Interventions in

Pediatric Obesity

Endocrinology RoundsEndocrinology Rounds

33rdrd June, 2009 June, 2009

Cheril ClarsonCheril Clarson

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Adipocytokines

*p<0.05 vs 0 months§p<0.05 vs lifestyle alone

r2 =0.19, p<0.05

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Insulin Sensitivity and Birthweight

r2 = 0.25, p<0.02 r2 = 0.25, p<0.02

Baseline LDL cholesterol correlates with birthweight, p<0.05

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REACH

Reduction of Adolescent Risk Factors for Type 2 Diabetes and Diabetes-related Cardiovascular

Disease

Activity and metformin (as glumetza) intervention in obese adolescents

Funded by: Canadian Institutes of Health Research: Cardiovascular Complications of Diabetes Team Grant Children’s Health Foundation

Investigators: Cheril L Clarson, David J Hill, Stuart HarrisMichelle Jackman, Farid H Mahmud, Harry Prapavessis,Kevin Shoemaker, Justine WilsonStudy Co-Ordinator: Maggie Watson Ext 56111Study Administrator: Tracy Robinson

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Objectives

Primary objective is reduction in BMI

Secondary objective is an improvement in risk factors for T2D and CVD as measured by: body composition, physical activity, physical fitness, insulin resistance, glycemic status, serum lipids and adipocytokines and vascular function

Improved BMIImproved metabolic healthImproved vascular health

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Key Elements

Measures to optimize compliance Social work screening prior to study entry Group mediated cognitive behavioural interventions Long acting metformin, once daily dosing

Rigorous outcome measures DEXA for body composition Objective measures of fitness and activity Glycemic status detailed with OGTT as well as HOMA Vascular assessment with PAT, 24 hr EKG, US

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Inclusion Criteria

Age 10-16 years Obese, defined as BMI greater than the 95th

percentile for age and gender Metformin naïve subjects Able to swallow pills Able to function in a group

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Activity Intervention

Weeks 1 to 12, HSL, UWO Exercise sessions 3 per week, each session lasting for 1 hour and conducted with groups of 10 or more Intensive exercise group - cycle erogometer, treadmill,

stepper and resistance training equipment Moderate exercise group - steps, dynabands, fit balls and

weights GMCB 20 mins/week- aimed at developing self-regulatory

skills needed for exercise adherence

Weeks 13 to 104, Memorial Boy’s & Girls Club Moderate exercise sessions 1 per week

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Latino Families in Action Implementing and Evaluating a Community-based

Obesity Prevention Program for a High-risk

Paediatric Population

The Project TeamBetty Harvey Stewart HarrisMeizi HeCheril ClarsonDanielle Battram Gillian MandichLinda Khoshaba

Funded By:

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Study Backgound

80% (1.5 million) Canada’s Latin immigrants live in Ontario

Latino adults T2D 3-4 times >general population

London has one of the fastest growing Latino populations in Canada

Pilot study of 150 Latino children aged 6-12 yrs: 35% overweight 24% obese

(24% and 12 % for London non-Latino children)

Harvey B, 2003 CDAHe M 2003 Public Health ReportForeyt JP 2003 Permanente J

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Latino Families in Action

Program Culturally and linguistically sensitive 6-month program Families undergo intensive one-on-one case management Addresses key factors contributing to childhood obesity and

facilitates strategies to combat these factors

Location YMCA

Outcome Measures – Changes in: BMI and obesity % body fat measured BIA Fitness level by 20-meter shuttle Physical & sedentary behaviours, self efficacy to active living

Screened n = 178Age 6-12 yrs

Excluded n = 11171 not overweight

or obese4 declinedEnrolled n = 67

BMI > 85%

Intervention6 month intensive risk managementlinguistically, socioeconomically relevantfamily-oriented program

Results

Junk food consumption -3.3 times/week Fruit & vegetable consumption +1.1 servings/dayScreen-related activities -55 min/dayPhysical activity level +46 min per day BMI Z-score -0.1

Delivered by trained lay health advisors

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A Group Based Lifestyle Intervention

for Obese Children and their

Families

Dr. Albert Carron, School of Kinesiology

Shauna Burke Albert CarronCheril ClarsonJennifer Irwin Jason GillilandMeizi HeMichelle Jackman, Rob Petrella, Harry PrapavessisKevin Shoemaker

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Program

Aim To develop, implement, and assess the

effectiveness of a 4-week lifestyle intervention for obese children and their families

Objectives To increase physical activity behaviour during and following the intervention To improve physiological and

psychological outcomes, as well as dietary patterns and self-efficacy

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Assessments Prior to CHAMP

1) Initial Meeting (UWO) Demographic Questionnaire Quality of Life Acticals DEXA Scan Vessel Wall Imaging

2) Bloodwork and Physical Assessment (CH, LHSC) Fasting Bloodwork Physical Assessment

Phone Conversation with Dietitian Child Lifestyle Questionnaire Child’s Self-Efficacy Towards Healthy Living Questionnaire

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Intervention Components

Group-based physical activity for children

Group-based educational sessions related to nutrition, physical activity, and behaviour modification

Weekly group-based family training sessions

Post-intervention group support for children & families

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Program Details Children attended “CHAMP camp” for

4-weeks (9am-4pm) August 2008

Transportation provided

Primary location: Canadian Centre for Activity and Aging UWO

Secondary location: YMCA Central Branch

Weekly field trips for children (Spikes, Laser Quest, Fleetway, East Park)

Family members attended 4 weekend family education sessions (10am – 2pm) at UWO

Cost per family for 4-week program: $200 (included transportation, family membership at YMCA, field trips, t-shirts, etc.

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Provincial Council for Children’s

Health

PCCH Expert Panel for Child and Youth Overweight and Obesity:

A Proposed Service Delivery Framework for Healthy Weights for Children and Youth across the Continuum of Care

August 2008

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Health Outcome Measures

Ultimate Outcome: To delay, reverse or prevent childhood and/or early

onset adult co-morbidities e.g. sleep disordered breathing, CVD and T2D

Primary Performance Measure: Reduction in weight

Secondary Outcome Measures: Improvement in risk factors related to sleep

disordered breathing, CVD and T2D

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Health Outcome Measures

A BMI decrease of 0.3-0.5 SDS has been associated

with the following improvements:

Lipid profile 8-10% improvement (0.3-0.5 mmol/L) BP 5% decrease (3-10 mm Hg) HOMA-IR 30% decrease (1.5)Improvement in apnea/hypopnea indexImprovement in QOL measures (Peds QL)

Nemet D, 2005, PediatrSavoye M, 2007, JAMAEpstein LH, 1994, Health Psychol

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Tertiary Level of Care

Core Team Advanced practice nurse 0.5 Clinic clerk 1.0 Dietitian 1.0 Exercise specialist 1.0 Pediatrician 0.3 Psychologist 0.3 Social worker 1.0

Cost per teamTotal annual operating budget $609,224Start up costs $11,1539

Assessment / Treatment Visits (Year One)

Tertiary Staffing Time Required with Patient

Initial Assessment:

Medical 45 minutes

Psycho-Social 45

Nutrition 45

Fitness/Physical Activity 45

Ongoing Treatment

Medical/APN 20 minutes every 3 mths x 1 yr as needed

Psycho-Social 30 minutes every 2 weeks for 3 mths30 minutes monthly for 9 mos

Nutrition 30 minutes every 2 wks for 3 mths30 minutes monthly for 9 mos

Fitness/Physical Activity 30 minutes every 2 weeks for 3 mths30 minutes monthly for 9 mths

Total 495 minutes per allied health125 minutes per MD/APN

Assessment/Treatment Visits (Year

One)

120 new patients per team Cost per new patient: $5077

Tertiary Staffing Time Required with Patient

Maintenance/Follow-Up

Medical/APN 1 visit x 20 minutes

Psycho-Social 1-3 visits x 20 minutes

Nutrition 1-3 visits x 20 minutes

Fitness/Physical Activity 1-3 visits x 20 minutes

Total 20 to 60 minutes per allied health20 minutes for MD/APN

Follow-Up Visits (Year Two)

115 new patients per team120 follow up patients per teamAverage cost per patient $2592

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HIP Kids

Subjects Age 8-18 years BMI >95%Objectives Decreased rate of weight gain and BMI Improved nutrition Increased physical activity Improved QOL Reduction of metabolic risk factors for CVD and T2DProgram Screening for suitability for entry Assessment/Treatment visits as in PCCH Report 15 visits in year one Multidisciplinary team

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Future Directions

Strategies to optimize screening and compliance

Sustainability

Genetic variance and scaling of intervention

Key windows of development for intervention in metabolic programming

Maternal health and childhood obesity