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].