1. Pediatric Obesity Kerry K. Sease, MD, MPH Medical Director, New Impact
Program Director, Pediatric Residency Program
Greenville Hospital System University Medical Center

2. Objectives Define overweight and obesity
Recognize co-morbid complications of overweight and obesity
Employ motivational interviewing techniques for counseling

3. The Obesity Burden
Childhood obesity has more than tripled in the past 30 years.
Children aged 6–11 years
7% in 1980 to nearly 20% in 2008.
Adolescents aged 12–19 years
5% to 18% over the same period.
> 1/3 children and adolescents overweight or obese.
Ogden CL, Carroll MD, Curtin LR, Lamb MM, Flegal KM. Prevalence of high body mass index in US children and adolescents, 2007–2008. Journal of the American Medical Association 2010;303(3):242–249.
National Center for Health Statistics. Health, United States, 2010: With Special Features on Death and Dying. Hyattsville, MD; U.S. Department of Health and Human Services; 2011.

5. What the studies show
~60% of overweight children with at least 1 cardiovascular risk factor
10% BMI-for-age at or below the 85th percentile
25% of overweight children had 2 or more risk factors
Psychosocial consequences of overweight are significant
Overweight in children linked to:
social discrimination
negative self-image in adolescence
parental neglect
behavioral and learning problems
Freedman DS, Dietz WH, Srinivasan SR, et al. The relation of overweight to cardiovascular risk factors among
Children and adolescents: the Bogalus heart study. Pediatrics. 1999;103(6):
Freedman DS, Kahn LK, Dietz WH, et al. Relationship of childhood obesity to coronary heart disease risk factors
in adulthood: the Bogalusa heart study. Pediatrics. 2001;108(3):

6. What we know Higher prevalence of intermediate metabolic
consequences and risk factors for adverse health outcomes
insulin resistance
elevated blood lipids
increased blood pressure
impaired glucose tolerance

7. What we know Severe childhood overweight/obesity pseudotumor cerebri
slipped capital femoral epiphysis
tibia vara
steatohepatitis
cholelithiasis
sleep apnea

8. **
**Increased risk of injury and prolonged recovery time

9. Long Term Risks
Overweight adolescents have a 70% chance of becoming overweight or obese adults
30% of boys and 40% of girls born in 2000 are at risk to develop Type 2 DM
Early recognition BMI (kg/m2) should be routine practice – prevention is key
BMI < 5% = underweight
BMI 5-84% = healthy weight
BMI % = overweight
BMI > 95% = obese
US Department of Health and Human Services. (2001). The Surgeon General’s Call to Action to
Prevent and Decrease Overweight and Obesity. (Rockville, MD)
Vehkat Narayan,K. (2003) JAMA.290:

11. A Staged Approach - Overview
Stage 1 - Prevention Plus
Family visits with physician or health professional
Frequency individualized to family needs and risk factors
Stage 2 - Structured Weight Management
Family visits with physician or health professional with training in childhood weight management.
May include visits with a dietitian, exercise therapist or counselor
May include self-monitoring, goal setting and rewards
Frequency monthly or individualized to family needs and risk factors

12. A Staged Approach - Overview
Stage 1 and 2 Behavioral Recommendations
Decrease screen time to 2 or fewer hours a day.
Minimize sugar-sweetened beverages.
Consume at least 5 servings of fruits and vegetables daily.
Be physically active 1 hour or more daily.
Prepare more meals at home as a family.
Consume a healthy breakfast daily.
Involve the whole family in lifestyle changes

13. A Staged Approach - Overview
Stage 3 - Comprehensive, Multidisciplinary Intervention
Multidisciplinary team with experience in childhood obesity
Frequency often weekly group sessions for 8-12 weeks with follow up
Stage 4 - Tertiary Care Intervention (for select children only when provided by experienced programs with established clinical or research protocols)
Medications - sibutramine, orlistat
Very-low-calorie diets
Weight control surgery - gastric bypass or banding/sleeve gastrectomy
(Childhood Obesity Action Network, NICHQ, 2007)

14. (Childhood Obesity Action Network, NICHQ, 2007)
Modifiable risk factors
(Childhood Obesity Action Network, NICHQ, 2007)

15. Behavior Modification
Behavior modification means changing what you do
Physicians may need to consider changing their behaviors as well
% Obese Patients Receiving...
Weight Reduction Counseling 15%-36% 
Exercise Counseling 18%-33%  
Nutrition Counseling 23%-42% 
Blood Pressure Measurement 57%-68%
Source: Rimm & Masters, 1979 Source: Stafford RS. Farhat JH. Misra B. Schoenfeld DA.
National patterns of physician activities related to obesity management. Archives of Family Medicine. 9(7):631-8, 2000

16. FM (n = 74) Peds (n = 213) Poor 11% 6% Fair 30% 17% Average 44% 47%
Ability to Counsel
FM (n = 74)
Peds (n = 213)
Poor
11% 6%
Fair
30%
17%
Average
44%
47%
Good
15%
27%
Excellent 0% 3%
Efficacy of Counseling
23%
48%
33%
36%
35% 9%
0.5%

17. Provider Perceived Barriers to Effective Treatment
(Health Care Systems Work Group of the South Carolina Coalition for Obesity Prevention Efforts (SCCOPE), 2007)

18. Weight Management Counseling
Sensitive with nonjudgmental tone toward both the child and the parents
family-based management strategy cannot be over-emphasized
assess the family's therapeutic readiness
Assess parental perceptions about their child's weight
delay intensive therapy if not receptive
focus on parental counseling and education in hopes of improving motivation

19. Motivational Interviewing
Patient Centered
Blank Canvas
Develop Discrepancy
How does current behavior conflict with core values?
Minimize Unsolicited Advice
Roll with Resistance
Support Self-Efficacy
Usual Suspects
Express Empathy
Good Nonverbal Listening skills
Problem solving partners

20. Patient-Centered Communication Empathize/Elicit - Provide - Elicit
Reflect
What is your understanding?
What have you heard about?
What do you want to know?
Provide
Advice or information
Choices or options
Elicit
What do you make of that?
Where does that leave you?

21. Nutrition The path to optimal nutrition...... Nutrition basics
Stoplight diet
Healthy plate model
WHOA
SLOW GO

22. Physical Activity Age Minimum Activity Comments Infants Toddler
No requirements        
Physical Activity should encourage motor development 
Toddler
1.5 hrs
30 minutes planned physical activity AND 60 minutes unstructured activity (free play) 
Preschool
2 hrs
60 minutes planned physical activity AND 60 minutes unstructured activity (free play) 
School Age
1 hr or more
Break up into segments of 15 minutes or more  

23. Benefits of Exercise A child who is active will:
have stronger muscles and bones
have a leaner body because exercise helps control body fat
be less likely to become overweight
decrease the risk of developing type 2 diabetes
possibly lower blood pressure and blood cholesterol levels
have a better outlook on life

24. 5 -2-1-0 Consistent Messaging 5 servings fruits and vegetables
2 hours or less screen time
1 hour or more physical activity
0 sugary drinks

25. Resources Choose My Plate We Can Let’s Move Let’s Go!
Let’s Go!
We Can
Let’s Move

26. Advocacy Educate Your Patients Encourage Healthy Activities
Create a Healthy Office Environment
Promote a Healthy Community

27. Chronic Care Model Environment Medical System Chinese proverb
Family/Patient
Self-Management
Family
School
Worksite
Community
Information Systems
Decision Support
Delivery System Design
Self Management Support
“The normal physician treats the problem;
the good physician treats the person;
the best physician treats the community.”
Chinese proverb
(Childhood Obesity Action Network, NICHQ, 2007)

28. (The Economist – December 2003)