Management of child and adolescent obesity

1. Management of child and adolescent obesity Barwon Division 9th November 2008 Speaker: Dr Colin Bell, Program Director, Good for Kids. Good for Life

2. Acknowledgement Louise A Baur Discipline of Paediatrics & Child Health, Univ. Sydney; NSW Centre for Overweight & Obesity The Children’s Hospital at Westmead Email: louiseb3@chw.edu.au

3. Obesity • One of today’s most blatantly visible – yet most neglected – public health problems • The public health equivalent of climate change • The Millennium Disease WHO; www.who.int/nut/obs.htm; Laing & Rayner, Obesity Reviews 2007; www.iotf.org

4. ObesityOne of the most common chronic diseases in childhood and adolescence1:4 school-aged children are overweight or obese

5. Are these children presenting to general practice?

6. YesBut in even higher numbers than for the general populationAnd NOT for the problem of overweight or obesity

7. In Australia, of every 200 children presenting to their GP, 60 are overweight or obese (23 obese) – and 1 is offered weight management intervention BEACH data set, Annual national random survey of 1000 GP surgeries 2002-2006, Children aged 2- 17 years, Self-reported heights & weights Cretikos M et al, Medical Care, 2008, in press.

8. What GPs say are the barriers to management of paediatric obesity in general practice • Lack of time • Lack of reimbursement • Lack of parent / patient motivation • Lack of effective interventions • Lack of support services • Complex, difficult problem • Inadequate training • Parent / child sensitivity Results of focus groups held with NSW GPs. King L et al. British Journal of General Practice. 2007; 57:124-129.

9. So, what can be done in general practice?

10. Case 1: Katie – 6 years of age • Chinese ethnic origin; only child of busy parents (father has two jobs; mother works as a cleaner) • Mother brings her to you with an intercurrent illness (URTI) which is simply managed • But you note incidentally that Katie looks quite plump for her age

11. How do you confirm your impression that Katie is overweight?

12. How do you confirm your impression that Katie is overweight? Measure height & weight Calculate BMI Plot on BMI for age chart

13. Clinical example of Katie Girl aged 6 years Weight 33 kg Height 120 cm BMI 22.9 kg/m2 Overweight or obese? Normal weight? Unsure?

14. Katie Girl aged 6 years Weight 33 kg Height 120 cm BMI 22.9 kg/m2 (>>97th centile for age; obese range)

15. You’ve confirmed your clinical impression that Katie’s BMI is in the obese range Would you raise this issue with Katie’s mother? If so: why? If not: why not?

16. Factors to consider • Health risks for Katie • Severity of obesity • Associated co-morbidities • Family history of obesity, diabetes and related disorders • Approach to raising the issue • Avoid stigmatising • Avoid blaming • Solution-focussed • Supportive

17. What would you ask about in the family history? Are there high-risk ethnic groups?

18. High risk family history & ethnicity • Enquire re F/H of obesity and type 2 diabetes: • Obesity, type 2 diabetes, premature heart disease, obstructive sleep apnoea, hypertension, dyslipidaemia • Enquire re parental eating disorders & bariatric surgery • Ethnic groups at higher risk of diabetes etc • Indian sub-continent, Mediterranean/Middle-Eastern, Maori & Pacific Islander, Aboriginal & Torres Strait Islander, probably east Asian

19. Katie’s family history • Family history: • Obesity – maternal grandmother • Type 2 diabetes – maternal grandmother • Chinese ethnic origin

20. Katie’s medical assessment • Mild teasing by classmate at school • No other co-morbidities suggested by history or physical examination

21. How would you raise this issue with Katie’s mother?

22. Little direct evidence to guide approach but the following may be useful • Regular assessment of growth and plotting of BMI allows the issue of growth and weight to be raised • Be non-judgmental and sensitive • Example of an introduction: • “I notice that Katie’s weight (or weight adjusted for height) is high for her age. Is that something you’ve been concerned about? ….. Would you like to discuss it at some stage?”

23. Katie’s mother is interested in talking further about this issue, as she knows that Katie has been teased about her weight. Obesity is not the original reason for today’s consultation …. and your waiting room is crowded! What would your next steps be?

24. Acknowledge the importance of dealing with the issue Make another appointment – with Katie’s mother (+/- other carers) - to start discussions re weight management intervention Do not include Katie in the weight management intervention – she’s only 6 years of age! Next steps

25. Weight status of children in the Parents-only vs. Parents + Child treatments(Golan. Int J Pediatr Obes 2006) Parents + child Parents-only 65 Baseline a b 55 45 6 months 45.5 45.0 43 41.6 35 Overweight Percentage 12 months 32 31.8 25 * 15 BMI +0.32 ** BMI -1.09 5 BMI -1.28 Change within each group * p=0.003 ** p=0.001 Change between groups a p=0.02 b p<0.05

26. Be developmentally sensitive • For younger, pre-adolescent children: Focus on parents as the agents of change. Consider excluding the child from the consultations • For adolescents: Include some adolescent-only sessions

27. Katie’s mother returns a week later when Katie is at school, in order to discuss strategies for weight management. What approach would you use? What strategies might you discuss?

28. The basics • Family focus • Developmentally appropriate approach • Long-term behaviour change • Both sides of the energy balance equation need to be addressed • Set small, achievable goals • Regular follow-up and support

29. The Big Five (CHW Program) • Choose water as your main drink • Eat breakfast each day • Eat together once a day as a family without the TV being on • Spend at least 60 minutes outside every day (playing or being physically active) • Limit screen time to less than 2 hours per day (TV, electronic games, DVDs, computer, Ipod, MP3 or videos etc)

30. The first law of thermodynamics Energy is conservedEnergy in = energy out

31. Practical tips regarding food - 1 • The person who buys the food and who cooks it needs to be engaged in the treatment approach • Regular meals – especially breakfast • Water as the main beverage • limit soft drinks, fruit juice, cordial • Eat together as a family • Make a ritual of meal-times • No TV or other distractions

32. Practical tips regarding food - 2 • Store healthy snacks – for morning & afternoon teas • One approach for the whole family • What foods are in the cupboards? These will invariably be eaten! • Check serve sizes – are these appropriate for a child?

33. TV viewing and a screen-friendlylifestyle • Look at TV, video game and computer usage - for the whole family • How many TVs are there in the house? Is there one in Katie’s bedroom? Who turns the TV on or off? • Explore alternatives • Parental overview vital

34. Practical tips regarding activity - 1 • Family approach to television, video-games, computer use • Plan TV viewing with the TV Guide • Limit to <2 hours per day • No TV on during meals • Transport to/from school • Walking instead? • Dropping off at a distance from the school gate? • Use of the family car. Is it needed for short trips?

35. Practical tips regarding activity - 2 • For most, organised activity is less important than increased opportunities for incidental activity • “Mucking around” outside is vital: • balls, skipping ropes, swings, trampolines … • backyards?, parks?, other playgrounds? • Whole-family opportunities for physical activity? • Role-modelling of parents

36. 15 10 Calisthenics Gym-aerobics 5 Lifestyle 0 -5 % Change in Overweight -10 -15 -20 -25 0 5 10 Time (y) Different “exercise” programs (Epstein, 1996)

37. 0 -5 Exercise % change in overweight -10 Combined Sedentary -15 -20 0 4 12 0 14 Time (months) Targeting sedentary behaviour (Epstein, 1996)

38. What happened with Katie? • Mother identified the following as issues she’d like to change: • Soft drink intake (evening meal and afternoon tea in particular) • TV viewing (accompanies mother while she does her cleaning jobs – mother turns on TV to act as child-minder for Katie; TV on while eating at home) • School lunch “treats”

39. What happened with Katie? • Strategies • Only water offered at meal-times • TV viewing – colouring in equipment, books and games brought so that Katie is occupied while mother works; some extra support for child-minding from neighbour; TV turned off when the family eats • Katie booked in to After School Care three days a week • School lunch box – no more packets of crisps!

40. Katie’s anthropometry 6 months later Weight unchanged Height 123 cm (  3 cm) What has happened to BMI?

41. Katie’s anthropometry 6 months later Weight unchanged Height 123 cm (  3 cm) BMI 21.8 kg/m2

42. In what circumstances would you organise further investigations? If so – what ones?

43. Further investigations – when? • Age: adolescents > younger children • Severe obesity (esp. central obesity) • High risk family history: • 1st and 2nd degree relatives with heart disease, type 2 diabetes (incl. GDM), dyslipidaemia, sleep apnoea etc • High risk ethnic group: • Indian sub-continent, Mediterranean & Middle-Eastern, Maori & Pacific Islander, Aboriginal & Torres Strait Islander, probably east Asian • Clinical suggestion of co-morbidities

44. Further investigations – what ones? • Initial fasting blood tests (others dependent upon results*): • Glucose • LFTs (ALT, AST) • Lipids (TG, HDL cholesterol, LDL cholesterol) • Insulin • ?TSH??? • Consider referral for sleep assessment • Other investigations that MAY be warranted: OGTT, liver ultrasound

45. When would you refer on?

46. When to refer on? • Will depend upon your expertise and the resources available • Paediatrician referral: • Severe obesity • Presence of co-morbidities • Strong family history of co-morbidities • Mental health unit referral: • Significant psychosocial distress

47. When to refer on? • To other health professionals eg • Dietitian • Nurse (Early Childhood nurse, community nurse) • Clinical psychologist • Physiotherapist • Exercise scientist etc • Ideally for all patients, but hampered by cost & availability

48. How often should the patient/parent be seen in follow-up?

49. Frequency of follow-up? • Frequent follow-up is important in the first few weeks and months in order to aid behaviour change • CHW practice: • 3 fortnightly consultations, • Then progressively less frequent thereafter • Consider shared care with other health professionals

50. Good for Kids • To mainstream healthy eating and physical activity for children (up to 15 yrs) and their families in the Hunter New England region • ↓ sweetened drink consumption ↑ non-sweetened drinks • ↓ energy dense foods ↑ fruit and vegetables • ↑ physical activity (sport, play, leisure) • ↓ time spent in small screen recreation (TV, video games)