The Overweight Child: Tips for the Primary Care Provider

(1)

The Overweight Child: Tips for the Primary Care Provider

Wendy Slusser, MD, MS,

Health Science Clinical Professor

Director, UCLA FIT for Healthy Weight Program Mattel Children’s Hospital UCLA

UCLA Schools of Public Health and Medicine

(2)

Which spice reduces your appetite?

•  A. Oregano

•  B. Cinnamon

•  C. Garlic

•  D. Ginger

•  E. Curry

(3)

Learning Objectives

•  Identify three community and patient based strategies to prevent pediatric obesity.

•  Identify three community and patient based strategies to manage pediatric obesity.

(4)

Background of the Overweight Problem

•  Rapid rate of increase of overweight over the last two decades

•  Risk of an overweight child becoming an overweight adult

•  Rise in co-morbidities

•  Economic Burden

•  Lack of training among primary care providers

(5)

0%

5%

10%

15%

20%

25%

1963-65 &

1966-70

1971-74 1988-94 1999-2002 2007-8 2009-10 2011-12

Obese* Children in the U.S.

(*BMI≥95th percentile)

6-11 years old 12-19 years old

Source: www.NICHQ.org; Ogden,CL et al., JAMA. 2010;303(3):242-249; JAMA. 2012;307(5):483-490;

JAMA 2014;311(8):806-814.

(6)

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

All race Non-Hispanic White Non-Hispanic Black Non-Hispanice Asian Hispanic

2007-8 2009-10 2011-12

From: JAMA. 2010;303(3):242-249; JAMA. 2012;307(5):483-490; JAMA 2014;311(8):806-814.

Obese and Overweight* Children 2-5 years old in the U.S. by race (*BMI≥85th percentile)

(7)

Background of the Overweight Problem

(8)

Risk of overweight in adulthood

•  Overweight children and adolescents have a 30-70% risk of growing up to be an overweight adult.

(9)

Background of the Overweight Problem

(10)

Overweight children have higher risk of developing:

• non-insulin dependent diabetes

• gallbladder diseases

• sleep apnea

• asthma

• mental disorders

• high blood pressure

• Musculoskeletal complaints

• Poor school performance

Associated Morbidities

(11)

Background of the Overweight Problem

(12)

What are the top three co-morbidities that drive the health care costs for

pediatric obesity?

A.  Non-insulin dependent diabetes, sleep apnea, asthma

B.  Asthma, mental disorders, high blood pressure C. Mental disorders, Musculoskeletal and GI

complaints

D. High blood pressure, non-insulin dependent diabetes, sleep apnea

(13)

Economic Burden:

In 2004:

– privately insured obese children

annual health care costs: $3,743 (all children $1,108)

– Medicaid insured obese children

annual health care costs: $6,730 (all children, $2,446)

From:William MD, Chang S, (2005). Childhood Obesity: Costs, Treatment Patterns, Disparities in Care, and Prevalent Medical Conditions. Ann Arbor, Mich: THOMSON MEDSTAT RESEARCH BRIEF accessed, January 26, 2010. http://www.medstat.com/pdfs/childhood_obesity.pdf

(14)

Background of the Overweight Problem

•  Economic burden

(15)

Stages of Obesity Treatment

•  Stage 1: Prevention Plus

•  Stage 2: Structured Weight Management

•  Stage 3: Comprehensive

Multidisciplinary Intervention

•  Stage 4: Tertiary Care Intervention

From:Barlow, S Expert committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report. Pediatrics, 2007.

(16)

Stage 1: Prevention Plus

•  Once Overweight or obesity is diagnosed.

•  Focus is on basic healthy lifestyle eating and activity habits.

•  Goal is improved habits and as a result improved habitus (BMI Status).

•  Frequent Monitoring.

From: Expert committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report. Pediatrics, 2007.

(17)

What is the intervention with the strongest evidence for obesity prevention and

management

A. Minimize Sugar-sweetened beverages with a goal of 0.

B. Increasing to 5 fruit and vegetable servings or more per day.

C. Consume a healthy breakfast.

D. Reduce foods that are high in energy density.

E. Meal frequency and snacking.

(18)

Focus is on basic healthy

lifestyle eating and activity habits

–  Minimize Sugar-sweetened beverages with a goal of 0**.

–  Increase meals prepared at home**.

–  Education and modification of portion sizes**

–  Reduction of inactive time to < 2 hours/day and if less than 2 years old to 0 time**.

–  Increasing active time for children and families to

>=1 hour each day**.

–  Involve the whole family in lifestyle changes.

–  Cultural sensitivity

** = strong evidence

(19)

Focus is on basic healthy

lifestyle eating and activity habits

– Increasing to 5 fruit and vegetable servings or more per day*.

– Reduction of 100% fruit juices*.

– Consume a healthy breakfast*.

– Reduce foods that are high in energy density *.

– Meal frequency and snacking *.

– Involve the whole family in lifestyle changes.

– Cultural sensitivity

*weaker evidence, but may be important for some individuals

(20)

Laboratory Assessment

•  >85-94 percentile Fasting lipids No risk factors

•  85th-94^th percentile Fasting lipids, with risk factors Fasting glucose,

AST/ALT

•  ≥95 percentile Fasting lipids,

Fasting glucose, AST/ALT

(21)

Goal: Improved Habits and in turn Habitus

After 3-6 months, if child has not

made appropriate

improvements move to stage 2.

(22)

Stage 2: Structured Weight Management

•  Prevention Plus behavior change, but more support and structure

•  Specific eating and activity goals with:

– planned diet, structured daily meals and snacks.

– Supervised physical activity.

– Monitoring behaviors with logs.

– Additional reduction in inactive time – Planned reinforcement

(23)

Education and Support: the 5 – 2 – 1 – 0 – Blastoff!

•  5: or more fruit and vegetable servings per day

•  2: No more than 2 hours of screen time per day for 2 year olds and over and 0 time for under 2

•  1: year or more of breastfeeding with appropriate foods introduced at around 6 months.

•  0: sweetened beverages

•  Blastoff: Move, be active and have fun!

(24)

At least 5 fruit and vegetable servings per day

•  Offer healthy choices at school, home, and team sporting events

•  Model healthy eating behaviors

–  Practice eating family meals

From: choosemyplate.gov, accessed 3-19-2014

(25)

Adolescent Fruit and Vegetable Servings by Frequency of Family Meals

.

0 0.5 1 1.5 2 2.5 3 3.5 4

Fruit and Vegetable Servings p > .001

Never 1-2 Times 3-6 Times 7+ Times

From: Neumark-Sztainer D, et al. J Am Diet Assoc. 2003;103(3):317-322

(26)

Mean Total Fruit and Vegetable Serving

Frequencies in One Day Pre and Post Salad Bar Intervention in three LAUSD Elementary Schools

0 0.5 1 1.5 2 2.5 3 3.5 4 4.5

1998, Pre-Salad Bar Intervention

2000, Post Salad Bar Intervention

Mean Servings p<0.001

From: Slusser WM, Cumberland WG, Browdy BL, Lange L, Neumann C.

Public Health Nutr. 2007;

10(12):1490-1496.

(27)

5 -2 or less hours of television viewing

•  Strategies

– Choose as a family 1-2 hours of

television shows to watch and then turn off the TV when desired shows are finished

– Remove television and/or computer from child’s bedroom

From: Prevention of Pediatric Overweight and Obesity. Policy statement from the Committee on Nutrition PEDIATRICS Vol. 112 No. 2 August 2003, pp. 424-430

(28)

AAP Recommendation

•  0-2 years old: no television

•  >2 years old: <2 hours/day of TV and other entertainment media

From: Children, Adolescents, and Television (RE0043), Committee on Public Education www.aap.org/policy/re0043.html

(29)

7/17/15 29

What can you do to support social justice and prevent obesity?

A. Promote breastfeeding

B. Reduce alcohol consumption C. Reduce cigarette smoking

D. Promote gum chewing

(30)

7/17/15 30

Answer: Breastfeeding

Support women who live in poverty to breastfeed:

it provides equal opportunities for infants to grow and develop optimally.

(31)

5-2- 1 or more years of breastfeeding

•  Key points for support:

–  Pregnancy

–  Newborn period –  3- 5 days of age –  One month old

–  Mother going back to work

•  Resource

–  www.cdc.gov/

breastfeeding

From: Gartner L, Eidelman A, and Pediatrics Section on Breastfeeding. Breastfeeding and the Use of Human Milk 2005;115;496-50

(32)

-23%

-42%

-64%

-40% -39%

-19%

-36%

-24%

-70%

-60%

-50%

-40%

-30%

-20%

-10%

0%

32

Infant Benefits from Breastfeeding Optimally Reduced Risk of Disease

AHRQ, 2007

(33)

Biological Theories of Why Breastfeeding:

Reduces the Risk of Childhood Obesity

•  Infants-studies under way to evaluate:

•  Infants self-regulate at the breast

•  Different feeding patterns & maternal behavior

–  Breastfeeding mothers are less controlling of the child’s feeding at one-year

•  Reduced risk for early growth acceleration

•  Leptin, ghrelin, adiponectin considered to play a role

•  Reduces the risk of obesity by 4% for each month of breastfeeding

Dewey, K. Is breastfeeding protective against child obesity?

J Hum Lact. 2003 Feb;19(1):9-18; Ip S et al (2007) Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries.

http://archive.ahrq.gov/downloads/pub/evidence/pdf/brfout/brfout.pdf

accessed 3-19-2014; Miralles O et al A physiologic Role of breast milk leptin in body weight control in developing infants.Obesity. 2006;14(8):1371-7.

.

(34)

Conclusions

•  “The evidence for the association is nearly all

epidemiologic, so it is difficult to tease-out true causality.

Epidemiologic criteria:

temporality, dose-response effects and reasonably good consistency of findings.”

•  “Biologic explanation is more tentative.”

Communication with Larry Grummer-

Strawn, PhD Chief Nutrition Branch, CDC, 2011

(35)

7/17/15 35

Pop quiz

•  How can hospitals and employers

save money, reduce hospital infection rates, reduce disparities, and attract new patients and employees?

(36)

7/17/15 36

Answer: Baby Friendly

Baby Friendly Hospital

(172 BFH in US, 52 in CA) Baby Friendly Workplace

Baby Friendly Daycare

From: http://www.babyfriendlyusa.org/find-facilities

Institute of Medicine (IOM). 2011. Early Childhood Obesity Prevention Policies. Washington, DC: The National Academies Press.

(37)

7/17/15 37

Baby Friendly Work Place

! Set up lactation rooms

(38)

Baby Friendly Hospital Initiative addresses disparities

•  Low-income and black women who gave birth at a US Baby-Friendly hospital, breastfed at equal rates at six months when compared to the overall US population.

•  There are elevated rates of initiation and

exclusive breastfeeding among the women who delivering at the US Baby Friendly Hospitals (29) in 2003, regardless of demographic factors that are traditionally linked with low breastfeeding rates.

From Merewood, A et al Breastfeeding rates in US Baby-Friendly hospitals: results of a national survey. Pediatrics. 2005 Sep;116(3):628-34.

(39)

Ten Steps to Successful Breastfeeding

1. Have a written breastfeeding policy that is routinely communicated to all health care staff.

2. Train all health care staff in skills necessary to implement this policy.

3. Inform all pregnant women about the benefits and management of breastfeeding.

4. Help mothers initiate breastfeeding within an hour of birth.

5. Show mothers how to breastfeed, and how to maintain lactation even if they should be separated from their infants.

(40)

Ten Steps to Successful Breastfeeding

6. Give newborn infants no food or drink other than breast milk, unless medically indicated.

7. Practice rooming-in - mothers and infants remain together - 24 hours a day.

8. Encourage breastfeeding on demand.

9. Give no artificial teats or pacifiers to breastfeeding infants.

10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.

(41)

Baby Friendly Hospital Initiative

addresses disparities

(42)

Healthy People 2020

Increase:

•  Ever breastfed from 73.9% baseline to 81.9%.

•  At 6 months any breastfeeding from 43.4% baseline to 60.5%.

•  At 1 year any breastfeeding from 22.7% baseline to 34.1%.

•  Exclusively breastfed through 3 months from 33.1% baseline to 44.3%.

•  Exclusively breastfed through 6 months from 13.6% baseline to 23.7%.

(43)

Healthy People 2020

•  Increase the proportion of employers that have worksite lactation support programs from 25%

baseline to 38%.

•  Reduce the proportion of breastfed newborns who receive formula supplementation within the first 2 days of life from 25.6% to 15.6%.

•  Increase the proportion of live births that occur in

facilities that provide recommended care for lactating mothers and their babies from 2.9% baseline

(currently at 6.9%) to 8.1%.

(44)

5-2-1-

0

sweetened drinks and Education and modification of portion sizes

•  USDA MYPlate •  Focus on 1-2 changes/month –  Modification of fruit juice

and sugary drink consumption

•  Eliminate soda

•  Limit juice to half a cup per day

–  Reducing milk to 1% fat after 2 years old

–  Limit high fat food –  Review portion size

From: choosemyplate.gov

(45)

What can you do that:

" is fun

" makes you feel good

" improves your health

" makes you look younger

" is free

(46)

(47)

5-2-1-0-Blastoff! families Increasing active time for children

Access to Parks: ie safety, location, fitness zones

CDC Recommendation

60 minutes of moderate exercise per day

Aerobic activity

Muscle Strengthening Bone Strengthening

From:

• www.cdc.gov/nccdphp/dnpa/physicalactivity.htm

• www.cdc.gov/nccdphp/dnpa/recommendations.htm

(48)

Increasing active time for children and families

•  Become a role model and incorporate physical activity into daily activities.

(49)

Increasing active time at the work site

•  Incorporate physical activity into daily activities

From:

•  www.cdc.gov/nccdphp/dnpa/physicalactivity.htm

•  www.cdc.gov/nccdphp/dnpa/recommendations.htm

(50)

Cultural Openess

•  Strategies

–  Follow the ABCs of counseling

•  Active listening

•  Body language (no barriers)

•  Caring and open mind

–  Motivational Interviewing

•  “... method of communication rather than a set of

techniques. It is not a bag of tricks for getting people to do what they don’t want to do; rather, it is a fundamental way of being with & for people - a facilitative approach to

communication that evokes change.”

From: Miller & Rollnick 2002 and Slusser W and Kroeger M (1992) in Woodward-Lopez G and Creer AE lactation Management Curriculum: A Faculty Guide for Schools of Medicine, Nursing, and Nutrition. Third edition, 1995 UCSD and Wellstart International.

(51)

Nutrition During the Life Course

Optimal Compromised

Prenatal • Breastfeeding education • No breastfeeding education

Infant • Introduce solid foods at 6 months

• Continues to Breastfeed >= 1 year

• Introduce solid foods at 4 months or younger

• No breastfeeding

Toddler • Change to 1% milk

• TV watching < 2 hours per day

• Continues to drink whole milk

• TV watching > 2 hours per day

Preschool (2-5)

• Drinks 1/2 cup of juice per day

• Physical activity ≥ 60 minutes per day

• Drinks >1 cup of juice per day

• Physical activity ≤ 30 minutes per day

Elementary (6-12)

• Infrequent soda consumption

• Frequent family meals

• Drinks 1 or more sodas per day

• Infrequent family meals

Middle &

High School (13-18)

• Infrequent fast food meals • Frequent fast food meals

(52)

Health and Developmental Outcomes

0 5 10 15 20 25 30 35

Prenatal Infant

Toddler

2-5 6-12 13-14 15-18

Body Mass Index

Optimal

Comprimised

(53)

Wellness for Life

The Purpose:

(54)

Organizations & Institutions

Media Law

Popular Culture

Professional Education

Public Education Public

Parks

Community/Neighborhood

Home Visitation

Child Care

Employer

Lactation Specialists Hospitals

Health Care Providers

Insurers

Parent, Infant, Child

Friends/Family

Fathers

Friends

Family Neighbors

Coworkers

(55)

Personal Goals

•  Become a role model

–  Provide support for healthier

environments for

your employees and colleagues

–  Exercise regularly

(56)

Haiku – by Samuel Bruce, 3

^rd

Grader

May 2002

Fruit comes from flowers Fruit is very good to eat I like to eat fruit