Obesity (Peds-II)

ENVIRONMENTAL

Over past 30 years, we have created a culture where imbalance between energy intake & energy expenditure is vast.

Screening

(Assessment Not Standardized!) O Screening for type 2 diabetes, dyslipidemia & NAFLD is recommended for children with BMI ≥ 85th percentile. O Vitamin D O At Duke (Healthy Lifestyles): -serum insulin & TSH added O Additional testing that may be considered: -sleep studies, MS films, pelvic ultrasound

BMI 95%-98%

1) Prevention message 2) 5-3-2-1-almost none message If those don't work: 3)Structured Weight Management! -Frequent PCP visits -Written diet & exercise plans & monitoring (written,apps)

BMI 85%-94%

1) Prevention message PLUS: 2) 5-3-2-1-almost none message: O 5 veggies and fruits/day O 3 meals/day O 2 hrs (or less) of screen time/day O 1 hrs (or more of activity/day) O Almost no(ne) sweet drinks/day

BMI >99%

1) Prevention messages 2) 5-3-2-1-almost none messages 3) Structured weight management If those don't work, 4)Comprehensive multidisciplinary intervention O Registered Dietician O Exercise Specialists O Behavioral Specialist 5)Tertiary care interventions O Meal replacement O Specific diets O Bariatric surgery for select adolescents

We have made some progress...

43% decrease in obesity among 2-5 year olds in past decade (2002-2012) -important because children who are obese between ages of 3-5 are 5x more likely to be obese as adults -"obesity & it's complications become fixed" at this age; harder to change patterns -decreased consumption of sugary beverages, increased breastfeeding & overall decrease in daily consumption of calories

More SCREEN TIME

43% of children, age 2 or younger, watch TV every day 41% of children 2-6 years old and 43% of children use screen media for more than 2 hours per day Children, ages 8-18, watch an average of 3 hours of TV per day (with over 7 hrs. media total)

Duke Healthy Lifestyles Program: WHO SHOULD GO?

BMI >99% - send them right on over! BMI 95-99% - continued BMI increase after 3-6 months of good, concerted effort in your office. (prevention, 5-3-2-1-AN, & frequent visits with structured weight management tools) -If you are seeing BMI stabilization or decrease, keep up good work! -Follow them closely! BMI < 95% -typically don't see anymore

CO-MORBIDITIES

Cardiovascular O Elevated BP O Dyslipidemia Endocrine O Insulin resistance/Overt type 2 diabetes O PCOS O Irregular menses OSA GI Problems O NAFLD/NASH O Gallstones O GERD Orthopedic problems O Blount disease O SCFE

Duke Healthy Lifestyles Program

Clinical care, advocacy, education & research! O Eat, Breathe, Chant, Dream the Prevention & 5-3-2-1-AN messages. O Have on-site Physical Therapy O Have on-site Registered Dieticians. O Have on-site counseling services O Have on-site lab services with outstanding phlebotomists O Have every person on staff trained in Motivational Interviewing. O Have protocols for specific nutrition plans -Glycemic Index -STEPS - controlled carb for kids O Have Adolescent Weight Loss Surgery Program O Bull City Fit -a community-based fitness and wellness program -partners with Durham County Parks & Recreation

HISTORY

Current eating habits O Who feeds the child? O Identify high calorie foods O Identify eating patterns Physical activity O Identify any barriers to activity O Play time? O After-school and week-end activities O Screen time? Significant PMH/medications Family History: O Obesity in any first degree relatives? O History of co-morbidities associated with obesity? Psychosocial History: O School performance, social issues (Is the child a target for bullying?) O Any signs of depression O Tobacco use? Review of systems: O Headaches O Snoring; daytime somnolence O Abdominal pain O Altered gait, hip and/or knee pain O Menstrual irregularities O Urinary frequency, polyuria, polydipsia O Insomnia, anhedonia

MANAGEMENT Resource

Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report (Barlow et al. Pediatrics December 2007, Vol 120.Suppl 4)

Empowering Change

For child(ren): O He/she is strong, smart, & capable of making good choices when given the chance. For parent(s): O Responsibility for creating a healthy environment belongs to them O identify barriers & limits then move forward For communities: O Partner with schools, churches, youth organizations to promote physical activity & healthy eating

Recess/PE

Nationwide: O 4% elementary schools O 8% middle schools O 2% high schools provide daily Physical Education Recess has been reduced or eliminated in many schools.

Obesity by BMI

O 5%-85% = normal O 85%-95% = overweight O ≥ 95% = obese Severe obesity: BMI >99th percentile -BMI growth curves stop at 95th percentile...what to do? -4% of children aged 5-17 in US are above 99th percentile

School Lunch

O 94% of American Schools exceeded federal recommendations for fat & saturated fat. O Up to 50% of a child's total calories can come from school O Vending machines & commercial venders dominate lunchroom for middle & high school kids.

What if my patient doesn't have access to a Healthy Lifestyles sort of program?

O Don't be afraid to see kids frequently to discuss & monitor weight as it relates to health. O Find yourself some good tracking tools. Know your community resources: O Registered Dieticians - O Physical Therapists O Counselors O Community Programs (YMCA, Parks and Rec)

Find some language to talk about this!

O Don't use word "obese" when speaking with families & pts O Consider things like: -low risk, medium risk, high risk. -Weight as it relates to health. O Be culturally-sensitive in your approach & management

Prevention Message: encourage for EVERYONE

O Family meals at home O Active Family/Play time O Yearly BMI checks - starting at age 2 O Breastfeeding (future pregnancies)

EXAM

O General appearance -dysmorphism, stature, pattern of obesity O Skin and hair -acanthosis O BP (use correct cuff size) O HEENT: -funduscopic exam, tonsillar hypertrophy O Abdomen: -tenderness, organomegaly O GU: -sexual maturity O MS: -edema; -Blount disease, -SCFE, -size of hands & feet

CAUSES

O Genetic Disease (<1%) -suspect genetic syndromes in children with onset of obesity before the age of 2 years O Endocrine Disease (<1%) O Metabolic Programming O Environmental Factors (biggest role)!

Why are so many more of our children obese?

O Larger % of food consumed outside home -¼ Americans eats a fast-food meal each day -Increased availability of cheap calories O More calories consumed/day; -larger portion sizes O Wide-spread use of high fructose corn syrup O More screen time O Big food advertising -Direct marketing of food to children -Food Industry spent $1.5 Billion last year on marketing directly to children. (In contrast, USDA spent $220 million in 2004 on nutrition education)

Prevalence

Obesity among children all ages TRIPLED from 1976-2011: • 2 - 5 years: 5 % to 12.1% • 6 - 11 years: 6.5% to 18% • 12-19 years: 5% to 18.4% 2011: Overweight or obese (BMI≥85 percentile) -26.7 percent of preschool children (2 to 5 years) -32.6 percent of school-aged children (6 to 11 years) -33.6 percent of adolescents (12 to 19 years)

Stats

Rate of Pediatric Obesity has tripled since 1970. 1/3 of all kids in US are overweight or obese Obese children are almost 6x more likely than children with healthy weights to have an impaired quality of life (equal to that of children undergoing treatment for cancer)

Genetics

Studies of twins, adoptees, and families all strongly suggest the existence of genetic factors in human obesity. -heritability of obesity estimated from twin studies is high. Similarly, in adoptees the BMI correlates with that of their biologic parents rather than that of their adoptive parents Genes that contribute to 'common obesity' have been difficult to identify "Genetics loads the gun, the environment pulls the trigger" O Genetic factors play a permissive role and interact with environmental factors to produce obesity O If 1 parent is obese a child has a 40% chance of obesity. If both parents are obese, chance obesity increases to 80%.