Practical Considerations for the Busy Family Physician

1
Practical Considerations for the Busy Family
Physician
Childhood Obesity
Family Medicine Grand Rounds Denver April 1,
2009

• Walt Larimore, M.D.
• Medical Director DiscoveryHealth.com/HealthTeach
  er.com
• Associate Medical Director Mission Medical
  Clinic

2
Goals

• Talk about the Childhood Obesity Epidemic (or,
  How Bad Is It?)
• Talk about a Family-Based Intervention and the
  Results of Using It (or, What Hope Is There?)
• Talk about how healthcare professionals can make
  a difference (or, What Can I Do?)

3
Topic OneHow Bad is it?
4
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6
Obesity Trends Among U.S. AdultsBRFSS, 1985
(BMI 30, or 30 lbs. overweight for 5 4
person)
7
Obesity Trends Among U.S. AdultsBRFSS, 1986
(BMI 30, or 30 lbs. overweight for 5 4
person)
8
Obesity Trends Among U.S. AdultsBRFSS, 1987
(BMI 30, or 30 lbs. overweight for 5 4
person)
9
Obesity Trends Among U.S. AdultsBRFSS, 1988
(BMI 30, or 30 lbs. overweight for 5 4
person)
10
Obesity Trends Among U.S. AdultsBRFSS, 1989
(BMI 30, or 30 lbs. overweight for 5 4
person)
11
Obesity Trends Among U.S. AdultsBRFSS, 1990
(BMI 30, or 30 lbs. overweight for 5 4
person)
12
Obesity Trends Among U.S. AdultsBRFSS, 1991
(BMI 30, or 30 lbs. overweight for 5 4
person)
13
Obesity Trends Among U.S. AdultsBRFSS, 1992
(BMI 30, or 30 lbs. overweight for 5 4
person)
14
Obesity Trends Among U.S. AdultsBRFSS, 1993
(BMI 30, or 30 lbs. overweight for 5 4
person)
15
Obesity Trends Among U.S. AdultsBRFSS, 1994
(BMI 30, or 30 lbs. overweight for 5 4
person)
16
Obesity Trends Among U.S. AdultsBRFSS, 1995
(BMI 30, or 30 lbs. overweight for 5 4
person)
17
Obesity Trends Among U.S. AdultsBRFSS, 1996
(BMI 30, or 30 lbs. overweight for 5 4
person)
18
Obesity Trends Among U.S. AdultsBRFSS, 1997
(BMI 30, or 30 lbs. overweight for 5 4
person)
19
Obesity Trends Among U.S. AdultsBRFSS, 1998
(BMI 30, or 30 lbs. overweight for 5 4
person)
20
Obesity Trends Among U.S. AdultsBRFSS, 1999
(BMI 30, or 30 lbs. overweight for 5 4
person)
21
Obesity Trends Among U.S. AdultsBRFSS, 2000
(BMI 30, or 30 lbs. overweight for 5 4
person)
22
Obesity Trends Among U.S. AdultsBRFSS, 2001
(BMI 30, or 30 lbs. overweight for 5 4
person)
1014 1519 2024
25
23
Obesity Trends Among U.S. AdultsBRFSS, 2002
(BMI 30, or 30 lbs. overweight for 5 4
person)
1014 1519 2024
25
24
Obesity Trends Among U.S. AdultsBRFSS, 2003
(BMI 30, or 30 lbs. overweight for 5 4
person)
1014 1519 2024
25
25
Obesity Trends Among U.S. AdultsBRFSS, 2004
(BMI 30, or 30 lbs. overweight for 5 4
person)
1014 1519 2024
25
26
Obesity Trends Among U.S. AdultsBRFSS, 2005
(BMI 30, or 30 lbs. overweight for 5 4
person)
1519 2024 25-29
30
27
Obesity Trends Among U.S. AdultsBRFSS, 2006
(BMI 30, or 30 lbs. overweight for 5 4
person)
1519 2024 25-29
30
28
Obesity Trends Among U.S. AdultsBRFSS, 2007
(BMI 30, or 30 lbs. overweight for 5 4
person)
1519 2024 25-29
30
29
Obesity Trends Among U.S. AdultsBRFSS, 2007
(BMI 30, or 30 lbs. overweight for 5 4
person)
1519 2024 25-28
29
30
Obesity Trends Among U.S. Teens10 to 17
year-olds who are overweight or obeseAnne E.
Casey Foundation, 2007
21-25 25-30 30-34
34-38
31
Obesity Trends Among U.S. AdultsBRFSS, 1990,
1995, 2007
(BMI ?30, or about 30 lbs overweight for 54
person)
1998
1990
2007
No Data lt10 1014
1519 2024 2529
30
32

• Four times as many kids were were obese in 2000
  as compared to 1970.

33

• HTN in children rose from from 2.7 (198894) to
  3.7 (19992002).
• Among Mexican-American male children, the rise
  was from 3.1 to 5.3.

40 increase
70 increase
Din-Dzietham R, Liu Y, Bielo MV, Shamsa F. High
Blood Pressure Trends in Children and Adolescents
in National Surveys, 1963 to 2002. Circulation.
20071161488-1496.
34
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35

• As a result, children as young as 4-6 years old
  are experiencing illnesses that we only saw in
  adults in the pastdiabetes, HTN, heart disease,
  hardening of the arteries, and arthritis.

Burke V. Obesity in childhood and cardiovascular
risk. Clin Exp Pharmacol Physiol.
200633(9)831-7.
36
Metabolic Syndrome in Children

• By age 12-14, half of obese children have
  metabolic syndrome.
• Even at ages 8-11, as many as 9.5 of obese kids
  have metabolic syndrome.
• A kid at age 8 with metabolic syndrome will
  become a type 2 diabetic and/or develop heart
  disease in 10 years or less.

Messiah, S.E. Journal of Pediatrics, published
online April 23, 2008. http//www.cbsnews.com/stor
ies/2008/06/25/health/webmd/main4209498.shtml
37
Screening for Diabetes in Children

• Both the American Diabetes Association and the
  Canadian equivalent recommend screening for
  dysglycemia in obese children ages 10 and older
  who are at risk for type 2 diabetes. Fasting
  plasma glucose is the preferred test.

Morrison K, et al "Cardiometabolic complications
in childhood obesity are we screening the right
children, with the appropriate test?" ENDO
Meeting 2008 Abstract P1-287.
38
Screening for Diabetes in Children

• 8.7 of 173 obese children screened positive for
  pre-diabetes according to fasting plasma glucose.
  
• However, nearly a quarter (24.3) screened
  positive according to a two-hour oral glucose
  tolerance test (Plt0.01).

Morrison K, et al "Cardiometabolic complications
in childhood obesity are we screening the right
children, with the appropriate test?" ENDO
Meeting 2008 Abstract P1-287.
39
Screening for Diabetes in Children

• The most surprising finding?
• The prevalence of pre-diabetes in the study was
  similar in children younger than 10 (20.8) and
  in those 10 and older (25.8).

Morrison K, et al "Cardiometabolic complications
in childhood obesity are we screening the right
children, with the appropriate test?" ENDO
Meeting 2008 Abstract P1-287.
40

• Both BMI and waist circumference were associated
  with elevated blood pressure.

Din-Dzietham R, Liu Y, Bielo MV, Shamsa F. High
Blood Pressure Trends in Children and Adolescents
in National Surveys, 1963 to 2002. Circulation.
20071161488-1496.
41

• In children, a 1 cm increase in waist
  circumference raises the likelihood of HTN by 10
  and pre-HTN by 5.

Din-Dzietham R, Liu Y, Bielo MV, Shamsa F. High
Blood Pressure Trends in Children and Adolescents
in National Surveys, 1963 to 2002. Circulation.
20071161488-1496.
42

• Nearly 3 out of 4 cases of hypertension are
  undiagnosed in children.

Hansen ML, Gunn PW, Kaelber DC. JAMA 2007(Aug
22)298(8)874-9.
43

• There could be 1.5 million children that
  neither they, nor their parents, nor their
  clinicians know they have high blood pressure.

ABC News Interview with Dr. David Kaelber of
Boston Childrens Hospital. http//www.abcnews.go.c
om/Health/CardiacHealth/story?id3507125page1
44

• Unless this upward trend in high blood pressure
  is reversed, we could be facing an explosion of
  new cardiovascular disease cases in young adults
  and adults.

Interview with Rebecca Din-Dzietham, MD.
http//www.medicalnewstoday.com/articles/82148.php
45

• Ultrasound measurment of the thickness of the
  inner walls of neck arteries of 70 obese children
  with an average age of 13 found that the state of
  their arteries was more typical of a 45 year old.

Dr. Geetha Raghuveer of the University of
Missouri Kansas City School of Medicine and
Children's Mercy Hospital. Nov 11, 2008.
http//www.reuters.com/article/healthNews/idUSTRE4
AA7SR20081111.
46

• In these children, their "vascular age" generally
  was three decades older than their chronological
  age.

Dr. Geetha Raghuveer of the University of
Missouri Kansas City School of Medicine and
Children's Mercy Hospital. Nov 11, 2008.
http//www.reuters.com/article/healthNews/idUSTRE4
AA7SR20081111.
47

• According to Emory University researchers, more
  than a quarter of the phenomenal growth in health
  care spending over the past 15 years is
  attributable to obesity.

Thorpe KE, Florence CS, Howard DH, Joski P. The
impact of obesity on rising medical spending.
Health Aff (Millwood). 2004 Jul-DecSuppl Web
ExclusivesW4-480-6.
48

• Recent research suggests that obese teenagers
  have a dramatically increased risk of dying by
  the time they reach middle age.

Engeland A, Bjorge T, Tverdal A, Sogaard AJ.
Obesity in adolescence and adulthood and the risk
of adult mortality. Epidemiology. 2004
Jan15(1)79-85.
49

• Very high
• adolescent BMI
• was associated with a 30-40 higher adult
  mortality compared with medium BMI.

Engeland A, Bjorge T, Tverdal A, Sogaard AJ.
Obesity in adolescence and adulthood and the risk
of adult mortality. Epidemiology. 2004
Jan15(1)79-85.
50

• Childhood obesity appears to lessen life
  expectancy markedly
• depending upon the sex and race of the
  individual, obesity lowers life expectancy from
  eight to twenty years !

Fontaine KR, Redden DT, et. al., Years of Life
Lost Due to Obesity, JAMA, January 8, 2003, Vol.
289, No. 2, 187-193.
51

• Severely obese kids have a terrible quality of
  life
• similar to those suffering from cancer.

Schwimmer JB, Burwinkle TM, Varni JW.
Health-Related Quality of Life of Severely Obese
Children and Adolescents, JAMA, April 9, 2003,
Vol. 289, No. 14, 1813.
52

• They are five to ten times as likely to be
  depressed or anxious
• and 50 to 100 more likely to bully or be
  bullied.

Schwimmer JB, Burwinkle TM, Varni JW.
Health-Related Quality of Life of Severely Obese
Children and Adolescents, JAMA, April 9, 2003,
Vol. 289, No. 14, 1813.
53

• Obesity has become the second-leading cause of
  preventable death in the United States, after
  smoking.

Mokdad AH, Marks JS, Stroup DF, Gerberding JL.
Actual Causes of Death in the United States,
2000. JAMA 20042911238-1245.
54

• One report estimates that, in the U.S., 14 of
  deaths from cancer in men and 20 of deaths in
  women were due to overweight and obesity.

Calle EE, Rodriguez C, Walker-Thurmond K, Thun
MJ. Overweight, obesity, and mortality from
cancer in a prospectively studied cohort of U.S.
adults. NEJM 2003 348(17)16251638.
55

• Every month, the Social Security Administration
  pays 77 million to citizens whose disability is
  obesity-related

Olick D. Fat takes a toll on the U.S. economy.
The bigger Americans get, the heavier the strain
on Uncle Sam. CNBC. March 4, 2003.
http//www.msnbc.msn.com/id/3072883/
56

• Overweight-obesity in young adulthood and middle
  age has long-term adverse consequences for health
  care costs in older age.

• Daviglus ML, Liu K, Yan LL, et al. Relation of
  Body Mass Index in Young Adulthood and Middle Age
  to Medicare Expenditures in Older Age.
  JAMA. 20042922743-2749.

57

• Total average annual Medicare charges were
• normal weight 7205
• overweight 8390
• obese 10,128
• severe obese 13,674
• P lt 0.001

90

• Daviglus ML, Liu K, Yan LL, et al. Relation of
  Body Mass Index in Young Adulthood and Middle Age
  to Medicare Expenditures in Older Age.
  JAMA. 20042922743-2749.

58

• Estimate extra lifetime medical costs attributed
  to obesity for 20-year-olds who are over a
  healthy weight by

• Eric Finkelstein, economist for RTI
  International the journal Obesity, 2008.

59
30-69 pounds White ? 16,490 Black ?
12,290 White ? 21,550 Black ? 5,340

• Eric Finkelstein, economist for RTI
  International the journal Obesity, 2008.

60
30-69 pounds White ? 16,490 Black ?
12,290 White ? 21,550 Black ? 5,340
gt 70 pounds White ? 16,720 Black ?
14,580 White ? 29,460 Black ? 23,750
19
37
445

• Eric Finkelstein, economist for RTI
  International the journal Obesity, 2008.

61

• For every two hours or more of TV per day a girl
  watches, the risk of becoming obese jumps 23,
  while the risk of developing diabetes increases
  14.

Hu FB, Li TY, Colditz GA, et al. Television
watching and other sedentary behaviors in
relation to risk of obesity and type 2 diabetes
mellitus in women. JAMA. 2003289(14)1785-91.
62

• French fries are the most popular food (fruit,
  vegetable, starch) eaten by children 19 to 24
  months old.

Fox M, Reidy K, Karwe V, Ziegler P. Average
Portions of Foods Commonly Eaten by Infants and
Toddlers in the United States. J Am Diet Assoc.
2006 Jan106(1 Suppl 1)S66-76.
63

• The average teenage boy drinks two 12 oz sodas
  per day
• or more than 700 cans (or over 68 gallons) per
  year.

National Health and Nutrition Examination Survey,
1999-2000
64

• The average teenage girl drinks 1.4 twelve oz
  sodas per day
• or more than 500 cans (or 48 gallons) per year.

National Health and Nutrition Examination Survey,
1999-2000
65

• At 500 cans per year that's more than 62 pounds
  of sugar from soda alone. 700 cans is more than
  86 pounds of sugar.

National Health and Nutrition Examination Survey,
1999-2000
66

• For every additional serving per day of soda
  consumed the risk of becoming obese increases by
  about 60.

Ludwig DS, Peterson KE, Gortmaker SL. Relation
between consumption of sugar-sweetened drinks and
childhood obesity a prospective, observational
analysis. Lancet. 2001 Feb 17357(9255)505-8.
67

• Due to the No Child Left Behind legislation,
  schools kids have less Physical Education and
  daily physical activity programs.

Bogden, J.F. Fit, healthy, and ready to learn a
school health policy guide. Alexandria (VA)
NASBE, 2000.
68

• PE and daily physical activity programs for all
  students (K-12) results in increased school
  performance.

Bogden, J.F. Fit, healthy, and ready to learn a
school health policy guide. Alexandria (VA)
NASBE, 2000.
69

• Several studies demonstrate that when childrens
  fitness needs are met, they do better on
  standardized tests.

Bogden, J.F. Fit, healthy, and ready to learn a
school health policy guide. Alexandria (VA)
NASBE, 2000.
70

• Yet 40 of U.S. schools are cutting PE or recess,
  believing extra class time will improve student
  scores on standardized tests.

Bogden, J.F. Fit, healthy, and ready to learn a
school health policy guide. Alexandria (VA)
NASBE, 2000.
71

• Without any question, the No. 1 barrier to
  physical activity in schools is the perception
  that time spent in PE and recess will undermine
  academic learning.

Harper T. The New PE. SkyWriting Column. Sky
Magazine 2004(Sep)88-90.
72
I suggest a new law

• No child left on his or her behind.

73

• Religious participation is associated with higher
  body weight.

Ferraro KF. Firm believers? Religion, body
weight, and well-being. Rev Relig Res
199839(3)224-244.
74

• Overeating may be one sin that pastors and
  priests regularly overlook.
• And as such, many firm believers may have
  not-so-firm bodies."

Ferraro KF. Firm believers? Religion, body
weight, and well-being. Rev Relig Res
199839(3)224-244.
75

• Supersize portions are resulting in supersized
  kids.

Nielsen SJ, Popkin BM. Patterns and trends in
food portion sizes, 1977-1998. JAMA
2003289(4)450-3.
76

• The serving size of an average soft drink
  increased from 13 ounces (144 calories) in 1977
  to almost 20 ounces (with 15 teaspoons of sugar
  and 250 calories) in 1998.

Nielsen SJ, Popkin BM. Patterns and trends in
food portion sizes, 1977-1998. JAMA
2003289(4)450-3.
77

• Cheeseburgers grew from 5.8 ounces (397 calories)
  in 1977 to 7.3 ounces (533 calories) in 1998.

Nielsen SJ, Popkin BM. Patterns and trends in
food portion sizes, 1977-1998. JAMA
2003289(4)450-3.
78

• Salty snacks grew from 1 ounce (132 calories) in
  1977 to 1.6 ounces (225 calories) in 1998.

Nielsen SJ, Popkin BM. Patterns and trends in
food portion sizes, 1977-1998. JAMA
2003289(4)450-3.
79

• These days, a single fast food meal can amount to
  two days worth of calories for the average
  child.

Larimore WL, Flynt, C. SuperSized Kids How to
protect your child from the obesity threat.
CenterStreet Publishers. 2006.
80

• Three pieces of pizza can exceed 1,600 calories
  and 80 grams of fat. And, that doesnt even
  include the soda or dessert.

Larimore WL, Flynt, C. SuperSized Kids How to
protect your child from the obesity threat.
CenterStreet Publishers. 2006.
81

• Advertisers know how to attract, allure, and
  addict our children to their unhealthy products.

Hoek J, Gendall P. Advertising and obesity a
behavioral perspective. J Health Commun.
200611(4)409-23.
82

• Advertisers know how to attract, allure, and
  addict our children to their unhealthy products.

Hoek J, Gendall P. Advertising and obesity a
behavioral perspective. J Health Commun.
200611(4)409-23.
83

• Parents of SuperSized kids are usually overweight
  or obese themselves.

Agras WS, Hammer LD, McNicholas F, Kraemer HC.
Risk factors for childhood overweight a
prospective study from birth to 9.5 years. J
Pediatr. 2004 Jul145(1)20-5.
84

• The factor that puts children at greatest risk of
  being overweight is having obese parents.

Agras WS, Hammer LD, McNicholas F, Kraemer HC.
Risk factors for childhood overweight a
prospective study from birth to 9.5 years. J
Pediatr. 2004 Jul145(1)20-5.
85
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87
Of parents whose children were in the top 5
percent BMIs, only 3 called their children
"overweight" 25 described their child as
"slightly overweight."
Tucker M. Parents of Obese Children Don't See
Them As Fat. Pediatric News. July 2000
88
For parents of slightly less obese children
(still within the top 15 percent of BMI), only
3 described their child as even "slightly
overweight."
Tucker M. Parents of Obese Children Don't See
Them As Fat. Pediatric News. July 2000
89

• Only 30 of the parents of obese teenagers
  correctly identified them as obese.

Goodman E, Hinden BR, Khandelwal S. Accuracy of
teen and parental reports of obesity and body
mass index. Pediatrics. 2000 Jul106(1 Pt
1)52-8.
90
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91

• Family lifestyles and traditions play a much
  larger role in the problem of obesity than
  heredity.

92

• Couch potatoes, sofa slugs, and obese offspring
  are not bornthey are raised.

93

• This generation of kids coming up may be the
  first in American history to have a shorter life
  span than their parents.

Larimore WL, Flynt, C. SuperSized Kids How to
protect your child from the obesity threat.
CenterStreet Publishers. 2006.
94
94
95
What Hope Is There?
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Topic TwoWhat hope is there?
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99
Tools to Help YOU Help Families in Your Practice

• SuperSized Kids Assessment Tool
• Family Fitness 8-Week Plan

100
SuperSized Kids Assessment Tool

• www.SuperSizedKids.com or www.DrWalt.com
• Family Assessment Quiz
• 10 Nutrition Questions
• 10 Activity Questions
• 5 Body Mass Index Questions
• 3 Grades A - F

101

• If any family member scores below an A on any of
  the three measures and the family desires change,
  what can you do?

102
Family Fitness 8-week plan

• Family Project
• Activities
• Mealtimes at Home
• Nutrition
• Rest
• Media (screen time)

103
Family Fitness 8-week plan Week 1

• Family Project
• Get a blank notebook and start a family health
  journal to keep track of your progress.
• Calculate the BMI (and blood pressure if
  possible) for each family member and record it in
  your journal.

104
Family Fitness 8-week plan Week 1

• Activities
• Take a blank activity pyramid (on page 128) and
  talk about what you could do as a family. Record
  your ideas in your journal.
• See how many steps you and each child can climb
  or how far you can quickly walk without getting
  short of breath. Write it down in the journal.

105
Family Fitness 8-week plan Week 1

• Mealtimes at Home
• Use an answering machine during dinner at home.
• Reduce the visits to fast-food restaurants by one
  per week.
• Switch from large to small dinner plates.

106
Family Fitness 8-week plan Week 1

• Nutrition
• Eat at least one serving of fruit or vegetables
  at each meal.
• Strategize with your kids about how to increase
  their intake of plant or other good proteins.
  Try one of their ideas this week.

107
Family Fitness 8-week plan Week 1

• Rest
• Cut out the caffeine (chocolate, cocoa, soft
  drinks) after 3 p.m.

108
Family Fitness 8-week plan Week 1

• Media
• Cut your childs media time (total TV, computer,
  cell phone, and video game time) to less than
  four hours a day.
• Remove the TV, computer, cell phones, and video
  game machines from the bedrooms and move them to
  a common area.

109
Family Fitness 8-week plan Week 2

• Family Project
• Have a family meeting to discuss your progress.
  What worked, what didnt? What was fun or
  un-rewarding? What else do you want to change?
  Make journal notes.
• As a family, learn how to read food labels by
  studying items in your kitchen. Plan to shop
  together for groceries.

110
Family Fitness 8-week plan Week 2

• Activities
• Begin planning exercise for the week for each
  family member.

111
Family Fitness 8-week plan Week 2

• Mealtimes at Home
• Turn off the TV during meals.
• Reduce desserts to smaller portions and no more
  than one per day.
• Try replacing one dessert with fresh fruit.
• Children who are old enough to do so can serve
  their own plates.

112
Family Fitness 8-week plan Week 2

• Nutrition
• Reduce red meat to no more than three meals a
  week.
• Try a new fish recipe or a vegetarian protein
  recipes.

113
Family Fitness 8-week plan Week 2

• Rest
• Set and enforce bedtime and wake-up time.

114
Family Fitness 8-week plan Week 2

• Media
• Try a TV-free night one day this week (or make it
  a media-free night).

115
Family Fitness Plan

• Does the 8-week Plan work?

116
Pilot Trial

• Family Fitness Challenge A Small Pilot Study
• Larimore, WL, Flynt, C, Rick S.
• Funded by Florida Hospital, Orlando
• Recruited 5 families to participate
• No chronic illnesses (diabetes, hypertension) or
  pregnancy
• At least one teen or pre-teen child
• At least two obese family members

117
Pilot Trial
118
Pilot Trial
N5
N9
N10
119
Pilot Trial
43
120
Pilot Trial
47
121
Pilot Trial
6
122
Pilot Trial
-8
-5
123
Pilot Trial
-5
124
Pilot Trial

• Feedback
• Number of family meal times increased.
• Family APGAR scores improved.
• Participants felt it was too easy,
• That anyone could do this!

125
Family Fitness Challenge A Pilot Trial

• Chief Researchers
• Walt Larimore, MD Cheryl Flynt, RD, MPH Linda
  Miner, PhD Stephanie Rick.
• Supported by a grant from Florida Hospital.

126
Family Fitness Challenge

• Partners Florida Hospital, American Heart
  Association, Orlando Magic NBA Basketball Team,
  Central Florida YMCA, Publix Supermarkets, Local
  Radio and TV stations.
• Recruited 100 Families to sign up on an Internet
  site and then register at a local CentraCare
  Office.

127
Family Fitness Challenge
128
Family Fitness Challenge
BMIz Scores
BMIP 85th to 94th percentile BMIz 1.0 1.6
129
Family Fitness Challenge
5
2
3
2
P0.06
130
Family Fitness Challenge
37
P0.11
131
Family Fitness Challenge
132
Family Fitness Challenge
56 reduction
37
24 increase
P0.044
133
Family Fitness Challenge
58 reduction
37
23 increase
P0.037
134
Limitations

• No control group.
• No long-term follow-up.
• Significant drop-out rate.
• Used only a single reading of BP.

135
Why May the 8-Week Family Fitness Plan Work?

• Is family-centered and uses family
  accountability.
• The family makes choices together.
• There is no identified patient.
• Uses an easy-to-do, evidence-based set of
  nutritional and activity choices.
• Emphasizes healthy choices not weight or BMI.

136
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137
The Lopez Family

• Angel Lopez is a single father with 2 kids Angel
  III, age 13, and Aimee, age 11.

138
The Lopez Family

• Angel wanted to find a way to motivate his kids
  to start taking better care of their health.

139
The Lopez Family

• With a family weight of 549 pounds, Angel was
  looking for something that would help motivate
  him and his children to make health lifestyle
  changes.

140
The Lopez Family

• Angel III realized that this program would not be
  so easy for him.
• He loved to watch TV and play video games.

141
The Lopez Family

• Father and son decided a good way to start would
  be to play outside for 30 minutes then they could
  have 30 minutes of s screen time.

142
The Lopez Family

• Aimee lead the effort for the whole family in
  making healthier food choices and to begin a
  family exercise program.

143
The Lopez Family

• Specifically they found success in
• Body Combat and Spinning classes at the gym,
• Ate more whole grains and cut out sodas.

144
The Lopez Family

• Specifically they found success in
• Completed several "screen free" days, and
• Agreed to an equal ratio of outdoor play time and
  screen time.

145
The Lopez Family Results

• The Lopez family lost 42 total pounds!
• They increased from 2 meals together per week as
  a family to 6 meals per week as a family.

146
The Lopez Family Results

• Angel said, I fell back in love with my kids!

147
The Lopez Family

• I asked Angel, Jr., Why wont you go back to
  video games?
• He answered, I like time with my dad.

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149
Topic ThreeWhat you can do
150
What you can do

• The Expert Committee on the Assessment,
  Prevention, and Treatment of Child and Adolescent
  Overweight and Obesity recommends addressing the
  issue of weight with all children at least once a
  year.

Childhood Obesity Highlights of AMA Expert
Committee Recommendations. Am Fam Physician.
200878(1)56-63, 65-66.
151
What you can do

• Physicians are urged to assess key dietary habits
  (e.g., consumption of sweetened beverages),
  physical activity habits, readiness to change
  lifestyle habits, and family history of obesity
  and obesity-related illnesses.
• Lab testing depends on the degree of obesity and
  associated illnesses.

Childhood Obesity Highlights of AMA Expert
Committee Recommendations. Am Fam Physician.
200878(1)56-63, 65-66.
152
What you can do

• A staged approach to treatment of childhood
  obesity is recommended.
• Most of these recommendations can be carried out
  by Primary Care Physicians for treatment and
  prevention.

Childhood Obesity Highlights of AMA Expert
Committee Recommendations. Am Fam Physician.
200878(1)56-63, 65-66.
153
What you can do

• These include advising families to
• limit consumption of sweetened beverages and fast
  food,
• limit screen time,
• engage in physical activity for at least 60
  minutes per day, and
• encourage family meals on most, and preferably
  all, days of the week.

Childhood Obesity Highlights of AMA Expert
Committee Recommendations. Am Fam Physician.
200878(1)56-63, 65-66.
154
What you can do

• Record a BMI Percentile on every child (gt 2 y.o.)
  at every visit (at least q year).
• Its easiest for your staff to do this with a BMI
  Percentile Calculator
• http//apps.nccd.cdc.gov/dnpabmi
• http//www.kidsnutrition.org/bodycomp/bmiz2.html

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157
What you can do

• Record a BMI Percentile on every child (gt 2
  y.o.) at every visit (at least q year).
• If lt50th percentile Congratulate
• If 50th 74th percentile Carefully watch
• If 75th 84th percentile Label and React
• If 85th 94th percentile Label and React
• If gt 95th percentile Label, React, and
  Consider
• Referral

158
What you can do

• Record a SBP and DBP Percentile on every child (gt
  2 y.o.) at every visit (at least q yr).
• For Boys
• http//www.uptodate.com/online/content/image.do?im
  ageKeycalc_pix/bloodpre.htmtitleBlood20Pressur
  e20Percentiles20for20Boys
• For Girls
• http//www.uptodate.com/online/content/image.do?im
  ageKeycalc_pix/bloodp1.htmtitleBlood20Pressure
  20Percentiles20for20Girls

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160
What you can do

• Record a SBP and DBP Percentile on every child (gt
  2 y.o.) at every visit (at least q yr).
• If lt90th percentile Congratulate
• If 90th 94th percentile Label and React
• If gt 95th percentile Label and React,

161
Why React?

• One study found that over a 12 month period, only
  42 of obese patients are advised by their
  physicians to lose weight.

Manson, et al. The escalating pandemics of
obesity and sedentary life style. Arch Intern Med
2004164249-58
162
Why React?

• This is unfortunate, as there is a nearly 3-fold
  increase in the odds that a patient will attempt
  weight loss if the recommendation is made by a
  trusted health care professional.

Donahue, et al. Results of expert meetings
Obesity and cardiovascular risk. Am Heart J
20011421088-90.
163
What you can do

• SuperFit Family Assessment Tool
• Appendix A in the book SuperSized Kids How to
  rescue your child from the obesity threat.
• Print off and use as a handout.
• Or use the Internet Animated Tool
• www.DrWalt.com or
• www.SuperSizedKids.com.

164
What you can do

• SuperFit Family Assessment Tool
• Have an assistant explain the tool and then have
  a parent fill it out during the same office
  visit.
• Have an assistant explain the tool for the parent
  to fill out at home and schedule a F/U visit to
  discuss the results. (Recommended)

165
What you can do

• Draw Lab (if appropriate)
• For children with a BMI between the 85th-94th
  percentiles, but who have no obesity-related
  illnesses, a fasting lipid profile should be
  done.
• If obesity-related illnesses, draw alanine
  transaminase, aspartate transaminase, and fasting
  blood glucose levels (or 2 hr GTT).

Childhood Obesity Highlights of AMA Expert
Committee Recommendations. Am Fam Physician.
200878(1)56-63, 65-66.
166
What you can do

• Draw Lab (if appropriate)
• For children with a BMI .95th percentile, draw
  fasting lipid profile, alanine transaminase,
  aspartate transaminase, fasting blood glucose
  levels (or 2 hr GTT), BUN, and creatinine levels.

Childhood Obesity Highlights of AMA Expert
Committee Recommendations. Am Fam Physician.
200878(1)56-63, 65-66.
167
What you can do

• At the 1st F/U visit
• Recheck the childs BMIP BPP, lab, and review
  the Assessment results.
• If any abnormalities, assign the 8-week Family
  Fitness plan, and schedule a F/U visit.
• Have an assistant explain the 8-week plan, found
  at
• Appendix B in the book
• Also at www.DrWalt.com.

168
What you can do

• At the 2nd F/U visit after the 8-week plan
• Recheck the childs BMIP BPP.
• If not improved, assign the Level Two 8-week
  Family Fitness plan and schedule F/U lab and OV.
• Find the Level Two 8-week plan at www.DrWalt.com.

169
What you can do

• At the 3rd F/U visit after the Level Two 8-week
  plan
• Recheck the childs BMIP BPP and review lab.
• If not normalized, consider referral
• Registered Dietician
• School Nurse
• Pediatric Endocrine Clinic
• Schedule F/U

170
What the Community can do

• Chapters in the book are devoted to
• Community Interventions
• School Interventions
• Government Interventions

171
What Institutions can do

• Obtain a Family Fitness Community Project Tool
  Kit
• Stephanie Rick
• Florida Hospital Publishing
• 683 Winyah Dr., Orlando, FL 32803
• Phone [phone]
• Email Stephanie.Rick_at_FLHOSP.ORG

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That's All Folks!