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Systematic Assessment and Treatment of Childhood Obesity

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Title: PowerPoint Presentation Author: James Hooker Last modified by: James Hooker Created Date: 1/4/2012 2:22:50 AM Document presentation format – PowerPoint PPT presentation

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Title: Systematic Assessment and Treatment of Childhood Obesity


1
Systematic Assessment and Treatment of Childhood
Obesity
  • Annette Frain, RD, LDN
  • Ben Hooker, MS, MD, MPH, FAAP

2
Disclosures
  • Annette Frain
  • This speaker is employed by Triad Adult and
    Pediatric Medicine, Inc and has no other
    financial sources to disclose.
  • Ben Hooker
  • This speaker is employed by Triad Adult and
    Pediatric Medicine, Inc and has no other
    financial sources to disclose.

3
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

4
(2)
5
(No Transcript)
6
Public Health (3)
  • Number of the heaviest (BMI gt 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.

7
Health Disparity
  • 1 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.

8
(No Transcript)
9
Health Risks NOW (4)
  • Obese children are more likely to have
  • 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.
  • Increased risk of impaired glucose tolerance,
    insulin resistance and type 2 diabetes.

10
Health Risks NOW
  1. Breathing problems, such as sleep apnea, and
    asthma.
  2. Joint problems and musculoskeletal discomfort.
  3. Fatty liver disease, gallstones, and
    gastro-esophageal reflux.
  4. Greater risk of social and psychological problems.

11
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.

12
(No Transcript)
13
Obesity Management Strategy
  • Obesity 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 messages
  • b. Motivational interviewing techniques

14
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.

15
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.

16
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.

17
Obesity Management (6)
  • At every PE appointment for children 2 years
  • HEIGHT, WEIGHT, and BMI
  • Accurately MEASURE height and weight, manual BP
  • CALCULATE BMI and plot according to percentile by
    age and gender
  • CDC child and teen BMI calculator (7)
  • HISTORY and PHYSICAL EXAM
  • 3. LABS

18
Risk Stratification
  • Once appropriate data is in hand, it is possible
    to assign a risk category to the patient.
  • This RISK CATEGORY determines treatment.

19
Determining Risk Category (7)
  • Start with BMI definition (by age and gender)
  • lt5th Underweight
  • 5th to lt85th Healthy weight
  • 85th to 94th Overweight
  • 95th to 98th Obese
  • 99th Obese (increased risk)

20
(8)
21
(9)
22
Truth? Or, just an excuse?
Im not fat! My mom says Im big-boned! I'm
not fat, I just haven't grown into my body yet!
I'm not fat, I'm buff!
23
(9)
24
Personal Risk Factors
  • Elevated BP for age and gender
  • Ethnicity (AA, NA, Hispanic, PI)
  • Puberty
  • Medications (steroids, anti-psychotics, AED)
  • Acanthosis nigricans
  • LGA or SGA at birth
  • Disabilities

25
Family Risk Factors
  • Type 2 DM
  • Hypertension
  • High cholesterol
  • Gestational diabetes in mother
  • First degree relative with early death from
    cardiac disease or stroke

26
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.

27
Lab Screening (10)
  • Per the provided algorithm
  • lt10 yrs BMI 85th, no risk factors
  • OR
  • 10 yrs BMI 85th to 94th, no risk factors
  • Consider fasting lipids.
  • 10 yrs BMI 85th to 94th, 2 risk factors
  • OR
  • 10 yrs BMI 95th,
  • Do fasting lipids every 6 months, plus fasting
    glucose, LFT.

28
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, then
  • Repeat at 16 to 19 years old

29
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.

30
Risk Stratification
  • Defined by BMI as overweight, obese, or obese
    (increased risk),
  • Identified risk factors by PE and history,
  • Collected blood for appropriate labs.
  • We are ready to get started on treatment, BUT

31
(14)
32
Are they ready? (15)
  • TRANSTHEORETICAL MODEL (TTM) OF CHANGE identifies
    5 stages of change
  • PRE-CONTEMPLATION
  • No intent to change in the next 6 months.
  • Unmotivated
  • CONTEMPLATION
  • Intend to change in the next 6 months.
  • Ambivalent

33
Stages of Change
  • 3. PREPARATION
  • Intends to take steps within 1 month.
  • Active, but in EARLY change.
  • ACTION
  • Has made obvious lifestyle changes.
  • More tempted to relapse.
  • MAINTENANCE
  • Working to prevent relapse, consolidate gains.
  • Less tempted to relapse.

34
(16)
35
Readiness to Change
  • Information alone does not motivate change.
  • A unilateral agenda is unlikely to work.

36
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.

37
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.

38
(17)
39
(10)
40
Prevention (10)
  • HEALTHY WEIGHT (BMI lt 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.

41
Step 1 Treatment
  • OVERWEIGHT (BMI 85-94th) WITH risk factors
  • OBESE (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.

42
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.

43
Eat Smart, Move More NC's Seven Target Behaviors
(18)
  • 1. Promote breastfeeding
  • 2. Increased physical activity
  • 3. More fruits and vegetables
  • 4. No sugar-sweetened beverages
  • 5. Reduce screen time
  • 6. More meals at home
  • 7. Smaller portions of food and drinks

44
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.

45
Warm Hand-Off
  • PCP assesses the familys 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.

46
  • IF,
  • Patient does not stabilize or improve after 3 to
    6 months of Step 1 treatment
  • OR
  • Patient gt 6 years old with BMI gt99th percentile
    at initial assessment
  • THEN
  • STEP 2 treatment

47
Step 2 Treatment
  • OVERWEIGHT WITH RISK FACTORS (no improvement
    after 3-6 months)
  • OBESE (no improvement after 3-6 months)
  • EXTREMELY OBESE (BMI gt99th) and gt6 YEARS OLD
  • Designated Provider (DP) with an interest in
    obesity
  • DP coordinates care with RD.
  • DP or RD sees these patients once per month.

48
Step 2 Treatment
  • DP 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.

49
Step 2 Treatment
  • GOAL 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

50
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 gt6 YEARS OLD (with no
    improvement after 3-6 months of Step 2 treatment)

51
Step 3 Treatment
  • Most intense phase
  • Often 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.

52
  • Given what we know
  • about the health benefits
  • of physical activity,
  • it should be mandatory
  • to get a doctors permission
  • NOT to exercise.
  • Author Unknown

53
(No Transcript)
54
Exercise
  • Physical activity is FUN!!!
  • Each family defines fun differently
  • Be aware of parents limitations
  • Have a sensitivity to the environment
  • Safety of the neighborhood
  • Access to exercise resources
  • Generally, we encourage limited screen time (lt2
    hours per day), but active videogames can be a
    compromise

55
(No Transcript)
56
Medications
(18)
  • 1. Hypertension
  • 2. Dyslipidemia
  • 3. Metabolic syndrome

57
(20)
58
Table 8-5. Anti-hypertensive Medications with
Pediatric Dosing (20) Angiotensin-converting
enzyme (ACE) inhibitorsDrug Initial
Dose Interval Evidence FDA Maximum
DoseBenazepril 0.2 mg/kg/day up to 10
mg/day Daily RCT YES 0.6 mg/kg/day up to 40
mg/dayCaptopril 0.3-0.5 mg/kg/dose (gt12
mos) TID RCT NO 6 mg/kg/day Case
series Fosinopril 5-10 mg/day Daily RCT YES(C
hildren gt50 kg) 40 mg/day Lisinopril 0.07
mg/kg/day up to 5 mg/day Daily RCT YES 0.6
mg/kg/day up to 40 mg/dayQuinapril 5-10
mg/day Daily RCT 80 mg/day
59
(20)
60
(21)
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