Obesity in children and adolescents Annual Conference/Saturday_Khater.pdf · of ALAT (NAFL) > 10...
Transcript of Obesity in children and adolescents Annual Conference/Saturday_Khater.pdf · of ALAT (NAFL) > 10...
Obesity in children and adolescents
Dr Beatrice Khater MenassaFamily Medicine Department
AUB-MCOctober 2012
OBJECTIVES Understand the impact of obesity
Review some causes
Learn tips to deal with patients
A 9 year old girl is worried that she is fat. She seems a little overweight to you so you decide to assess her. Which tool should you use to assess her weight?
A- Waist circumferenceB- BioimpedanceC- BMI (adjusted for age and
gender)D- Your experience “she looks fat”
BMI BMI (adjusted for age and
gender) is recommended as a practical estimate in children
Correlates with adiposity and complications of childhood overweight
All children > 2 years should have their height and weight measured and BMI calculated at least yearly
Waist circumference : not recommended as a routine but information about the risk of developing other long term health problems.
Warning
If the BMI < 85th percentile but has increased more than 3 to 4 units (kg/m2) per year and begins to cross percentile lines, particularly if the child > 4 years the child is at risk of becoming overweight
BMI percentile can be plotted on a chart or obtained from online calculators.
Overweight = BMI between the 85th and 94th percentile
Obesity = age- and gender-specific BMI at or above the 95th percentile
Public health problem in the US.
Since the 70s, childhood and adolescent obesity has increased three- to sixfold.
Approximately 12 to 18 % of children and adolescents 2 to 19 y. of age are obese ( [BMI] >95th percentile).
Ogden et al. JAMA. 2012
If current trends in childhood obesity continue, there will be an additional
65 million obese adultsin the US by 2030.
This translates into a potential 6 - 8.5 million new cases of diabetes
5 - 7.3 million new cases of heart disease,
an estimated direct medical cost of $48 to $66 billion
As the prevalence of obesity increases, so does the prevalence of the comorbidities associated with obesity
Psychosocial and Societal Consequences of Childhood Obesity
decreased health-related quality of life
lower body satisfaction and physical appearance–related self-concept
experience more teasing
vulnerability to bullying
decreased probability of employment and less financial support for college among women, as well as lower household incomes
Circulation. 2009 American Heart Association Childhood Obesity Research Summit Report
From child to adultA general rule : sedentary obese child who does not alter his or her caloric intake and lifestyle is unlikely to be of normal weight as an adult.
The severity of obesity during adolescence is an important predictor
TOP COUNTRIES WITH OBESITY AND DIABETES PROBLEMS
ADULT OBESE POPULATION Nauru 78.5% Tonga 56.0% Saudi Arabia35.6% U.A.E 33.7% U.S. 32.2% Bahrain 28.9% Kuwait 28.8% Seychelles25.1% United Kingdom24.2%
DIABETES IN ADULTSNauru 30.7%U.A.E19.5%Saudi Arabia 16.7%Bahrain 15.2%Kuwait 14.4%Oman 13.1%Tonga 12.9%Mauritius 11.1%Egypt 11.0%Mexico 10.6%
Medical consequences of childhood obesity
high blood pressure, early development of atherosclerosis, type 2 diabetes mellitus
nonalcoholic fatty liver disease
polycystic ovary disorder
disordered breathing during sleep
High cardiovascular risk in severely obese children and adolescents
Nearly two thirds of young (=12 years of age) severely obese children already have cardiovascular risk factors.
(50%) of young (=12 year) severely obese children already have hypertension.
Up to 54% of severely obese children have low HDL-cholesterol and up to 20% have high fasting glucose.
van Emmerik et al. Arch Dis Child2012.
The pandemic attributable to: relatively recent (from an evolutionary perspective)
adoption of a sedentary lifestyle, high availability of foods with high caloric content in
Western cultures + portion size dated genotypes diminishing family presence at meals, increasing use of computer-oriented play activity
Sugar sweetened beverages Increase in consumption of
SSB : potential contributor to the obesity pandemic
by virtue of the high added sugar content, low satiety, and incomplete compensation for total energy
Initiatives focusing on reducing the consumption of these drinks may help to prevent a further increase in childhood obesity
Caprio et al. N Engl J Med. 2012 Sep 21James, Kerr Int J Obes (Lond). 2005 Sep.
proposed policy solutions:-taxes on SSB - controversial and opposed strongly by the food industry.
- to prohibit SSB from being sold in containers larger than 16 oz in public
Pomeranz et al. N Engl J Med. 2012 Sep 21
More obesity, less sleep
Obesity ↑ and hours of sleep↓ Coincidence or association? Meta-analyses demonstrate that insufficient
sleep during childhood increases by 58-89%risk of obesity
Potential pathways:regulation of neuropeptides, decreased energy, circadian rhythm….
Capuccio et al. Sleep 2008 Levin F et al. J Clin Endocrin Metab 2006
Examination As with the history, the examination of the
overweight child or adolescent should evaluate the presence of comorbidities and underlying etiologies.
Assessment - dysmorphic features, suggesting a genetic syndrome
- affect, - fat distribution
Laboratory studies Not standardized
Evaluation of comorbidities
Stimulation for weight loss
Basic screening: lipid panel and measurement of ALAT (NAFL)
> 10 years of age + 2 or more risk factors (FH of DM2, high-risk ethnicity, acanthosis nigricans, or PCOS): screen for diabetes
Do interventions for preventing obesity in
children work?
Cochrane review examined the effectiveness of multiple interventions: diet and nutrition, physical activity, and lifestyle, alone or in combination
Dietary interventions alone showed no difference in BMI
When all the studies combined in a meta-analysis, children in the intervention groups had a -0.15 95% C.I -0.21 to -0.09) standardized mean change in BMI compared with control patients
Pooled analysis : interventions were effective in children up to 12 years of age, but no statistically significant benefit in adolescents 13 to 18 years of age.
interventions that promoted physical activity, alone or in combination with diet, are effective in slowing or preventing increases in BMI when compared with control interventions
(Strength of Recommendation: C)
The U.S. Preventive Services Task Force (USPSTF) recommends that clinicians offer children or refer them to comprehensive, intensive behavioral interventions to promote improvement in weight status
B Recommendation
SOLUTIONS
PREVENT and TREATin clinical practice PREVENTION
PREVENTION PLUS
STRUCTURED WIGHT MANAGEMENT
COMPREHENSIVE MULTIDISCIPLANRY
TERIARY CARE INTERVENTION
Prevention plus For children with BMI 85-95th
5 -2-1-0
Self monitoring
Family involvement
F/U Q1-3 months, if no improvement….
Structured weight management BMI 95-98th
Serving portions, supervised exercise
Monitor logs
F/U Q 1 month
If 3-6 month failure to target….
Comprehensive Multidisciplinary Interventions
Frequent visits to MD and dietitican Q week
Behavioral support
Motivational interview
Tertiary Care Intervention BMI>99th with comorbidities
All the previous + meal replacement+ pharmacotherapy+ bariatric surgery
Multidisciplinary team
Communication tips
Person-centered care: principles for health professionals
Advice, treatment and care should take into account child and family needs and preferences
. People should have the opportunity to make
informed decisions about their care and treatment,
Build partnership
Balance between the importance of involving parents and the right of the child to be cared for independently.
Avoid blaming approach (obesity is not a character flaw)
Be supportive
Use words as “unhealthy weight” or “weight problems”
Focus on health rather than appearance
Avoid discussing “ideal weight”
Initiate discussion with “some people are easy gainers” and need to “work extra-hard”
understanding the readiness tochange in a family can beuseful. Use the framework of“stages of change,”
Motivational interviewingtechniques may be helpful tomove patients and familiestoward greater readiness.
Parents need to be bettereducated about the definitionand health consequences ofobesity.
evaluation of the familystructure
Because overweight child’s perception of exercise difficulty:
*consider activities that are easily mastered
* increase in volume and intensity over time
*do not prescribe running activities in which they must compete with normal-weight youth
*learn pacing skills to exercise at an appropriate level without injury.
If patient not ready to change? offer the chance to return for further
consultations when ready to discuss weight again willing or able to make lifestyle changes
give information on the benefits of losing weight, healthy eating and increased physical activity
Michelle Obama's Plan to End Childhood Obesity Epidemic
Goal: Cut Child Obesity From 20% to 5% by 2030
70 recommendations for early childhood, for parents and caregivers, for school meals and nutrition education, for access to healthy food, and for increasing physical activity.
Scorekeeping will be up to the CDC, which reports child obesity rates every two years.
The thinner is not always the better
Programs such as the 2008 Physical Activity Guidelines for Americans, the Dietary Guidelines for Americans, the “5-2-1-0 Let's Go!” program, and the Let's Move! campaign provide sample community-based structured recommendations for childhood physical activity and dietary intake ( Table 1). [10] , [13] This updated Cochrane review provides evidence that these and other programs can help prevent childhood obesity. As a result, primary care physicians should encourage parents, educators, and policy makers to consider the use of these programs.
Physical Activity Guidelines for Americans[10]
60 minutes or more of physical activity daily Most activity should be of moderate or vigorous intensityMuscle-strengthening activity at least three days per weekBone-strengthening activity at least three days per week
http://health.gov/paguidelines/
Examples of aerobic activity: running, skipping, swimming, and dancing.
Examples of muscle-strengthening activity: playing on playground equipment, climbing trees.
Examples of bone-strengthening activity: running, jumping rope, and basketball.
Translating Scientific Evidence About Total Amount and Intensity of Physical Activity Into Guidelines
In scientific terms, total weekly physical activity in the range of 500 to 1,000 MET-minutes produces substantial health benefits for adults. How should this finding be simplified and translated into Guidelines that are understandable by the public?
METs and MET-minutes
A physiologic effect of physical activity : expends energy. A metabolic equivalent, or MET, is a unit useful for describing the
energy expenditure of a specific activity. MET : ratio of the rate of energy expended during an activity to
the rate of energy expended at rest. For example, 1 MET is the rate of energy expenditure??. A 4 MET activity expends 4 times the energy used by the body at
rest. If a person does a 4 MET activity for 30 minutes, he or she has
done 4 x 30 = 120 MET-minutes (or 2.0 MET-hours) of physical activity. A person could also achieve 120 MET-minutes by doing an 8 MET activity for 15 minutes.
Youth can achieve substantial health benefits by doing moderate-and vigorous-intensity physical activity for periods of time that add up to 60 minutes (1 hour) or more each day.
This activity should include aerobic activity as well as age-appropriate muscle- and bone–strengthening activities.
as with adults, the total amount of physical activity is more important for achieving health benefits than is any one component (frequency, intensity, or duration) or specific mix of activities (aerobic, muscle-strengthening, bone strengthening).
Even so, bone-strengthening activities remain especially important for children and young adolescents because the greatest gains in bone mass occur during the years just before and during puberty. In addition, the majority of peak bone mass is obtained by the end of adolescence.
Combined: Let's Move! Children: have fun being
active and eating healthy Parents: get on track to eat well and stay fitSchools: add healthy living to the lesson plan Community leaders: empower families to make healthy decisionsHealth care professionals: educate and support patients in living healthier
Dietary Guidelines for Americans Build a healthy plate
Cut back on foods high in solid fats, added sugars, and saltEat the right amount of calories for youBe physically active your wayUse food labels to help you make better choices
http://www.cnpp.usda.gov/dietaryguidelines.htm
Recommendations, guidelines, and consensus statements North American Society for Pediatric
Gastroenterology, Hepatology, and Nutrition (NASPGHAN) [5],
Expert Committee convened by the Maternal and Child Health Bureau (MCHB) of the Health Resources and Services Administration (HRSA)
American Heart Association [8], USPSTF international Obesity Consensus Working Group
When working with kids Treating children for overweight or obesity
may stigmatise them and put them at risk of bullying, which in turn can aggravate problem eating.
Confidentiality and building self-esteem are particularly important if help is offered at school.
Multicomponent interventions Weight management programmes should
include behaviour change strategies to increase people’s physical activity levels or decrease inactivity, improve eating behaviour and the quality of the person’s diet and reduce energy intake.
Implementing Effective Prevention and Treatment Options: Exercise and Sedentary Behaviors
sufficient evidence to recommend exercise in conjunction with nutritional and behavioral counseling to overweight children.
The benefits of exercise in the management of pediatric obesity are cumulative
Surgical Management
40-year evidence base for bariatric surgery in adolescents is small
important comorbidities improve procedures are generally safe, with
complications that are similar to those seen in adults
insufficient data to assess long-term risksor recidivism in young patients.
Motivational Interviewing for Pediatric Obesity Much of the counseling regarding behavior change that occurs in practice
is didactic and prescriptive, with limited results in achieving behavior change. Motivational interviewing is a client-centered, directive method for enhancing intrinsic motivation to change behaviors by exploring and resolving ambivalence. It has been applied successfully to obesity management.76 The goal of motivational interviewing is to facilitate fully informed, deeply contemplated, and internally motivated choices.77 The technique involves active listening, advising, informing, and asking. In conducting motivational interviewing, clinicians reflect about what they have heard from the patient before they provide information or advice. It is important to get the patient’s understanding, to ask permission before providing information, to emphasize patient and parent choices, and to try to give options for change. The focus should be on the outcome and not on the process. Barriers to motivational interviewing from the clinician’s perspective are a combination of time limitation, a sense of treatment futility (the belief that patients and their parents won’t listen), and concerns about efficacy (a belief that it will really work).19
James's BMI : 95th centile. You take a full history
assess for comorbid illnesses.
His height is normal and he is developing normally. Puberty has not yet started.
He and his family are willing and motivated to change. Which one of the following statements is correct?
Single strategy approaches to managing weight are recommended for children
The aim of weight management programmes for overweight children should always be weight loss
You should encourage parents of overweight children to lose weight if they are also overweight
Which one of the following statements about treating childhood obesity is correct?
You should encourage children to increase their physical activity even if they do not lose weight as a result
Children who are already overweight should do less than 30 minutes' activity per day
Drug treatment is a recommended option if children do not respond to simple dietary measures
Bariatric surgery is a recommended option if children do not respond to simple dietary measures
When to REFER Children who have comorbidities of obesity that require rapid weight loss warrant referral to pediatric obesity centers
for appropriate dietary, pharmacologic, and/or surgical therapy .These comorbidities include: Pseudotumorcerebri (should also be referred to a pediatric neurologist) Sleep apnea Obesity hypoventilation syndrome Slipped capital femoral epiphysis or Blount disease Other children who may merit referral to a pediatric obesity center include obese children younger than two years, and
children with severe obesity (eg, BMI >40 kg/m2, or >120 percent of the 95th percentile), even if they have no comorbidities [6]. Severely overweight children may benefit from referral to a pediatric obesity specialist for more intensive therapy than can usually be provided by the primary care provider.
Children with type 2 diabetes or polycystic ovary syndrome should be referred to a pediatric endocrinologist, and those with nonalcoholic fatty liver disease or cholelithiasis should usually be referred to a pediatric gastroenterologist.
Finally, certain overweight or obese children require referral to mental health specialists. These include: Overweight children who are depressed should be referred for psychologic evaluation and treatment, since weight loss
therapy may be ineffective without concurrent psychologic care [6]. Overweight children with findings suggestive of an eating disorder (eg, inability to control consumption of large
amounts of food, self-induced vomiting or laxative use to avoid weight gain, dorsal finger lesions) should be evaluated by a therapist with experience in eating disorders; such children require psychologic treatment and should not participate in weight control programs without the concurrence of a therapist [6].