Identifying, Treating and Preventing

the Disease of Pediatric Obesity

Children’s Hospital of Pittsburgh Weight Management Center

Ellen Cernich MS, LDN, CDE Ann Condon Meyers MS, LDN

Historical Perspective of Childhood Obesity

In the United States…

• Childhood obesity has more than doubled in children and quadrupled in adolescents in the past 30 years.

• The percentage of children aged 6–11 years in the United States who were obese increased from 7% in 1980 to nearly 18% in 2012.

• Similarly, the percentage of adolescents aged 12–19 years who were obese increased from 5% to nearly 21% over the same period.

• In 2012, more than one third of children and adolescents were overweight or obese.

Percentage of high school students who were obese* — selected U.S. states,

Youth Risk Behavior Survey, 2013

Prevalence of Self-Reported Obesity Among U.S. Adults, CDC, 2014

WHO most recent map of adult obesity, 2015

Definition of Overweight / Obesity

• Underweight Less than the 5th percentile

• Normal or Healthy Weight 5th percentile to less than the 85th percentile

• Overweight 85th to less than the 95th percentile

• Obese 95th percentile or greater

A.A.P. Stages of Obesity Prevention and Treatment

Barlow SE and the Expert Committee. Pediatrics 2007;120;S164-S192

Stages Description

1. Prevention Plus First step to focus on basic healthy lifestyle habits

2. Structured Weight Management • Specific nutrition and exercise goals are established

• Behaviors are monitored on a monthly basis

3. Comprehensive Multidisciplinary Intervention

Increases the specialists involved to maximize support for behavior changes

4. Tertiary Care Intervention • Offered to severely obese children • May include medication, low-calorie

diets, surgery

Risk Factors of Childhood Obesity

• High blood pressure and high cholesterol, which are risk factors for

cardiovascular disease (CVD). In one study, 70% of obese children had at least one CVD risk factor, and 39% had two or more.

• Increased risk of impaired glucose tolerance, insulin resistance and type 2 diabetes.

• Breathing problems, such as sleep apnea, and asthma as well as joint problems and musculoskeletal discomfort. • GI diseases such as liver disease, gallstones, and gastro-esophageal

reflux (i.e., heartburn). • Psychological stress such as depression, behavioral problems, and

issues in school. Low self-esteem and low self-reported quality of life. Impaired social, physical, and emotional functioning.

Lead to Consequences Later…

• Children who are obese are more likely to become obese adults.

• Adult obesity is associated with a number of serious health conditions including heart disease, diabetes, metabolic syndrome, and cancer.

• If children are obese, obesity and disease risk factors in adulthood are likely to be more severe.

Besides the health care community, who cares about overweight children?

Weight Management Center Children’s Hospital of Pittsburgh

Strengths:

• Experts in obesity treatment

• Multidisciplinary approach

• Comprehensive care

Limitations:

• Limited reach

• Not easily accessible

• High levels of attrition

• Resource intensive

Does the CHP program work?

• Results published in 2010 found:

• 52% decrease in BMI percentile (Adult programs report an average of 2 - 20% decrease in weight after 1 year.)

• Quality of life improves as measured by the patient and family in the families with weight loss (6.83 fold improvement) after 12 months.

• Program satisfaction after 3 months 93%, and after 12 months 86%.

Treatment Options – Who, What, Where and When

– Who, What, Where and When

Stages Description

1. Prevention Plus First step to focus on basic healthy lifestyle habits

2. Structured Weight Management • Specific nutrition and exercise goals are established

• Behaviors are monitored on a monthly basis

3. Comprehensive Multidisciplinary Intervention

Increases the specialists involved to maximize support for behavior changes

4. Tertiary Care Intervention • Offered to severely obese children • May include medication, low-calorie

diets, surgery

Barlow SE and the Expert Committee. Pediatrics 2007;120;S164-S192

AAP Stages of Obesity Prevention and Treatment

Weight Management Center Children’s Hospital of Pittsburgh

Strengths:

• Experts in obesity treatment

• Multidisciplinary approach

• Comprehensive care

Limitations:

• Limited reach

• Not easily accessible

• High levels of attrition

• Resource intensive

Hospital Team Members

• Medical Provider: Endocrinologist, PA, NP

• Nurse: Cholestech, A1C

• Wellness Advisor: LDN

• Behavior Psychologist

Community PCP’s: family centered to develop and maintain healthy lifestyle habits.

Strengths: • Community Based • Easily Accessible • Established relationship with

families • Ability to initiate prevention

measures

Limitations: • Limited connection to

resources and ongoing support

• Lack of standardization • Lack of expertise

• Primary Care Provider

• Practice Manager/Office Coordinator

• Lifestyle Coach

• Medical Assistant

• Office Staff

• Receptionist

• Scheduler

Community Team Members

Motivational Interviewing in the Clinical Setting

Collecting Information While Empowering the Family

to Succeed

This is not motivational interviewing: “What fits your busy schedule better? Exercising one hour a day or being dead 24

hours per day?”

Motivational Interviewing is…

a collaborative, person-centered form of guiding to elicit and strengthen motivation for change.

The way in which you talk with your patients about their health can substantially influence their personal

motivation for behavior change. - Rollnick, Miller & Butler, 2008

Four MI Principles Resist the righting reflex

P: I just don’t think our family has time for all these changes right now.

C: You feel overwhelmed by all of this, and you’re wondering what changes can fit into your life.

Understand your patient’s motivation

C: Making changes can be overwhelming, but when you think about how it could benefit your family, you feel encouraged.

Listen to your patient

C: I hear what you’re saying. You have some concerns about how to make these changes work for your family.

Empower your patient

C: You are ready to commit to a healthier lifestyle. When you have made commitments in the past, you have been successful.

Open-ended questions

Affirmation

Reflection

Summary

O A R S

Communication Skills

Ask Open-ended questions

What would you like to do for your child’s health?

Listen Reflectively and with purpose

You are prepared to make changes for the benefit of your child and your family.

Inform With permission and choices

I have some suggestions that might be helpful, would you like to hear them?

Open-ended Coaching Questions

What do you think about the amount of time you spend

watching TV ?

What could the benefits be for you, if you were a little bit

more active?

What makes you feel that now is a good time to try

something different?

What would you like to change first?

How might things be different for you, if you did make a

change?

How NOT TO do it

• Without first asking permission

• “Wagging your finger”

• In a moralistic or warning voice

How TO do it

• Get permission

• Honor autonomy

• Ask – Provide – Ask

• For suggestions, offer several instead of one

Giving Information and Advice

Ask, Provide, Ask

• ASK about existing knowledge/interest “What do you already know about ______________?”

• ASK permission! “There are some things others have found helpful. Are you

interested in hearing about them?”

• PROVIDE small “chunks” of information or feedback “A few things I have seen help other young children have been ______________.”

• ASK for interpretation or reaction “What do you think about these suggestions?” What are

your thoughts about trying one or two of them?

A tool for collecting topics of concern for the family

How will you know how you’re doing?

• Patient / family is doing most of the talking

• Patient / family is working harder than you

• Patient / family is making statements about change

• Patient / family resistance is minimized

Institute for Healthy Weight in Childhood

• Interactive web site or app that allows you to role play and get feedback using MI when talking about weight with families.

• Affiliated with AAP and sponsored by Nestle

• https://ihcw.aap.org/resources/Pages/default.aspx

• Practice for motivational interviewing

Or think of it this way…

• Doing motivational interviewing with someone else is like entering their home. One should enter with respect, interest and kindness, affirm what is good and refrain from providing unsolicited advice about how to arrange the furniture.

• Kamilla Venner

Forms to organize your visit

• Long form for an hour interview and motivational session is included in your packet along with references.

• If you develop a patient questionnaire to be filled out before your visit, it can lead you to the issues the family sees as important.

• A detailed food intake record can also help you identify areas of concern BUT it often makes the family defensive if you dwell on it.

Lifestyle Modules

Family Education:

1. Teaching tools used

2. Age group specifics

3. Role Playing

Teaching Tools

Lifestyle Lessons

Patient Self-Assessment

Tools

•Elicit ideas from the

patient for healthier drink

options:

“There are a lot of ideas

here for drinks that are

lower in sugar. What do

you think about these

ideas?

“What is one change you

think you could make?”

Education

Goals

Goal-setting: Collaborate with patient/family to

establish personal and family

goals

•“Invite” patient to establish

his/her own goals. “So where do

you want to start?” Try one new vegetable each week.

Limit sweet drinks to 6 ounces per day.

Eat a piece of fruit for lunch each day.

Eat dinner without the television on.

Take a family walk for 30 minutes on Saturdays.

Buy more fruit to have at home.

Limit “occasional”

foods to 1 serving/day

Tip Sheets • Add More Vegetables • Build a Healthy Meal • Changing Habits • Choose Beverages Wisely • Choose My Plate • Cut Back on Treats • Dairy • Dining Out: Pick or Pass • Facts About BMI • Focus on Fruits • Get Active Indoors • Getting Started with Pedometer • Healthy Body Image

• Healthy Plate Breakfast • Healthy Plate Dinner • Healthy Plate Lunch • Healthy Plate Snacks • Helpful and Harmful Phrases • Helpful Resources • Healthy Role Model • Kid-friendly Veggies & Fruits • Picky Eaters • Reduce Screen Time • Serving Size in Hand • Smart Shopping Veggies & Fruits • Vegetarians • Whole Grains

Additional Tip sheets for, Healthy Eating Habits

• Lifestyle Log

• Eat the Colors of the Rainbow

• Feeding Guide Log for Children

• Get Moving! Action Chart

Tracking Tools

56

Shop for the Colors of

the Rainbow!

Age Group Specifics

Toddler/Preschool: Drinks: Water and low fat, white milk only

Eat your fruit, don’t drink it

All meals/snacks at the table, no screens

Routine is necessary: meals, snacks

Appetites fluctuate –portions will be much smaller

Child Development –age appropriate expectations

Age Group Specifics

Toddler/Preschool: Offer fruit/veggie at each meal

Have daycare/caregivers keep food/drink log

Relatives need to be on same page

Parent must remain in control

Don’t use food as reward

Encourage free play—limit TV/screen time

Make snacks quality—fruits/veggies, dairy, whole grain

Don’t lock cabinets, special shelves, etc

Elementary: Drinks: Water and low fat, white milk

Eat your fruit, don’t drink it

School meals: flavored milk, double lunches/breakfast, juice, allowed 2nds

Communicate with the school

Don’t use food as reward— fun fitness instead

Meals/snacks at table –no screens

No exceptions for any family member

Age Group Specifics

Elementary: Picky eating can be a learned behavior

Make only one meal

Takes at least 15-20 times of trying new food

Keep offering fruits/veggies at meals/snacks

Daily fun fitness = 30 minutes

Screen time has to be limited

Boredom eating?

Age Group Specifics

Adolescents/Teens: No good or bad food –How much and how often

Use fitness/food tracker app –helps become aware of sleeping, water intake, food choices, steps

Weighing—depends on maturity, motivation level

Not eating at school- embarrassed ?

Calorie counting?

DRINKS, DRINKS, DRINKS…. Low calorie flavored water, selzter water

Age Group Specifics

Adolescents/Teens: Meals/snacks at table—not in bedroom, NO SCREENS

Slow down when eating

Parents make only one meal—keep offering fruits/veggies

Picky eaters don’t have to be forever

Emotional/boredom eating?

Hiding, sneaking, hoarding of food?

Buying food on their own or with friends, etc

Age Group Specifics

Parenting 101

• Out of sight, out of mind = Don’t buy it

• You are in control

• They aren’t going to like everything you make

• Involve kids in meal planning, shopping

• Make meal time a priority –sit at table, conversation, no screens

Parenting 101

• Parents are the Role Model –breakfast skipping, dislike of vegetables, etc

• Get all caregivers on the same page—grandparents, aunts/uncles, siblings

• Picky eaters: Have one acceptable food and one new food per meal

• Stages of child development

Points to Remember

• Practices must be ready to implement the program, and have the infrastructure to support it.

• Physician referral and advocacy of the program is vital.

• Success of children and families is highly influenced by motivation to change. Not all children or families are ready to engage in a weight management program.

• Behavior change is a key indicator of success and tracking this can be difficult if families do not return for follow-up visits.

• Visible indicators of success, such as change in weight, can be difficult to attain in children.

Role Play

Scenario # 1: Jake 12 yr old, male

Height: 64 inches

Weight: 183.5 lbs

BMI: 31.5 (98th percentile)

Blood Pressure: XX/XX mm/Hg

Family History of hypertension

Lifestyle Assessment: 5-6 sugary beverages/day; family

dines out on fast food 3-4 times/week; 2-3 hrs of screen

time on weeknights and 5-6 hrs of screen time on

weekends; no structured physical activity

Not concerned about weight

Scenario # 2: Claire 14 year old, female

BMI percentile: 99th

Participant in Healthy Habits for 2 months

Experiencing continued weight gain

Engaging in emotional and sneak eating

behaviors

Numerous psychosocial challenges identified

High motivation for weight loss yet low

motivation for physical activity

Case Study 3: Betty 13 year old, female

Prior success in a structured pediatric weight

management program

BMI percentile: 85th

Mother concerned about recent increase in weight

School lunch identified as potential barrier to

sustained weight management efforts

Patient motivated to maintain healthy weight and

wants to learn more about improving her food

choices

Prevention

Statistics for Childhood Obesity from the CDC

• Childhood obesity is associated with adult head of household’s education level for some children

• Childhood obesity among preschoolers is more prevalent among those from lower-income families

Poverty better predictor than race in childhood obesity

• A statistical model, based on information from more than 110,000 Massachusetts students, found that as children's family income dropped, rates of childhood obesity went up.

• Although the study found a link between poverty and childhood obesity, it didn't prove a cause-and-effect relationship.

• The study was published Jan. 7, 2016 in the journal Childhood Obesity.

There may be a correlation between education and poverty

Environmental factors fueling this epidemic

Advertising

• Nearly half of U.S. middle and high schools allow advertising of less healthy foods, which impacts students' ability to make healthy food choices.

• In addition, foods high in total calories, sugars, salt, and fat, and low in nutrients are highly advertised and marketed through media targeted to children and adolescents.

• Advertising for healthier foods is almost nonexistent in comparison.

Community Environment

• Half of the children in the United States do not have a park, community center, and sidewalk in their neighborhood.

• Only 27 states have policies directing community-scale design.

• One study showed that each additional hour spent in a car per day was associated with a 6% increase in the likelihood of obesity. Conversely, each additional kilometer walked per day was associated with a 4.8% reduction in the likelihood of obesity.

Energy Dense Foods and Beverages

• Sugar sweetened beverages are the largest source of added sugar and an important contributor of calories in the diets of children in the United States.

• High consumption of sugar sweetened beverages, which have few, if any, nutrients, has been associated with obesity.

• On a typical day, 80% of children and teens drink sugar sweetened beverages.

Increasing portion sizes

• Research shows that children eat more without realizing it if they are served larger portions.

School Lunch Programs

School Breakfast Programs

Referral to Children’s Hospital WMC

• Pediatrician or PCP should screen patient first. Screen should include BMI, growth chart, family history and blood pressure. Labs such as lipid panel, glucose and HA1C% are helpful as well but not required.

• Any patient who has a BMI over the 85th%tile may be referred up to 18 years of age.

• Family may call 412-692-5200 to schedule an appointment.

• Children’s main campus is in Lawrenceville. We also have a satellite in Bridgeville, PA off of US interstate 79 known as Children’s South.

Thank you for your interest.