Child obesity treatment - cgdrc.mui.ac.ir · Prevalence of BMI> 85th percentile in 6-year-old children at school entry (n=899,035) in Iran, 2007 • Meta-analysis

Treatment of Childhood ObesityTreatment of Childhood Obesity

Roya Kelishadi, MDProfessor of Pediatrics

Child Growth and Development Research CenterResearch Institute for Primary Prevention of Non-communicable Disease

Isfahan University of Medical Sciences

Oct2014

www.cgdrc.mui.ac.ir

GLOBAL WARNING

GLOBESITY

IS PEDIATRIC OBESITY•A Problem in Iranian Children &AdolescentsOR•JUST A Problem of WesternPopulations?

5

6

Prevalence of BMI> 85th percentile in 6-year-oldchildren at school entry (n=899,035) in Iran, 2007

• Meta-analysis• Trend in the prevalence of obesity and overweight among

Iranian children and adolescents: a systematic review andmeta-analysis.

• Kelishadi R, Haghdoost AA, Sadeghirad B,Khajehkazemi R.N t iti 2014 A 30(4) 393 400 d i• Nutrition. 2014 Apr;30(4):393-400. doi:10.1016/j.nut.2013.08.011. Epub 2013 Dec 12.

• PMID: 24332523 [PubMed - in process]

Metaanalysis

Complications ofchildhood obesity

Objectives

� Increase awareness on childhood obesityamong pediatricians so they can workwith their patients and parents to identifywith their patients and parents to identifyat-risk patients and take preventive orcorrective action.

Childhood Obesity

� Epidemic – Widespread in population(adults and children)

�Progressive – Childhood obesity becomesadult obesity

�Alters Development – Physically�Alters Development – Physically,emotionally, psychosocially

�Chronic disease – Lifelong morbidityaccelerates “adult” disease into childhood

� Increases morbidity/mortality – Firstgeneration to have shorter lifespan thanparents

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 agethreatening 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. ��;��(��):��-��.

Expert Committee Recommendations

� Purpose: Update pediatric obesity prevention andtreatment 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. ��;��(Supplement �):��-��.


� Assessment – BMI/nutrition/activity/readiness tochange

� Evidence based/evidence informed/expert opinion onhigh 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

� Prevention

� Prevention Plus

� Structured Weight ManagementStructured Weight Management

� Comprehensive Multidisciplinary Protocol

� Tertiary Care Protocol


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; ��.

Recommendations with Consistent Evidence

� Multiple studies show consistent association betweenrecommended behavior and either obesity risk orenergy balance.• Limit consumption of sugar sweetened beverages.

Li i TV (� h � � h � ld)• Limit TV (� hours <� years, <� hours >� years old).• Remove TV from primary sleeping area.• Eat breakfast daily.• Limit eating out.• Encourage family meals.• Limit portion size.

Recommendations with Mixed Evidence

� Some studies demonstrated evidence for weight orenergy balance benefit but others did not or thestudies were too few or too small.• � or more fruits and vegetable servings/day ( age

appropriate servings recommended)

Recommendations Where Evidence Suggests

� Studies have not examined association with weight orenergy balance, or the studies were too few or toosmall, but expert committee thinks it could supporthealthy 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 �� minutes a day.• Limit consumption of energy dense foods.

Assessment of Obesity

� Calculate, chart, and classify BMI for all children �–��years of age at least yearly.

� Assess dietary patterns.

� Assess activity/inactivity.

� Assess readiness for change.

� Assess obesity related comorbidities.

� Assess ongoing progress.

BMI – Calculate, Chart, Classify

• BMI is a screening measure, determines furtherevaluation

• BMI based on age and gender and is a populationbased reference

• Underweight BMI <�%• “Normal weight” BMI �%–��%• Overweight BMI >��%–��%• Obese BMI ��%–��%• Morbid (severe) obesity BMI >��%

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. ��;��(�):��-��.

Prevention

� All children are considered “at risk for obesity.”� Message at well visits

• Simplep

• Consistent

• Cumulative prevention

� “Gateway message” to nutrition, activity, and high riskbehavior

BMI ��th Percentile Cut-Points (kg/m�)

American Academy of Pediatrics. Pediatric Obesity Clinical Decision Support Chart. Elk Grove Village, IL: American Academy of Pediatrics; ��.

Weight Loss Targets


BMI

� Children with a BMI >��% have a greater rate ofcardiovascular risk factors.

� Children (age ��) with a BMI >��% followed intoadulthood (age ��).• ��% BMI >��• ��% BMI >��

• ��% with BMI >��

• ��% with BMI >��

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. ��;��(�):��-��.

� Promote breastfeeding.� Diet and physical activity

• � or more servings of fruits and vegetables per day• � or fewer hours of screen time per day, and no television in

the room where the child sleeps• � hour or more of daily physical activity

Prevention of BMI 5%–84%

• � hour or more of daily physical activity• No sugar-sweetened beverages

www.aap.org/bookstore

Prevention BMI �%–��%

� Portions• Age appropriate• “Parents provide, child decides”• ��–�� minute increments of exercise

� Structure• Breakfast• Family dinners, no TV• Limit fast food• Outdoor time

� Balance• Food groups• Limit refined sugar• Screen time alternatives

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

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; ��.

Prevention Plus BMI >��%

� Build on prevention.

� Eating behaviors• Family meals should happen at least � to � times per

week.

• Allow the child to self-regulate his or her meals and avoidoverly restrictive behaviors—“Parents provide, childdecides.”

• Structure activity.

Prevention Plus BMI >��%

� Within this category, the goal should be weightmaintenance with growth that results in a decreasingBMI as age increases.

� Monthly follow-up for � to � months; if noMonthly follow up for � to � months; if noimprovement go to Stage �.

Assess Dietary Patterns

� Additional practices to be considered for evaluationduring the qualitative dietary assessment include:• Excessive consumption of foods that are high in energy

density

• Meal frequency and snacking patterns (including quality)

Dietary Assessment

� Consumption of sugar sweetened beverages� Daily breakfast� Eating out� Family meals� Portion size� � or more servings of fruits and vegetables

C l i� Calcium� Fiber� Balanced macronutrients (food groups)� Energy dense foods� Readiness to change

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

Physical Activity/Inactivity

� Advise �� minutes of at least moderate physicalactivity per day and �� minutes of vigorous activity� times a week.• Refer to community activity programs.• Encourage development of family activities.• Consider pedometer useConsider pedometer use.

� Decrease level of sedentary behavior.� Limit screen time to <� hours per day.� No TV/computer in bedroom

Structured Weight Management

� Dietary and physical activity behaviors• Development of a plan for utilization of a balanced

macronutrient diet emphasizing low amounts ofenergy-dense foods

• Increased structured daily meals and snacks• Supervised active play of at least �� minutes a day• Screen time of � hour or less a day

Structured Weight Management

� Weight maintenance that• Decreases BMI as age and height increases

� Weight loss should not exceed• ��g/month in children aged �–�� yearsor• An average of �Kg/week in older overweight/obeseAn average of �Kg/week in older overweight/obese

children and adolescents

� If no improvement in BMI/weight after � to �months, patient should be advanced to Stage �.

Family History

� Focused family history• Obesity, type � diabetes, cardiovascular disease

(particularly hypertension), and early deaths from heart(particularly hypertension), and early deaths from heartdisease or stroke

� Family history may be the touch point foremphasizing family involvement.

Review of SystemsObesity Assessment: Findings on Review of Systems and Possible Etiologies


Severe Obesity Related Emergencies

� Hyperglycemichyperosmolar state

� DKA

� Pulmonary emboli

� Cardiomyopathy ofobesity

Comorbidities Requiring ImmediateAttention

� Pseudotumor cerebri

� Slipped capital femoralepiphysis

� Blount’s disease� Blount s disease

� Sleep apnea

� Asthma

� Nonalcoholichepatosteatosis

� Cholelithiasis

Chronic Obesity Related ComorbidConditions

� Insulin resistance(metabolic syndrome)

T II di b� Type II diabetes

� Polycystic ovary syndrome

� Hypertension

� Hyperlipidemia

� Psychological

Physical ExaminationObesity Assessment: Physical Examination Findings and Possible Etiologies


Laboratory Evaluation

� BMI >��% <��%• Fasting blood glucose, lipid profile,

• AST, ALT q � years

� BMI >��%� BMI >��%• Fasting blood glucose, lipid profile,

• AST, ALT q � years

• Laboratory evaluation as always depends on clinicalassessment.

Medical Screening by BMI Category


Comprehensive MultidisciplinaryProtocol

� Multidisciplinary obesity care team• Physician, nurse, dietician, exercise trainer, social worker,

psychologist

� Eating and activity goals are the same as in Stage �.

� 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

Comprehensive MultidisciplinaryProtocol

� Behavior modification• Involvement of primary caregivers/families in children

under age �� years

• Training of primary caregivers/families for all childrenTraining of primary caregivers/families for all children

� Goal• Weight maintenance or gradual weight loss until BMI is

<��th percentile and should not exceed ��g/month inchildren aged �–� years, or � Kg/week in older obesechildren and adolescents

Tertiary Care Protocol

� Referral to pediatric tertiary weight managementcenter with access to a multidisciplinary teamwith expertise in childhood obesity and whichoperates under a designed protocolC i d di d i i li d h� Continued diet and activity counseling and theconsideration of such additions as mealreplacement, very-low-calorie diet, medication,and surgery

Partnership with Families

� Families have a critical role in influencing a child’shealth.

� Effective interaction with families is the cornerstone� Effective interaction with families is the cornerstoneof lifestyle change.

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.up with these on revisits.� Be aware of cultural norms, significance of meals and

eating for family/community, beliefs about specialfoods, and feelings about body size.

� Motivational interviewing

Obesity treatment pyramid

- Appropriate weightgain in pregnancy

-Encouragingbreastfeedingbreastfeeding-Adequateduration ofbreastfeeding

-Avoiding food forcing

-Learning to havehealthy food choices

-Regular daily physical activity-Reducing the screen time

-Balance between energy intake andexpenditure

- Early sleeping- Enough sleep

-Coping with stress

-Slow eating

-Drinking enough water

etc…..

Medications• FDA weight loss drug withdrawals• Sibutramine (Meridia) a selective serotonin

norepinephrine reuptake inhibitor (SNRI)• Fenfluramine and dexfenfluramineFenfluramine and dexfenfluramine• Rimonabant (Acomplia)

• Anorexiants are administered to manage obesity inadults. Indications include weight loss and maintenanceof weight loss, in conjunction with a reduced calorie diet,specifically in patients who are obese with an initial bodymass index (BMI) of 30 or 27 mg/m2 and other riskfactors (eg, diabetes mellitus, dyslipidemia,hypertension).

• Orlistat (Alli, Xenical)Orlistat is a gastrointestinal lipase inhibitor that inducesweight loss by inhibiting nutrient absorption.

• Adrenergic Agonists• Adrenergic agonists are stimulants that release tissue

stores of epinephrine, causing subsequent alpha- and/orbeta-adrenergic stimulation. These drugs have providedbenefits to patients with obesity and are approved inadults for short-term use (8-12 wk).

• Caffeine• Phentermine is a sympathomimetic amine that increases

the release and reuptake of norepinephrine and dopamine.• Diethylpropion is a sympathomimetic amine that is

effective as an adjunct for anoretic therapy of exogenousobesity.

• Herbs/plants?• Green coffee

Green tea/white tea

- Citrus fruits/peels- Artichoke- …..

THANK YOU FOR YOUR ATTENTION

Child obesity treatment - cgdrc.mui.ac.ir · Prevalence of BMI> 85th percentile in 6-year-old children at school entry (n=899,035) in Iran, 2007 • Meta-analysis

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