Obes basics101
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Obesity Basics 101: Role of the Pediatrician provides guidance for pediatricians in assessing and treating childhood obesity. The document outlines a 3 step process: [1] assess BMI and growth charts, [2] take a thorough history of diet, physical activity, family history and medical risks, and [3] develop an individualized treatment plan focused on behavior change through diet and activity goals and support. The role of the pediatrician is to carefully screen for obesity risks, understand factors influencing weight, and partner with families to motivate healthy lifestyle changes.
![Principles of Treatment
Establish rapport
– Who is this person?
– Typical day
Set the agenda
– Multiple behaviors: Which is patient most
interested in changing? Diet, activity?
– Single behaviors (I’m concerned about…)
Assess Confidence & Importance
– Scale 0-10
– Why isn’t the number lower?
[Adapted from Rollnick et al, Health Behavior Change]](https://image.slidesharecdn.com/obesbasics101-150109003108-conversion-gate02/85/Obes-basics101-45-320.jpg)
![Guiding Principles
Effective communication
– “Are you concerned about your child’s
weight?”
– “I’m concerned [child’s] weight is getting
ahead of his height.”
– To older child: “Is your weight ever a problem
for you?”
Beware/avoid pejorative terms (obesity)
Negotiate for family change](https://image.slidesharecdn.com/obesbasics101-150109003108-conversion-gate02/85/Obes-basics101-46-320.jpg)
![Goals, Strategies, Targets:
General to Specific
Goal Strategy Target
↓ Wt ↓ fatty foods Cut out fried potatoes
Change to low fat milk
Eat new food Eat one fruit every day
Be more active Walk to/from school [x] d/wk
Limit TV to 2 hr/d max
[Adapted from Rollnick et al, Health Behavior Change]](https://image.slidesharecdn.com/obesbasics101-150109003108-conversion-gate02/85/Obes-basics101-48-320.jpg)
![9 yr old GG
Diet hx:
[Brk: 2 sl pizza + ice cream (2 scoops)
Lunch: double cheeseburger & fries
Dinner: hamburger, bun, 2 scoops of ice cream]
Fruits & Vegetables: nil!
Breakfast: poor choices; routines: few limits;
“doesn’t know when to stop eating”
Often skips lunch, eats through evening](https://image.slidesharecdn.com/obesbasics101-150109003108-conversion-gate02/85/Obes-basics101-55-320.jpg)
![GG: Recommendations
Diet & Eating
↓ portions/size of breakfast (max 2-3 pancakes or 1
piece french toast) [achievable goal]
– Eat only in the kitchen, w/ adult present [a.g.]
– “Close the kitchen” between meals/snacks
– Keep ice cream out of house [clean up environment]
Activity – continue soccer & jump rope
Behavior
– Kept “health calendar” [self monitoring]
– Weigh self q 2 wk (set a start date) [s.m.]](https://image.slidesharecdn.com/obesbasics101-150109003108-conversion-gate02/85/Obes-basics101-59-320.jpg)
Obes basics101
- 1. Obesity Basics 101: Role of the Pediatrician Soumya Ranjan Parida Basic B.Sc. Nursing 4th year Sum Nursing College
- 2. Objectives After this session, participants will be able to… Interpret growth charts, exam findings Elicit focused diet and activity history Assess risk: co-morbidities & persistence Describe best practices for achieving behavior change; Code strategically for reimbursement “Practice” cases
- 3. Step 1: Assess BMI & Growth
- 4. Step 1: Assess BMI / Growth Chart If there was an infectious disease that had… – double - tripled in prevalence, – was afflicting 25-30% of children of all ages, – had life life-long, potentially life threatening impact… Would we be acting? Would we take 10 sec to plot a point?
- 5. Are MD’s Using the BMI Charts? 31 % of pediatricians: “Never” 11% : “Always” Use of BMI (cf ht & wt) associated with: – Greater assessment of “fatness” – Greater concern about co-morbidities “Visual diagnosis” subject to under- diagnosis Perrin et al, J Peds 2004
- 6. Body Mass Index Metric measurements: Weight kg Height2 m2 (weight (kg) ÷ height (cm) ÷ height (cm) English measurements: Weight (lb) ÷ Height (in) ÷ Height (in) x 703
- 7. Referral BMI Charts: Why BMI? Boys: 2 to 20 years BMI BMI BMI BMI • BMI α body fatness • BMI = screening tool • Allows tracking of weight relative to height • Age-specific BMI values • Identify high risk patterns: –Rapid changes in BMI –Risk of complications • Childhood BMI tracks into adulthood
- 8. Referral BMI Charts:Definitions Boys: 2 to 20 years BMI BMI BMI BMI • At risk of overweight: 85-95th BMI % for age • Overweight: • > 95th BMI % for age
- 9. Can you see risk? • 4 year old girl • Is her BMI-for-age - 5th to <85th percentile: normal? - >85th to <95th percentile: “at risk for overweight”? - >95th percentile: “overweight” ? Photo from UC Berkeley Longitudinal Study, 1973
- 10. 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 = 85-95th percentile “At risk for overweight”
- 11. Can you see risk? • 3 year old boy • Is his BMI-for-age - 5th to <85th percentile: normal? - >85th to <95th percentile: - >95th percentile: overweight? Photo from UC Berkeley Longitudinal Study, 1973 CDC
- 12. 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 BMI BMI BMI=18.3 BMI-for-age ~ 95th percentile “overweight”
- 13. Referral Boys: 2 to 20 years BMI BMI BMI BMI Use of BMI: Progression of Excessive Weight Gain 3 yr old boy
- 14. Referral Boys: 2 to 20 years BMI BMI BMI BMI Use of BMI: Progression of Excessive Weight Gain 3 yr old boy
- 15. Early Identification – BMI vs Visual Diagnosis ≈ 95th % >> 95th %85-95th %
- 16. BMI: Summary BMI > 95th % strongly correlates with body fat BMI crossing major percentile line warrants anticipatory guidance (at minimum)
- 17. Step 2 Assessment: History, history, history!
- 18. 4 Essential Components of History Diet Physical activity Family History (if not known) Review of Systems GOALS: 1. Identify targets for behavior change 2. Assess risk (co-morbidities, risk of persistence)
- 20. Diet History: 4 points (2 B’s, 2 Fs’) Beverages – Juice/soda/sports drinks/milk Breakfast – Skipping meals promotes later overeating – Content? Simple carbs? – Eating routines Fruits & vegetables – Goal ≥ 5 servings/d Frequency of eating out (any restaurant/take out) – High risk for excessive portion sizes + high fat
- 21. Targeted Feeding History – Young Patients Infant feeding – Bottle practices (adding cereal?) – Responsive to infant hunger cues or propping – Food choices (blueberry buckle?) Toddlers – Beverages – juice/milk – Food choices – F/V vs sweets, French fries – Frequency/routines - grazing – Portions – toddler vs adult
- 22. Early Introduction of Solids? 29% of infants receive solids before 4 mo Only 6% of infants reached 6 mo w/o solids!! > 50% of a WIC sample put cereal in bottle – “because the doctor said my milk was too thin” Early solids (0-3 mo) = problem? ↑ risk of developing early markers of type 1 diabetes (islet autoimmunity); ↑ risk of obesity = ??? Reflection of maternal/family feeding behaviors
- 23. Portion Sizes: Toddler vs Adult Recommended Serving Sizes for Toddlers: Fruits: ½ piece 2-4 oz juice Grains: ½ sl bread ¼ - ½ c pasta Milk: 4 oz x 4/d
- 24. Feeding practices & structure Family meals ↑ F/V; ↓ soft drinks Structured eating routines – (not grazing, not skipping meals) Avoid eating in front of TV ↓ F/V, ↑ soft drinks – ↑ TV time, ↑ probability of TV in bedroom Present appropriate portions “You provide, they decide” (NFK: to a point!!)
- 25. Portion Sizes & Intake: Children • Doubling an age - appropriate portion of entrée → ↑ 25% entrée & ↑ 15% total energy intakes •Children consumed 25% less of an entrée when allowed to serve themselves vs. being served a large portion • (Stomach ≅ size of child’s fist) **P<.01
- 26. Diet History: 4 points (2 B’s, 2 Fs’) Beverages – Juice/soda/sports drinks/milk Breakfast – Skipping meals promotes later overeating – Content? Simple carbs? – Eating routines Fruits & vegetables – Goal ≥ 5 servings/d Frequency of eating out (any restaurant/take out) – High risk for excessive portion sizes + high fat
- 27. Targeted Physical Activity Assessment
- 28. Physical Activity Hx: 4 points (SSOB) Screen time - hr/day – TV, video, video games, computer – TV in bedroom? Sports/organized physical activity Outdoor time – After-school, weekend activities (w/ family?) Barriers – To walking/biking to school, free play
- 29. ↓ energy expenditure w/ ↓ physical activity (TV < videogames, school work, arts) ↑ energy intake – during or from ads Low income preschoolers: – 40% with TV in bedroom –TV in bedroom α ↑ TV hrs & overweight Reduction of TV time: relative ↓ in BMI AAP: NO TV < 2 yr Limit Screen Time
- 30. Unstructured gross motor play important for development: – Brain/cognitive – Social & emotional Parental support for child’s activity positively associated w/ children’s level of activity Outdoor time is one of strongest predictors of children’s overall activity level Promote Physical Activity
- 31. Kids CAN Now Be Little Adults! Stroller capacity now for children 4-6 yr olds 45 lb in front, 50 lb back capacity (max = 66 lb) “Safer & faster” in crowds Accessories: cup holders, food tray, cell phone pocket, storage bins, “all terrain wheels” “Containerizing children?” $149.99 (Amazon.com)
- 32. • Environments/facilities • Safety (developmental benefit vs risks) • Family structures/working parents / busy schedules • Encourage ≤ 60 min sedentary time at a stretch Physical Activity: Issues
- 33. Physical Activity Hx: 4 points (SSOB) Screen time - hr/day – TV, video, video games, computer – TV in bedroom? Sports/organized physical activity Outdoor time – After-school, weekend activities (w/ family?) Barriers – To walking/biking to school, free play
- 34. Family History
- 35. Family Hx: Risk for Persistence 1 parent ob: O.R. = 3 2 parent ob: O.R. > 10 < 3 yr, parental obesity stronger predictor cf child’s weight
- 36. Family History: Risk of Co-morbidities Obesity Cardiovascular disease – Hyperlipidemia/metabolic syndrome – Hypertension Type 2 diabetes Psychologic history – Depression, disordered eating
- 38. Risk Factors for Co-Morbidities History Condition? – Developmental delay Genetic disorder – Poor linear growth Endocrinopathy – Headaches Pseudotumor – Night-time breathing problems Sleep apnea – Daytime sleepiness Sleep apnea – Abdominal pain Gall bladder dis – Hip or knee pain Slip cap fem epiph – Menstrual abnormalities PCO – Binge eating/purging Eating disorder
- 39. Physical Exam
- 40. Physical Exam Findings Short stature Depressed affect ↑ blood pressure Skin: acanthosis nigricans, dark striae Eyes: papilledema Hepatomegaly Extremities (tenderness, small hands/feet, bowed legs) Neuro – DTR’s
- 42. Labs - Considerations Risk factors, impact on treatment, motivation, cost Fasting: – Lipoprotein profile – Glucose (+/- insulin?) ≈ ≥ 10 yr, BMI ≥ 85th %, + FHx/non-Caucasian/Signs of insulin resistnance (2/3) Hepatic transaminases ? Glucose tolerance ? Sleep study ? ECHO
- 43. After Assessment, Then What?!
- 44. Principles of Treatment Assess – USE BMI Charts!! Readiness to change – Barriers to change (“What’s going to be hard?”) – Motivators for change (variable; kid vs parent) – Involve patient/parent in identifying changes Family involvement BOTH eating/diet + physical activity recommendations (esp for Rx) Value the child See Barlow et al, Pediatrics 1998;102(3)
- 45. Principles of Treatment Establish rapport – Who is this person? – Typical day Set the agenda – Multiple behaviors: Which is patient most interested in changing? Diet, activity? – Single behaviors (I’m concerned about…) Assess Confidence & Importance – Scale 0-10 – Why isn’t the number lower? [Adapted from Rollnick et al, Health Behavior Change]
- 46. Guiding Principles Effective communication – “Are you concerned about your child’s weight?” – “I’m concerned [child’s] weight is getting ahead of his height.” – To older child: “Is your weight ever a problem for you?” Beware/avoid pejorative terms (obesity) Negotiate for family change
- 47. Principles of Treatment Diet: simple & explicit Physical activity: choice, fun Goals & rewards – Proximal vs distal, weight vs behavior Individualized joint problem solving – choose a few things Barriers to change usually bigger problem than motivation; choose your “battles” Avoid being judgmental & avoid stigmatization
- 48. Goals, Strategies, Targets: General to Specific Goal Strategy Target ↓ Wt ↓ fatty foods Cut out fried potatoes Change to low fat milk Eat new food Eat one fruit every day Be more active Walk to/from school [x] d/wk Limit TV to 2 hr/d max [Adapted from Rollnick et al, Health Behavior Change]
- 49. Fun Challenge “Ask for less, they’ll give you more” Responsive to peer/social approval (want to please adults) Sensitive to looks Social interaction Simple & explicit “If you can’t count it, you can’t change it” Motivators for Children
- 50. 4 Components of Behavioral Strategies Clean up / Control the environment – E.g. Eliminate sugar sweetened beverages from home; serve fruits & veg Self-monitoring behavior Set achievable, specific goals “If you can’t count it you can’t change it” Rewarding successful behavioral change E.g. Praise, privileges, time w/ parents; ∅ food, $$$ Dietz & Robinson, NEJM, 2005
- 51. Setting the Agenda/Negotiating Change Where to Begin? DIET Beverages? Breakfast? Other? ↑ Frt/Veg ↓ Freq Eat Out MD: Assess Risk Jointly Choose
- 52. Setting the Agenda/Negotiating Change Where to Begin? PHYSICAL ACTIVITY ↑ Sports? ↑ Outdoor Play ↓Screen/TV time ↓ Barriers MD: Assess Risk Jointly Choose Other??
- 53. GG 9-1/2 yr old girl, healthy Cc: Parents: – concern about ↑’g wt & effects on health – Want pt to become more committed to health – Importance: 10/10; Confidence: 9/10 What is the problem? – “She loves food; watches food network on cable, cookbooks, etc” – Patient: eating makes her “feel better” – Importance: 5/10; Confidence: 7/10)
- 54. GG: School Aged Child Girls: 2 to 20 years BMI BMI BMI BMI BMI = 33.7 (190% of ideal, c/w severe o.w.)
- 55. 9 yr old GG Diet hx: [Brk: 2 sl pizza + ice cream (2 scoops) Lunch: double cheeseburger & fries Dinner: hamburger, bun, 2 scoops of ice cream] Fruits & Vegetables: nil! Breakfast: poor choices; routines: few limits; “doesn’t know when to stop eating” Often skips lunch, eats through evening
- 56. GG Activity history: Screen time: < 2 hr TV/d; computer < 1x/wk Sports: Competitive jump roping, soccer – 2-4x/wk PMHX: benign; h/o hyperlipidemia FHx: BMI: Dad 26; Mom 22; + hx T2DM, obesity, hypertension, g.b. disease ROS: mild joint c/o; o/w negative
- 57. GG Exam: positive acanthosis nigricans, o/w unremarkable except for overweight status Assessment: – Severe overweight – At risk for insulin resistance, hyperlipidemia – Multiple dietary problems »Excessive portion sizes »Lack of structure/limits on eating »High risk foods in household
- 58. Setting the Agenda: A Joint Proposition ↓Grazing Eat at table Continue Sports Family Meals ↓Portions ? ? Food Choices
- 59. GG: Recommendations Diet & Eating ↓ portions/size of breakfast (max 2-3 pancakes or 1 piece french toast) [achievable goal] – Eat only in the kitchen, w/ adult present [a.g.] – “Close the kitchen” between meals/snacks – Keep ice cream out of house [clean up environment] Activity – continue soccer & jump rope Behavior – Kept “health calendar” [self monitoring] – Weigh self q 2 wk (set a start date) [s.m.]
- 60. GG: School Aged Child Girls: 2 to 20 years BMI BMI BMI BMI
- 61. Essential Components of History + Strategy for Intervention Assess BMI Diet (2 F’s, 2 B’s) - + P.E. Physical activity (SSOB) - +/- Labs Family History (if not known) Review of Systems Behavior Change: Clean up Environment Self-monitoring Set achievable goals Reward successful behavior
Editor's Notes
- #8: All the necessary information is recorded and Sam’s BMI can be plotted. On the BMI-for-age chart, find Sam’s age on the horizontal axis and visually draw a vertical line up from that point, then find his BMI on the vertical axis and visually draw a horizontal line across from that point. The point where the two intersect represents Sam’s BMI-for-age. When plotted on the growth chart, Sam’s BMI-for-age falls just below the 25th percentile curve. Percentile indicates the rank of a measure in a group of 100. This means that of 100 children the same sex and age as Sam, fewer than 25 children will have a BMI lower than his.
- #9: All the necessary information is recorded and Sam’s BMI can be plotted. On the BMI-for-age chart, find Sam’s age on the horizontal axis and visually draw a vertical line up from that point, then find his BMI on the vertical axis and visually draw a horizontal line across from that point. The point where the two intersect represents Sam’s BMI-for-age. When plotted on the growth chart, Sam’s BMI-for-age falls just below the 25th percentile curve. Percentile indicates the rank of a measure in a group of 100. This means that of 100 children the same sex and age as Sam, fewer than 25 children will have a BMI lower than his.
- #10: This is another 4-year-old girl. Does she appear at risk of overweight?
- #11: This girl’s height is 39.2 inches and her weight is 38.6 pounds. Using her height and weight we calculated BMI-for-age to be 17.8. Plotted on the BMI-for-age chart for girls, her BMI-for-age falls on the 94th percentile. Likewise, when plotted on the weight-for-stature grid, it falls above the 94th percentile. She is classified as at risk of overweight. The point of this exercise is to demonstrate the difficulty of making an accurate visual assessment of at risk of overweight. BMI-for-age must be determined and plotted on the appropriate growth chart.
- #12: In the next three slides, we want you to do a self-test to see how well you can screen for risk of overweight in children by looking. We want you to try to identify children with a BMI-for-age equal to or greater than the 85th percentile and less than the 95th percentile. It has been said that “few medical conditions can be diagnosed as confidently by untrained individuals as gross obesity.” Yet it is very difficult to distinguish children who are at risk of overweight from normal children. In childhood, the distinction is made more difficult by age-related physiological variations. So, see how you do with the three photos we will show you. This first one is a boy who is 3 years old. Does he appear underweight, normal, at risk of overweight, or overweight?
- #13: This boy’s height is 39.7 inches and his weight is 41 pounds. Using his height and weight, we calculated his BMI-for-age to be 18.3. Plotted on the BMI-for-age chart for boys, his BMI-for-age falls above the 95th percentile. Likewise, when plotted on the weight-for stature grid, it falls above the 95th percentile.
- #14: All the necessary information is recorded and Sam’s BMI can be plotted. On the BMI-for-age chart, find Sam’s age on the horizontal axis and visually draw a vertical line up from that point, then find his BMI on the vertical axis and visually draw a horizontal line across from that point. The point where the two intersect represents Sam’s BMI-for-age. When plotted on the growth chart, Sam’s BMI-for-age falls just below the 25th percentile curve. Percentile indicates the rank of a measure in a group of 100. This means that of 100 children the same sex and age as Sam, fewer than 25 children will have a BMI lower than his.
- #15: All the necessary information is recorded and Sam’s BMI can be plotted. On the BMI-for-age chart, find Sam’s age on the horizontal axis and visually draw a vertical line up from that point, then find his BMI on the vertical axis and visually draw a horizontal line across from that point. The point where the two intersect represents Sam’s BMI-for-age. When plotted on the growth chart, Sam’s BMI-for-age falls just below the 25th percentile curve. Percentile indicates the rank of a measure in a group of 100. This means that of 100 children the same sex and age as Sam, fewer than 25 children will have a BMI lower than his.