Pediatric Obesity Initiative: Your Office and POWER

Pediatric Obesity Initiative: Your Office and POWER Brandi Rudolph, MD Resident, Pediatrics, Psychiatry, Child and Adolescent Psychiatry Indiana University School of Medicine, Indianapolis, IN

Questions • How do I calculate BMI and know its significance? - calculating BMI - interpreting BMI • What is the link between lifestyle and obesity? - nutrition - (in) activity - environment - genetics • What are the complications of obesity? - liver disease - metabolic syndrome: definition and significance - cause and effect of endocrine issues • What are the treatment options? - nutrition education - activity education - pharmacotherapy - surgical options • What you can do?

Body Mass Index (BMI) BMI = kg/m2 BMI adult: 20-25 Normal 25-29 Overweight/at risk > 30 Obese Obese I 30-34.9 Obese II 35-39.9 Extreme obese > 40 Super obese >50 Mega obese >70

Pediatric BMI Interpretation is Age-Dependent • Pediatrics BMI • 5-85% = Normal • 85-95% = Overweight • > 95% = Obesity

Obesity Causes

Obesity Leads To First generation to live sicker and die younger

NAFLD and NASH • NAFLD and NASH are common among obese children and can lead to progressive liver disease, even in childhood • Prevalence in adults: >10% of general population and >50% of obese persons • Prevalence in children: 3% of children and >20% of obese children

Metabolic Syndrome • Link between insulin resistance and hypertension, dyslipidemia, type 2 diabetes, and prothrombotic, inflammatory vascular environment • Long-term complication is cardiovascular disease; also consider liver disease, PCOS, premature puberty etc • NHANES III (1988-1994): prevalence 6.8% in overweight adolescents and 28.7% in obese teens • Males > females; ethnic differences

Endocrine Causes of Obesity • Growth hormone deficiency • Hypothyroidism • Hypercortisolism • Primary hyperinsulinism • Pseudohypoparathyroidism • Acquired Hypothalamic

Endocrine Effects of Obesity • Type 2 Diabetes • Insulin Resistance • Acanthosis nigricans. May improve with improved insulin resistance

Cardiovascular Health and Obesity • AAP guidelines: Lipid screening and cardiovascular health in childhood. Pediatrics July 2008

Modalities of Obesity Treatment Pharmacotherapy Lifestyle Modification* Surgery Nutrition Therapy Physical Activity *Adherence to Improved Nutrition and Physical Activity Stunkard. Obes Res. 1996;4:293

Pharmacotherapy: A Primer • Should not be considered as short-term fix/sole Rx • 2 main drug groups: • Lowered intake by appetite/ satiety, e.g., sibutramine (approved >16 years with program) • Malabsorption, e.g., orlistat ( approved >12 years with program) • Others: • Dietary supplements • Drugs with Other Indications • Investigational drugs

Surgery: A Primer • Indications in Adults: • BMI  40 • BMI 35-40 with severe obesity-related disease and unable to lose weight with non-surgical therapy • Pediatric indications: consider for motivated teens with BMI> 40, failure of organized weight loss attempts > 6 months, near- complete skeletal maturity, and significant co-morbidities in a multidisciplinary experienced center.

A Guide to Selecting Treatment BMI category Treatment 25-26.9 27-29.9 30-34.9 35-39.9 40 Diet, physical activity, and behavior therapy With co-morbidity + + + + With co-morbidity + + + Pharmacotherapy With co-morbidity + Surgery The Practical Guide. 2000

Take Home Tips to Get Started • Change full diary to low fat • Change caloric beverages to those without • Change from frying to baking, grilling, broiling • Change sweet snacks to fruit; crunchy/salty to veggies • Eat at designated place with distraction • Plan snacks into day – not grab and go • Active play daily – “break a sweat”

Recommendations for Obesity Prevention • Limit sugar-sweetened beverages (CE) • Encourage recommended servings of fruits and vegetables (ME) • Limit screen time to 2 hours/day (CE) • Remove screen from primary sleeping area (CE) • Eat breakfast daily (CE) • Limit restaurants especially fast foods (CE) • Eat meals as family – more appropriate choices (CE) • Limit portion size (CE) • Authoritative, not authoritarian parenting • CE – consistent evidence; ME- mixed evidence Davis MM, Pediatrics 2007

References • Barlow SE and Dietz WH. Obesity evaluation and treatment: expert committee recommendations. Pediatrics 1998:102;E29. • Baker S, Barlow S, Cochran W et al. Overweight children and adolescents: a clinical report of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr 2005;40:533-543 • Diets WH and Robinson TN. Overweight children and adolescents. N Engl J Med 2005;352:2100-9 • Barlow SE and Dietz WH. Obesity Evaluation and Treatment: Expert Committee Recommendations. Pediatrics 2007;102, S164 • Committee on Nutrition: American Academy of Pediatrics. Prevention of pediatric overweight and obesity. Pediatrics 2003:112;424-430. • Weiss R, Dziura J, Burgert TS et al. Obesity and the metabolic syndrome in children and adolescents. N Engl J Med 2004:350;2362-2374. • Inge TH, Krebs NF, Garcia VF et al. Bariatric surgery for severely overweight adolescents: concerns and recommendations. Pediatrics 2004:114;217-223. • www.nichq.org Expert Recommendations

Psychology and Obesity Ann M. Lagges, Ph.D., H.S.P.P. Assistant Professor of Clinical Psychology in Clinical Psychiatry Indiana University School of Medicine

Stradmeijer, Bosch, Koops and Sedell (2000) • Compared 73 overweight and 70 normal weight children ages 10-16. • Results • Overweight = higher Total Problem Behavior scores on the Child Behavior Checklist (CBCL) as reported by mothers and teachers • This difference between overweight and normal weight children was more marked for children under 13. • Overweight children had lower self-competence scores on physical appearance, athletic competence, social acceptance and global self-worth.

Falkner et al (2001) • Compared 4742 male and 5201 female students in 7th, 9th and 11th grades • Obese girls compared to normal weight girls • 1.63 times less likely to hang out with friends in past week • 1.49 times more likely to report serious emotional problems in the past year • 1.79 times more likely to report hopelessness • 1.73 times more likely to report a suicide attempt • 1.51 times more likely to report being held back a grade • 2.09 times more likely to consider themselves poor students.

Falkner et al (2001) • Obese boys compared to normal weight boys • 1.91 times less likely to hang out with friends in the past week • 1.34 times more likely to report friends don’t care about them • 1.38 times more likely to report emotional problems in the past year • 1.46 times more likely to consider themselves poor students • 2.18 times more likely to expect to quit school

Pearce, Boergers, and Prinstein (2002) 416 students in 9th to 12th grade Obese boys reported more overt victimization than average weight peers Obese girls reported more relational victimization than average weight peers Obese girls are less likely to date than average weight peers Obese boys and girls are more dissatisfied with their dating status than average weight peers

Morgan et al (2002) Studied relationship between loss of control over eating and psychological distress in a sample of 112 overweight children (ages 6-10) Overweight children reporting loss of control over eating had greater severity of obesity and higher levels of anxiety, depressive symptoms and body dissatisfaction

Decaluwe, Braet, Moens & Vlierberghe (2006) • 196 Belgian families with an overweight 10 – 16 year old • Child Behavior Checklist • Internalizing problems – boys 49.3%, girls 53.1% • Externalizing problems – boys 42.7%, girls 41.4% • Maternal and Paternal psychopathology were associated with greater psychopathology in the kids • Compared to a normative group, parents of overweight kids were more likely to show less positive parenting and more ineffective parenting (such as inconsistent discipline)

Jelalian, et al (2007) Review of the literature indicates higher levels of depressive disorders and anxiety disorders in obese children and adolescents Binge eating is also more common in obese children and adolescents Presence of a psychiatric disorder can complicate interventions for obesity and will need to be addressed if interventions for obesity are to have the best chance of succeeding.

Psychosocial Treatment for Obesity in Children and Adolescents

Jelalian and Saelens (1999) • Meta-analysis of 42 studies of randomized, non-school based studies of obesity intervention programs. • For children (12 and younger) • Behavior modification of eating and physical activity superior to education alone and wait list control • Most behavioral interventions result in a 5-20% decrease in overweight (short-term) • Little evidence to suggest that exercise interventions without dietary changes will result in decrease in overweight

Jelalian and Saelens (1999) • Components of successful programs for children • Self-monitoring of diet and activity • Stimulus control strategies • Contingency management • ***There is not enough data to determine which component is most crucial

Jelalian and Saelens (1999) • Long-term maintenance • Minimal long-term data - a few studies show 30% achieving non-obese status at 5 and 10 year follow-up • Parent involvement appears to be crucial • Specifically, the critical factor may be that parents serve as models for eating and activity

Epstein, Paluch, Kilanowski & Raynor (2004) Children aged 8-12 Stimulus control programs and positive reinforcement programs with goal of reduction in sedentary activity produced equal and significant reductions in sedentary activity When combined with diet change program using the “Traffic Light Diet” resulted in significant decreases in BMI.

Saelens et al (2002) • A controlled study of adolescent obesity treatment • 44 overweight adolescents randomly assigned to multiple component behavioral weight intervention (Healthy Habits - HH) or to single session physician counseling (Typical Care -TC) • Healthy Habits program • 4 month program • 11 planned telephone contacts by bachelor’s level counselor each lasting 15-20 minutes • Mail contact • Phone conversations and mailed materials addressed behavioral skills including self-monitoring, goal setting, problem solving, stimulus control, self-reward and pre-planning

Saelens et al (2002) • Results • HH program resulted in better change in BMI z-scores than TC at post-treatment and 3- month follow up • HH adolescents displayed higher use of behavioral skills

Herrera, Johnston & Steele (2004) • Ages 6-18 with no effect found for age • Base intervention: nutritional education, exercise education and goal instruction • 3 groups • Base intervention alone • Base intervention plus cognitive intervention (monitoring negative thoughts, restructuring negative thoughts, self-reinforcement) • Base intervention plus behavioral intervention (self-monitoring, praise and modeling, reinforcement and contracting)

Herrera, Johnston & Steele (2004) • Results • Behavioral intervention was associated with greater reduction in percentage over ideal BMI • Not clear that the cognitive intervention produced superior results than the base intervention alone • Study did not address if adding cognitive interventions to the behavioral plus base intervention condition would lead to even greater improvement.

Lifestyle Education (Physical Activity) Anne Graves, BS, ACSM HFS Clarian Health Senior Program Coordinator / POWER Exercise Physiologist

1. Understand Physical inactivity and effect on youth2. Establish an awareness of physical activity guidelines for youth.3. Identify and Examine approaches to increasing physical activity in youth. 4. Use available research to create a plan for working with children to increase time spent in physical activity

Where are we at? Although Children are naturally active, a significant amount of children are considered to get inadequate amounts of physical activity everyday.

Physical Inactivity

Why Has Energy Expenditure Decreased? • Fewer physical household chores • Less need and opportunities for manual transportation (walking, biking) • More attractive sedentary leisure-time activities • Less school physical education and other physical activity • More people who model decreased physical activity • Increased percentage of households where both parents work.

Causes

Importance of Physical Activity in Youth

Can an Exercise Plan make a difference? • Caloric expenditure by improving daily activities is small, but accumulative. • Studies have shown that exercise plus diet is more effective in weight loss than diet alone. • Regular exercise for a child with obesity has been shown to increase lean muscle mass, reduce blood pressure and improve psychological health. • Regular exercise can result in a decreased risk for cardiovascular disease, diabetes, osteoporosis, COPD and even some cancers.

Pediatric Obesity Initiative: Your Office and POWER