Using Evidence to Treat Using Evidence to Treat Overweight and Obesity: Overweight and Obesity: ADA’s Pediatric Weight ADA’s Pediatric Weight Management MNT GuidelinesManagement MNT Guidelines

Nancy Copperman, MS,RD,CDNNancy Copperman, MS,RD,CDNDirector, Public Health InitiativesDirector, Public Health InitiativesOffice of Community HealthOffice of Community HealthNorth Shore Long Island Jewish Health SystemNorth Shore Long Island Jewish Health System

EAL PWM Expert EAL PWM Expert Workgroup MembersWorkgroup Members Christina W. Biesemeier, MS, RD, Christina W. Biesemeier, MS, RD,

LD, FADA, ChairLD, FADA, Chair Joyce B. Bittle, PhD, RD, LDN Joyce B. Bittle, PhD, RD, LDN Nancy M. Copperman, MS, RD, CND Nancy M. Copperman, MS, RD, CND Heather S. Holden, RD, LDN Heather S. Holden, RD, LDN Shelley Kirk, PhD, RD, LD Shelley Kirk, PhD, RD, LD Aida C. G. Miles, MMSc, RD, LD Aida C. G. Miles, MMSc, RD, LD Lorrene D. Ritchie, PhD, RD Lorrene D. Ritchie, PhD, RD Denise Sofka, MPH,RD Denise Sofka, MPH,RD

Presentation Presentation ObjectivesObjectives

Review the process for developing the Pediatric Weight Review the process for developing the Pediatric Weight Management (PWM) Nutrition Practice Guideline, Management (PWM) Nutrition Practice Guideline, emphasizing emphasizing practical tips for implementing key practical tips for implementing key recommendations, ratings and supporting evidence.recommendations, ratings and supporting evidence.

Describe the major PWM Guideline recommendations Describe the major PWM Guideline recommendations and how they are integrated into Alliance Healthcare and how they are integrated into Alliance Healthcare Initiative for the treatment of overweight and obese Initiative for the treatment of overweight and obese children, adolescents and their families.children, adolescents and their families.

Learn coverage details and enrollment requirements for Learn coverage details and enrollment requirements for RD participation in the Alliance Healthcare Initiative.RD participation in the Alliance Healthcare Initiative.

Questions &TopicsQuestions &Topics

Factors Associated with Childhood OverweightFactors Associated with Childhood Overweight Foods and Nutrients Foods and Nutrients

– Dairy and Calcium Dairy and Calcium Is intake of calcium related to adiposity in Is intake of calcium related to adiposity in

children? children? Is intake of dairy related to adiposity in children? Is intake of dairy related to adiposity in children?

– Fruit Juice Fruit Juice Is intake of 100% fruit juice related to adiposity Is intake of 100% fruit juice related to adiposity

in children?in children? – Fruits and Vegetables Fruits and Vegetables

Is intake of fruits and vegetables related to Is intake of fruits and vegetables related to adiposity in children?adiposity in children?

– Sweetened Beverages Sweetened Beverages Is intake of calorically-sweetened beverages Is intake of calorically-sweetened beverages

related to adiposity in children? related to adiposity in children?

Questions & TopicsQuestions & Topics

Family Influences Family Influences

Family resources: psychological, social and Family resources: psychological, social and financial financial – In general, what is the relationship between In general, what is the relationship between

parental feeding strategies and childhood parental feeding strategies and childhood obesity? obesity?

– Are parental attitudes towards their own Are parental attitudes towards their own dietary intakes (Dietary restraint and dietary intakes (Dietary restraint and disinhibition) associated with higher risk or disinhibition) associated with higher risk or prevalence of overweight among children? prevalence of overweight among children?

– What is the relationship between household What is the relationship between household food insecurity and childhood overweight? food insecurity and childhood overweight?

Questions & TopicsQuestions & Topics

Family Influences Family Influences Diet and Family Activity Management Diet and Family Activity Management

Strategies Strategies – Is parental control over child dietary intake Is parental control over child dietary intake

associated with higher risk or prevalence associated with higher risk or prevalence of overweight among children?of overweight among children?

– Is eating out related to adiposity in Is eating out related to adiposity in

children? children?

– Is portion size related to adiposity in Is portion size related to adiposity in children? children?

Questions & TopicsQuestions & Topics

Family Influences Family Influences Parent/Child Relationship or Emotional Parent/Child Relationship or Emotional

Climate Climate – Is family functioning associated with higher Is family functioning associated with higher

risk or prevalence of overweight among risk or prevalence of overweight among children? children?

– Is parental concern about, or criticism of, their Is parental concern about, or criticism of, their child's weight status associated with higher child's weight status associated with higher risk or prevalence of overweight among risk or prevalence of overweight among children? children?

– Is using food as a reward (instrumental Is using food as a reward (instrumental feeding) and emotional feeding associated feeding) and emotional feeding associated with higher risk or prevalence of overweight with higher risk or prevalence of overweight among children? among children?

Questions & TopicsQuestions & Topics

Physical Activity and Inactivity Physical Activity and Inactivity Television viewing Television viewing Video games Video games Physical Activity Physical Activity Sports Activity Sports Activity

Questions & TopicsQuestions & Topics

II. Interventions Associated with II. Interventions Associated with Childhood OverweightChildhood Overweight

Prevention Prevention – School-based Interventions School-based Interventions

Treatment Treatment – Treatment focus: dietary, physical activity, Treatment focus: dietary, physical activity,

behavioral, adjunct therapies behavioral, adjunct therapies – Treatment format: family, education, Treatment format: family, education,

individual vs. group, peer modeling individual vs. group, peer modeling – Treatment supports: medications, Treatment supports: medications,

measuring energy expenditure measuring energy expenditure

PWM Guideline PWM Guideline Recommendations and Recommendations and the Nutrition Care the Nutrition Care ProcessProcess Algorithms based on NCPAlgorithms based on NCP Nutrition AssessmentNutrition Assessment

– Food Nutrition HxFood Nutrition Hx– Biochemical and Medical DataBiochemical and Medical Data– AnthropometricsAnthropometrics– Physical ExaminationPhysical Examination– Client HistoryClient History

PWM Guideline PWM Guideline Recommendations and Recommendations and the Nutrition Care the Nutrition Care ProcessProcess Nutrition DiagnosisNutrition Diagnosis Nutrition InterventionNutrition Intervention

– Nutrition prescriptionNutrition prescription– Food/nutrient deliveryFood/nutrient delivery– Nutrition educationNutrition education– Nutrition CounselingNutrition Counseling– Coordination of CareCoordination of Care

PWM Guideline PWM Guideline Recommendations and Recommendations and the Nutrition Care the Nutrition Care ProcessProcess

Monitoring and EvaluationMonitoring and EvaluationNutrition-related behavioral-environmental Nutrition-related behavioral-environmental

outcomesoutcomes

Food and nutrient intake outcomesFood and nutrient intake outcomes

Nutrition-related physical sign/symptom Nutrition-related physical sign/symptom outcomesoutcomes

Nutrition-related pt/client-centered outcomesNutrition-related pt/client-centered outcomes

Guideline RatingsGuideline Ratings

StrongStrong- evidence Grade I or II- evidence Grade I or IIPractitioners should followPractitioners should follow

FairFair- evidence Grade II or III- evidence Grade II or IIIPractitioners should follow but be awarePractitioners should follow but be awareof new informationof new information

WeakWeak-evidence suspect or well done -evidence suspect or well done studies show little advantage to 1 studies show little advantage to 1 approach verses anotherapproach verses anotherPractitioners should be cautious in deciding Practitioners should be cautious in deciding whether to follow guideline, alert for new info, whether to follow guideline, alert for new info, pt preference more influential in decisionpt preference more influential in decision

Guideline RatingsGuideline Ratings

ConsensusConsensus- Expert opinion- Grade IV- Expert opinion- Grade IVPractitioners should be flexible in deciding whether to Practitioners should be flexible in deciding whether to followfollow Pt preference more influential in decisionPt preference more influential in decision

Insufficient Evidence-Insufficient Evidence- both a lack of both a lack of pertinent evidence (Grade V) and/or an pertinent evidence (Grade V) and/or an unclear balance between benefits and harmsunclear balance between benefits and harmsPractitioners should feel little constraint in deciding Practitioners should feel little constraint in deciding whether to followwhether to follow , , be alert for new infobe alert for new infoPt preference substantial influence in decisionPt preference substantial influence in decision

Additional Guideline Additional Guideline RatingsRatings

In addition to the strength of the In addition to the strength of the guideline ratings, the guideline ratings, the recommendations can be worded as recommendations can be worded as conditionalconditional or or imperativeimperative statements. Conditional statements statements. Conditional statements clearly define a specific situation, while clearly define a specific situation, while imperative statements are broadly imperative statements are broadly applicable to the target population applicable to the target population without restraints on their pertinence.without restraints on their pertinence.

EJ is a 16 yr male referred for weight management. EJ is a 16 yr male referred for weight management. He has previously tried to loss weight on his own by He has previously tried to loss weight on his own by reducing portion sizes at meals and increasing reducing portion sizes at meals and increasing physical activity. Initially he is successful but after a physical activity. Initially he is successful but after a couple of weeks he gains back all the weight he lost couple of weeks he gains back all the weight he lost plus some additional weight. He typically eats fast plus some additional weight. He typically eats fast food meals daily, drinks 2 quarts of sweetened food meals daily, drinks 2 quarts of sweetened beverages throughout the day and has 4 hrs of beverages throughout the day and has 4 hrs of screen time daily. His family is supportive of his screen time daily. His family is supportive of his efforts but does not join him when he modifies his efforts but does not join him when he modifies his diet and exercise habits. EJ would like to be diet and exercise habits. EJ would like to be successful in managing his weight.successful in managing his weight.

Anthropometrics, Laboratory and Physical Findings:Anthropometrics, Laboratory and Physical Findings:BMI 32 >97th %, BP wnl, Ht. 68 Wt. 210 lbBMI 32 >97th %, BP wnl, Ht. 68 Wt. 210 lbFasting insulin, glucose wnlFasting insulin, glucose wnlFasting lipid profile reveals elevated triglycerides and Fasting lipid profile reveals elevated triglycerides and a low HDL a low HDL

Applying the Guidelines to a CaseApplying the Guidelines to a Case

AssessmentAssessment

PWM: Assessing Foods and Pediatric Overweight

PWM: Assessing Child and Family Diet PWM: Assessing Child and Family Diet Behaviors in Pediatric OverweightBehaviors in Pediatric Overweight

PWM: Assessing Physical Activity and PWM: Assessing Physical Activity and Sedentary BehaviorsSedentary Behaviors

PWM: Determination of Total Energy PWM: Determination of Total Energy ExpenditureExpenditure

PWM: Assessing Family Climate PWM: Assessing Family Climate Factors Factors

What are the effects of EJ’s frequent What are the effects of EJ’s frequent fast food meals and daily sweetened fast food meals and daily sweetened beverage consumption on his weight beverage consumption on his weight status?status? Dietary factors that may be associated Dietary factors that may be associated

with an with an increase in the risk of increase in the risk of overweightoverweight and should be included in and should be included in Nutrition Assessment are: Nutrition Assessment are: increased increased total dietary fat intake and increased total dietary fat intake and increased calorically sweetened beveragescalorically sweetened beverages. ADA . ADA Evidence Analysis has shown that Evidence Analysis has shown that these factors are positively associated these factors are positively associated with childhood overweight. with childhood overweight. StrongStrongImperativeImperative

What are the effects of EJ’s What are the effects of EJ’s frequent fast food meals and frequent fast food meals and large portion sizes on his large portion sizes on his weight status?weight status? Child and family diet behavior factors that Child and family diet behavior factors that

may be associated with an may be associated with an increase in the increase in the risk of overweightrisk of overweight and should be included and should be included in Nutrition Assessment are: parental in Nutrition Assessment are: parental restriction of highly palatable foods, restriction of highly palatable foods, consumption of food away from home, consumption of food away from home, increased portion size of mealsincreased portion size of meals, breakfast , breakfast skipping. ADA Evidence Analysis has shown skipping. ADA Evidence Analysis has shown that these factors are positively associated that these factors are positively associated with childhood overweight. with childhood overweight. FairFairImperativeImperative

What is the effect of 4 hrs of What is the effect of 4 hrs of Screen Time /Day on EJ’s Screen Time /Day on EJ’s weight status?weight status? Physical activity and sedentary Physical activity and sedentary

behavior factors that may be behavior factors that may be associated with an associated with an increase increase in the in the risk of overweightrisk of overweight and should be and should be included in Nutrition Assessment are: included in Nutrition Assessment are: excessive television viewing, and excessive television viewing, and excessive use of video gamesexcessive use of video games. ADA . ADA Evidence Analysis has shown that Evidence Analysis has shown that these factors are positively associated these factors are positively associated with childhood overweight. with childhood overweight. FairFairImperative Imperative

How would an RD determine How would an RD determine the TEE for EJ?the TEE for EJ?

If possible, RMR should be measured (e.g., If possible, RMR should be measured (e.g., indirect calorimetry). If RMR cannot be indirect calorimetry). If RMR cannot be measured, then the equations for estimating measured, then the equations for estimating total energy expenditure in overweight youth total energy expenditure in overweight youth provided in the provided in the 2005 US Institutes of 2005 US Institutes of Medicine "Dietary Reference Intakes for Medicine "Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids Cholesterol, Protein, and Amino Acids (Macronutrients), " (Macronutrients), " may be used. Estimated may be used. Estimated energy needs should be based on Total energy needs should be based on Total Energy Expenditure Energy Expenditure ConsensusConsensusConditionalConditional

TEE in Overweight Boys Ages 3 TEE in Overweight Boys Ages 3 Through 18 Years in a Weight Through 18 Years in a Weight Maintenance ProgramMaintenance Program

TEE = 114 – (50.9 × age [TEE = 114 – (50.9 × age [16y16y]) + PA(]) + PA(1.121.12) × ) × (19.5 × weight [(19.5 × weight [95.45Kg95.45Kg] + 1161.4 × height ] + 1161.4 × height [[1.72m1.72m]) =]) =3381.2 3381.2

Where PA is the physical activity coefficient:Where PA is the physical activity coefficient: PA = 1.00 if PAL is estimated to be = 1.0 < 1.4 PA = 1.00 if PAL is estimated to be = 1.0 < 1.4

(sedentary) (sedentary) PA = 1.12 if PAL is estimated to be = 1.4 < 1.6 (low PA = 1.12 if PAL is estimated to be = 1.4 < 1.6 (low

active)active) PA = 1.24 if PAL is estimated to be = 1.6 < 1.9 PA = 1.24 if PAL is estimated to be = 1.6 < 1.9

(active) (active) PA = 1.45 if PAL is estimated to be = 1.9 < 2.5 (very PA = 1.45 if PAL is estimated to be = 1.9 < 2.5 (very

active) active)

How would an RD determine a How would an RD determine a weight management goal for weight management goal for EJ?EJ?

www.pediatrics.org/cgi/doi/10.1542/www.pediatrics.org/cgi/doi/10.1542/peds.2007-2329C peds.2007-2329C

Sarah E. Barlow and the Expert Committee. Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report. Pediatrics. 2007;120;S164-S192.

Expert Committee Expert Committee Weight TargetsWeight Targets

#95%-98% - until BMI<85#95%-98% - until BMI<85thth% with no more % with no more than an average of 2lb/weekthan an average of 2lb/week

Age12-18 yrs

85th -94th % 95th – 98th % >99th %

Weight Maintenance Or slowing of weight gain

Weight loss# Weight Loss

(not to exceed 2lb/week)

How does the fact that EJ’s How does the fact that EJ’s family does not model family does not model behaviors affect his weight?behaviors affect his weight? Family climate factors that may be associated Family climate factors that may be associated

with an with an increase in the risk of overweightincrease in the risk of overweight and should be included in Nutrition and should be included in Nutrition Assessment are: parental dietary disinhibition Assessment are: parental dietary disinhibition and restraint, negative aspects of family and restraint, negative aspects of family functioning (such as functioning (such as lack of parental supportlack of parental support or or over-possessiveness), and parental concern over-possessiveness), and parental concern about child’s weight status. ADA Evidence about child’s weight status. ADA Evidence Analysis has shown that these factors are Analysis has shown that these factors are positively associated with childhood positively associated with childhood overweight. overweight. Fair ImperativeFair Imperative

Nutrition DiagnosisNutrition Diagnosis

NI-1.5 Excessive energy intakeNI-1.5 Excessive energy intake NI 2.2 Excessive oral food/beverage intakeNI 2.2 Excessive oral food/beverage intake NI-51.2 Excessive fat intakeNI-51.2 Excessive fat intake NI-53.2 Excessive intake of CHONI-53.2 Excessive intake of CHO NC-2.2 Altered nutrition-related lab valuesNC-2.2 Altered nutrition-related lab values NB-1.1 Food, nutrition and nutrition NB-1.1 Food, nutrition and nutrition

related knowledge deficitrelated knowledge deficit NB-2.1 Physical inactivityNB-2.1 Physical inactivity

Intervention: Nutrition PrescriptionIntervention: Nutrition PrescriptionWould EJ benefit from an Would EJ benefit from an individualized nutrition individualized nutrition prescription?prescription? A nutrition prescription should be formulated as A nutrition prescription should be formulated as

part of the dietary intervention in a part of the dietary intervention in a multicomponent pediatric weight management multicomponent pediatric weight management program. The exact specification of nutrients and program. The exact specification of nutrients and energy is often translated into a specific eating energy is often translated into a specific eating plan. Nutrition interventions are selected based plan. Nutrition interventions are selected based on the nutrition prescription. on the nutrition prescription. Research shows Research shows that when individualized nutrition prescription is that when individualized nutrition prescription is included, improvements in weight status in included, improvements in weight status in children and adolescents are consistent. When children and adolescents are consistent. When an individualized nutrition prescription is not an individualized nutrition prescription is not included, results are less consistent. included, results are less consistent. StrongStrongImperativeImperative

Intervention:Intervention:Nutrition PrescriptionNutrition Prescription Energy RestrictionEnergy RestrictionPWM: Energy Restricted DietsPWM: Energy Restricted Diets Altered Macronutrient DietsAltered Macronutrient DietsPWM: Reduced Glycemic Load DietPWM: Reduced Glycemic Load DietPWM: Very Low Carbohydrate DietPWM: Very Low Carbohydrate DietPWM: Using Protein Sparing Modified PWM: Using Protein Sparing Modified

Fast Diets for Pediatric Weight LossFast Diets for Pediatric Weight LossPWM: Very Low Fat Diet (<20% Daily PWM: Very Low Fat Diet (<20% Daily

Energy Intake from Fat)Energy Intake from Fat)

Is energy restriction Is energy restriction appropriate for EJ?appropriate for EJ?

If energy restriction is appropriate based on the If energy restriction is appropriate based on the registered dietitian's professional judgment, then registered dietitian's professional judgment, then a balanced macronutrient diet that contains no a balanced macronutrient diet that contains no fewer than 1200 kcal per day is recommended to fewer than 1200 kcal per day is recommended to improve weight status within a multicomponent improve weight status within a multicomponent pediatric weight management program in pediatric weight management program in adolescents ages 13-18adolescents ages 13-18 who are medically who are medically monitored. monitored. Research indicates that energy Research indicates that energy restricted balanced macronutrient diets no lower restricted balanced macronutrient diets no lower than 1200 kcal per day are associated with both than 1200 kcal per day are associated with both short term and longer term (>1 year) improved short term and longer term (>1 year) improved weight status and body composition among 13-18 weight status and body composition among 13-18 year-old adolescents.year-old adolescents.StrongStrongConditionalConditional

Is a reduced glycemic Is a reduced glycemic load diet an option for load diet an option for EJ?EJ? If an ad libitium reduced glycemic load diet is If an ad libitium reduced glycemic load diet is

selected for use in selected for use in adolescents (age 13-18)adolescents (age 13-18), , then this diet could be used to produce then this diet could be used to produce modest, short term and longer term modest, short term and longer term improvement in weight status and body improvement in weight status and body composition. Limited research shows that an composition. Limited research shows that an ad libitium reduced glycemic load diet results ad libitium reduced glycemic load diet results in short term improvement in weight status in short term improvement in weight status and body composition in this age group. One and body composition in this age group. One study shows weight status improvement at 1 study shows weight status improvement at 1 year.year.FairFairConditionalConditional

Is a Protein Sparing Is a Protein Sparing Modified Fast Diet an Modified Fast Diet an option for EJ?option for EJ? If overweight (>120% IBW) children and If overweight (>120% IBW) children and adolescents with adolescents with

serious medical complicationsserious medical complications would benefit from would benefit from rapid weight loss, then a Protein Sparing Modified Fast Diet rapid weight loss, then a Protein Sparing Modified Fast Diet (PSMF) could be utilized in a short-term intervention (typically 10 (PSMF) could be utilized in a short-term intervention (typically 10 weeks) under the supervision of a multidisciplinary team of weeks) under the supervision of a multidisciplinary team of healthcare providers who specialize in pediatric overweight. healthcare providers who specialize in pediatric overweight. Research shows that short term use of a PSMF brings about Research shows that short term use of a PSMF brings about short term and longer term improvement in weight status and short term and longer term improvement in weight status and body composition when part of a medically supervised, body composition when part of a medically supervised, multicomponent program. multicomponent program. WeakWeakConditionalConditional

The Protein Sparing Modified Fast Diet is not recommended for The Protein Sparing Modified Fast Diet is not recommended for long-term weight management for overweight children or long-term weight management for overweight children or adolescents. There are few well designed studies to support the adolescents. There are few well designed studies to support the use of this intervention for longer than 10 weeks.use of this intervention for longer than 10 weeks.WeakWeakImperativeImperative

Nutrition EducationNutrition EducationWould Nutrition education be Would Nutrition education be an effective intervention for EJ?an effective intervention for EJ? In a multicomponent program, if there In a multicomponent program, if there

is a nutrition diagnosis for food and is a nutrition diagnosis for food and nutrition-related knowledge deficit, nutrition-related knowledge deficit, then nutrition education should be then nutrition education should be tailored to the nutrition prescription. tailored to the nutrition prescription. Research shows that if nutrition Research shows that if nutrition education is not tailored to nutrition education is not tailored to nutrition prescription, improvement in weight prescription, improvement in weight status is not consistent.status is not consistent. FairFairConditionalConditional

Nutrition CounselingNutrition Counseling

PWM: Nutrition Counseling and Behavior Therapy Strategies in the Treatment of Overweight in Children and Adolescents

PWM: Family Participation in Treating PWM: Family Participation in Treating Pediatric Overweight in Children and Pediatric Overweight in Children and AdolescentsAdolescents

PWM: Nutrition Counseling: Setting PWM: Nutrition Counseling: Setting Weight Goals with Patient and FamilyWeight Goals with Patient and Family

Should nutritional Should nutritional counseling for EJ include counseling for EJ include self monitoring?self monitoring? Nutrition counseling delivered by an Nutrition counseling delivered by an

RD (which is inclusive of goal setting, RD (which is inclusive of goal setting, self monitoringself monitoring, stimulus control, , stimulus control, problem solving, contingency problem solving, contingency management, cognitive restructuring, management, cognitive restructuring, use of incentives and rewards, and use of incentives and rewards, and social supports) should be a part of the social supports) should be a part of the behavior therapy component of a behavior therapy component of a multicomponent pediatric weight multicomponent pediatric weight management program. management program. ConsensusConsensusImperativeImperative

Should nutritional Should nutritional counseling for EJ include counseling for EJ include self monitoring?self monitoring? Behavior therapy strategies should be Behavior therapy strategies should be

included as part of a multicomponent included as part of a multicomponent pediatric weight management program. pediatric weight management program. Research shows that when behavior Research shows that when behavior therapy strategies are included within therapy strategies are included within the context of a multidisciplinary team, the context of a multidisciplinary team, weight status and body composition weight status and body composition improve. improve. StrongStrongImperativeImperative

Should family-based counseling Should family-based counseling be a part of EJ nutrition be a part of EJ nutrition counseling?counseling?

Parent/caregiver may be included in Parent/caregiver may be included in multicomponent pediatric weight multicomponent pediatric weight management programs when treating management programs when treating adolescentsadolescents. A limited body of research . A limited body of research indicates that programs with or without indicates that programs with or without parent/caregiver participation may be parent/caregiver participation may be effective for improvements in weight effective for improvements in weight status and adiposity in adolescents.status and adiposity in adolescents.FairFairConditionalConditional

Coordination of Nutrition Care: Coordination of Nutrition Care: Would the RD collaborating Would the RD collaborating with other health providers with other health providers improve the effectiveness of improve the effectiveness of EJ’s intervention?EJ’s intervention? Dietitian should collaborate with Dietitian should collaborate with

members of the healthcare team (as members of the healthcare team (as available) in planning and implementing available) in planning and implementing behavior, physical activity, and adjunct behavior, physical activity, and adjunct therapy strategies. Effective therapy strategies. Effective multicomponent pediatric weight multicomponent pediatric weight management interventions benefit from management interventions benefit from the diverse expertise of different the diverse expertise of different healthcare professionals. healthcare professionals. ConsensusConsensusImperativeImperative

Counseling for changes in Counseling for changes in Physical Activity and Physical Activity and InactivityInactivity

PWM: Decreasing Sedentary PWM: Decreasing Sedentary Behaviors in Children and Behaviors in Children and AdolescentsAdolescents

PWM: Physical Activity in the Treatment of Childhood and Adolescent Overweight

Should EJ reduce Should EJ reduce sedentary activities?sedentary activities? Adolescents should be counseled to Adolescents should be counseled to

reduce or limit sedentary activities reduce or limit sedentary activities (e.g. TV, video games, “screen time”). (e.g. TV, video games, “screen time”). Limited intervention research indicates Limited intervention research indicates that reducing sedentary activities may that reducing sedentary activities may have both long and short term benefits have both long and short term benefits in terms of overweight.in terms of overweight.

Weak ImperativeWeak Imperative

Is there a benefit to Is there a benefit to increased Physical Activity increased Physical Activity for EJ?for EJ? Physical activity should be included as Physical activity should be included as

part of a multicomponent pediatric part of a multicomponent pediatric weight management program. weight management program. Research indicates that increasing Research indicates that increasing physical activity as part of a physical activity as part of a multicomponent program results in multicomponent program results in significant improvements in weight significant improvements in weight status and/or body composition in status and/or body composition in children and adolescents. children and adolescents. StrongStrongImperativeImperative

Adjunct TherapiesAdjunct Therapies

PWM: Adjunct Therapies: Use of PWM: Adjunct Therapies: Use of Weight Loss Medications in Weight Loss Medications in Treating Overweight in Treating Overweight in AdolescentsAdolescents

PWM: Adjunct Therapies: Weight PWM: Adjunct Therapies: Weight Loss Surgery and Adolescent Loss Surgery and Adolescent OverweightOverweight

Is EJ a candidate for Is EJ a candidate for weight loss weight loss medication?medication? The The dietitian should collaboratedietitian should collaborate with with

the health care team regarding the use the health care team regarding the use of weight loss medications as an of weight loss medications as an adjunct therapy within a adjunct therapy within a multicomponent pediatric weight multicomponent pediatric weight management program for adolescents. management program for adolescents. Clinical outcomes are likely to be Clinical outcomes are likely to be enhanced with the participation of a enhanced with the participation of a dietitian. dietitian. ConsensusConsensusImperativeImperative

Is EJ a candidate for Is EJ a candidate for weight loss weight loss medication?medication? Criteria: Criteria: BMI>27 with obesity related diseases BMI>27 with obesity related diseases

or BMI 30or BMI 30 If a weight loss medication is selected as an adjunct If a weight loss medication is selected as an adjunct

therapy, then an over the counter or prescription therapy, then an over the counter or prescription gastrointestinal lipase inhibitor (e.g., orlistat) approved gastrointestinal lipase inhibitor (e.g., orlistat) approved by the FDA for use in adolescents may be recommended by the FDA for use in adolescents may be recommended to treat overweight adolescents participating in a to treat overweight adolescents participating in a multicomponent pediatric weight management program. multicomponent pediatric weight management program. Research indicates that a gastrointestinal lipase inhibitor Research indicates that a gastrointestinal lipase inhibitor further improves weight status and body composition in further improves weight status and body composition in some individuals within a multicomponent adolescent some individuals within a multicomponent adolescent weight management program. However, the FDA has weight management program. However, the FDA has not studied or approved the use of this class of not studied or approved the use of this class of medication for children under the age of 12.medication for children under the age of 12.FairFairConditionalConditional

Is EJ a candidate for Is EJ a candidate for weight loss surgery?weight loss surgery?

Dietitians should collaborate with other members Dietitians should collaborate with other members of the health care team regarding the of the health care team regarding the appropriateness of weight loss surgery for appropriateness of weight loss surgery for severely overweight adolescents who have not severely overweight adolescents who have not achieved weight loss goals with less invasive achieved weight loss goals with less invasive weight loss methods and who meet specified weight loss methods and who meet specified criteria (see Conditions of Application below). criteria (see Conditions of Application below). Research indicates that for a subset of Research indicates that for a subset of adolescents who meet the recommended adolescents who meet the recommended criteria, weight loss surgery may be effective in criteria, weight loss surgery may be effective in bringing about significant short term and long bringing about significant short term and long term weight loss. Overweight children (< 13 term weight loss. Overweight children (< 13 years of age) are generally not considered to be years of age) are generally not considered to be appropriate candidates for weight loss surgery. appropriate candidates for weight loss surgery. ConsensusConsensusImperativeImperative

Is EJ a candidate for Is EJ a candidate for weight loss surgery?weight loss surgery?Recommended criteria for adolescents being considered Recommended criteria for adolescents being considered

for weight loss surgery (based on for weight loss surgery (based on PediatricsPediatrics 2004;114:217-2232004;114:217-223))

Experienced failure of >= 6 months of organized Experienced failure of >= 6 months of organized weight loss attempts as determined by their weight loss attempts as determined by their primary care provider primary care provider

Have met certain anthropometric and medical Have met certain anthropometric and medical criteria criteria – Be severely obese (BMI >= 40) with serious Be severely obese (BMI >= 40) with serious

obesity-related medical complications or have a obesity-related medical complications or have a BMI >= 50 with less severe co-morbidities BMI >= 50 with less severe co-morbidities

– Have co-morbidities related to obesity that might Have co-morbidities related to obesity that might be resolved with durable weight loss be resolved with durable weight loss

– Have attained a majority of skeletal maturity Have attained a majority of skeletal maturity (generally >= 13 years of age for girls and >= 15 (generally >= 13 years of age for girls and >= 15 years of age for boys) years of age for boys)

Is EJ a candidate for Is EJ a candidate for weight loss surgery?weight loss surgery?Recommended criteria for adolescents being considered for Recommended criteria for adolescents being considered for

weight loss surgery (based on weight loss surgery (based on PediatricsPediatrics 2004;114:217-2004;114:217-223223))

Demonstrate commitment to comprehensive Demonstrate commitment to comprehensive medical and psychological evaluations both before medical and psychological evaluations both before and after weight loss surgery and after weight loss surgery

Be capable and willing to adhere to nutritional Be capable and willing to adhere to nutritional guidelines post-operatively guidelines post-operatively

Possess decisional capacity and participate in the Possess decisional capacity and participate in the decision process to undergo weight loss surgery. In decision process to undergo weight loss surgery. In other words, the adolescent must want the other words, the adolescent must want the intervention and understand what is involved. intervention and understand what is involved.

Have a supportive family environment. Have a supportive family environment. Be evaluated by a multi-disciplinary team who is Be evaluated by a multi-disciplinary team who is

involved in the patient selection, preparation, and involved in the patient selection, preparation, and surgery as well as immediate and long-term post-surgery as well as immediate and long-term post-operative follow-up care. operative follow-up care.

Treatment Format Treatment Format OptionsOptions

PWM: Treatment Format Options: PWM: Treatment Format Options: Group Versus Individual Group Versus Individual InterventionIntervention

Would group or individual Would group or individual nutrition intervention be better nutrition intervention be better for EJ?for EJ?

Either group or individual nutrition intervention Either group or individual nutrition intervention may be used as part of a multicomponent may be used as part of a multicomponent pediatric weight management program.pediatric weight management program. Limited research that compares individual Limited research that compares individual versus group format does not indicate versus group format does not indicate differences in overall pediatric weight status. differences in overall pediatric weight status. However, two studies suggest that some However, two studies suggest that some dietary outcome measures may be improved dietary outcome measures may be improved with an individual counseling format. with an individual counseling format. WeakWeakImperativeImperative

Monitoring and Monitoring and EvaluationEvaluation PWM: Optimal Length of Weight PWM: Optimal Length of Weight

Management Therapy in Children Management Therapy in Children and Adolescentsand Adolescents

What is the length of What is the length of tx EJ should receive?tx EJ should receive? During the intensive treatment phase, Medical During the intensive treatment phase, Medical

Nutrition Therapy for pediatric overweight Nutrition Therapy for pediatric overweight should last at least three months or until initial should last at least three months or until initial weight management goals are achieved. weight management goals are achieved. Because overweight is a chronic, often life-Because overweight is a chronic, often life-long, condition, it is critical that a weight long, condition, it is critical that a weight management plan be implemented after the management plan be implemented after the intensive phase of treatment. A greater intensive phase of treatment. A greater frequency of contacts between the patient and frequency of contacts between the patient and practitioner may lead to more successful practitioner may lead to more successful weight loss and maintenance. weight loss and maintenance. ConsensusConsensusImperativeImperative

Overall recommendation for Overall recommendation for pediatric overweight pediatric overweight interventionsinterventions Interventions to reduce pediatric overweight Interventions to reduce pediatric overweight

should be multicomponent and include diet, should be multicomponent and include diet, physical activity, nutrition counseling, and physical activity, nutrition counseling, and parent/caregiver participation. A large body parent/caregiver participation. A large body of strong research indicates that clinically of strong research indicates that clinically supervised, multicomponent weight supervised, multicomponent weight management programs are more successful management programs are more successful than single component programs for short-than single component programs for short-term and longer-term (>1 year) improvement term and longer-term (>1 year) improvement in child and adolescent overweight. in child and adolescent overweight. StrongStrongImperativeImperative

Overall recommendation for Overall recommendation for pediatric overweight pediatric overweight interventionsinterventions Weight maintenance is generally Weight maintenance is generally

recommended in overweight children 2-5 recommended in overweight children 2-5 years old within a multicomponent weight years old within a multicomponent weight management intervention with active management intervention with active participation of parent/caregiver. Weight loss participation of parent/caregiver. Weight loss may be recommended when the child has may be recommended when the child has serious medical complications. Research was serious medical complications. Research was not identified on the efficacy and safety of not identified on the efficacy and safety of weight loss interventions among children weight loss interventions among children ages 2-5. ages 2-5. ConsensusConsensusImperativeImperative

Expert Panel Expert Panel RecommendationsRecommendations Overweight and Obesity Overweight and Obesity

definitionsdefinitions Prevention strategiesPrevention strategies Staged Intervention StrategiesStaged Intervention Strategies Anthropometric, Laboratory and Anthropometric, Laboratory and

Physical exam Physical exam Client-Centered CounselingClient-Centered Counseling