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Systematic Assessment and Treatment of Childhood Obesity

Systematic Assessment and Treatment of Childhood Obesity. Annette Frain, RD, LDN Ben Hooker, MS, MD, MPH, FAAP. Disclosures. Annette Frain This speaker is employed by Triad Adult and Pediatric Medicine, Inc and has no other financial sources to disclose. Ben Hooker

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Systematic Assessment and Treatment of Childhood Obesity

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  1. Systematic Assessment and Treatment of Childhood Obesity Annette Frain, RD, LDN Ben Hooker, MS, MD, MPH, FAAP

  2. Disclosures Annette Frain This speaker is employed by Triad Adult and Pediatric Medicine, Inc and has no other financial sources to disclose. Ben Hooker This speaker is employed by Triad Adult and Pediatric Medicine, Inc and has no other financial sources to disclose.

  3. How bad is the problem? (1) Since 1980, obesity among children and adolescents has almost tripled. 9.5% of children 0 to 2 years are OBESE (≥95% Weight : Length ratio) 14.8% of 2 to 19 year olds are OVERWEIGHT 16.9% of 2 to 19 year olds are OBESE

  4. (2)

  5. Public Health (3) Number of the heaviest (BMI > 97%) children is increasing, even if overall percentage has stabilized. North Carolina will spend over $11 billion dollars annually by 2018 on health care costs attributable to obesity. Allowing this problem to continue to grow at its current pace will have dire economic, social, and public health consequences, including lower life expectancy in the 21st century.

  6. Health Disparity 1 of 7 low-income, preschool-aged children is obese. The rate of obese and overweight HISPANIC and AFRICAN-AMERICAN children ages 2-19 is 38.2% and 35.9%, respectively, while their CAUCASIAN counterparts are at 29.3%. Childhood obesity rates of AFRICAN AMERICANS and HISPANICS increased by 120% between 1986-1998, but among non-Hispanic whites it grew by only 50%.

  7. Health Risks: NOW (4) Obese children are more likely to have: • High blood pressure and high cholesterol (risk factors for cardiovascular disease). In one study, 70% of obese children had at least one CVD risk factor, and 39% had two or more. • Increased risk of impaired glucose tolerance, insulin resistance and type 2 diabetes.

  8. Health Risks: NOW • Breathing problems, such as sleep apnea, and asthma. • Joint problems and musculoskeletal discomfort. • Fatty liver disease, gallstones, and gastro-esophageal reflux. • Greater risk of social and psychological problems.

  9. Health Risks: LATER (4) • Obese children are more likely to become obese adults. • If children are overweight, obesity in adulthood is likely to be more severe. • Adult obesity is associated with a number of serious health conditions including heart disease, diabetes, and some cancers.

  10. Obesity Management Strategy Obesity management is like management of any other CHRONIC DISEASE: Requires patient-centered and well-coordinated care (MD/PNP, RD, Behavioral Health, Nursing, Exercise), preferably within the context of a Patient Centered Medical Home. Obese children seen by general pediatricians can be effectively managed using standardized practices: a. Evidence-based messages b. Motivational interviewing techniques

  11. Obesity Management System (5) SORT: Identify all practice methods currently used to manage obesity in the practice. Evaluate practices for effectiveness and discontinue duplicate practices. SET IN ORDER: Order practices into a logical practice protocol for assessing, risk stratifying, and step-wise management of obesity.

  12. Obesity Management System SHINE: Improve each step already in place to achieve the desired goal. STANDARDIZING: Make execution of each step consistent across the practice. Make standard the evidence-based messages used, intervals between visits, documentation, referrals, etc.

  13. Obesity Management System SUSTAIN: Ongoing system assessment in the form of continuous PDSA cycles. Patient input is critical to ensure the program is and remains patient-centered.

  14. Obesity Management (6) At every PE appointment for children ≥2 years: • HEIGHT, WEIGHT, and BMI: • Accurately MEASURE height and weight, manual BP • CALCULATE BMI and plot according to percentile by age and gender • CDC child and teen BMI calculator(7) • HISTORY and PHYSICAL EXAM 3. LABS

  15. Risk Stratification Once appropriate data is in hand, it is possible to assign a risk category to the patient. This RISK CATEGORY determines treatment.

  16. Determining Risk Category (7) Start with BMI definition (by age and gender): <5th% Underweight 5th% to <85th% Healthy weight 85th% to 94th% Overweight 95th% to 98th% Obese ≥99th% Obese (increased risk)

  17. (8)

  18. (9)

  19. Truth? Or, just an excuse? “I’m not fat! My mom says I’m big-boned!” “I'm not fat, I just haven't grown into my body yet!” “I'm not fat, I'm buff!”

  20. (9)

  21. Personal Risk Factors Elevated BP for age and gender Ethnicity (AA, NA, Hispanic, PI) Puberty Medications (steroids, anti-psychotics, AED) Acanthosis nigricans LGA or SGA at birth Disabilities

  22. Family Risk Factors Type 2 DM Hypertension High cholesterol Gestational diabetes in mother First degree relative with early death from cardiac disease or stroke

  23. Lab Screening (11) • FH of dyslipidemia or premature CVD or dyslipidemia (male first degree relative ≤55 yrs, female first degree relative ≤65 yrs). • Patients for whom FH is not known or those with other CVD risks: overweight, obese, HTN, cigarette smoking, or diabetes. • Screen with FASTING lipid profile.

  24. Lab Screening (10) Per the provided algorithm: <10 yrs BMI ≥ 85th%, no risk factors OR ≥10 yrs BMI 85th to 94th%, no risk factors Consider fasting lipids. ≥10 yrs BMI 85th to 94th%, ≥2 risk factors OR ≥10 yrs BMI ≥ 95th%, Do fasting lipids every 6 months, plus fasting glucose, LFT.

  25. However… (12) Recent research: FH is not sensitive or specific in identifying those children who may need medication. Proposing UNIVERSAL screening: First at 9 to 11 years old, then Repeat at 16 to 19 years old

  26. However… (13) FASTING is currently still recommended, but: Study from UNC (fasting v. NON-FASTING): Total Cholesterol and HDL were same, LDL varied slightly, TG varied the most. It may be as effective to draw lipids at the same visit that prompts the decision to do so.

  27. Risk Stratification • Defined by BMI as overweight, obese, or obese (increased risk), • Identified risk factors by PE and history, • Collected blood for appropriate labs. We are ready to get started on treatment, BUT…

  28. (14)

  29. Are they ready? (15) TRANSTHEORETICAL MODEL (TTM) OF CHANGE identifies 5 stages of change: • PRE-CONTEMPLATION: No intent to change in the next 6 months. “Unmotivated” • CONTEMPLATION: Intend to change in the next 6 months. “Ambivalent”

  30. Stages of Change 3. PREPARATION: Intends to take steps within 1 month. “Active”, but in EARLY change. • ACTION: Has made obvious lifestyle changes. More tempted to relapse. • MAINTENANCE: Working to prevent relapse, consolidate gains. Less tempted to relapse.

  31. (16)

  32. Readiness to Change Information alone does not motivate change. A unilateral agenda is unlikely to work.

  33. When you find a “ready patient”… TOGETHER you work to find what motivates them to make lifestyle changes. MOTIVATIONAL INTERVIEWING: To move a family that is not ready to change closer to making changes. To create a shared agenda to change lifestyle for the family that is ready to change.

  34. Motivational Interviewing Child is the focus, but family is also engaged. Foster a co-operative relationship. Incremental changes add up over time to produce a healthier lifestyle.

  35. (17)

  36. (10)

  37. Prevention (10) HEALTHY WEIGHT (BMI < 85th%) OVERWEIGHT (BMI 85-94th%), no risk factors Reinforce healthy behaviors, Address questions and concerns, Correct any misconceptions, Follow on a yearly basis to reassess BMI and risk factors.

  38. Step 1 Treatment OVERWEIGHT (BMI 85-94th%) WITH risk factors OBESE (BMI ≥ 95th%) Treatment starts with the coordinated efforts of the PCP and RD. Meet with PCP or RD once every 1 to 3 months. Review previous visit and identify ways to make progress.

  39. Step 1 Treatment Evidence-based messages about healthier eating and physical activity are the content of patient-provider dialogue. Information is important to advance the patients understanding of the problem of obesity, but is not sufficient to motivate the patient to change.

  40. Eat Smart, Move More NC's Seven Target Behaviors (18) 1. Promote breastfeeding 2. Increased physical activity 3. More fruits and vegetables 4. No sugar-sweetened beverages 5. Reduce screen time 6. More meals at home 7. Smaller portions of food and drinks

  41. Step 1 Treatment Managed by PCP +/- RD Visits every 1-3 months If RD involved, the two clinicians must communicate regularly. BEHAVIORAL HEALTH CLINICIAN may also become involved, if appropriate. GOAL: Slow velocity of weight gain, then BMI decreases as patient grows in height.

  42. “Warm Hand-Off’ PCP assesses the family’s “readiness to change,” finds they are ready to make lifestyle changes. PCP calls the RD in to give more detailed nutrition counsel. Calling the RD in on the spot increases the impact of counseling and improves the chances that the family will follow-up. Continued contact between PCP and RD ensures consistent messages and helps the patient and family continues to perceive this as an important issue.

  43. IF, Patient does not stabilize or improve after 3 to 6 months of Step 1 treatment OR Patient > 6 years old with BMI >99th percentile at initial assessment THEN STEP 2 treatment

  44. Step 2 Treatment OVERWEIGHT WITH RISK FACTORS (no improvement after 3-6 months) OBESE (no improvement after 3-6 months) EXTREMELY OBESE (BMI >99th%) and >6 YEARS OLD Designated Provider (DP) with an interest in obesity DP coordinates care with RD. DP or RD sees these patients once per month.

  45. Step 2 Treatment DP starts with a comprehensive history and physical exam to collect data to RISK STRATIFY the patient. Also, perform detailed screening for Psychosocial factors that may make change difficult. May be appropriate to involve the BEHAVIORAL HEALTH CLINICIAN. Entire family is still the target.

  46. Step 2 Treatment GOAL: Weight maintenance, allowing BMI to decrease as the patient grows. IF Patient fails to improve or stabilize over 3 to 6 months THEN STEP 3 treatment

  47. Step 3 Treatment OVERWEIGHT WITH RISK FACTORS (no improvement after 3-6 months of Step 1 or 3-6 months of Step 2 treatment) OBESE (no improvement after 3-6 months of Step 1 or 3-6 months of Step 2 treatment) EXTREMELY OBESE and >6 YEARS OLD (with no improvement after 3-6 months of Step 2 treatment)

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