Weight Management for Pediatric Patients: Expert Committee Recommendations Sandra G Hassink, MD, FAAP Director Weight Management Clinic A I DuPont Hospital for Children Wilmington, DE
Mar 29, 2015
Weight Management for Pediatric Patients: Expert Committee Recommendations
Sandra G Hassink, MD, FAAPDirector Weight Management Clinic
A I DuPont Hospital for Children Wilmington, DE
Case - An 8 year old boy
An 8 year old boy comes to your office after an absence of 2 years.
Mother reports that he has gained 30 lbs since you last saw him
Now what?
Expert Committee Recommendations
June 2007 (Published Pediatrics Supplement December 2007)
AssessmentPreventionPrevention PlusStructured Weight ManagementComprehensive Multidisciplinary ProtocolTertiary Care Protocol
Assessment of Obesity
Calculate, chart and classify BMI for all children 2-18 yrs 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 based on age and gender and is a population based referenceUnderweight 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 et al J Pediatr 2007 ;150;12-17
Case an 8 year old boy
Weight 71 kg (156.2 lbs)
Height 150 cm (4’11”)
BMI 31.5
BMI
BMI 31.5 for an 8 year old boy is >99%Children with BMI > 99% greater rate of cardiovascular risk factors Children (age 12) with BMI>99% followed into adulthood (age 27)
100% BMI>3090% with BMI>3565% with BMI>40
Freedman et al. Cardiovascular Risk Factors and Excess Adiposity Among Overweight Children and Adolescents: The Bogalusa Heart Study. Journal of Pediatrics. 2007; 15: 12-7
Continuous Assessment
Calculate, chart and classify BMI for all children 2-18 yrs at least yearly
Prevention BMI 5%-84% - Diet
Promote breastfeeding Diet and physical activity:
5 Five or more servings of fruits and vegetables per day 2 Two or fewer hours of screen time per day, and no television in the room where the child sleeps 1 One hour or more of daily physical activity 0 No sugar-sweetened beverages
Prevention BMI 5%-84% - Diet
PortionsAge appropriate“Parent’s provide child decides”
StructureBreakfastFamily dinners, no TVLimit fast food
BalanceFood groupsLimit refined sugar
Prevention Dietary Patternsminimum once /year at well visits
Self-efficacy and readiness to changeSmall incremental steps for changeFamily supportPositive Self monitoringSetbacks are normal, trouble shoot, support return to planIdentify high risk nutritional behaviors
PreventionAll children 2-19 yrs BMI >5%<84%
Eating Behaviors
Eating breakfast daily.
Limiting eating out at restaurants, particularly fast food restaurants.
Encouraging family meals in which parents and children eat together.
Limiting portion size.
Prevention PlusBMI >85%
Build on Prevention
Eating behaviors: Family meals should happen at least 5-6 times per week
Allowing the child to self-regulate his or her meals and avoiding overly restrictive behaviors “Parents provide child decides”
Prevention PlusBMI >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 3-6 months, if no improvement go to Stage 2.
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)
Case - 8 year old boy Assess dietary patterns
Breakfast at home (cereal with 2% milk)Breakfast at school Surprise to Mom (french toast, chocolate milk)School lunch (extra money for ice cream, sometimes trades food)Snack at home (Juice and potato chips)Dinner (2/7 nights order out), 2nds at homeBeverages at home, soda, gator aid, juice
5 glasses/day
Assess Physical Activity/Inactivity
Self-efficacy and readiness to change
Physical (Built) Environment
Social/community support for activity
Barriers to physical activity
Assess patient and family’s activity and exercise habits
Assess outdoor activity
Physical Activity/Inactivity
Advise 60 minutes of at least moderate physical activity per day and 20 minutes vigorous activity 3x/week
Refer to community activity programs
Encourage development of family activities
Consider pedometer use
Decrease level of sedentary behavior
Limit screen time <2 hrs/day
No TV/computer in bedroom
Case 8 year old boy Activity/Inactivity
Physical education 1x/week
Recess daily but “stands around”
No after school outdoor time
Screen time 4 hours/day
TV in bedroom
Structured Weight ManagementStage 2
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 per day Screen time of 1 hour or less per day
Structured Weight ManagementStage 2
Increased monitoring (e.g., 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
Structured Weight ManagementStage 2
Weight maintenance that Decreasing 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/wk in older overweight/obese children and adolescents.
If no improvement in BMI/weight after 3-6 months, patient should be advanced to Stage 3
Comprehensive Multidisciplinary Protocol Stage 3Multidisciplinary obesity care team
Physician, nurse, dietician, exercise trainer, social worker, psychologist.
Eating and activity goals are the same as in Stage 2Activities 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 Multidisciplinary Protocol Stage 3
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 less than 85th percentile and should not exceed 1 lb/month in children aged 2-5 years, or 2 lbs/wk in older obese children and adolescents.
Tertiary Care ProtocolStage 4
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.
Family History
Focused family historyObesity, 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
Our 8 year old has a father with hypertension, obesity and sleep apnea and a maternal grandmother with diabetes.
Review of Systems
Copyright AAP 2008
Severe Obesity Related Emergencies
Hyperglycemic Hyperosmolar stateDKAPulmonary emboliCardiomyopathy of obesity
Co-morbidity's Requiring Immediate Attention
Pseudotumor Cerebri
Slipped Capital Femoral Epiphysis
Blount’s Disease
Sleep Apnea
Asthma
Non alcoholic hepatosteatosis
Cholelithiasis
Chronic-Obesity Related Co Morbid Conditions
Insulin Resistance (Metabolic Syndrome)
Type II Diabetes
Polycystic Ovary Syndrome
Hypertension
Hyperlipidemia
Psychological
Case of an 8 year old boy: Review of systems
MedicalSnoring with pauses, daytime tiredness
? Sleep apnea
Gold standard: Nighttime polysomnography
PsychosocialPoor school performance over past year
? Sleep apnea
ADD
? Teasing, low self esteem
Physical Examination
Copyright AAP 2008
Case of an 8 year old boyPhysical examinationBlood pressure 118/78 (>905<95%)
Pre hypertension
Skin – Mild acanthosis nigricansFamily history of diabetes
Insulin resistance
Pharynx – Enlarged tonsilsOverlap upper airway obstruction from enlarged tonsils
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
Partnership with Families
Families have a critical role in influencing a child’s health
» Cohen RY et al Health Educ Q 1989;16;245-253
Effective interaction with families is the cornerstone of lifestyle change
Communication
Positive discussion of what healthy lifestyle changes families can make (evidence base)Allow for personal family choicesHave families set specific achievable goals and follow up with these on revisitsBe aware of cultural norms, significance of meals and eating for family/community, beliefs about special foods, and feelings about body size.
Modeling in the office
Waiting roomBooks, posters, videos promoting healthy lifestyle
Staff role modelsDrinking water, healthy snacks, physical activity
Consistent messages, involvement with community
Lifestyle Change
Listen
Ask
Provide
Assess
Partner
Revisit
Reassess
Interactions around Lifestyle Change
Four essential skillsAskingInformingAdvising Listening
Three styles of communication Following – information gatheringGuiding- clarification of values, confidence, importanceDirecting – post decisional planning
» Rollnick S et al BMJ 2005;331;961-963
Stages of Change
Pre-contemplation: Resistant to ChangeContemplation: Aware That a Problem Exists but Ambivalent Toward Change Preparation: Intend to Take Action in Near FutureAction: Involved in ChangeMaintenance: Involved in Sustaining Change and Working to Prevent RelapseRelapse: A Return to the Problem BehaviorAdapted From Prochaska and DiClemente, 1986.
Stages of Change
Stages of change vary between individuals
Stages of change vary with time and circumstance in the same individual
Assessing readiness to change can help direct the conversation toward what is possible at that particular visit
Ingredients of Readiness to Change
Importance (Why should I change?)(Interest)
Confidence (How will I do it?) (self-efficacy)
Rollnick S, Mason P, Butler C. Health Behavior Change: A Guide for Practitioners New York: Churchill Livingstone; 2001.
Precontemplation /Resistance
Identify roadblocks, triggers, fears,
barriers etc.
Don’t try to push patient into action.
Don’t give up or become apathetic or sarcastic.
Acknowledge that now may not be the best time.
Assure patient that you are there to help when the
time is right.
Ask permission to provide information.
Follow-up at next visit.
Case - 8 year old boy Assess dietary patterns
Breakfast at home (cereal with 2% milk)Breakfast at school Surprise to Mom (french toast, chocolate milk)School lunch (extra money for ice cream, sometimes trades food)Snack at home (Juice and potato chips)Dinner (2/7 nights order out), 2nds at homeBeverages at home, soda, gator aid, juice
5 glasses/day
Case - 8 year old boy
Breakfast at home (cereal with 2% milk)Breakfast at school Surprise to Mom (french toast, chocolate milk)
Mother not happy with his double breakfast, decided right away to stop school breakfast.
Case - 8 year old boy
Beverages at home, soda, gator aid, juice5 glasses/day
After discussion about acanthosis, family history of diabetes and obesity, mother thought she could stop buying soda and sugared beverages, even though her son would initially be “unhappy”
Case 8 year old boy Activity/Inactivity
Physical education 1x/week
Recess daily but “stands around”
No after school outdoor time
Screen time 4 hours/day
TV in bedroom
Case 8 year old boy Activity/Inactivity
Screen time 4 hours/dayAll physical activity changes seemed hard to mother and son
They decided to “look into” the local Boys and Girls Club to see if he could go there after school.
You ask them to keep track of his screen time and see them in one month.