1. 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

2. 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?

3. Expert Committee Recommendations June 2007 (Published Pediatrics Supplement December 2007) Assessment Prevention Prevention Plus Structured Weight Management Comprehensive Multidisciplinary Protocol Tertiary Care Protocol

4. 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

5. BMI- Calculate, Chart, Classify BMI based on age and gender and is a population based reference Underweight 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

6. Case an 8 year old boy Weight 71 kg (156.2 lbs) Height 150 cm (411) BMI 31.5

10. American Academy of Pediatrics Obesity Decision Support Chart 2007

11. 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>30 90% with BMI>35 65% 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

12. Continuous Assessment Calculate, chart and classify BMI for all children 2-18 yrs at least yearly

14. 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

15. Prevention BMI 5%-84% - Diet Portions Age appropriate Parents provide child decides Structure Breakfast Family dinners, no TV Limit fast food Balance Food groups Limit refined sugar

16. Prevention Dietary Patterns minimum once /year at well visits Self-efficacy and readiness to change Small incremental steps for change Family support Positive Self monitoring Setbacks are normal, trouble shoot, support return to plan Identify high risk nutritional behaviors

17. Prevention All 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.

19. Prevention Plus BMI >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

20. Prevention Plus BMI >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.

21. 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)

22. 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 home Beverages at home, soda, gator aid, juice 5 glasses/day

23. 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 familys activity and exercise habits Assess outdoor activity

24. 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

25. 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

26. Structured Weight Management Stage 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

27. Structured Weight Management Stage 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

28. Structured Weight Management Stage 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

29. Comprehensive Multidisciplinary Protocol Stage 3 Multidisciplinary obesity care team Physician, nurse, dietician, exercise trainer, social worker, psychologist. Eating and activity goals are the same as in Stage 2 Activities 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

30. 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.

31. Tertiary Care Protocol Stage 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.

32. Family History Focused family history Obesity, 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.

33. Review of Systems Copyright AAP 2008

34. Severe Obesity Related Emergencies Hyperglycemic Hyperosmolar state DKA Pulmonary emboli Cardiomyopathy of obesity

35. Co-morbidity's Requiring Immediate Attention Pseudotumor Cerebri Slipped Capital Femoral Epiphysis Blounts Disease Sleep Apnea Asthma Non alcoholic hepatosteatosis Cholelithiasis

36. Chronic-Obesity Related Co Morbid Conditions Insulin Resistance (Metabolic Syndrome) Type II Diabetes Polycystic Ovary Syndrome Hypertension Hyperlipidemia Psychological

37. Case of an 8 year old boy: Review of systems Medical Snoring with pauses, daytime tiredness ? Sleep apnea Gold standard: Nighttime polysomnography Psychosocial Poor school performance over past year ? Sleep apnea ADD ? Teasing, low self esteem

38. Physical Examination Copyright AAP 2008

40. Case of an 8 year old boy Physical examination Blood pressure 118/78 (>905<95%) Pre hypertension Skin – Mild acanthosis nigricans Family history of diabetes Insulin resistance Pharynx – Enlarged tonsils Overlap upper airway obstruction from enlarged tonsils

42. 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

44. Partnership with Families Families have a critical role in influencing a childs health »Cohen RY et al Health Educ Q 1989;16;245- 253 Effective interaction with families is the cornerstone of lifestyle change

45. Communication Positive discussion of what healthy lifestyle changes families can make (evidence base) Allow for personal family choices Have families set specific achievable goals and follow up with these on revisits Be aware of cultural norms, significance of meals and eating for family/community, beliefs about special foods, and feelings about body size.

46. Modeling in the office Waiting room Books, posters, videos promoting healthy lifestyle Staff role models Drinking water, healthy snacks, physical activity Consistent messages, involvement with community

47. Lifestyle Change Listen Ask Provide Assess Partner Revisit Reassess

48. Interactions around Lifestyle Change Four essential skills Asking Informing Advising Listening Three styles of communication Following – information gathering Guiding- clarification of values, confidence, importance Directing – post decisional planning »Rollnick S et al BMJ 2005;331;961-963

49. Stages of Change Pre-contemplation: Resistant to Change Contemplation: Aware That a Problem Exists but Ambivalent Toward Change Preparation: Intend to Take Action in Near Future Action: Involved in Change Maintenance: Involved in Sustaining Change and Working to Prevent Relapse Relapse: A Return to the Problem Behavior Adapted From Prochaska and DiClemente, 1986.

50. 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

51. 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.

52. Precontemplation /Resistance Identify roadblocks, triggers, fears, barriers etc. Dont try to push patient into action. Dont 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.

53. 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 home Beverages at home, soda, gator aid, juice 5 glasses/day

54. 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.

55. Case - 8 year old boy Beverages at home, soda, gator aid, juice 5 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

56. 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

57. Case 8 year old boy Activity/Inactivity Screen time 4 hours/day All 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.