Nancy Copperman, MS,RD,CDN Director, Public Health Initiatives Office of Community Health

1. Using Evidence to Treat Overweight and Obesity: ADA’s Pediatric Weight Management MNT Guidelines Nancy Copperman, MS,RD,CDN Director, Public Health Initiatives Office of Community Health North Shore Long Island Jewish Health System

2. EAL PWM Expert Workgroup Members • Christina W. Biesemeier, MS, RD, LD, FADA, Chair • Joyce B. Bittle, PhD, RD, LDN • Nancy M. Copperman, MS, RD, CND • Heather S. Holden, RD, LDN • Shelley Kirk, PhD, RD, LD • Aida C. G. Miles, MMSc, RD, LD • Lorrene D. Ritchie, PhD, RD • Denise Sofka, MPH,RD

3. Presentation Objectives • Review the process for developing the Pediatric Weight Management (PWM) Nutrition Practice Guideline, emphasizing practical tips for implementing key recommendations, ratings and supporting evidence. • Describe the major PWM Guideline recommendations and how they are integrated into Alliance Healthcare Initiative for the treatment of overweight and obese children, adolescents and their families. • Learn coverage details and enrollment requirements for RD participation in the Alliance Healthcare Initiative.

4. Questions &Topics • Factors Associated with Childhood Overweight • Foods and Nutrients • Dairy and Calcium • Is intake of calcium related to adiposity in children? • Is intake of dairy related to adiposity in children? • Fruit Juice • Is intake of 100% fruit juice related to adiposity in children? • Fruits and Vegetables • Is intake of fruits and vegetables related to adiposity in children? • Sweetened Beverages • Is intake of calorically-sweetened beverages related to adiposity in children?

5. Questions & Topics • Family Influences • Family resources: psychological, social and financial • In general, what is the relationship between parental feeding strategies and childhood obesity? • Are parental attitudes towards their own dietary intakes (Dietary restraint and disinhibition) associated with higher risk or prevalence of overweight among children? • What is the relationship between household food insecurity and childhood overweight?

6. Questions & Topics • Family Influences • Diet and Family Activity Management Strategies • Is parental control over child dietary intake associated with higher risk or prevalence of overweight among children? • Is eating out related to adiposity in children? • Is portion size related to adiposity in children?

7. Questions & Topics • Family Influences • Parent/Child Relationship or Emotional Climate • Is family functioning associated with higher risk or prevalence of overweight among children? • Is parental concern about, or criticism of, their child's weight status associated with higher risk or prevalence of overweight among children? • Is using food as a reward (instrumental feeding) and emotional feeding associated with higher risk or prevalence of overweight among children?

8. Questions & Topics • Physical Activity and Inactivity • Television viewing • Video games • Physical Activity • Sports Activity

9. Questions & Topics • II. Interventions Associated with Childhood Overweight • Prevention • School-based Interventions • Treatment • Treatment focus: dietary, physical activity, behavioral, adjunct therapies • Treatment format: family, education, individual vs. group, peer modeling • Treatment supports: medications, measuring energy expenditure

10. PWM Guideline Recommendations and the Nutrition Care Process • Algorithms based on NCP • Nutrition Assessment • Food Nutrition Hx • Biochemical and Medical Data • Anthropometrics • Physical Examination • Client History

11. PWM Guideline Recommendations and the Nutrition Care Process • Nutrition Diagnosis • Nutrition Intervention • Nutrition prescription • Food/nutrient delivery • Nutrition education • Nutrition Counseling • Coordination of Care

12. PWM Guideline Recommendations and the Nutrition Care Process • Monitoring and Evaluation Nutrition-related behavioral-environmental outcomes Food and nutrient intake outcomes Nutrition-related physical sign/symptom outcomes Nutrition-related pt/client-centered outcomes

13. Guideline Ratings • Strong- evidence Grade I or II Practitioners should follow • Fair- evidence Grade II or III Practitioners should follow but be aware of new information • Weak-evidence suspect or well done studies show little advantage to 1 approach verses another Practitioners should be cautious in deciding whether to follow guideline, alert for new info, pt preference more influential in decision

14. Guideline Ratings • Consensus- Expert opinion- Grade IV Practitioners should be flexible in deciding whether to follow Pt preference more influential in decision • Insufficient Evidence- both a lack of pertinent evidence (Grade V) and/or an unclear balance between benefits and harms Practitioners should feel little constraint in deciding whether to follow , be alert for new info Pt preference substantial influence in decision

15. Additional Guideline Ratings • In addition to the strength of the guideline ratings, the recommendations can be worded as conditionalor imperativestatements. Conditional statements clearly define a specific situation, while imperative statements are broadly applicable to the target population without restraints on their pertinence.

16. Applying the Guidelines to a Case EJ is a 16 yr male referred for weight management. He has previously tried to loss weight on his own by reducing portion sizes at meals and increasing physical activity. Initially he is successful but after a couple of weeks he gains back all the weight he lost plus some additional weight. He typically eats fast food meals daily, drinks 2 quarts of sweetened beverages throughout the day and has 4 hrs of screen time daily. His family is supportive of his efforts but does not join him when he modifies his diet and exercise habits. EJ would like to be successful in managing his weight. Anthropometrics, Laboratory and Physical Findings: BMI 32 >97th %, BP wnl, Ht. 68 Wt. 210 lb Fasting insulin, glucose wnl Fasting lipid profile reveals elevated triglycerides and a low HDL

17. Assessment • PWM: Assessing Foods and Pediatric Overweight • PWM: Assessing Child and Family Diet Behaviors in Pediatric Overweight • PWM: Assessing Physical Activity and Sedentary Behaviors • PWM: Determination of Total Energy Expenditure • PWM: Assessing Family Climate Factors

18. What are the effects of EJ’s frequent fast food meals and daily sweetened beverage consumption on his weight status? • Dietary factors that may be associated with an increase in the risk of overweight and should be included in Nutrition Assessment are: increased total dietary fat intake and increased calorically sweetened beverages. ADA Evidence Analysis has shown that these factors are positively associated with childhood overweight. StrongImperative

19. What are the effects of EJ’s frequent fast food meals and large portion sizes on his weight status? • Child and family diet behavior factors that may be associated with an increase in the risk of overweight and should be included in Nutrition Assessment are: parental restriction of highly palatable foods, consumption of food away from home, increased portion size of meals, breakfast skipping. ADA Evidence Analysis has shown that these factors are positively associated with childhood overweight. FairImperative

20. What is the effect of 4 hrs of Screen Time /Day on EJ’s weight status? • Physical activity and sedentary behavior factors that may be associated with an increase in the risk of overweight and should be included in Nutrition Assessment are: excessive television viewing, and excessive use of video games. ADA Evidence Analysis has shown that these factors are positively associated with childhood overweight. FairImperative

21. How would an RD determine the TEE for EJ? • If possible, RMR should be measured (e.g., indirect calorimetry). If RMR cannot be measured, then the equations for estimating total energy expenditure in overweight youth provided in the 2005 US Institutes of Medicine "Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids (Macronutrients), " may be used. Estimated energy needs should be based on Total Energy Expenditure ConsensusConditional

22. TEE in Overweight Boys Ages 3 Through 18 Years in a Weight Maintenance Program • TEE = 114 – (50.9 × age [16y]) + PA(1.12) × (19.5 × weight [95.45Kg] + 1161.4 × height [1.72m]) =3381.2 • Where PA is the physical activity coefficient: • PA = 1.00 if PAL is estimated to be = 1.0 < 1.4 (sedentary) • PA = 1.12 if PAL is estimated to be = 1.4 < 1.6 (low active) • PA = 1.24 if PAL is estimated to be = 1.6 < 1.9 (active) • PA = 1.45 if PAL is estimated to be = 1.9 < 2.5 (very active)

23. How would an RD determine a weight management goal for EJ? • www.pediatrics.org/cgi/doi/10.1542/peds.2007-2329C • Sarah E. Barlow and the Expert Committee. Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report. Pediatrics. 2007;120;S164-S192.

24. Expert Committee Weight Targets #95%-98% - until BMI<85th% with no more than an average of 2lb/week

25. How does the fact that EJ’s family does not model behaviors affect his weight? • Family climate factors that may be associated with an increase in the risk of overweight and should be included in Nutrition Assessment are: parental dietary disinhibition and restraint, negative aspects of family functioning (such as lack of parental support or over-possessiveness), and parental concern about child’s weight status. ADA Evidence Analysis has shown that these factors are positively associated with childhood overweight. Fair Imperative

26. Nutrition Diagnosis • NI-1.5 Excessive energy intake • NI 2.2 Excessive oral food/beverage intake • NI-51.2 Excessive fat intake • NI-53.2 Excessive intake of CHO • NC-2.2 Altered nutrition-related lab values • NB-1.1 Food, nutrition and nutrition related knowledge deficit • NB-2.1 Physical inactivity

27. Intervention: Nutrition PrescriptionWould EJ benefit from an individualized nutrition prescription? • A nutrition prescription should be formulated as part of the dietary intervention in a multicomponent pediatric weight management program. The exact specification of nutrients and energy is often translated into a specific eating plan. Nutrition interventions are selected based on the nutrition prescription. Research shows that when individualized nutrition prescription is included, improvements in weight status in children and adolescents are consistent. When an individualized nutrition prescription is not included, results are less consistent. StrongImperative

28. Intervention:Nutrition Prescription • Energy Restriction PWM: Energy Restricted Diets • Altered Macronutrient Diets PWM: Reduced Glycemic Load Diet PWM: Very Low Carbohydrate Diet PWM: Using Protein Sparing Modified Fast Diets for Pediatric Weight Loss PWM: Very Low Fat Diet (<20% Daily Energy Intake from Fat)

29. Is energy restriction appropriate for EJ? • If energy restriction is appropriate based on the registered dietitian's professional judgment, then a balanced macronutrient diet that contains no fewer than 1200 kcal per day is recommended to improve weight status within a multicomponent pediatric weight management program in adolescents ages 13-18 who are medically monitored. Research indicates that energy restricted balanced macronutrient diets no lower than 1200 kcal per day are associated with both short term and longer term (>1 year) improved weight status and body composition among 13-18 year-old adolescents.StrongConditional

30. Is a reduced glycemic load diet an option for EJ? • If an ad libitium reduced glycemic load diet is selected for use in adolescents (age 13-18), then this diet could be used to produce modest, short term and longer term improvement in weight status and body composition. Limited research shows that an ad libitium reduced glycemic load diet results in short term improvement in weight status and body composition in this age group. One study shows weight status improvement at 1 year.FairConditional

31. Is a Protein Sparing Modified Fast Diet an option for EJ? • If overweight (>120% IBW) children and adolescents with serious medical complications would benefit from rapid weight loss, then a Protein Sparing Modified Fast Diet (PSMF) could be utilized in a short-term intervention (typically 10 weeks) under the supervision of a multidisciplinary team of healthcare providers who specialize in pediatric overweight. Research shows that short term use of a PSMF brings about short term and longer term improvement in weight status and body composition when part of a medically supervised, multicomponent program. WeakConditional • The Protein Sparing Modified Fast Diet is not recommended for long-term weight management for overweight children or adolescents. There are few well designed studies to support the use of this intervention for longer than 10 weeks.WeakImperative

32. Nutrition EducationWould Nutrition education be an effective intervention for EJ? • In a multicomponent program, if there is a nutrition diagnosis for food and nutrition-related knowledge deficit, then nutrition education should be tailored to the nutrition prescription. Research shows that if nutrition education is not tailored to nutrition prescription, improvement in weight status is not consistent.FairConditional

33. Nutrition Counseling • PWM: Nutrition Counseling and Behavior Therapy Strategies in the Treatment of Overweight in Children and Adolescents • PWM: Family Participation in Treating Pediatric Overweight in Children and Adolescents • PWM: Nutrition Counseling: Setting Weight Goals with Patient and Family

34. Should nutritional counseling for EJ include self monitoring? • Nutrition counseling delivered by an RD (which is inclusive of goal setting, self monitoring, stimulus control, problem solving, contingency management, cognitive restructuring, use of incentives and rewards, and social supports) should be a part of the behavior therapy component of a multicomponent pediatric weight management program. ConsensusImperative

35. Should nutritional counseling for EJ include self monitoring? • Behavior therapy strategies should be included as part of a multicomponent pediatric weight management program. Research shows that when behavior therapy strategies are included within the context of a multidisciplinary team, weight status and body composition improve. StrongImperative

36. Should family-based counseling be a part of EJ nutrition counseling? • Parent/caregiver may be included in multicomponent pediatric weight management programs when treating adolescents. A limited body of research indicates that programs with or without parent/caregiver participation may be effective for improvements in weight status and adiposity in adolescents.FairConditional

37. Coordination of Nutrition Care: Would the RD collaborating with other health providers improve the effectiveness of EJ’s intervention? • Dietitian should collaborate with members of the healthcare team (as available) in planning and implementing behavior, physical activity, and adjunct therapy strategies. Effective multicomponent pediatric weight management interventions benefit from the diverse expertise of different healthcare professionals. ConsensusImperative

38. Counseling for changes in Physical Activity and Inactivity • PWM: Decreasing Sedentary Behaviors in Children and Adolescents • PWM: Physical Activity in the Treatment of Childhood and Adolescent Overweight

39. Should EJ reduce sedentary activities? • Adolescents should be counseled to reduce or limit sedentary activities (e.g. TV, video games, “screen time”). Limited intervention research indicates that reducing sedentary activities may have both long and short term benefits in terms of overweight. Weak Imperative

40. Is there a benefit to increased Physical Activity for EJ? • Physical activity should be included as part of a multicomponent pediatric weight management program. Research indicates that increasing physical activity as part of a multicomponent program results in significant improvements in weight status and/or body composition in children and adolescents. StrongImperative

41. Adjunct Therapies • PWM: Adjunct Therapies: Use of Weight Loss Medications in Treating Overweight in Adolescents • PWM: Adjunct Therapies: Weight Loss Surgery and Adolescent Overweight

42. Is EJ a candidate for weight loss medication? • The dietitian should collaborate with the health care team regarding the use of weight loss medications as an adjunct therapy within a multicomponent pediatric weight management program for adolescents. Clinical outcomes are likely to be enhanced with the participation of a dietitian. ConsensusImperative

43. Is EJ a candidate for weight loss medication? • Criteria: BMI>27 with obesity related diseases or BMI 30 • If a weight loss medication is selected as an adjunct therapy, then an over the counter or prescription gastrointestinal lipase inhibitor (e.g., orlistat) approved by the FDA for use in adolescents may be recommended to treat overweight adolescents participating in a multicomponent pediatric weight management program. Research indicates that a gastrointestinal lipase inhibitor further improves weight status and body composition in some individuals within a multicomponent adolescent weight management program. However, the FDA has not studied or approved the use of this class of medication for children under the age of 12.FairConditional

44. Is EJ a candidate for weight loss surgery? • Dietitians should collaborate with other members of the health care team regarding the appropriateness of weight loss surgery for severely overweight adolescents who have not achieved weight loss goals with less invasive weight loss methods and who meet specified criteria (see Conditions of Application below). Research indicates that for a subset of adolescents who meet the recommended criteria, weight loss surgery may be effective in bringing about significant short term and long term weight loss. Overweight children (< 13 years of age) are generally not considered to be appropriate candidates for weight loss surgery. ConsensusImperative

45. Is EJ a candidate for weight loss surgery? Recommended criteria for adolescents being considered for weight loss surgery (based on Pediatrics2004;114:217-223) • Experienced failure of >= 6 months of organized weight loss attempts as determined by their primary care provider • Have met certain anthropometric and medical criteria • Be severely obese (BMI >= 40) with serious obesity-related medical complications or have a BMI >= 50 with less severe co-morbidities • Have co-morbidities related to obesity that might be resolved with durable weight loss • Have attained a majority of skeletal maturity (generally >= 13 years of age for girls and >= 15 years of age for boys)

46. Is EJ a candidate for weight loss surgery? Recommended criteria for adolescents being considered for weight loss surgery (based on Pediatrics2004;114:217-223) • Demonstrate commitment to comprehensive medical and psychological evaluations both before and after weight loss surgery • Be capable and willing to adhere to nutritional guidelines post-operatively • Possess decisional capacity and participate in the decision process to undergo weight loss surgery. In other words, the adolescent must want the intervention and understand what is involved. • Have a supportive family environment. • Be evaluated by a multi-disciplinary team who is involved in the patient selection, preparation, and surgery as well as immediate and long-term post-operative follow-up care.

47. Treatment Format Options PWM: Treatment Format Options: Group Versus Individual Intervention

48. Would group or individual nutrition intervention be better for EJ? Either group or individual nutrition intervention may be used as part of a multicomponent pediatric weight management program. Limited research that compares individual versus group format does not indicate differences in overall pediatric weight status. However, two studies suggest that some dietary outcome measures may be improved with an individual counseling format. WeakImperative

49. Monitoring and Evaluation • PWM: Optimal Length of Weight Management Therapy in Children and Adolescents

50. What is the length of tx EJ should receive? • During the intensive treatment phase, Medical Nutrition Therapy for pediatric overweight should last at least three months or until initial weight management goals are achieved. Because overweight is a chronic, often life-long, condition, it is critical that a weight management plan be implemented after the intensive phase of treatment. A greater frequency of contacts between the patient and practitioner may lead to more successful weight loss and maintenance. ConsensusImperative