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
Topic OneHow Bad is it?

• Obesity Trends Among U.S. AdultsBRFSS, 2006

3
Obesity Trends Among U.S. AdultsBRFSS, 1990,
1995, 2006
(BMI ?30, or about 30 lbs overweight for 54
person)
1995
1990
2006
No Data lt10 1014
1519 2024 2529
30
4
The Obesity Epidemic

• In 2002, four times as many kids were obese as
  compared to 1970.
• Ogden CL, Flegal KM, Carroll MD, Johnson CL.
  Prevalence and trends in overweight among US
  children and adolescents, 1999-2002. JAMA
  2002288(14)1728-32.
• As a result, children as young as four to six
  years old are experiencing illnesses that we only
  saw in adults in the pastdiabetes, heart
  disease, and hypertension.
• Burke V. Obesity in childhood and cardiovascular
  risk. Clin Exp Pharmacol Physiol.
  200633(9)831-7.

5
Diabetes in Children

• As the prevalence of obesity has increased in
  recent decades, several studies have reported an
  increasing proportion of youth with apparent type
  2 DM, especially among racial/ethnic minority
  populations.

Dabelea D, Pettitt DJ, Jones KL, Arslanian SA.
Type 2 diabetes mellitus in minority children and
adolescents an emerging problem. Endocrinol
Metab Clin North Am. 199928709-729.
6
Diabetes in Children

• Among older youth (10-20 yrs), type 1 DM is most
  frequent among Hispanic and African American
  adolescents.
• Overall, type 2 DM is still relatively
  infrequent, but the highest rates (17.0 to 49.4
  per 100,000 person-years) are among 15- to
  19-year-old minority kids.

Dabelea D, Pettitt DJ, Jones KL, Arslanian SA.
Type 2 diabetes mellitus in minority children and
adolescents an emerging problem. Endocrinol
Metab Clin North Am. 199928709-729.
7
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 synd. will become
  a type 2 diabetic 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
8
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.
9
Screening for Diabetes in Children

• Nearly a quarter (24.3) of 173 obese children
  screened positive for pre-diabetes according to
  fasting plasma glucose and a two-hour oral
  glucose tolerance test, compared with only 8.7
  using fasting plasma glucose alone (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.
10
Screening for Diabetes in Children

• In what Dr. Morrison described as a new and
  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.
11
The Obesity Epidemic

• 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.
• 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.

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The Obesity Epidemic

• 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.
• 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

13

• 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, M.D.
• http//www.medicalnewstoday.com/articles/82148.php
  

14

• 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.
• 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.

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The Obesity Epidemic

• According to Emory University researchers, more
  than 25 of the phenomenal growth in health care
  spending over the past 15 years is causes by
  obesity.
• Thorpe KE, Florence CS, Howard DH, Joski P. The
  impact of obesity on rising medical spending.
  Health Aff 2004 Jul-DecSuppl Web
  ExclusivesW4-480-6.
• 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.

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The Obesity Epidemic

• 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.
• And 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.

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The Obesity Epidemic

• Severely obese kids have a terrible quality of
  lifesimilar to those suffering from cancer.
  
• They are 5-10 times as likely to be depressed or
  anxious and 50-100 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.
• Obesity has become the 2nd leading cause of
  preventable death in the U.S., after smoking.
• Mokdad AH, Marks JS, Stroup DF, Gerberding JL.
  Actual Causes of Death in the United States,
  2000. JAMA 20042911238-1245.

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The Obesity Epidemic

• 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.
• 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/

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The Obesity Epidemic

• Overweight-obesity in middle age has long-term
  adverse consequences for health care costs in
  older age.
• For nonoverweight, overweight, obese, and
  severely obese men in middle age, total average
  annual Medicare charges were, respectively,
  7205, 8390, 10,128, and 13,674 (Plt.001).
• 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.

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The Obesity Epidemic

• For white males, black males, white females, and
  black females at 20 years old, who were 70 or
  more pounds overweight, compared to 30-69 pounds
  overweight, total Medicare charges were estimated
  to be 10, 19, 37, and 445 higher,
  respectively (Plt.001).
• Eric Finkelstein, economist for RTI
  International the journal Obesity, 2008.

21
The Obesity Epidemic

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

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The Obesity Epidemic

• Of parents whose children were in the top 5
  percent BMIs, only 3 called their children
  "overweight" 25 described their child as
  "slightly overweight.
• 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.

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The Obesity Epidemic

• Only 30 of the parents of obese teenagers
  correctly identified them as obese.
• Family lifestyles and traditions play a much
  larger role in the problem of obesity than
  heredity.
• Tucker M. Parents of Obese Children Don't See
  Them As Fat. Pediatric News. July 2000.

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The Obesity Epidemic

• For every two hours or more of TV per day a woman
  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.

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The Obesity Epidemic

• French fries are the most popular vegetable eaten
  by children 19-24 mos 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.
• The average teenage boy drinks two 12 oz sodas
  per day or more than 700 cans (or over 68
  gallons) per year.
• 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

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The Obesity Epidemic

• French fries are the most popular vegetable eaten
  by children 19-24 mos 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.
• The average teenage boy drinks two 12 oz sodas
  per day or more than 700 cans (or over 68
  gallons) per year.
• 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

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The Obesity Epidemic

• 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
• 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.

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The Obesity Epidemic

• Due to No Child Left Behind, schools kids have
  less Physical Education and daily physical
  activity programs.
• Yet for all students (K-12) physical activity
  results in increased school performance and
  improved performance on standardized testing.
• Bogden, J.F. Fit, healthy, and ready to learn a
  school health policy guide. Alexandria (VA)
  NASBE, 2000.

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The Obesity Epidemic

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

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The Obesity Epidemic

• 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.
• Bogden, J.F. Fit, healthy, and ready to learn a
  school health policy guide. Alexandria (VA)
  NASBE, 2000.
• I suggest a new law No child left on his or her
  behind.

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The Obesity Epidemic

• Religious participation is associated with higher
  body weight.
• "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.

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The Obesity Epidemic

• Supersize portions are resulting in supersized
  kids.
• 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.
• Cheeseburgers grew from 5.8 ounces (397 calories)
  in 1977 to 7.3 ounces (533 calories) in 1998.
• 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.

33
The Obesity Epidemic

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

34
The Obesity Epidemic

• 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.
• 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.

35
Topic TwoWhat hope is there?
36
SuperSized Kids Assessment Tool

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

37
What Can You Do?

• If any family member scores below an A on any of
  the three measures and the family desires change,
  what can you do?
• The clinically proven, SuperSized Kids 8-week
  plan, is found in the SuperSized Kids book or
  at www.DrWalt.com.

38
SuperSized Kids 8-week plan

• Family Project
• Activities
• Mealtimes at Home
• Nutrition
• Rest
• Media

39
Family Fitness Challenge
P0.06
40
Family Fitness Challenge
37
P0.044
41
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.

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Topic ThreeWhat you can do
43
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.
44
What you can do

• Family 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.
45
What you can do

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

Childhood Obesity Highlights of AMA Expert
Committee Recommendations. Am Fam Physician.
200878(1)56-63, 65-66.
46
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.
47
What you can do

• Record a BMI Percentile on every child at every
  visit.
• 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

48
What you can do

• Record a SBP and DBP Percentile on every child at
  every visit (no less than once a year).
• If lt90th percentile Congratulate
• If 90th 94th percentile Label and React
• If gt 95th percentile Label and React,

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Why React?

• One study found that over 12 months, 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
• 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 healthcare professional.
• Donahue, et al. Results of expert meetings
  Obesity and cardiovascular risk. Am Heart J
  20011421088-90.

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What you can do

• SuperFit Family Assessment Tool
• Appendix A in the book SuperSized Kids How to
  rescue your child from the obesity threat
• Also available at www.DrWalt.com or
  www.SuperSizedKids.com.
• Have a professional explain the tool.
• Schedule a F/U visit to discuss the results.

51
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.

52
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)

53
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).

54
What you can do

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

55
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.

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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.

57
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

58
What the Community can do

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

59
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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