 6-18 year old 95 Cville
2000-2003, among 8-12 year olds
11

The annual cost of overweight in the Unites
States, according to CDC 2005 Statistics, is 117
billion annually..and growing...
12
  • So.. What is the cause of this epidemic?

13
Etiology of Childhood Obesity
  • Childhood obesity is a disorder of energy
    imbalance……….
  • Excessive energy intake (food intake) plus
  • Lack of energy expenditure (lack of physical
    activity and excessive time spent in sedentary
    activities)
  • Rarely may be associated with other endocrine
    disorders such as Cushings Disease or
    hypothyroidism…

14
May be genetic predisposition for overweight
(disproportionately may affect certain ethnic
groups). But genes have not changed in 30 years…
Genetics????
15
Why is childhood obesity a problem?
  • Easier to eat 100 calories than work them off!!
  • Obese children become obese adults.
  • Study 84 of obese teens had adult BMI 30.
  • Children born in the US in 2000 estimated to have
    a 35 chance to developing diabetes.
  • First generation in US history to have
    life-expectancy shorter than their parents.

16

Obesity is a Multi-Faceted Entity with Many
Co-Morbidities
17
  • Obesity is a Chronic Illness….

18

19
Obesity is directly related to
  • Hypertension
  • Insulin Resistance
  • Hyperlipidemia- triglycerides,
  • Type 2 Diabetes
  • All components of the Metabolic Syndrome,
    constellation of clinical findings for
    CVD/Diabetes

20
Childhood Obesity as a Medical Problem
  • Bogalusa Heart Study, community based study
    (5-17 yr.olds
  • followed for 20 yrs.) of cardiovascular
    disease risk factors,
  • showed that 60 of overweight children (BMI
    95th for age and sex) had,
  • two cardiovascular risk factors such as
  • - hyperinsulinemia
  • - hypertension
  • - hyperlipidemia
  • 65 of that no.as adults went on to have a BMI
    35kg/m2 (Obese).
  • Childhood overweight/obesity is predictor of
    adult overweight/obesity.
  • J Pediatrics 200715012-7

21
But…..
  • We do not have enough longitudinal data to
    predict if elevated insulin, hyperlipidemia or
    hypertension in the young predicts cardiovascular
    disease in the adult…

22
So, What Can You do in Your Practice??
23
Coding…
  • 783.1 Excessive weight gain
  • 701.2 Acanthosis Nigricans
  • 251.1 Hyperinsilinemia
  • 790.2 Impaired Glucose Tolerance
  • 250.00 Type 2 Diabetes
  • 401.0 Hypertension
  • Resources
  • wwww.calmedfoundation.org
  • www.aap.org/obesity/physeducation.htm

24
Reimbursement……
  • WHO PAYS????????????

25
Payments Comparison FY04-07
26
Payments Comparison FY2008
27
Four Stages of Intervention
  • Prevention All Children, ages 2-19 BMI
  • Prevention Plus BMI 85
  • Structured Weight Management
  • Comprehensive Multidisciplinary
  • Tertiary Care Protocol 99
  • Based on Expert Committee Recommendations
    Regarding the prevention, Assessment, and
    Treatment Of Child and Adolescent Overweight and
    Obesity, Pediatrics Volume 120, Supplement 4,
    Dec2007,

28
  • PREVENTION

29
An Ounce of Prevention…
  • Is worth a pound of cure

30
is for all children and should include
conversation/education re
Prevention
  • Promote breastfeeding
  • Family Structure/Mealtime
  • Limited screen time
  • Regular physical activity Fun/Play
  • Age appropriate portion sizes
  • Parenting support
  • Yearly BMI monitoring to pick up earliest cues
    for weight escalation

31
Assessment
  • BMI
  • History- Prenatal /Family
  • Dietary patterns/Activity patterns
  • Co-morbidities
  • Portion sizes!!

32
5, 2, 1, 0
  • 5 Fruits and Vegetables
  • 2 Hours of Screen time per day- MAX…..
  • 1 Hour of PA per day.. Really need 2… PLAY
  • 0 Sugary Beverages…
  • www.mcph.org/Major_Activities/keepmehealthy.htm

33
Screening Fasting Labs- Prevention
  • Lipid Profile-varies with age
  • Yearly from 2 yrs. on..
  • Pediatrics Vol. 122 Number 1, July 2008

34
BMI at or passing the 85th Percentile……
35
Prevention Plus Stage 1 PCP Office
36
Prevention Plus- children between the 85th - 94th
  • More focused attention on individual/family
    lifestyle habits-whole family change ..
  • 5,2,0,1
  • Follow-up 1-2 months for 6 months BMI check/goal
    reassessment
  • Goal-
  • Weight maintenance/increased growth velocity
    with weight normalization- 85
  • Health focus
  • Lab support for targeted co-morbidities-
    lipids/insulin/LFTs

37
Readiness to Change Stages
  • Resistant to Change
  • Aware of problem but ambivalent
  • Intent to take action in the future
  • Involved in Change
  • Involved in Sustaining Change and working to
    Prevent Relapse
  • Return to Problem Behavior
  • Scale 0-10- why is number not lower or higher?
  • Adapted from Rollnick et al. Health Behavior
    Change

38
Review of Systems Screening for Co-morbidities….
  • Snoring, pauses in breathing, daytime sleepiness,
    napping, sleep hygiene- OSA
  • Bedwetting/encopresis
  • GERD
  • Asthma Sx-SOB/wheezing w/activity vs.
    deconditioning
  • 3 Ps-Type 2
  • NASH
  • Musculoskeletal issues- Blount's Disease

39
More…
  • Psychosocial/Family dynamics
  • Developmental delays
  • Emotional issues- Huge….Bingeing/emotional
    eating/abuse.. Need attention before changes can
    be made..
  • Puberty/Menarche/Tanner Stage
  • Hirsutism/Acne/Menstrual Hx.-PCOS

40
PE should include screening for …
  • Assessment for growth velocity/ mid parental
  • height prediction/accelerated growth/small
    stature
  • -hirsutism, moon facies, hypertension,
    global obesity/dev delays
  • (LabsCortisol/24 Hour urine for cortisol and
    creatinine)- Cushing's..
  • Endo referral
  • -abnormal facies (dysmorphic features),
    developmental delays, short
  • stature, abnormal genitalia, think syndrome
  • Prader Willi, Turners (webbed neck). Poor
    linear growth, hypothyroidism FT4/TSH
  • Genetics Evaluation

41
Ask about Diet History
  • Sugary beverages
  • Portion sizes- have age appropriate food
    models/plates caregivers can see
  • F Vs
  • Structured meal times/skipping meals/grazing/binge
    ing/sneaking food/emotional eating
  • Eating Out
  • Self- regulated feeds.

42
Physical Activity-PLAY!!!!!!
  • All screen time- AAP recommends 2 hours max… TV
    IN BEDROOM?????
  • Outdoor play/imaginary play
  • Organized Sports- Gym/ teams
  • Barriers- Safety/busy schedules/clothing
  • Pedometer/ activity calendar

43

Mental Health Evaluation
  • Key…. as many children have disordered eating
    with bingeing, emotional eating, food sneaking
    secondary to unresolved emotional issues
  • These issues must be addressed before any changes
    in lifestyle can be made…

44
Review Risk Factors
  • PRENATAL HISTORY-
  • IUGR/Gestational Diabetes/Excessive
    prenatal weight gain
  • FAMILY HISTORY for co-morbidities
  • parents, sibs,grandparents, aunts or
    uncles-
  • Type 2 diabetes
  • hyperlipidemia
  • hypertension
  • early onset vascular incidents obesity

45
Physical Assessment
  • Oropharynx - crowded, tonsillar hypertrophy - OSA
  • Check for accelerated age by molar eval.
  • Tanner Stage
  • Abdomen organomegally
  • Extremities- Small hands/feet bowing of tibiae
  • Flat affect
  • BP
  • Skin - acne/skin break down, striae and…

46
Acanthosis Nigricans
  • Dark, velvety skin seen mainly in
    skin folds
  • Neck
  • Axillae
  • Under breasts
  • Groin
  • Antecubital/ popliteal areas

Clinically indicative for hyperinsulinemia
47
Labs- Might include
  • Insulin If FH positive for Type 2, or insulin
    20, BMI 85th, 10 years
  • obtain 2hr OGTT/75 Gm
  • Gold Standard/Type 2
  • Impaired Glucose 140-199
  • Diabetes- 200 and above.
    (1)
  • Comprehensive Metabolic Panel- SGOT/SGPT-if I.5
    x normal, repeat in 3 months after lifestyle
    intervention.. Still hi BMI 99 percent consider
    obtaining GI consult
  • Hbg A1c
  • Sleep study/orthopedic eval/ECHO

48
5, 2, 1, 0
  • 5 Fruits and Vegetables
  • 2 Hours of Screen time per day- MAX…..
  • 1 Hour of PA per day.. Really need 2… PLAY
  • 0 Sugary Beverages…
  • www.mcph.org/Major_Activities/keepmehealthy.htm

49
Motivational Interviewing
  • The PCP motivates families to make healthy
    behavior changes utilizing negotiation.. What
    would you be willing to change to improve your
    health or your childs health… Mom would you be
    willing to remove all the junk food…Jr., would
    you be willing to reduce your sodas to 2/ day…
    PROCESS
  • BFN……Brief Focused NEGOTIATIONs- everybodys
    opinions are valued and voiced.
  • Written Goals

50
Principles of Treatment
  • Assess using BMI
  • Assess Readiness to Change
  • Barriers to Change/Motivators
  • for both parent and child
  • Assess Parent/Family Involvement
  • Goals for PA and Nutrition addressed
  • Positive supportive attitude for the family

51
Children are Rewarded….
  • Rewards are negotiated..
  • - No food items
  • - Nothing which costs
  • Earn back screen time- 10 minutes/day
  • for goal accomplishment
  • Privileges

52
Goal for Prevention Plus……
  • Weight maintenance/increased growth velocity with
    weight return to below 85th
  • Healthy lifestyle habits for LIFE..through
    education

53
Messages
  • Simple
  • Fun
  • Positive
  • Rewards for goal attainment
  • NP models healthy behaviors, reinforces messages
    with educational hand-outs
  • Office healthy lifestyle zone….

54
Typical kiddo
  • 4 year old Hispanic girl, BMI crossing the 85th
    percentile
  • Accelerated growth velocity
  • BP nl./triglcerides may be elevated
  • Stay at home with Dad- Runs after Dad all day
  • Consumes 6-7 cups of 4 oz. juice per day, whole
    milk, 20 oz./day, grazes all day/large portion
    sizes-
  • Goes to bed late, gets up late.. May skip
    breakfast
  • Developmentally appropriate
  • Both parents present.. Somewhat engaged
  • Both parents overweight
  • Positive FH for obesity/ Type 2- Dad

55
Intervention
  • Import of familys involvement at young
    age/discuss development/parenting
  • Discuss need for structure 3 meals /2 snacks
  • Assess/ discuss parents need to model behavior/
    parent provides /child decides..
  • Assess readiness for parental change
  • As always discuss medical issues/ risk factors/
    FH and the MEDICAL PLAN- weight maintenance,
    continued linear growth velocity, parental goal
    adherence/whole household changes.

56
Goals Negotiated..
  • Add daily structure- B-L-D/ 2 snacks with healthy
    snack hand-out/appropriate bedtime..
  • Reduce sugary bevs to1 cup of juice per day
  • Increased water for all family members/
  • Reduce portion sizes/smaller plate/ serve from
    kitchen
  • Seconds FVs

57
What are the goals/ targets/successes to look for…
  • Weight maintenance for kids before puberty-
    continued linear growth.
  • Kids whose BMI is above the 99th percentile may
    lose 1 pound per week but focus on health and
    goal adherence.
  • Behavior and lifestyle change.
  • Decreased BMIz score
  • Reduction in lipids, insulin with lifestyle
    change..
  • Ideal Body Weight not helpful….

58
BMI 95-98th Percentile……obese
59
  • Structured Weight Management
  • Stage 2
  • PCP with support

60
Structured Weight Management
  • Used if prevention plus has not been effective
    ,BMI is between 95th - 98th percentiles.
  • more frequent follow-up/6 month trial
  • written diet and exercise plans/goals
  • motivational interviewing..
  • might include measuring cups, pedometers, dietary
    logs
  • whole family/caregiver involvement..
  • Generally managed with nutritional counseling or
    expert team members..

61
Goal for Structured weight Management….
  • Weight maintenance with increasing growth
    velocity
  • Weight loss 1 pound per month, children 2-11 or 2
    pound per week, older children and adolescents.
  • Tighter monitoring of 5 2 0 1
  • Visits every 2 weeks
  • Rewards
  • No change in 3-6 months.. Stage 3

62
  • Comprehensive Multidisciplinary Intervention
  • Stage 3

63
Comprehensive Multidisciplinary Intervention……….
  • is used when 3 - 6 months of structured lifestyle
    intervention has failed to achieve targets.
  • more frequent visits with mulitidisciplinary
    team- dietician, medical champion exercise and
    behavioral specialists/experts … CFC
  • Eval for co-morbidities

64

65
More extensive labs
66
warranted for acne/hirsutism and/or irregular
menses
PCOS Labs
  • Bioavailable testosterone (SHBG/Total
    Testosterone/Free testosterone)
  • May also look at Estradiol/17 Hydroxyprogesterone/
    LH/FSH if concern for Pituitary or Adrenal
    Dysfunction
  • Treatment Modalities
  • PCOS labs positive (elevated
    testosterone, low SHBG) and
  • oligomenorrhea, acne hirsutism, first
    line Metformin 1Gm BID
  • Biguanide/Anti-androgen
  • GI side effects- start slowly ( 6
    weeks to attain full dosage /take with meals)
  • Check LFTs in 6 weeks and every 6
    months thereafter.
  • irregular menses, may not normalize for
    6-12 months on Met so may add OCP after neg.
    pregnancy test- like to use Yasmin progesterone
    is a Spiranolactone
  • derivative.
  • Spiranolactone for significant hirsutism
    50 mg. 2x/ day…. May increase to 100 mg.
  • LIFESTYLE MODIFICATION/WEIGHT LOSS STABILIZATION
    KEY….

67
- Insulin level greater than
20, positive FH for type 2, obtain 2 hr.
OGTT/75. GM Glucose challenge normal OGTT, BMI
generous ( 95th ) may treat with Metformin 1 Gm
twice a day after meals for 6 mos. -Repeat
insulin -Monitor LFTs Positive OGTT/Type 2 DM-
treat with Metformin up to 1 Gm twice a
day -Monitor HgA1c -Endo referral
Lifestyle Modification Key…..
Hyperinsulinemia
Inability of cells to absorb glucose with insulin
signal
68
Benchmarks for TC and LDL in Children and
Adolescents 8 yrs. And older….
LIPIDS
  • Acceptable- TC
  • Borderline- 170-199, 110-129
  • Elevated- 200 130
  • Triglycerides- 150
  • Screening 2 years, fasting Lipid Profile
  • Treatment if LDL 190 0r 160 with Cardiovascular
    hx. Or 2 additional risk factors.
  • Adapted from the NCEP guidelines for children and
    adolescents Daniels, Greer Pediatrics
    2008122198-208

69
Lipid Management
  • Six months of dietary and lifestyle change before
    pharmocologic intervention- no evidence based
    approach for specific age of drug intervention..
  • Increased soluble fiber/whole grains- 5 age of
    the child/day
  • Plant stanols and sterols- lower absorption of
    dietary cholesterol- 20 gms/ day-
  • Increased omega 3 rich foods- fish 3x/week- anti
    inflammatory/antioxidant
  • 5-9 F and Vs
  • Limit sugary beverages- 4-6 oz. per day
  • Bake food
  • Reduce/eliminate saturated fats..calories
  • Activity-
  • No change…..referral for cardiac eval and
    possible statin initiation..

70
Indications for Antihypertension Drug Therapy in
Children
Hypertension
  • 3 elevations of BP 95th percentile for age/ht
    according to guidelines despite dietary/lifestyle
    changes and or weight reduction…Salt reduction,
    decreased fast and prepared foods…
  • Type 2 Diabetes

71
  • What else can an NP/PCP
  • DO?

72
At All Annual Checkups and all Sick Visits…
  • Calculate/Plot BMI -
  • Measure blood pressure and compare to BP
    guidelines for age,
  • ht and sex. (1)
  • Classify weight category and share graph with
    caregiver.
  • BFN- Provide Brief Focused Negotiated message-
    4-6 minutes…5201
  • Follow-up in 2 weeks..
  • 1Fourth Report on Diagnosis, Evaluation and
  • Treatment on High Blood pressure in
  • Children and Adolescents, Peds, 114 (2), 2004

73
In Addition
  • Hand-outs to reinforce behaviors and educate
  • make your office and waiting room a healthy
    lifestyle zone…..posters, hand-outs
  • model healthy behaviors yourself..

74
  • Tertiary Care Intervention

75
Tertiary Care Intervention
  • BMI 99th percentile
  • Associated co-morbidities
  • Structured weight management and comprehensive
    multidisciplinary intervention were not
    effective.
  • Bariatric Surgery/Dietary Restriction Plans/
  • Inpt. management

76
What do we do at the Childrens Fitness Clinic?
77
CFC Stats - Our Average Referral
  • Gender
  • 57 Female
  • 43Male
  • Race
  • 55 Caucasian
  • 35 African American
  • 10 Other
  • Mean Age
  • 10.8 years
  • Mean BMI
  • 34.7 for females
  • 35.8 for males
  • Both greater than the 95th percentile
  • The average patient referred to the CFC is
    already obese with many co-morbidities

78
When to Refer to us..
  • Childs BMI above the 85th percentile and
  • No success with 6 months of
  • lifestyle modification
  • Lipids/BP abnormal post intervention
  • PCOS issues- need for multidisciplinary team
  • Want to see kids early…….0-21

79
CFC Initial evaluation
  • Child and family meet individually with nurse
    practitioner, nutritionist and exercise
    physiologist.
  • Comorbidities are identified/ managed or
    subspecialty referrals made.
  • Focus is on the health of the child and healthy
    family behaviors
  • Specific goals are negotiated with child and
    family for changes in diet and physical activity
    patterns using motivational interviewing and
    behavior modification.
  • Families are instructed on how to monitor their
    childs progress and set rewards. Parenting!!!

80
Frequency of visits
  • 7 Visits….
  • Initial visit- 2 hours with all team members
    then….
  • In 2 weeks to increase motivation, offer
    encouragement and problem solve any issues.
  • Once a month for remaining 5 visits…

81
Parents/Caregivers/Health Care Providers….
For Health Success
  • Recognize Overweight/ Obesity as an important
    health issue

  • Model healthy lifestyle behaviors themselves.
  • Take responsibility for their childs/patients
    health education or parenting and success.
  • Provide a positive, healthy, safe environment for
    dialogue
  • AND….
  • Take an active role in their childs/patients
    school life including policy making for physical
    activity and food delivery.

82
Parents MUST be engaged for success to
occur….
83
Conquering CHO involves us all..
  • Family, PCPs ,Schools, Policy Makers
  • Community partners/champions/tertiary
  • treatment centers and Childrens Hospitals…
  • for childhood obesity prevention,
  • education and treatment……

84
It takes an Orchestra……
85
The Ten Minute Intervention-BFN
  • 5… F and Vs- Two Bite Rule
  • 2….Hours of Screen Time
  • 0… Sugary Beverages
  • 1- 2…Hours of FUN.. Physical Activity
  • Monitor portion sizes
  • Reward goal accomplishment- Earn back screen time
  • http//www.mcph.org/Major_Activities/keepmehealthy
    .htm

86
References
  • Wyllie,R 2205 Obesity in childhood an overview
    Current Opinion in Pediatrics 17 (5) 632-635
  • OBrien S, Holubkov and Reis 2004 Identification,
    Evaluation and Management of Obesity in an
    Academic Primary Care Center Pediatrics 114e
    154-e 159
  • Expert Committee Recommendations Regarding the
    Prevention, Assessment and Treatment of Child and
    Adolescent Overweight and Obesity Summary
    Report Pediatrics 2007, 120 4/S164
  • www.pediatrics.org/cgi.content/full/120/Suppl
    ement_4/S164
  • Freedman, David S, Mei, Srivasan, Berenson,
    Deitz, Cardiovascular Risk Factors and Excess
    Adiposity Among Overweight Children and
    Adolescents the Bogalusa Heart Study, Jan 2007

87
References
  • http//www.nhlobi.nih.gov/guidelines/hypertsnsion/
    child_tbl.htm
  • Daniels, Greer and the committee on Nutrition.
    Pediatrics 2008 122198-208,Lipid Screening and
    Cardiovascular Health in Childhood
    http//www.pediatrics.org/cgi/content/full/122/1/1
    98
  • The Fourth Report on the Diagnosis, Evaluation,
    and Treatment of High Blood Pressure in Children
    and Adolescents, Pediatrics, Vol. 114, No. 2,
    August 2004- Revised 2005

88
(No Transcript)
About PowerShow.com