Pediatric Obesity in Primary Care Sandra G. Hassink, MD, FAAP Director, Nemours Obesity Initiative Alfred I. duPont Hos

1. TM Prepared for your next patient. Pediatric Obesity in Primary Care Sandra G. Hassink, MD, FAAP Director, Nemours Obesity Initiative Alfred I. duPont Hospital for Children Wilmington, DE

2. Disclaimers • Statements and opinions expressed are those of the authors and not necessarily those of the American Academy of Pediatrics. • Mead Johnson sponsors programs such as this to give healthcare professionals access to scientific and educational information provided by experts. The presenter has complete and independent control over the planning and content of the presentation, and is not receiving any compensation from Mead Johnson for this presentation. The presenter’s comments and opinions are not necessarily those of Mead Johnson.  In the event that the presentation contains statements about uses of drugs that are not within the drugs' approved indications, Mead Johnson does not promote the use of any drug for indications outside the FDA-approved product label.

3. Objectives • Increase awareness on childhood obesity among pediatricians so they can work with their patients and parents to identify at-risk patients and take preventive or corrective action.

4. Childhood Obesity Epidemic– Widespread in population (adults and children) Progressive – Childhood obesity becomes adult obesity Alters Development – Physically, emotionally, psychosocially Chronic disease – Lifelong morbidity accelerates “adult” disease into childhood Increases morbidity/mortality – First generation to have shorter lifespan than parents

5. Obesity and Normal Development Deconditioned Derailed from normal activity Depressed, teased and bullied Disease burden Decreased quality of life Diminished educational and job opportunities

6. Trends in Obesity Among Childrenand Adolescents: United States, 1963–2008 Note: Obesity is defined as body mass index (BMI) greater than or equal to sex- and age-specific 95th percentile from the 2000 CDC Growth Charts. CDC/NCHS, National Health Examination Surveys II (ages 6–11), III (ages 12–17), and National Health and Nutrition ExaminationSurveys (NHANES) 1999–2000, 2001–2003, 2003–2004, 2005–2006, and 2007–2008.

7. Prevalence of Obesity* and Overweight†AmongChildren Aged 2–5 Years, by Race and Ethnicity

8. Prevalence of Obesity in Infancy Birth to 1 year 11.1% of children 0–11 months were >95% weight/length. 1 to 2 years 17.0% of children 12–23 months were >95% weight/length. 2 to 3 years 12.9% of children 24–35 months had a BMI >95%. 3 to 4 years 15.2% of children 36–47 months had a BMI >95%. Centers for Disease Control and Prevention. 2009 Pediatric Surveillance. National Summary of Trends in Growth Indicators by Age. Children Aged <5 Years. Available at http://www.cdc.gov/pednss/pednss_tables/pdf/national_table20.pdf.

9. Obesity Trajectory Phase I – Steady increase in childhood obesity Phase II – Emergence of serious obesity related comorbidities Phase III – Medical complications lead to life threatening disease—death in middle age Phase IV – Acceleration of obesity epidemic by transgenerational transmission Ludwig DS. Childhood obesity—the shape of things to come. N Engl J Med. 2007;357(23):2325-2327.

10. Age-adjusted Percentage of U.S. AdultsWho Were Obese or Who Had Diagnosed Diabetes CDC’s Division of Diabetes Translation. National Diabetes Surveillance System. Available at http://www.cdc.gov/diabetes/statistics.

11. Expert Committee RecommendationsJune 2007 Purpose: Update pediatric obesity prevention and treatment recommendations. Focus Pediatric practice change “Universal prevention” Parents/families as partners in lifestyle change Obesity in the context of the Chronic Disease model Connections to the community Medical Home Assessment of Child and Adolescent Overweight and Obesity. Pediatrics. 2007;120(Supplement 4):163-288.

12. Expert Committee Recommendations Assessment – BMI/nutrition/activity/readiness to change Evidence based/evidence informed/expert opinion on high risk behavior for obesity Stepwise approach to prevention and treatment Addressed obesity management in primary and tertiary care Multidisciplinary approach Family centered/parenting/motivational interviewing Assessment of Child and Adolescent Overweight and Obesity. Pediatrics. 2007;120(Supplement 4):163-288.

13. Expert Committee Recommendations Assessment Prevention Prevention Plus Structured Weight Management Comprehensive Multidisciplinary Protocol Tertiary Care Protocol Assessment of Child and Adolescent Overweight and Obesity. Pediatrics. 2007;120(Supplement 4):163-288.

14. Universal Assessment of Obesity Risk: Steps to Prevention and Treatment American Academy of Pediatrics. Pediatric Obesity Clinical Decision Support Chart. Elk Grove Village, IL: American Academy of Pediatrics; 2008.

15. Recommendations with Consistent Evidence Multiple studies show consistent association between recommended behavior and either obesity risk or energy balance. Limit consumption of sugar sweetened beverages. Limit TV (0 hours <2 years, <2 hours >2 years old). Remove TV from primary sleeping area. Eat breakfast daily. Limit eating out. Encourage family meals. Limit portion size.

16. Recommendations with Mixed Evidence Some studies demonstrated evidence for weight or energy balance benefit but others did not or the studies were too few or too small. 5 or more fruits and vegetable servings/day (9 age appropriate servings recommended)

17. Recommendations Where Evidence Suggests Studies have not examined association with weight or energy balance, or the studies were too few or too small, but expert committee thinks it could support healthy weight and would not be harmful Eat a diet rich in calcium. Eat a diet high in fiber. Eat a diet with balanced macronutrients (food groups). Breastfeeding Promote moderate-vigorous activity 60 minutes a day. Limit consumption of energy dense foods.

18. Assessment of Obesity Calculate, chart, and classify BMI for all children 2–18 years of age at least yearly. Assess dietary patterns. Assess activity/inactivity. Assess readiness for change. Assess obesity related comorbidities. Assess ongoing progress.

19. BMI – Calculate, Chart, Classify BMI is a screening measure, determines further evaluation BMI based on age and gender and is a population based reference Underweight BMI <5% “Normal weight” BMI 5%–84% Overweight BMI >85%–94% (IOM classification) Obese BMI 95%–99% (IOM classification) Morbid (severe) obesity BMI >99% Freedman DS, Mei Z, Srinivasan SR, et al. Cardiovascular Risk Factors and Excess Adiposity Among Overweight Children and Adolescents: The Bogalusa Heart Study. J Pediatr. 2007;150(1):12-17.

20. Prevention All children are considered “at risk for obesity.” Message at well visits Simple Consistent Cumulative prevention “Gateway message” to nutrition, activity, and high risk behavior

21. BMI 99th Percentile Cut-Points (kg/m2) American Academy of Pediatrics. Pediatric Obesity Clinical Decision Support Chart. Elk Grove Village, IL: American Academy of Pediatrics; 2008.

22. Weight Loss Targets American Academy of Pediatrics. Pediatric Obesity Clinical Decision Support Chart. Elk Grove Village, IL: American Academy of Pediatrics; 2008.

23. BMI Children with a BMI >99% have a greater rate of cardiovascular risk factors. Children (age 12) with a BMI >99% followed into adulthood (age 27). 100% BMI >30 90% with BMI >35 65% with BMI >40 Freedman DS, Mei Z, Srinivasan SR, et al. Cardiovascular Risk Factors and Excess Adiposity Among Overweight Children and Adolescents: The Bogalusa Heart Study. J Pediatr. 2007;150(1):12-17.

24. Promote breastfeeding. Diet and physical activity 5 or more servings of fruits and vegetables per day 2 or fewer hours of screen time per day, and no television in the room where the child sleeps 1 hour or more of daily physical activity No sugar-sweetened beverages Prevention of BMI 5%–84%

25. Prevention BMI 5%–84% Portions Age appropriate “Parents provide, child decides” 10–15 minute increments of exercise Structure Breakfast Family dinners, no TV Limit fast food Outdoor time Balance Food groups Limit refined sugar Screen time alternatives

26. PreventionMinimum Once a Year at Well Visits Self-efficacy and readiness to change Small incremental steps for change Family support Positive Self monitoring Setbacks are normal, trouble shoot, support return to plan Identify high risk nutritional/activity behaviors

27. Universal Assessment of Obesity Risk: Steps to Prevention and Treatment American Academy of Pediatrics. Pediatric Obesity Clinical Decision Support Chart.Elk Grove Village, IL: American Academy of Pediatrics; 2008.

28. Prevention Plus BMI >85% Build on prevention. Eating behaviors Family meals should happen at least 5 to 6 times per week. Allow the child to self-regulate his or her meals and avoid overly restrictive behaviors—“Parents provide, child decides.” Structure activity.

29. Prevention Plus BMI >85% Within this category, the goal should be weight maintenance with growth that results in a decreasing BMI as age increases. Monthly follow-up for 3 to 6 months; if no improvement go to Stage 2.

30. Assess Dietary Patterns Additional practices to be considered for evaluation during the qualitative dietary assessment include: Excessive consumption of foods that are high in energy density Meal frequency and snacking patterns (including quality)

31. Dietary Assessment Consumption of sugar sweetened beverages Daily breakfast Eating out Family meals Portion size 5 or more servings of fruits and vegetables Calcium Fiber Balanced macronutrients (food groups) Energy dense foods Readiness to change

32. Assess Physical Activity/Inactivity Screen time TV in room Daily activity Self-efficacy and readiness to change Physical (built) environment Social/community support for activity Barriers to physical activity Assess patient’s and family’s activity and exercise habits. Assess outdoor activity.

33. Physical Activity/Inactivity Advise 60 minutes of at least moderate physical activity per day and 20 minutes of vigorous activity 3 times a week. Refer to community activity programs. Encourage development of family activities. Consider pedometer use. Decrease level of sedentary behavior. Limit screen time to <2 hours per day. No TV/computer in bedroom.

34. Structured Weight Management Dietary and physical activity behaviors Development of a plan for utilization of a balanced macronutrient diet emphasizing low amounts of energy-dense foods Increased structured daily meals and snacks Supervised active play of at least 60 minutes a day Screen time of 1 hour or less a day

35. Structured Weight Management Increased monitoring (eg, screen time, physical activity, dietary intake, restaurant logs) by provider, patient, and/or family This approach may be amenable to group visits with patient/parent component, nutrition, and structured activity.

36. Structured Weight Management Weight maintenance that Decreases BMI as age and height increases Weight loss should not exceed 1 lb/month in children aged 2–11 years or An average of 2 lb/week in older overweight/obese children and adolescents If no improvement in BMI/weight after 3 to 6 months, patient should be advanced to Stage 3.

37. Family History Focused family history Obesity, type 2 diabetes, cardiovascular disease (particularly hypertension), and early deaths from heart disease or stroke Family history may be the touch point for emphasizing family involvement.

38. Review of SystemsObesity Assessment: Findings on Review of Systems and Possible Etiologies American Academy of Pediatrics. Pediatric Obesity Clinical Decision Support Chart. Elk Grove Village, IL: American Academy of Pediatrics; 2008.

39. Severe Obesity Related Emergencies Hyperglycemic hyperosmolar state DKA Pulmonary emboli Cardiomyopathy of obesity

40. Comorbidities Requiring ImmediateAttention Pseudotumor cerebri Slipped capital femoral epiphysis Blount’s disease Sleep apnea Asthma Nonalcoholic hepatosteatosis Cholelithiasis

41. Chronic Obesity Related ComorbidConditions Insulin resistance (metabolic syndrome) Type II diabetes Polycystic ovary syndrome Hypertension Hyperlipidemia Psychological

42. Physical ExaminationObesity Assessment: Physical Examination Findings and Possible Etiologies American Academy of Pediatrics. Pediatric Obesity Clinical Decision Support Chart. Elk Grove Village, IL: American Academy of Pediatrics; 2008.

43. Laboratory Evaluation BMI >85% <94% Fasting lipid profile, AST, ALT q 2 years BMI >95% Fasting lipid profile, AST, ALT q 2 years, fasting glucose Laboratory evaluation as always depends on clinical assessment.

44. Medical Screening by BMI Category American Academy of Pediatrics. Pediatric Obesity Clinical Decision Support Chart. Elk Grove Village, IL: American Academy of Pediatrics; 2008.

45. Comprehensive Multidisciplinary Protocol Multidisciplinary obesity care team Physician, nurse, dietician, exercise trainer, social worker, psychologist Eating and activity goals are the same as in Stage 2. Activities within this category should also include: Structured behavioral modification program, including food and activity monitoring and development of short-term diet and physical activity goals

46. Comprehensive MultidisciplinaryProtocol Behavior modification Involvement of primary caregivers/families in children under age 12 years Training of primary caregivers/families for all children Goal Weight maintenance or gradual weight loss until BMI is <85th percentile and should not exceed 1 lb/month in children aged 2–5 years, or 2 lb/week in older obese children and adolescents

47. Tertiary Care Protocol Referral to pediatric tertiary weight management center with access to a multidisciplinary team with expertise in childhood obesity and which operates under a designed protocol Continued diet and activity counseling and the consideration of such additions as meal replacement, very-low-calorie diet, medication, and surgery

48. Partnership with Families Families have a critical role in influencing a child’s health. Effective interaction with families is the cornerstone of lifestyle change.

49. Communication Positive discussion of what healthy lifestyle changes families can make (evidence base) Allow for personal family choices. Have families set specific achievable goals and follow up with these on revisits. Be aware of cultural norms, significance of meals and eating for family/community, beliefs about special foods, and feelings about body size. Motivational interviewing

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