1. Pediatric Obesity Elizabeth H. Kwon MD, MPH

3. OBESITY DEFINED According to the AMA’s Expert Committee on the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity in 2005 (Co-funded by Health Resources and Services Administration (HRSA) and the Centers for Disease Control and Prevention (CDC)) According to the AMA’s Expert Committee on the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity in 2005 (Co-funded by Health Resources and Services Administration (HRSA) and the Centers for Disease Control and Prevention (CDC)) Overweight Overweight BMI for age 85%ile to 94%ile BMI for age 85%ile to 94%ile Obese Obese BMI for age >=95%ile BMI for age >=95%ile

4. Causes of Pediatric Obesity Caloric Intake has Increased Caloric Intake has Increased Less supervised family meals Less supervised family meals More eating out/ Fast food/ Restaurants More eating out/ Fast food/ Restaurants Portions sizes are much larger Portions sizes are much larger Fried foods/ Trans fats Fried foods/ Trans fats High Calorie Beverages High Calorie Beverages Increased availability of calorically dense, ready-to- eat food Increased availability of calorically dense, ready-to- eat food More chips, cakes, cookies, donuts, crackers, candy… More chips, cakes, cookies, donuts, crackers, candy… Pop tarts, Easy Mac, Canned Ravioli, frozen pizzas… Pop tarts, Easy Mac, Canned Ravioli, frozen pizzas… (From Cochran, W., Pediatric Obesity: A Huge Problem in the USA)

5. Causes of Pediatric Obesity Less Physical Activity Less Physical Activity More sedentary activities like video games, TV and computer  less time to run around More sedentary activities like video games, TV and computer  less time to run around TV/Computer --Average 2.5 hours/day with 20% >5 hours day TV/Computer --Average 2.5 hours/day with 20% >5 hours day Studies show higher BMI’s, obesity and cholesterol with more TV Studies show higher BMI’s, obesity and cholesterol with more TV 40% of low-income children 1-5y.o had a TV in their room 40% of low-income children 1-5y.o had a TV in their room Schools have less or no gym time – in order to achieve “No Child Left Behind” goals Schools have less or no gym time – in order to achieve “No Child Left Behind” goals More kids in after school programs without much physical activities More kids in after school programs without much physical activities “More dangerous world”—keeps children inside more than previous decades “More dangerous world”—keeps children inside more than previous decades (From Cochran, W., Pediatric Obesity: A Huge Problem in the USA)

6. Causes of Pediatric Obesity Genetics Genetics One parent obese  3x risk One parent obese  3x risk Two parents obese  10x risk Two parents obese  10x risk ( Hassink, A Parent’s Guide to Childhood Obesity 2006) Environmental Environmental Energy imbalance Energy imbalance (Energy In>Energy Used  Energy Stored at Fat) (From Cochran, W., Pediatric Obesity: A Huge Problem in the USA)

7. Increasing Percent of Obese Children and Adolescents From Comorbidities of Pediatric Obesity—William Cochran, MD

8. 12. 5 Million US Children are Overweight today… 12. 5 Million US Children are Overweight today…

9. Racial Disparities in Overweight/Obesity Prevalence The NHANES in 1988-1994 versus the NHANES in 2002 showed overweight prevalence in non- Hispanic Black (20.5%) and Mexican-American (22.2%) increased at a faster rate than in Whites. The NHANES in 1988-1994 versus the NHANES in 2002 showed overweight prevalence in non- Hispanic Black (20.5%) and Mexican-American (22.2%) increased at a faster rate than in Whites.

10. Childhood Obesity has Medical Consequences Diabetes Mellitus type II Diabetes Mellitus type II Psychosocial Psychosocial Hypertension Hypertension Hyperlipidemia Hyperlipidemia Asthma Asthma Sleep Apnea Sleep Apnea Arthritis Arthritis SCFE SCFE Blount’s Disease Blount’s Disease Steatohepatitis Gallstones Pancreatitis Metabolic Syndrome Polycystic Ovarian Syndrome Skin Infections Back Pain Pseudotumor Cerebri

11. Prevalence of Diabetes in US 1990 versus 2001 From : Narayan et al. 2003, Sinha et. Al 2002, Weiss et al, 2003

12. Life years lost from Diabetes in the US from Narayan et al., 2003 If diagnosed at age 10 years White male: 16.5 yrs female: 18.0 yrs Hispanic male: 19.0 yrs female: 16.0 yrs Black male: 22.0 yrs female: 23.0 yrs If diagnosed at age 40 years If diagnosed at age 40 years White White male: 1.01 yrs male: 1.01 yrs female: 13.5 yrs female: 13.5 yrs Hispanic Hispanic male: 11.5 yrs male: 11.5 yrs female: 12.4 yrs female: 12.4 yrs Black Black male: 13.0 yrs male: 13.0 yrs female: 17.0 yrs female: 17.0 yrs

13. Hypertension 60% of Children with persistently elevated blood pressure had weight >120% Ideal Body Weight (Lauer J Pediatrics 1975;86:697-706.) 60% of Children with persistently elevated blood pressure had weight >120% Ideal Body Weight (Lauer J Pediatrics 1975;86:697-706.) Overweight adolescents have 8.5 x increased risk of hypertension as adults (Srinivasan Metab 1996;45:235-240) Overweight adolescents have 8.5 x increased risk of hypertension as adults (Srinivasan Metab 1996;45:235-240)

14. Hyperlipidemia Obesity in adolescence is associated with Obesity in adolescence is associated with 2.4 times more likely to have cholesterol >240mg/dl 2.4 times more likely to have cholesterol >240mg/dl 3 times more likely to have LDL>160mg/dl 3 times more likely to have LDL>160mg/dl 8 times more likely to have HDL<35 mg/dl by the time they are adults aged 27-31 y.o. 8 times more likely to have HDL<35 mg/dl by the time they are adults aged 27-31 y.o. (From Srinivasan Metab 1996;45:235-240)

15. Steatohepatitis Affects 20-25% of Obese Children (Tazewa Acta Paeditr-1997; 86:238-241) while 83% of Children with Steatohepatitis are Obese (Comorbidities of Pediatric Obesity, William Cochran MD) Affects 20-25% of Obese Children (Tazewa Acta Paeditr-1997; 86:238-241) while 83% of Children with Steatohepatitis are Obese (Comorbidities of Pediatric Obesity, William Cochran MD) Can progress to fibrosis or frank cirrhosis. Can progress to fibrosis or frank cirrhosis. Obesity and type 2 diabetes are the strongest predictors for fibrosis progression (Angulo P. Keach JC, Batts KP, Lindor KD, Hepatology 1999; 30(6) 1356-62.) Obesity and type 2 diabetes are the strongest predictors for fibrosis progression (Angulo P. Keach JC, Batts KP, Lindor KD, Hepatology 1999; 30(6) 1356-62.)

16. Cholelithiasis Is caused by obesity in 8-33% of childhood cases (Friesen Clin Pediatr 1989 7:294) Is caused by obesity in 8-33% of childhood cases (Friesen Clin Pediatr 1989 7:294) Is associated with obesity in 50% of adolescent cases (Crichlow Dig Dis. 1972; 17:68-72) Is associated with obesity in 50% of adolescent cases (Crichlow Dig Dis. 1972; 17:68-72) May be associated with weight loss (Crichlow Dig Dis. 1972, 17:68-72). May be associated with weight loss (Crichlow Dig Dis. 1972, 17:68-72).

17. SCFE and Blount’s 50-75% of SCFE patients are obese 50-75% of SCFE patients are obese (Wilcox, J Pediatric Orthopedics 1988:8: 196-200) 2/3 of Blount’s Disease patients are obese (Dietz, J Pediatrics 1982: 101: 735-737)

18. Obstructive Sleep Apnea 40% of severely obese children had central hypoventilation (Silvesti, Pediatric Pulmonology 1993; 16:124-139) 40% of severely obese children had central hypoventilation (Silvesti, Pediatric Pulmonology 1993; 16:124-139) Abnormal sleep patterns were found in 94% of obese children in one study Abnormal sleep patterns were found in 94% of obese children in one study OSA leads to decreases in learning, attention span and memory OSA leads to decreases in learning, attention span and memory (Rhodes, J Pediatrics 1995;127:741-744; Greengerg GD, Watson RK, Deptula D., Sleep 1987; 10(3):254-62.) And increases in pulmonary hypertension, systemic hypertension and right heart failure (Tal A, Lieberman A, Margulis G, Sofer S., Pediatric Pulmonology 1988;4(3):139-43; Marcus CL, Greene MG, Carroll JL., American J Respiratory Critical Care Medicine 1998; 157 (4 PT1): 1098-103; Massumi RA, Sarin RK, Pooya M, Reichelderfer, Dis Chest 1969; 55(2): 110-4.)

19. Pseudotumor Cerebri 30-80% of children with pseudotumor cerebri have obesity 30-80% of children with pseudotumor cerebri have obesity (Scott, American J Ophthalmology 1997; 124: 253-255) Increased Intracranial Pressure can lead to visual impairment or blindness Increased Intracranial Pressure can lead to visual impairment or blindness (Comorbidities of Pediatric Obesity, William Cochran)

20. Physical Exam Hypertension Hypertension Acanthosis Nigricans Acanthosis Nigricans Papilledema Papilledema Thyroid Thyroid Hepatomegaly Hepatomegaly Bowed legs/Osgood Sclatter’s Bowed legs/Osgood Sclatter’s Depression Depression Short Stature Short Stature

21. Laboratory Tests BMI 85-94%ile with no other risk-->Fasting lipid profile BMI 85-94%ile with no other risk-->Fasting lipid profile BMI 85-94%ile with risk factors (family history of obesity, family history of obesity-related diseases, elevated lipid levels, elevated blood pressure, smoking)  Fasting lipid profile, LFT’s, fasting glucose BMI 85-94%ile with risk factors (family history of obesity, family history of obesity-related diseases, elevated lipid levels, elevated blood pressure, smoking)  Fasting lipid profile, LFT’s, fasting glucose BMI >=95%ile  Fasting lipid profile, LFT’s, fasting glucose BMI >=95%ile  Fasting lipid profile, LFT’s, fasting glucose Repeat tests every 2 years after age 10. Other possible suggested tests by endocrinologists: Fasting Insulin Fasting Insulin HbA1C HbA1C Thyroid function tests Thyroid function tests

22. Obese Children are Likely to Become Obese Adults From Pediatric Obesity: A Huge Problem in the USA—William Cochran MD

23. Obesity Increases Mortality “Because of the increasing rates of obesity, unhealthy eating habits, and physical inactivity, we may see the first generation that will be less healthy and have a shorter life expectancy than their parents” --Richard H. Carmona, MD, MPH, FACS, Surgeon General U.S. Dept of Health and Human Services, 2004

24. Psychosocial Impact of Childhood Obesity Increased rates of Depression Increased rates of Depression Poorer Self-Esteem—may last til adulthood Poorer Self-Esteem—may last til adulthood 10-11 year olds prefer friends with handicaps than obese (Richardson, 1961) 10-11 year olds prefer friends with handicaps than obese (Richardson, 1961) 6-10 year olds associate obesity with laziness (Staffieri,1967) 6-10 year olds associate obesity with laziness (Staffieri,1967) Obese Females have lower college acceptance rates than non-obese females (Canning, 1966) Obese Females have lower college acceptance rates than non-obese females (Canning, 1966) Obese Adolescent Females as young adults had less education, less income, higher poverty rates and decreased rate of marriage versus non-obese females (National Longitudinal Survey of Youth, 1993) Obese Adolescent Females as young adults had less education, less income, higher poverty rates and decreased rate of marriage versus non-obese females (National Longitudinal Survey of Youth, 1993)

25. Economic Consequences of Obesity In 2002, the estimated cost of obesity in the US was $117 billion dollars. In 2002, the estimated cost of obesity in the US was $117 billion dollars. Hospital Costs associated with pediatric obesity are rising: Hospital Costs associated with pediatric obesity are rising: In 1979: $35 million In 1979: $35 million In 1999: $127 million In 1999: $127 million From Pediattric Obesity: A Huge Problem in the USA—William Cochran, MD

26. What can we do about Childhood Obesity? What can we do about Childhood Obesity? PREVENTION IS KEY SINCE TREATMENT IS SO MUCH MORE DIFFICULT

27. Prevention of Childhood Obesity Advise Pregnant Women to gain the recommended amount of weight during pregnancy Advise Pregnant Women to gain the recommended amount of weight during pregnancy LGA, SGA and infants of diabetic mothers have increased rates of obesity (Hediger M.., Pediatrics 104, p. 33, 1999) LGA, SGA and infants of diabetic mothers have increased rates of obesity (Hediger M.., Pediatrics 104, p. 33, 1999) Encourage Breastfeeding Encourage Breastfeeding 8 out of 11 studies noted a lower rate of obesity in children if breastfed vs. formula fed ( Dewey 2003) 8 out of 11 studies noted a lower rate of obesity in children if breastfed vs. formula fed ( Dewey 2003) Longitudinal study of breastfed vs. formula fed infants (Bergmann 2003) Longitudinal study of breastfed vs. formula fed infants (Bergmann 2003) BMI the same at birth BMI the same at birth BMI at 3 & 6 months > in formula fed vs. breastfed infants BMI at 3 & 6 months > in formula fed vs. breastfed infants Rate of obesity at 6 years was tripled in formula fed vs. breastfed Rate of obesity at 6 years was tripled in formula fed vs. breastfed (From Cochran, W., Pediatric Obesity: A Huge Problem in the USA)

28. Prevention of Childhood Obesity CALCULATE AND PLOT BMI on ALL CHILDREN OVER 2 YEARS OLD at all WELL CHILD EXAMS. CALCULATE AND PLOT BMI on ALL CHILDREN OVER 2 YEARS OLD at all WELL CHILD EXAMS. PLOT WEIGHT-FOR-LENGTHS ON ALL CHILDREN UNDER 2 YEARS OLD! PLOT WEIGHT-FOR-LENGTHS ON ALL CHILDREN UNDER 2 YEARS OLD! If there was an infectious disease that had… If there was an infectious disease that had… double - tripled in prevalence, double - tripled in prevalence, was afflicting 25-30% of children of all ages, was afflicting 25-30% of children of all ages, had life life-long, potentially life threatening impact… had life life-long, potentially life threatening impact… Would we be acting? Would we take 10 sec to plot a point? (From Krebs, N., Hassink S., Obeesity Basics 101: Role of the Pediatrician)

29. Prevention of Childhood Obesity Are MD’s Using the BMI Charts? Are MD’s Using the BMI Charts? 31 % of pediatricians: “Never” 31 % of pediatricians: “Never” 11% : “Always” 11% : “Always” According to a 2006 AAP Periodic Survey, only a little more than half the pediatricians assessed a BMI. According to a 2006 AAP Periodic Survey, only a little more than half the pediatricians assessed a BMI. Use of BMI by MD’s was associated with: Use of BMI by MD’s was associated with: Greater assessment of “fatness” Greater assessment of “fatness” Greater concern about co-morbidities Greater concern about co-morbidities “Visual diagnosis” subject to under-diagnosis of obesity “Visual diagnosis” subject to under-diagnosis of obesity (Perrin et al, J Peds 2004, and Krebs, N., Hassink S., Obeesity Basics 101: Role of the Pediatrician) (Perrin et al, J Peds 2004, and Krebs, N., Hassink S., Obeesity Basics 101: Role of the Pediatrician)

30. Can you see risk? 4 year old girl Is her BMI-for-age a) 5th to <85th percentile: “normal”? b) >85th to <95th percentile: “overweight”? c) >95th percentile: “obese” ? (Photo from UC Berkeley Longitudinal Study, 1973) (Slide Courtesy Krebs, N., Hassink S., Obeesity Basics 101: Role of the Pediatrician)

31. Measurements: Age=4 y Height=99.2 cm (39.2 in) Weight=17.55 kg (38.6 lb) Plotted BMI-for-Age Girls: 2 to 20 years BMI BMI=17.8 85-95 th percentile Answer: b)“overweight” (Slide Courtesy Krebs, N., Hassink S., Obeesity Basics 101: Role of the Pediatrician)

32. Can you see risk? 3 year old boy Is his BMI-for-age : a) 5th to <85th percentile: “normal” b) >85th to <95th percentile: “overweight”? c) >95th percentile: “obese”? (Slide Courtesy Krebs, N., Hassink S., Obeesity Basics 101: Role of the Pediatrician) Photo from UC Berkeley Longitudinal Study, 1973 CDC

33. Measurements: Age = 3 y 3 wks Height = 100.8 cm (39.7 in) Weight = 18.6 kg (41 lb) Plotted BMI-for-Age Boys: 2 to 20 years BMI BMI=18.3 Answer: BMI-for-age ~ 95 th percentile“obese” (Slide Courtesy Krebs, N., Hassink S., Obeesity Basics 101: Role of the Pediatrician)

34. Slide Courtesy Krebs, N., Hassink S., Obeesity Basics 101: Role of the Pediatrician) Referral Boys: 2 to 20 years BMI BMI>95% strongly correlates with body fat Slide Courtesy Krebs, N., Hassink S., Obeesity Basics 101: Role of the Pediatrician) 3 yr old boy

35. Early Identification – BMI vs Visual Diagnosis (Slide Courtesy Krebs, N., Hassink S., Obeesity Basics 101: Role of the Pediatrician)  95 th % >> 95 th% 85-95 th %

36. Nutrition Advice ALL children should be counseled (not just those with BMI’s>85%ile) ALL children should be counseled (not just those with BMI’s>85%ile) Beverages Guidelines— Beverages Guidelines— Lowfat Milk (3 dairy servings/day) Lowfat Milk (3 dairy servings/day) Juice/juice drinks (120calories/8oz.) Juice/juice drinks (120calories/8oz.) Ages 1-6  4-6 oz/day Ages 1-6  4-6 oz/day Ages 7-18  8-12 oz/day Ages 7-18  8-12 oz/day Don’t buy it for the house—>just drink it when out/school/afterschool Don’t buy it for the house—>just drink it when out/school/afterschool No Soda/Iced Tea/ Lemonade/Gatorade unless it’s diet No Soda/Iced Tea/ Lemonade/Gatorade unless it’s diet Lots of Water Lots of Water Make it inviting and convenient -> put bottles in the fridge, fun sippy cups with iced water, pitchers of water with lemon wedges etc. Make it inviting and convenient -> put bottles in the fridge, fun sippy cups with iced water, pitchers of water with lemon wedges etc.

37. Nutrition Advice 5 Fruits and Vegetables per day 5 Fruits and Vegetables per day Draw out a plate with 2/3 plate with fruit vegetables, and 1/3 carbs and meat… Draw out a plate with 2/3 plate with fruit vegetables, and 1/3 carbs and meat… Whole Grains and High Fiber foods (Fiber=Age+5) Whole Grains and High Fiber foods (Fiber=Age+5) Use Canola/Vegetable oils not butter Use Canola/Vegetable oils not butter Limit Fried Foods Limit Fried Foods No Trans Fats No Trans Fats Keep track of what child eats at school, afterschool, daycare etc. Keep track of what child eats at school, afterschool, daycare etc. Do not use food as a reward Do not use food as a reward Do not skip meals Do not skip meals

38. f NUTRITION ADVICE Pediatric Annals March 2010 f NUTRITION ADVICE Pediatric Annals March 2010

39. Nutrition Advice Give appropriate portions for age: Allow child to decide on how much he/she wants (within reason) Give appropriate portions for age: Allow child to decide on how much he/she wants (within reason) Studies showed children consumed 25% less of an entrée when allowed to serve themselves rather than being served a large portion (Fisher et al., AJCN, 2003) Studies showed children consumed 25% less of an entrée when allowed to serve themselves rather than being served a large portion (Fisher et al., AJCN, 2003) Don’t force a child to clean the plate Don’t force a child to clean the plate Try to eat at home rather than out Try to eat at home rather than out Eat food at the table (not in front of the TV) Eat food at the table (not in front of the TV) Eating in front of the TV is associated with: Eating in front of the TV is associated with: higher intake of fat and salt higher intake of fat and salt Lower intake of fruits/ vegetables Lower intake of fruits/ vegetables Eating without awareness  encourages overeating Eating without awareness  encourages overeating 60-80% of commercials during children’s shows relate to food 60-80% of commercials during children’s shows relate to food Eat slowly/Stop when full Eat slowly/Stop when full Read Labels Read Labels

40. Nutrition Guidelines

42. frrom Pediatric Annals March 2010

43. Encourage Physical Activity COUNSEL ALL CHILDREN at WELL CHILD CHECKS (not just those with BMI>85%ile) COUNSEL ALL CHILDREN at WELL CHILD CHECKS (not just those with BMI>85%ile) Limit screen time with TV and video games to less than 2 hrs/day Limit screen time with TV and video games to less than 2 hrs/day Make it active by running/dancing during commercials or requiring running/ dancing for the first 30 minutes to be able to watch the next 1-1/2 hours. Make it active by running/dancing during commercials or requiring running/ dancing for the first 30 minutes to be able to watch the next 1-1/2 hours. Don’t use the remote control Don’t use the remote control Encourage 60 minutes/day of activity Encourage 60 minutes/day of activity Encourage organized sports Encourage organized sports Encourage outdoor time Encourage outdoor time Parents have to support the child’s activity--Otherwise it will not likely happen. Parents have to support the child’s activity--Otherwise it will not likely happen. Plan family field trips on weekends Plan family field trips on weekends

44. (Slide Courtesy of Krebs, N., Hassink S., Obeesity Basics 101: Role of the Pediatrician)

45. (Slide Courtesy Krebs, N., Hassink S., Obeesity Basics 101: Role of the Pediatrician)

46. Treatment of Obesity “The new recommendations detail treatment strategies organized in a stepwise protocol format. By facilitating a more aggressive approach to weight management in the primary care setting (eg. More frequent follow-up visits, more timely and appropriate referrals to nutritionists and exercise specialists), the greater the likelihood of success.” “The new recommendations detail treatment strategies organized in a stepwise protocol format. By facilitating a more aggressive approach to weight management in the primary care setting (eg. More frequent follow-up visits, more timely and appropriate referrals to nutritionists and exercise specialists), the greater the likelihood of success.” -- Contemporary Pediatrics Volume 25, no. 4 -- Contemporary Pediatrics Volume 25, no. 4

47. Stage 1:Prevention Plus Protocol The Committee recommends a staged approach based on age and progress on decreasing BMI as follows: The Committee recommends a staged approach based on age and progress on decreasing BMI as follows: The MD should recommend: The MD should recommend: >=5 servings of fruits and vegetables /day >=5 servings of fruits and vegetables /day <2 hours of screen time/day and no tv or computers in the child’s sleeping area <2 hours of screen time/day and no tv or computers in the child’s sleeping area >1 hours of physical activity/day >1 hours of physical activity/day No sugar-sweetened beverages No sugar-sweetened beverages Eat breakfast every day Eat breakfast every day Limit fast food Limit fast food GOAL  weight maintenance  decrease BMI GOAL  weight maintenance  decrease BMI Follow patients as often as monthly for 3-6 months Follow patients as often as monthly for 3-6 months If there is no progress  GO TO STAGE 2 If there is no progress  GO TO STAGE 2

48. Stage 2: Structured weight management protocol Physicians should: Physicians should: Develop a plan for an organized diet with structured daily meals and snacks with nutritionist advice Develop a plan for an organized diet with structured daily meals and snacks with nutritionist advice Recommend that the child have active play for at least 1 hour a day and further restrict screen time to one hour or less per day Recommend that the child have active play for at least 1 hour a day and further restrict screen time to one hour or less per day Suggest improved monitoring of exercise, screen time or diet by patient and/or family Suggest improved monitoring of exercise, screen time or diet by patient and/or family GOAL  maintain weight or lose weight GOAL  maintain weight or lose weight (no more than 1 lb./month in children aged 2 to 11 OR 2 lbs./week in those aged 12 and older) (no more than 1 lb./month in children aged 2 to 11 OR 2 lbs./week in those aged 12 and older) Follow patients as often as monthly for 3-6 months Follow patients as often as monthly for 3-6 months If there is no progress  GO TO STAGE 3 If there is no progress  GO TO STAGE 3

49. Stage 3: Comprehensive multidisciplinary protocol REFER to a multidisciplinary team for more aggressive and coordinated management including evaluation by a psychologist with consideration given to behavior modification and motivational counseling REFER to a multidisciplinary team for more aggressive and coordinated management including evaluation by a psychologist with consideration given to behavior modification and motivational counseling Stage 3 interventions include the same eating and activity goals as stage 2 plus psychological counseling that may involve the entire family Stage 3 interventions include the same eating and activity goals as stage 2 plus psychological counseling that may involve the entire family GOAL  weight maintenance or loss (no more than 1 lb./month ages 2-5, or 2 lbs./week ages 6 and up )til BMI<85%ile GOAL  weight maintenance or loss (no more than 1 lb./month ages 2-5, or 2 lbs./week ages 6 and up )til BMI<85%ile Follow up may be provided weekly Follow up may be provided weekly

50. Stage 4: Tertiary Care Protocol For patients with BMI>95%ile with comorbidities or who have not responded to Stage 1-3 strategies For patients with BMI>95%ile with comorbidities or who have not responded to Stage 1-3 strategiesOR For patients with BMI>99%ile with no improvement after 6-12 months of a Stage 3 regimen For patients with BMI>99%ile with no improvement after 6-12 months of a Stage 3 regimen MUST be referred to a tertiary weight management center that usually include dietary and activity counseling, low-calorie diets and sometimes even medications and surgery.

51. From Contemporary Pediatrics Volume 25, No. 4 April 2008

52. An obesity action plan for children An obesity action plan for children From Contemporary pediatrics Volume 25, no. 4 April 2008

53. Treatment of Obesity Important to communicate effectively with patient and family Important to communicate effectively with patient and family Try to assess a typical day—to better identify ways to change diet and activity Try to assess a typical day—to better identify ways to change diet and activity Try to be sensitive and not use words that may offend (“obese”, “fat”). Try to avoid being judgmental and stigmatizing. Try to be sensitive and not use words that may offend (“obese”, “fat”). Try to avoid being judgmental and stigmatizing. “Are you concerned about your child’s weight?” “Are you concerned about your child’s weight?” “I’m concerned that your child’s weight is getting ahead of his height” “I’m concerned that your child’s weight is getting ahead of his height” (older child) “Is your weight ever a problem for you?” (older child) “Is your weight ever a problem for you?”

54. Motivational Interviewing “Recent studies have demonstrated the efficacy of motivational interviewing in helping patients change their health behaviors.” “MI is a patient-centered method for enhancing intrinsic motivation to change by exploring and resolving ambivilance.” “MI is a patient-centered method for enhancing intrinsic motivation to change by exploring and resolving ambivilance.” “MI is patient centered, not doctor centered.” “MI is patient centered, not doctor centered.” “The physician listens to the patient’s perspective on how the problem affects daily life and seeks to understand the patient’s point of view without judging or criticizing the behavior.” “The physician listens to the patient’s perspective on how the problem affects daily life and seeks to understand the patient’s point of view without judging or criticizing the behavior.” from Pediatric Annals March 2010

55. 3 Communcation Styles of Motivational Interviewing Following (history taking) Following (history taking) Open-ended questions Open-ended questions Reflective listening Reflective listening Agenda setting Agenda setting Asking permission Asking permission Directing Directing Commonly used by physicians—clinicians tells patients what to do and how to do it Commonly used by physicians—clinicians tells patients what to do and how to do it Guiding Guiding The physician helps the patient find his/her way and acts more like a tutor. The physician helps the patient find his/her way and acts more like a tutor. The patient is encouraged to explore his/her own motivation and goals. The patient makes the case for change The patient is encouraged to explore his/her own motivation and goals. The patient makes the case for change

56. Four Guiding Principles of Motivational Interviewing Resist arguing and trying to persuade your patient to change behavior Resist arguing and trying to persuade your patient to change behavior Otherwise patient will become defensive Otherwise patient will become defensive Understand your patient’s motivation Understand your patient’s motivation Ask them why they might want to change and might do it Ask them why they might want to change and might do it Listen to your patient Listen to your patient For example  Your patient may have the answers as to how to defeat the barriers to exercise in his daily life. For example  Your patient may have the answers as to how to defeat the barriers to exercise in his daily life. Empower your patient Empower your patient A physician’s belief in the patient’s ability to change can be all a patient needs to succeed. A physician’s belief in the patient’s ability to change can be all a patient needs to succeed. frrom Pediatric Annals March 2010

58. Motivational Counseling Script (cont’d)

59. Treatment of Obesity Negotiate for family change—otherwise, it will be almost impossible for the patient to change. Negotiate for family change—otherwise, it will be almost impossible for the patient to change. Try to get all family members to come to at least one visit so everyone is on the same page. Try to get all family members to come to at least one visit so everyone is on the same page. The family’s kitchen and habits have to change. The family’s kitchen and habits have to change. Food diaries Food diaries Activity logs Activity logs Pedometers. Pedometers. Handouts Handouts on food nutritional content/ portion sizes on food nutritional content/ portion sizes on healthy recipes snacks on healthy recipes snacks on exercise ideas on exercise ideas reviewing eating habits, activity goals reviewing eating habits, activity goals

60. Treatment of Obesity BUT TREATMENT IS VERY DIFFICULT BUT TREATMENT IS VERY DIFFICULT Thus, PREVENTION OF PEDIATRIC OBESITY IS THE MOST EFFECTIVE WAY TO COMBAT CHILDHOOD OBESITY. Thus, PREVENTION OF PEDIATRIC OBESITY IS THE MOST EFFECTIVE WAY TO COMBAT CHILDHOOD OBESITY. IT IS VITAL that pediatricians help develop, encourage healthy eating and activity habits. IT IS VITAL that pediatricians help develop, encourage healthy eating and activity habits.

61. BARRIERS TO THERAPY OF PEDIATRIC OBESITY Lack of commitment of primary care physicians Lack of commitment of primary care physicians Many physicians do not address obesity Many physicians do not address obesity Price 1989 Price 1989 17% of pediatricians felt physicians did not need to counsel parents of obese children 17% of pediatricians felt physicians did not need to counsel parents of obese children 33% did not feel that normal weight is important to child health 33% did not feel that normal weight is important to child health 22% felt competent in treating obesity 22% felt competent in treating obesity 11% felt treatment of obesity was gratifying 11% felt treatment of obesity was gratifying (Slide Courttesy of Cochran, W., Pediatric Obesity: A Huge Problem in the USA)

62. BARRIERS TO THERAPY OF PEDIATRIC OBESITY Time commitment Time commitment Lack of reimbursement Lack of reimbursement Tershakovec 1999 Tershakovec 1999 Median reimbursement rate 11% Median reimbursement rate 11% Lack of standard treatment protocol Lack of standard treatment protocol Social / environmental barriers Social / environmental barriers Slide Courtesy of Cochran, W., Pediatric Obesity: A Huge Problem in the USA)

63. PREVENTION: SCHOOL Promote physical activity Promote physical activity Provide nutritious meals Provide nutritious meals Control vending machines Control vending machines Have nutrition education incorporated into regular school curriculum. Have nutrition education incorporated into regular school curriculum. Encourage children to walk or bike to school safely. Encourage children to walk or bike to school safely. Slide Courtesy of Cochran, W., Pediatric Obesity: A Huge Problem in the USA)

64. PREVENTION: COMMUNITY Have safe playgrounds Have safe playgrounds Provide safe places for bike riding and walking Provide safe places for bike riding and walking Promote physical activity outside of school Promote physical activity outside of school Slide Courtesy of Cochran, W., Pediatric Obesity: A Huge Problem in the USA)

65. PREVENTION: INSURANCE AND GOVERNMENT Acknowledge obesity as a medical condition for which one can be reimbursed. Acknowledge obesity as a medical condition for which one can be reimbursed. Provide reimbursement for anticipatory guidance for nutrition and physical activity Provide reimbursement for anticipatory guidance for nutrition and physical activity Slide Courtesy of Cochran, W., Pediatric Obesity: A Huge Problem in the USA)

66. LET’S MOVE Campaign The White House Obesity Initiative and Your Family What is the White House Obesity Initiative? The First Lady’s national campaign against childhood obesity called “Let’s Move” is a comprehensive and coordinated initiative with many partners. The focus is to prevent childhood obesity. The campaign has four pillars: healthy schools, access to affordable and healthy food, raising children’s physical activity levels, and empowering families to make healthy choices. The American Academy of Pediatrics (AAP) is proud to join the White House in this initiative

67. White House Obesity Initiative FAQ for Families Why do parents need to know their child’s BMI? Parents need to know their child’s BMI because prevention is the best medicine. By plotting BMI and monitoring physical activity and nutrition throughout childhood, parents and pediatricians can keep an eye out for children at-risk of becoming overweight and take action early to prevent future obesity. By catching at-risk children early, families in partnership with their pediatrician can explore ways to make changes to live healthier active lives.

68. From the House Obesity Initiative FAQ for Families How do I talk with my children about making healthy active changes? Talk with your children about the importance of the whole family being healthy. Get together with your family and decide ways your family can make healthier choices. Talk with the whole family and decide what changes to make together. Remember to make it fun to try new things together.

69. What can families do to lead healthier lives? Healthy active living can be fun and family-oriented. Make healthy choices together – grow a garden, play outdoor games, cook as a family. Have fun! As parents, it’s important to set a good example. There are a lot of things families can do to be healthier and it can be overwhelming trying to decide where to start. From the House Obesity Initiative FAQ for Families

70. 5-2-1-0- RX But it is important to remember that small changes can make a big difference. The AAP recommends starting with one of these behaviors: 5 – Eat 5 fruits and vegetables a day. 2 – Limit screen time (TV, computer, video games) to 2 hours each day. Children younger than 2 should have no screen time at all. 1 – Strive for 1 hour of physical activity a day. 0 – Limit sugar-sweetened drinks. From the House Obesity Initiative FAQ for Families

71. 5-2-1-0 Rx. For Healthy Active Living

72. 5-2-1-0 Rx. Cont’d To start, families can pick one of these behaviors and set specific goals to improve their health. In addition to 5, 2, 1, 0, goals, families can make small changes in their family routines to help everyone lead healthier active lives. Science suggests these activities can help prevent obesity: · Eating breakfast every day; · Eating low-fat dairy products like yogurt, milk, and cheese; · Regularly eating meals together as a family; · Limiting fast food, take-out food, and eating out at restaurants; · Preparing foods at home as a family; · Eating a diet rich in calcium; and · Eating a high fiber diet. From the House Obesity Initiative FAQ for Families

73. How do we start to make changes to our family’s routine? You can start in small steps. Small changes can make a big difference in your child’s health. First Lady Michelle Obama gives a few concrete examples of doing just that – putting water in your child’s lunch box, providing a fruit serving at breakfast, and curbing fast food consumption. TheAAP’s healthy active living prescription available at www.aap.org/obesity/whitehouse is designed to help you and your pediatrician identify some areas where you might want to begin. Small changes you make every day can make a big difference in your family’s health in the long run! From the House Obesity Initiative FAQ for Families

74. How can our communities support healthy active children? The environments our children live in have a profound impact on the foods they eat and the amount of activity they get. Some communities lack full-service grocery stores, but have an abundance of fast food restaurants. In turn, families may fall back on these fast food options because healthy, fresh foods are not available nearby. Working with community leaders to encourage the creation of healthy, fresh food options can make a difference in the choices available for families. From the House Obesity Initiative FAQ for Families

75. How can our communities support healthy active children? (cont’d) Communities can also ensure that children have a safe place to play. Community centers, green space, parks – these all provide an opportunity for kids to be active. Encourage your community to have fun and safe places for children to play – inside and outside – so they have options for fun and safe activities. From the House Obesity Initiative FAQ for Families

76. How can pediatricians and parents partner on healthy active living? Your pediatrician can partner with you on a prescription for healthy active living that is right for your family. He or she knows your family and understands the nutritional and physical activity needs for your child. Your pediatrician is also familiar with your community and may be able to help you find needed resources to support your healthy active lifestyle goals. Together, you and your pediatrician can help your family get started on the path to leading healthier lives. From the House Obesity Initiative FAQ for Families

77. EAT WELL PLAY HARD or else……

78. Relevant WEBSITES Relevant WEBSITES www.aap.org/obesity/whitehouse/index.html www.aap.org/obesity/whitehouse/index.html Let’s move campaign by First Lady Michele Obama endorsed by the AAP Let’s move campaign by First Lady Michele Obama endorsed by the AAP www.nichq.org/NICHQ/Programs/ConferencesAndTra ining/ ChildhoodObesity/ActionNetwork/htm www.nichq.org/NICHQ/Programs/ConferencesAndTra ining/ ChildhoodObesity/ActionNetwork/htm www.nichq.org/NICHQ/Programs/ConferencesAndTra ining/ ChildhoodObesity/ActionNetwork/htm www.nichq.org/NICHQ/Programs/ConferencesAndTra ining/ ChildhoodObesity/ActionNetwork/htm Pediatrician can join the Childhood Obesity Action Network Pediatrician can join the Childhood Obesity Action Network http://www.verbnow.com http://www.verbnow.com http://www.verbnow.com CDC site for 9-13 year olds to promote physical activity CDC site for 9-13 year olds to promote physical activity www.aap.org/obesity/index.html www.aap.org/obesity/index.html www.aap.org/obesity American Academy of Pediatrics web site regarding obesity American Academy of Pediatrics web site regarding obesity http://www.bam.gov http://www.bam.gov http://www.bam.gov Site to answer kids questions Site to answer kids questions

79. Relevant WEBSITES http://147.208.9.133/ http://147.208.9.133/ http://147.208.9.133/ A free dietary assessment tool to keep up to a 20-day food log A free dietary assessment tool to keep up to a 20-day food log http://www.kidnetic.com/ http://www.kidnetic.com/ http://www.kidnetic.com/ An interacitve website for 9-13 year olds and families re healthy eating and activity An interacitve website for 9-13 year olds and families re healthy eating and activity http://www.trowbridge-associates.com http://www.trowbridge-associates.com http://www.trowbridge-associates.com Pediatric BMI wheels Pediatric BMI wheels http://www.usda.gov/cnpp/kidspyra http://www.usda.gov/cnpp/kidspyra http://www.usda.gov/cnpp/kidspyra Pediatric food pyramid Pediatric food pyramid (From Cochran, W., Pediatric Obesity: A Huge Problem in the USA)