weight management for pediatric patients: expert committee recommendations sandra g hassink, md,...

Weight Management for Pediatric Patients: Expert Committee Recommendations

Sandra G Hassink, MD, FAAPDirector Weight Management Clinic

A I DuPont Hospital for Children Wilmington, DE

Case - An 8 year old boy

An 8 year old boy comes to your office after an absence of 2 years.

Mother reports that he has gained 30 lbs since you last saw him

Now what?

Expert Committee Recommendations

June 2007 (Published Pediatrics Supplement December 2007)

AssessmentPreventionPrevention PlusStructured Weight ManagementComprehensive Multidisciplinary ProtocolTertiary Care Protocol

Assessment of Obesity

Calculate, chart and classify BMI for all children 2-18 yrs at least yearly

Assess dietary patterns

Assess Activity/Inactivity

Assess Readiness for Change

Assess obesity related comorbidities

Assess ongoing progress

BMI- Calculate, Chart, Classify

BMI based on age and gender and is a population based referenceUnderweight BMI<5% “Normal weight” BMI 5%-84% Overweight BMI > 85%-94% (IOM classification)Obese BMI 95%-99% (IOM classification)Morbid (severe) obesity BMI>99%

» Freedman et al J Pediatr 2007 ;150;12-17

Case an 8 year old boy

Weight 71 kg (156.2 lbs)

Height 150 cm (4’11”)

BMI 31.5

BMI

BMI 31.5 for an 8 year old boy is >99%Children with BMI > 99% greater rate of cardiovascular risk factors Children (age 12) with BMI>99% followed into adulthood (age 27)

100% BMI>3090% with BMI>3565% with BMI>40

Freedman et al. Cardiovascular Risk Factors and Excess Adiposity Among Overweight Children and Adolescents: The Bogalusa Heart Study. Journal of Pediatrics. 2007; 15: 12-7

Continuous Assessment

Calculate, chart and classify BMI for all children 2-18 yrs at least yearly

Prevention BMI 5%-84% - Diet

Promote breastfeeding Diet and physical activity:

5 Five or more servings of fruits and vegetables per day 2 Two or fewer hours of screen time per day, and no television in the room where the child sleeps 1 One hour or more of daily physical activity 0 No sugar-sweetened beverages

Prevention BMI 5%-84% - Diet

PortionsAge appropriate“Parent’s provide child decides”

StructureBreakfastFamily dinners, no TVLimit fast food

BalanceFood groupsLimit refined sugar

Prevention Dietary Patternsminimum once /year at well visits

Self-efficacy and readiness to changeSmall incremental steps for changeFamily supportPositive Self monitoringSetbacks are normal, trouble shoot, support return to planIdentify high risk nutritional behaviors

PreventionAll children 2-19 yrs BMI >5%<84%

Eating Behaviors

Eating breakfast daily.

Limiting eating out at restaurants, particularly fast food restaurants.

Encouraging family meals in which parents and children eat together.

Limiting portion size.

Prevention PlusBMI >85%

Build on Prevention

Eating behaviors: Family meals should happen at least 5-6 times per week

Allowing the child to self-regulate his or her meals and avoiding overly restrictive behaviors “Parents provide child decides”

Prevention PlusBMI >85%

Within this category, the goal should be weight maintenance with growth that results in a decreasing BMI as age increases.

Monthly follow-up for 3-6 months, if no improvement go to Stage 2.

Assess Dietary Patterns

Additional practices to be considered

for evaluation during the qualitative

dietary assessment include: Excessive consumption of foods that

are high in energy density

Meal frequency and snacking patterns

(including quality)

Case - 8 year old boy Assess dietary patterns

Breakfast at home (cereal with 2% milk)Breakfast at school Surprise to Mom (french toast, chocolate milk)School lunch (extra money for ice cream, sometimes trades food)Snack at home (Juice and potato chips)Dinner (2/7 nights order out), 2nds at homeBeverages at home, soda, gator aid, juice

5 glasses/day

Assess Physical Activity/Inactivity

Self-efficacy and readiness to change

Physical (Built) Environment

Social/community support for activity

Barriers to physical activity

Assess patient and family’s activity and exercise habits

Assess outdoor activity

Physical Activity/Inactivity

Advise 60 minutes of at least moderate physical activity per day and 20 minutes vigorous activity 3x/week

Refer to community activity programs

Encourage development of family activities

Consider pedometer use

Decrease level of sedentary behavior

Limit screen time <2 hrs/day

No TV/computer in bedroom

Case 8 year old boy Activity/Inactivity

Physical education 1x/week

Recess daily but “stands around”

No after school outdoor time

Screen time 4 hours/day

TV in bedroom

Structured Weight ManagementStage 2

Dietary and physical activity behaviors; Development of a plan for utilization of a balanced macronutrient diet emphasizing low amounts of energy-dense foods Increased structured daily meals and snacks Supervised active play of at least 60 per day Screen time of 1 hour or less per day

Structured Weight ManagementStage 2

Increased monitoring (e.g., screen time, physical activity, dietary intake, restaurant logs) by provider, patient and/or family

This approach may be amenable to group visits with patient/parent component, nutrition and structured activity

Structured Weight ManagementStage 2

Weight maintenance that Decreasing BMI as age and height increases;

Weight loss should not exceed 1 lb/month in children aged 2-11 years, Or an average of 2 lb/wk in older overweight/obese children and adolescents.

If no improvement in BMI/weight after 3-6 months, patient should be advanced to Stage 3

Comprehensive Multidisciplinary Protocol Stage 3Multidisciplinary obesity care team

Physician, nurse, dietician, exercise trainer, social worker, psychologist.

Eating and activity goals are the same as in Stage 2Activities within this category should also include:

Structured behavioral modification program, including food and activity monitoring and development of short-term diet and physical activity goals

Comprehensive Multidisciplinary Protocol Stage 3

Behavior modification Involvement of primary caregivers/families in children under age 12 years Training of primary caregivers/families for all children

Goal Weight maintenance or gradual weight loss until BMI less than 85th percentile and should not exceed 1 lb/month in children aged 2-5 years, or 2 lbs/wk in older obese children and adolescents.

Tertiary Care ProtocolStage 4

Referral to pediatric tertiary weight management center with access to a

multidisciplinary team with expertise in childhood obesity and which operates

under a designed protocol. Continued diet and activity counseling and

the consideration of such additions as meal replacement, very-low-calorie diet, medication, and surgery.

Family History

Focused family historyObesity, type 2 diabetes, cardiovascular disease (particularly hypertension), and early deaths from heart disease or stroke

Family history may be the touch point for emphasizing family involvement

Our 8 year old has a father with hypertension, obesity and sleep apnea and a maternal grandmother with diabetes.

Review of Systems

Copyright AAP 2008

Severe Obesity Related Emergencies

Hyperglycemic Hyperosmolar stateDKAPulmonary emboliCardiomyopathy of obesity

Co-morbidity's Requiring Immediate Attention

Pseudotumor Cerebri

Slipped Capital Femoral Epiphysis

Blount’s Disease

Sleep Apnea

Asthma

Non alcoholic hepatosteatosis

Cholelithiasis

Chronic-Obesity Related Co Morbid Conditions

Insulin Resistance (Metabolic Syndrome)

Type II Diabetes

Polycystic Ovary Syndrome

Hypertension

Hyperlipidemia

Psychological

Case of an 8 year old boy: Review of systems

MedicalSnoring with pauses, daytime tiredness

? Sleep apnea

Gold standard: Nighttime polysomnography

PsychosocialPoor school performance over past year

? Sleep apnea

ADD

? Teasing, low self esteem

Physical Examination

Copyright AAP 2008

Case of an 8 year old boyPhysical examinationBlood pressure 118/78 (>905<95%)

Pre hypertension

Skin – Mild acanthosis nigricansFamily history of diabetes

Insulin resistance

Pharynx – Enlarged tonsilsOverlap upper airway obstruction from enlarged tonsils

Laboratory Evaluation

BMI >85% <94% Fasting lipid profile, AST, ALT q 2 years

BMI >95% Fasting lipid profile, AST, ALT q 2 years, fasting glucose

Laboratory evaluation as always depends on clinical assessment

Partnership with Families

Families have a critical role in influencing a child’s health

» Cohen RY et al Health Educ Q 1989;16;245-253

Effective interaction with families is the cornerstone of lifestyle change

Communication

Positive discussion of what healthy lifestyle changes families can make (evidence base)Allow for personal family choicesHave families set specific achievable goals and follow up with these on revisitsBe aware of cultural norms, significance of meals and eating for family/community, beliefs about special foods, and feelings about body size.

Modeling in the office

Waiting roomBooks, posters, videos promoting healthy lifestyle

Staff role modelsDrinking water, healthy snacks, physical activity

Consistent messages, involvement with community

Lifestyle Change

Listen

Ask

Provide

Assess

Partner

Revisit

Reassess

Interactions around Lifestyle Change

Four essential skillsAskingInformingAdvising Listening

Three styles of communication Following – information gatheringGuiding- clarification of values, confidence, importanceDirecting – post decisional planning

» Rollnick S et al BMJ 2005;331;961-963

Stages of Change

Pre-contemplation: Resistant to ChangeContemplation: Aware That a Problem Exists but Ambivalent Toward Change Preparation: Intend to Take Action in Near FutureAction: Involved in ChangeMaintenance: Involved in Sustaining Change and Working to Prevent RelapseRelapse: A Return to the Problem BehaviorAdapted From Prochaska and DiClemente, 1986.

Stages of Change

Stages of change vary between individuals

Stages of change vary with time and circumstance in the same individual

Assessing readiness to change can help direct the conversation toward what is possible at that particular visit

Ingredients of Readiness to Change

Importance (Why should I change?)(Interest)

Confidence (How will I do it?) (self-efficacy)

Rollnick S, Mason P, Butler C. Health Behavior Change: A Guide for Practitioners New York: Churchill Livingstone; 2001.

Precontemplation /Resistance

Identify roadblocks, triggers, fears,

barriers etc.

Don’t try to push patient into action.

Don’t give up or become apathetic or sarcastic.

Acknowledge that now may not be the best time.

Assure patient that you are there to help when the

time is right.

Ask permission to provide information.

Follow-up at next visit.

Case - 8 year old boy Assess dietary patterns

Breakfast at home (cereal with 2% milk)Breakfast at school Surprise to Mom (french toast, chocolate milk)School lunch (extra money for ice cream, sometimes trades food)Snack at home (Juice and potato chips)Dinner (2/7 nights order out), 2nds at homeBeverages at home, soda, gator aid, juice

5 glasses/day

Case - 8 year old boy

Breakfast at home (cereal with 2% milk)Breakfast at school Surprise to Mom (french toast, chocolate milk)

Mother not happy with his double breakfast, decided right away to stop school breakfast.

Case - 8 year old boy

Beverages at home, soda, gator aid, juice5 glasses/day

After discussion about acanthosis, family history of diabetes and obesity, mother thought she could stop buying soda and sugared beverages, even though her son would initially be “unhappy”

Case 8 year old boy Activity/Inactivity

Physical education 1x/week

Recess daily but “stands around”

No after school outdoor time

Screen time 4 hours/day

TV in bedroom

Case 8 year old boy Activity/Inactivity

Screen time 4 hours/dayAll physical activity changes seemed hard to mother and son

They decided to “look into” the local Boys and Girls Club to see if he could go there after school.

You ask them to keep track of his screen time and see them in one month.