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Obesity

Juan Espinosa, MD, Michael Cosimini, MD, and Solomon Behar, MD
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Pediatric obesity doc Juan Espinoza and Michael Cosimini discuss practical strategies for managing pediatric obesity from a primary care perspective.

Pearls:

  • When talking to patients about obesity, use person-first language and descriptive terms.

  • For prevention of obesity, use the 5-2-1-0 rule. Five or more servings of fruits and vegetables. Less than two hours a day of screen time. At least one hour per day of physical activity, and zero sugary drinks.

  • If there is no improvement in a patient’s BMI or weight status after 3 to 6 months, it is reasonable for the primary care doctor to escalate management to a multidisciplinary obesity care team.

 

  • Language and word choice are important when trying to mitigate weight stigmatization. According to the American Academy of Pediatrics Policy Statement published in the December 2017 Pediatrics, words like “obese” and “fat” hold negative connotations for family and can induce feelings of shame and embarrassment. Using people-first language can lessen the the potential for stigmatizing language. For example, instead of saying an “obese child,” physician should say “a child with obesity.”That being said, even the word "obesity," which physicians think of as a clinical term with diagnostic value, has a lot of negative connotations so when physicians are discussing weight with children and adolescent, using more descriptive terms like "unhealthy weight"  tends to be more valuable and preferable.

  • What is obesity really? Obesity is a disease state in which the normal physiologic mechanisms of energy balance of the body have been deranged. They can be deranged for a multitude of reasons including external, environmental, social, and economic factors. Obesity can also be driven by iatrogenic or  pharmacologic causes.

  • Obesity is thought of in three categories. Overweight, which is children between the 85th and 94th percentile for age and sex. Obesity, which is children who are greater than the 95th percentile for age and sex. Lastly, severe obesity, which is used to describe children who are 120% of the 95th percentile for age and sex.

    • New growth curves were introduced that use percent of the 95th percentile; specifically, they use increments of 10 percentile (i.e. 100%, 110%, 120% of the 95th percentile). These new curves are very useful when caring for children with obesity as they allow to more accurately track weight changes and they provide families with a visual aid.

  • What are the factors that physicians need to think about when evaluating a patient who has obesity? Obesity is a complex, multifactorial condition affected by genetic and non-genetic factors. There are social and economic factors, environmental factors, sleep, stress, and other diseases that can all influence weight. Less than 1% of children will have obesity secondary to either what is called a syndromic obesity or a monogenetic obesity.

  • What are the conditions associated with monogenetic obesity or syndromic obesity? The ones that are usually thought of include congenital leptin deficiency, PomC mutations, melanocortin-4 receptor abnormalities, Bardet-Biedl syndrome, Prader-Willi, Cohen syndrome, fragile X, Albright’s hereditary osteodystrophy, and Beckwith-Wiedemann. Consider one of these diagnoses if a patient has severe obesity and is under the age of five.

  • Are there complications of obesity that are seen in childhood? In addition to the immediate social and emotional consequences of stigma and bullying, obesity has a real medical impact on children.  Kids who have obesity are at an increased risk for polycystic ovarian syndrome (PCOS), anxiety, depression, abuse, slipped capital femoral epiphysis (SCFE), and Blount's disease. Given that obesity is a proinflammatory state it also increases a child’s risk for a variety of adult diseases like hypertension, dyslipidemia, diabetes, cardiovascular disease, sleep apnea, and osteoarthritis. A worse prognosis for other diseases, such as asthma and leukemia, is also seen in association with obesity.

  • The 2007 expert committee on prevention and treatment of obesity proposes 4 stages of obesity care. Stage one is prevention plus, so that is what physicians should be doing with every child regardless of their weight. Stage two is structured weight management and that is typically done by the primary care doctor as well, at times with the assistance of a nutritionist or another healthcare professional. Stage three, which are the comprehensive multidisciplinary interventions, is done at a tertiary care center with an obesity team. Finally, stage four are the more intensive tertiary care interventions. Those, broadly speaking, are surgery, pharmacotherapy, and some extreme very low calorie diets (these are typically not recommended).

    • Stage 1: Prevention Plus. This stage is focused on specific healthy eating and activity habits that all pediatrician should discuss with their patients. Experts recommend using the 5-2-1-0 rule, which stands for five or more servings of fruits and vegetables, two hours or less of recreational screen time, one hour or more of physical activity, and zero sugary drinks. During this stage, physicians can also talk about the importance of daily breakfast, limiting eating out, family meals, limiting portion size, and allowing younger children to self regulate meals.

    • Stage 2: Structured Weight Management. Following the implementation of the 5-2-1-0 rule, the next step is more targeted interventions and goal setting. Examples of targeted interventions include diet planning, structured meals, supervised exercise and additional reduction of television and other screen time to ≤1 hour per day.  

      • In pediatrics, the term diet planning refers to ensuring that the patient is getting a healthy balance of fruits, vegetables, grains, proteins, and getting the right amount of calories for age and weight.

      • Structure daily meals and snacks. Trying to get the families to create three structured meals: breakfast, lunch, and dinner. Then, depending on the child's age, either one or two snacks and making sure that those snacks are low calorie and healthy options like raw fruits and vegetables.

Barlow SE. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report.  Pediatrics 2007. Dec;120(4). PMID: 18055651

  • How often are patients coming to clinic during stage 2? Most of the evidence shows that short frequent visits are more effective than longer visits every three months. Five, ten, fifteen minute check-ins every four to six weeks can be very effective. During the visit, physicians should discuss targeted behavior goals: what was their most recent goal? did they achieve it, if not, what were the barriers that they identified to that goal? how are they going to get around those barriers? Lastly, at the end of the visit it is important to  set a new goal.

  • When should the patient be advanced to stage three? Based on the patient’s  progress, physicians decide whether they need a higher level of intervention or not. If there is no improvement in BMI or weight status after 3 to 6 months, it is reasonable for the primary care doctor to escalate management to a stage three.

  • What are the co-morbidities that need to be screened for? Dr. Espinosa thinks of screening in two stages. One is social, mental, and emotional health. The other tier are the medical conditions for which there are diagnostic tests including fatty liver disease, type 2 diabetes, dyslipidemia, hypertension and obstructive sleep apnea.

Editor's Note: Experts also recommend screening for menstrual irregularities, hip, knee, or leg pain as children with obesity are at increased risk for PCOS and different orthopedic conditions as discussed above.

 

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Hamburger and a Side of BPA Full episode audio for MD edition 197:12 min - 94 MB - M4APeds RAP November 2018 Written Summary 482 KB - PDF

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