primary care interventions for overweight and obesity, and ... · primary care interventions for...
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Primary care interventions for
overweight and obesity, and
related comorbidities, in the
pediatric population.BRIAN KNOX, MD
ASSOCIATE PROFESSOR
INTERNAL MEDICINE – PEDIATRICS
USF COM
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Primary care interventions for
overweight and obesity, and
related comorbidities, in the
pediatric population.AUGUST 22, 2015
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Disclosures
I have no disclosures to make
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Objectives
Provide effective diet and physical activity counseling to pediatric patients who are overweight and obese.
Identify pediatric patients who would benefit from referral to a tertiary weight disorders clinic.
Provide first line lifestyle interventions for pediatric patients with common weight related comorbidities.
Identify pediatric patients with common weight related comorbidities who would benefit from additional intervention beyond lifestyle counseling.
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Prevention
Strategies
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All Children
Limit sugar-sweetened beverage consumption
Encourage adequate servings of fruits and
vegetables
No screen time prior to age 2
Less than 2 hours screen time after age 2
Eat breakfast daily
Encourage family meals
Encourage recommended portion sizes
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Management
Strategies
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Universal assessment of obesity risk and steps to prevention and treatment.
Sarah E. Barlow Pediatrics 2007;120:S164-S192
©2007 by American Academy of Pediatrics
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Prevention Plus
What is it?
Office-based interventions setting specific goals for
families
More frequent visits
Mostly performed by scheduled counseling from a
medical provider
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Prevention Plus
Specific Behavioral Targets:
Consume at least 5 fruits / vegetables per day
Eliminate sugar-sweetened beverages
<2 hours screen time
Physically active >= 1 hour per day
Breakfast every day
Involve the whole family
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Prevention Plus
Implementation:
Stepwise, using realistic and attainable goals
Tailor frequency of visits to individual family
Motivational Interviewing skills recommended
Trial for 3-6 months, and if no improvement,
escalate to next step
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Structured Weight
Management
Similar behavioral targets:
Planned meals (3 per day)
Planned Snacks (1-2 per day)
No sugar sweetened beverages
Supervised active play, 60 minutes +
Screen time reduced further to <1 hour
Tracking of behavioral goals
Planned reinforcement for achieved goals
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Structured Weight
Management
Implementation:
Need dietician or clinician with additional nutritional
experience to structure meals and snacks
Psychologists / Counselors may be of benefit
Parenting skills
Motivation
Staff with motivational interviewing skills may be
used for follow up
Monthly visits recommended at this stage
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Comprehensive Multi-
Disciplinary Weight
Management Team approach should include:
Medical provider (Physician / PA / ARNP)
Behavioral provider (social worker, psychologist,
etc)
Dietician
Exercise specialist
Frequent office visits
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Tertiary Care
Failure of improvement in CMI should not
automatically trigger tertiary approach
These can be offered to severely obese adolescents who are carefully selected.
May utilize:
Medications
Very low calorie diet initiation under close
supervision
Bariatric surgery
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Medications
Orlistat
Approved for ages 12 +
Phentermine
Approved for ages 16 +
Diethylpropion
Approved for ages 16+
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Bariatric Surgery
Candidates should be:
Physically mature
Emotionally mature
BMI >40 with complications, or >50 without
More than 6 months of organized weight loss
attempts
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Primary Care
Management
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Using Motivational
Interviewing
Assess Patient’s Level of Concern and Attitudes
Concern about weight/nutrition/activity?
Readiness to change?
Past successes and challenges
Is Physician or Provider ready?
Need sufficient time for discussion
Open-minded, POSITIVE attitude
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Using Motivational
Interviewing
Empathize/elicit
“Your weight for height, or BMI may put you at increased risk of early diabetes”
“Have you had any concerns about nutrition or weight changes?”
“Would you be interested in talking about ways to reduce risk?”
“Have you thought of or tried making any changes?
“How ready do you or your family feel to make changes?”
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Using Motivational
Interviewing
Provide a menu of evidence-based interventions
“Some suggestions on how to reduce your risk are…”
“Are any of these something you and your family would like to work on? Other ideas?”
Elicit patient’s response to the advice provided:
What do you think of these ideas?
What might work for you?
What do you need to be successful?
What challenges do you see?
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Using Motivational
Interviewing
Simple messages and plans of action are most
effective
Pick single achievable goal with patient at each visit
Encourage active participation by family
At minimum monthly follow-up on progress with goals
individualize to patient needs
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Be Positive
Praise small successes at
EACH visit
Focus on achieving
goals set at each visit,
NOT on weight
Focus is on health
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Resources……THAT I FIND HANDY
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http://www.obesity.org/resources-
for/clinicians.htm
http://www.letsmove.gov
http://www.choosemyplate.gov
http://www.letsgo.org
https://healthychildren.org/english/health
y-living/pages/default.aspx
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Thank You!
I’m happy to answer any questions…