Assessing and managing child and adolescent obesity

Canberra, March 2017

Louise A BaurUniversity of Sydney: Discipline of Paediatrics & Child Health,

Sydney Medical School, The Children’s Hospital at Westmead, Sydney: Weight Management

Services Email: louise.baur@health.nsw.gov.au

Obesity• A serious chronic relapsing disease• For children and adolescents:

– It’s common• Australia - 6-8% obesity (1:4 overweight/obesity)*

– The rate of severe obesity has increased*– It can be serious

• Prevention is vital• → So, too, is effective management of those

already affected

• International Obesity Taskforce definition. See: Garnett, Baur, Cowell. Obesity Reviews 2011; 12:887-896; Garnett SP et al. PLOS ONE 2016; 11: e0154879

So what are some of the factors to consider in assessing and managing affected children and young people in

clinical practice?

Can you recognise risk?

Can you see risk? Are these children affected by underweight, healthy weight, overweight or obesity?

Photos from UC Berkeley Longitudinal Study, 1973; AND http://www.cdc.gov/GROWTHCHARTS/

Age 3 y 3 weeks Age 4 y 4 weeks Age 4 y

Photos from UC Berkeley Longitudinal Study, 1973; AND http://www.cdc.gov/GROWTHCHARTS/

Age 3 y 3 weeksBMI >95th centileObesity

Age 4 y 4 weeksBMI 10th centileHealthy weight

Age 4 yBMI 85th-95th centileOverweight

Can you see risk? Are these children affected by underweight, healthy weight, overweight or obesity?

Recognising the child with overweight or obesity (“above a healthy weight”)

• → routinely measure height & weight

• → plot BMI on a BMI-for-age chart:– Example:– Girl aged 6 years– Weight 33 kg– Height 120 cm– BMI 22.9 kg/m2

x

(>>97th centile for age; obesity range)

Same child

6 months later

Family-focused lifestyle intervention

Weight unchanged

Height 123 cm ( 3 cm)

BMI now 21.8 kg/m2

What about central fat distribution?

Central fat distribution

• Central fat distribution associated with increased cardio-metabolic risk –children, adolescents & adults

• Waist may be technically difficult to measure in some people with obesity

McCarthy HD. Int J Obes 2006; 30: 988–992; Garnett SP et al. Int J Obes 2008; 32, 1028–1030

Waist:height ratio

• Easy to calculate

• Values >0.5 (for people >6 y) associated with increased cardio-metabolic risk

McCarthy HD. Int J Obes 2006; 30: 988–992; Garnett SP et al. Int J Obes 2008; 32, 1028–1030

Waist:height ratio

• Easy to calculate

• Values >0.5 (for people >6 y) associated with increased cardio-metabolic risk

• “Keep your waist to less than half your height”

McCarthy HD. Int J Obes 2006; 30: 988–992; Garnett SP et al. Int J Obes 2008; 32, 1028–1030

Practice Points

• Measure height and weight routinely• Plot BMI on a BMI for age chart• Waist:height ratio

– Useful for almost all age groups

Are patients with overweight or obesity being seen in general practice?

In Australia, of every 200 children presenting to their family doctor, 60 are overweight or obese (23 obese) –

and 1 is offered weight management intervention

BEACH data set, Annual national random survey of 1,000 family doctor surgeries (data on 100 consecutive patients, of all ages); 2002-2006, >40,000 children aged 2-17 years, Self-reported heights & weights; Cretikos M et al, Medical Care 2008; 46:1163-1169 ; background prevalence of O&O 23-25%

In Australia, of every 200 children presenting to their family doctor, 60 are overweight or obese (23 obese) –

and 1 is offered weight management intervention

BEACH data set, Annual national random survey of 1,000 family doctor surgeries (data on 100 consecutive patients, of all ages); 2002-2006, >40,000 children aged 2-17 years, Self-reported heights & weights; Cretikos M et al, Medical Care 2008; 46:1163-1169 ; background prevalence of O&O 23-25%

In Australia, of every 200 children presenting to their family doctor, 60 are overweight or obese (23 obese) –

and 1 is offered weight management intervention

BEACH data set, Annual national random survey of 1,000 family doctor surgeries (data on 100 consecutive patients, of all ages); 2002-2006, >40,000 children aged 2-17 years, Self-reported heights & weights; Cretikos M et al, Medical Care 2008; 46:1163-1169 ; background prevalence of O&O 23-25%

What Australian family doctors say are the barriers to primary care management of

paediatric obesity

• Lack of time• Lack of reimbursement• Lack of parent/patient motivation• Lack of effective interventions• Lack of support services• Complex/difficult problem• Parent/child sensitivity• Inadequate training

Results of focus groups with Australian family doctors (general practitioners)King L et al. British Journal of General Practice 2007; 57:124-129.

But children and young people affected by overweight or

obesity aren’t just presenting to primary care

It’s a similar issue in secondary and tertiary care –and in other countries as well

Practice Point

• Children and adolescents with obesity present frequently to clinical services

Raising the issue of a child’s weight with the family

Raising the issue: 1

• You are seeing a child for an apparently unrelated reason (asthma, otitis media) and think the child may have a weight issue…..– How do you raise the issue?

Raising the issue: 1

• You are seeing a child for an apparently unrelated reason (asthma, otitis media) and think the child may have a weight issue…..– How do you raise the issue?

• Clinical practice guidelines recommend ….– Routinely measuring height & weight, calculating BMI, and plotting on growth

chart– Discussing growth chart sensitively with parent/young person.

2013 Australian NHMRC Clinical Practice Guidelines for the Management of Overweight & ObesityBarlow SE and the Expert Committee of the AAP. Pediatr 2007; 120:S164-S192

• “I’ve plotted weight adjusted for height here on the growth chart…. You can see that it’s above the healthy range for age…. Does that surprise you? …. Would you like to discuss it?

• Then recommend a further consultation to start addressing the weight issue

• Could the primary reason for the consultation be related to weight? (eg asthma, enuresis, fracture, lower limb pain, sleep disturbance …)

• If so, then highlight its importance

• Are there existing problems associated with excess weight?

• Start to explore or investigate these

x

Raising the issue: 2

• You’re seeing a child whose BMI is obviously in the obesity range, but you have a weight issue yourself– How do you raise the issue?

Raising the issue: 2

• You’re seeing a child whose BMI is obviously in the obesity range, but you have a weight issue yourself– How do you raise the issue?

• Clinical practice guidelines recommend ….– Routinely measuring height & weight, calculating BMI, and

plotting on growth chart– Discussing growth chart sensitively with parent/young

person

• Think in terms of any health issue. For example, if you had high blood pressure or diabetes would that stop you telling your patient that they have high blood pressure or diabetes?

Language and tone

• Don’t use:– Euphemisms: “chubby”, “plump”– Rule words: “should”, “must”, “ought”– “But”– The adjective “obese”

• Instead:– Talk about “above the healthy range”– Re-phrase e.g. “Have you had any thoughts/concerns about your child’s weight

before now?”– Use “however” e.g. “your child is growing well, however …”

Language and tone

• Don’t:– Be accusatory or dismissive– “Spring” it on them– Use “I told you so…” stories– Use “I lost weight by just….” stories

• Instead:– Be empathetic– Be respectful– Be culturally sensitive– Use sensitive language – people prefer “overweight” or

“weight problem”– Put it into context– Allow some “face saving”

Practice Points

• Use the growth chart to raise the issue sensitively• Is your patient “above a healthy weight”?

When should I organise clinical investigations?

Clinical investigations

• You are seeing a child with obesity.– What factors would influence your decision to organise further investigations?– Which ones?

When to investigate? • Age: adolescents > younger children• Higher levels of BMI (especially central obesity)• High risk family history:

– 1st and 2nd degree relatives with premature heart disease, type 2 diabetes/gestational diabetes, dyslipidaemia, sleep apnoea, bariatric surgery etc

• Higher risk ethnic groups:– Aboriginal & Torres Strait Islanders, Pacific,

Maori, Indian sub-continent, Mediterranean & Middle-Eastern, South-East Asian, Native American, African …

• Clinical suggestion of co-morbidities 2003 Australian NHMRC Clinical Practice Guidelines for the Management of Overweight & ObesityBarlow SE and the Expert Committee of the AAP. Pediatr 2007; 120:S164-S192

What investigations?• Initial fasting blood tests (others dependent upon

results):• Glucose• Liver function tests (ALT, AST)• Lipids (triglycerides, HDL cholesterol, LDL

cholesterol)• [Consider insulin - some controversy)]• [Thyroid function tests]

• Consider referral for sleep assessment

• Other investigations that MAY be warranted: oral glucose tolerance test, liver ultrasound

2003 Australian NHMRC Clinical Practice Guidelines for the Management of Overweight & ObesityBarlow SE and the Expert Committee of the AAP. Pediatr 2007; 120:S164-S192

Results for Peter aged 15 yBMI 36, waist 110 cm, waist:height ratio 0.62, Greek ethnic origin, acanthosis

nigricans. Strong family history of diabetes (father), obesity (both parents) and sleep apnoea (father)

Results for Peter aged 15 yBMI 36, waist 110 cm, waist:height ratio 0.62, Greek ethnic origin, acanthosis

nigricans. Strong family history of diabetes (father), obesity (both parents) and sleep apnoea (father)

* Insulin mU/L x 6 ≅ Insulin pmol/L**Insulin:glucose (pmol/mmol) ratio >15 consistent with insulin resistance

(Vuguin P et al. J Clin Endocrinol Metab 2001; 86:4618-4621)

• Fasting lipid profile– Triglycerides 2.2 mmol/L

(normal range [NR] <1.7)– Total cholesterol 5.1

mmol/L (NR <5.5)– HDL cholesterol 0.7

mmol/L (NR >0.9)

• Fasting insulin & glucose– Insulin 247 pmol/L (~40

mU/L)*– Glucose 4.8 mmol/L– Insulin:glucose 51.5**– No IGT on OGTT

Results for Peter aged 15 yBMI 36, waist 110 cm, waist:height ratio 0.62, Greek ethnic origin, acanthosis

nigricans. Strong family history of diabetes (father), obesity (both parents) and sleep apnoea (father)

• Liver function tests– Normal apart from

raised ALT 85 U/L (NR 10-50)

• Liver ultrasound– Diffuse increase in

fatty liver, consistent with fatty liver; gall bladder and common bile duct normal

* Insulin mU/L x 6 ≅ Insulin pmol/L**Insulin:glucose (pmol/mmol) ratio >15 consistent with insulin resistance

(Vuguin P et al. J Clin Endocrinol Metab 2001; 86:4618-4621)

• Fasting lipid profile– Triglycerides 2.2 mmol/L

(normal range [NR] <1.7)– Total cholesterol 5.1

mmol/L (NR <5.5)– HDL cholesterol 0.7

mmol/L (NR >0.9)

• Fasting insulin & glucose– Insulin 247 pmol/L (~40

mU/L)*– Glucose 4.8 mmol/L– Insulin:glucose 51.5**– No IGT on OGTT

Results for Peter aged 15 yBMI 36, waist 110 cm, waist:height ratio 0.62, Greek ethnic origin, acanthosis

nigricans. Strong family history of diabetes (father), obesity (both parents) and sleep apnoea (father)

• Liver function tests– Normal apart from

raised ALT 85 U/L (NR 10-50)

• Liver ultrasound– Diffuse increase in

fatty liver, consistent with fatty liver; gall bladder and common bile duct normal

* Insulin mU/L x 6 ≅ Insulin pmol/L**Insulin:glucose (pmol/mmol) ratio >15 consistent with insulin resistance

(Vuguin P et al. J Clin Endocrinol Metab 2001; 86:4618-4621)

• Fasting lipid profile– Triglycerides 2.2 mmol/L

(normal range [NR] <1.7)– Total cholesterol 5.1

mmol/L (NR <5.5)– HDL cholesterol 0.7

mmol/L (NR >0.9)

• Fasting insulin & glucose– Insulin 247 pmol/L (~40

mU/L)*– Glucose 4.8 mmol/L– Insulin:glucose 51.5**– No IGT on OGTT

Central obesity with:Dyslipidaemia

Insulin resistanceNon-alcoholic fatty liver disease

Practice Point

• Consider investigations in adolescents, and in those with more severe obesity, a concerning family history, higher risk ethnicity, or suspicion of co-morbidities

“Common or garden” obesity can be responsive to treatment –

provided it is made available!

Systematic reviews → family-based lifestyle interventions can be effective

* Oude Luttikhuis H et al. Interventions for treating obesity in children. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD001872. # Ho M et al. Effectiveness of lifestyle interventions in overweight children: a systematic review of randomised controlled trials. Pediatrics 2012; 130:e1647-e1671.

• 2009 Cochrane Review*: – “Family-based, lifestyle interventions with a behavioural

program ….. provide significant and clinically meaningful decreases in overweight in both children and adolescents … compared to standard care or self-help, in the short- and medium-term”

• 2012 systematic review#:– Lifestyle interventions:

– produce significant weight loss effects compared to no-treatment control or usual care

– also lead to significant improvements in LDL cholesterol, triglycerides and fasting insulin

Comparison: Lifestyle program versus usual care or minimal intervention. Outcome: BMI change

At the end of active treatment

At subsequent follow up

Studies with longer intervention periods

showed greater weight loss than

shorter term interventions

Meta-analysis of the effect of lifestyle interventions versus no treatment or wait-list control on:

LDL cholesterol (mmol/L)

Ho M et al. Pediatrics 2012; 130:e1647-e1671

Meta-analysis of the effect of lifestyle interventions versus no treatment or wait-list control on:

LDL cholesterol (mmol/L)

Insulin resistance (HOMA-IR)

Ho M et al. Pediatrics 2012; 130:e1647-e1671; HOMA-IR – homeostatic model of assessment - insulin resistance

So does treatment work?

• … Yes… lifestyle intervention can provide a modest to moderate level of medium- to long-term success in treatment-seeking patients with obesity

• …. provided it is made available!• … however….

…however …• There are still many research questions to be

addressed :– What level of intensity is needed, and when?– What works in different settings e.g. primary care, tertiary

care?– What works best for different age groups? Especially

adolescents!!!– How best to treat special patient groups e.g. developmental

disability, other disabilities?– What strategies would best help Indigenous young people,

or specific culturally and linguistically diverse groups?– What is the most cost-effective form of therapy?– What works for long-term maintenance treatment?– How best to integrate phone coaching, SMS, new media?– What is the role of bariatric surgery?

…however …• There are still many research questions to be

addressed :– What level of intensity is needed, and when?– What works in different settings e.g. primary care, tertiary

care?– What works best for different age groups? Especially

adolescents!!!– How best to treat special patient groups e.g. developmental

disability, other disabilities?– What strategies would best help Indigenous young people,

or specific culturally and linguistically diverse groups?– What is the most cost-effective form of therapy?– What works for long-term maintenance treatment?– How best to integrate phone coaching, SMS, new media?– What is the role of bariatric surgery?

Phew!!

…and there are often many barriers to providing treatment services in real-life settings

Barrier Potential intervention strategy

Poverty Focus on low-cost food alternativesProvision of low cost physical activity alternatives

Culturally & linguistically diverse patients

Culturally sensitive weight management advice

Learning disabilities & developmental disorders

Greater family involvementIntensive practical interventionsInvolvement of specialist support services

Illiteracy Minimise/eliminate written materialSimple key messagesFrequent phone support

Family in crisis Crisis interventionCase management until the situation stabilisesAdditional support services

Psychiatric disorders Mental health treatment & support servicesCase management until the situation stabilises

Minshall GA, Davies F, Baur LA. Behavioral management of pediatric obesity. In: Ferry RJ Jr (Ed). Management of Pediatric Obesity and Diabetes. New York: Humana Press; 2011

Can brief advice work in weight management?

→ Lancet study with UK GPs and adult patients

• Lancet 2016; 388:2492-2500• 137 UK GPs• Patients with obesity randomly assigned to:

– Support: Patient referred to weight management group (meet weekly for 12 weeks). If referral accepted, GP ensured that first appointment was made and offered follow-up

– Advice: GP advised the patient that their health would benefit from weight loss

• 1º outcome: weight change at 12 months• 2º outcomes: patients’ views – helpful, appropriate?• GP attended 90 minute online training course

(mainly filmed consultations)

• High levels of perceived helpfulness and appropriateness in both groups (overall 81%)

• Less than 1% thought it not helpful or appropriate

Practice Point

• A behaviourally informed, GP-delivered, opportunistic intervention is acceptable to patients and can be helpful with weight loss

So what are some of the “simple” initial strategies to be discussed with the

family of an affected or young person?

Initial management

• You are seeing a child or adolescent with obesity.– What are some of the initial strategies you might explore or recommend?

Soon to be released recommendations for use in NSW

clinical environments (general practices, NSW Health facilities …)

What then?

Keeping on, supporting your patients

• What strategies can you use to help your patients with ongoing weight management?

Keeping on, supporting your patients

• What fits your skill-set and practice, and local resources?• Frequent regular follow-up initially• Role of phone coaching, SMS reminders• Role of practice nurse?• Referral to other therapists e.g. dietitian, psychologist, exercise

professional, medical• Monitor, monitor, monitor – behaviours, plus weight (in those who are

treatment-seeking)

Level 170-80% of patients with o’wt/obesitySelf-care & community based care

Level 2High risk patientsCare management

Level 3

Obesity and the chronic disease care pyramid

Complex patientsCase management

Self-care supported by general practitioners, other 1o care, group programs

Secondary level care facilities; multidisciplinary teams; group programs

Tertiary care facilities & special obesity clinics; specialist teams; keyworker case manages & joins up care

Primary prevention & health promotion

Level 170-80% of patients with o’wt/obesitySelf-care & community based care

Level 2High risk patientsCare management

Level 3

Obesity and the chronic disease care pyramid

Complex patientsCase management

Self-care supported by general practitioners, other 1o care, group programs

Secondary level care facilities; multidisciplinary teams; group programs

Tertiary care facilities & special obesity clinics; specialist teams; keyworker case manages & joins up care

Primary prevention & health promotion

All parts of the pyramid are needed. What is available in this region?

https://go4fun.com.au/Run in each NSW Local Health District

For parents and family members

Free on-line training – Weight4KIDS

• Developed by The Children’s Hospital at Westmead, with NSW Health support

• A professional development online learning program• For all health professionals• 11 e-learning modules – covering all disciplines in the assessment and

treatment of children and adolescents above a healthy range• Access the program at http://weight4kids.learnupon.com

Thank you!

http://weight4kids.learnupon.com