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Tackling childhood obesity
Submit ResponseChildhood obesity is a serious problem because of its high prevalence and health consequences. Using the WHO standards and references, a body mass index (BMI) above the 95th percentile or two standard deviation scores (SDS), is used to define obesity (1). Ms K has been obese since the age of six. Both genetic and environmental factors contribute to her obesity (2). Her biological father is obese and her adoptive parents are overweight.
Many obesity-related medical conditions are now increasingly seen in children and adolescents, including hypertension, type 2 diabetes, polycystic ovary disease, nonalcoholic fatty liver disease and obstructive sleep apnea (3). Ms K already has acanthosis nigricans, which is associated with insulin resistance. She is of an age where she would be able to understand the risks of these complications and she and her family need to be educated on the risks of these medical problems.
However in this case, the psychological consequences of obesity outweigh the immediate medical consequences. Ms K. is in great psychological distress due to her problem of obesity. She experiences bullying in school and feels unable to fit in with her peers because she is not able to wear the same clothes. At home, she experiences stress from her parents when she craves for food.
Ms K. has already taken the first step to addressing her problem of obesity. She desires to lose weight and is ready to do so. However, both Ms K. and her parents would benefit from seeing weight loss not as a battle with food but as a lifestyle change. Theoretically obesity is a simple imbalanced equation where the intake of energy exceeds the expenditure and gets stored as fat. The strategies to target weight loss should be focused on long-term improvement in lifestyle and weight maintenance. Quick diets that result in transient weight loss are not encouraged as body weight tends to return to the starting weight or higher after the diet is stopped (4).
For a start, as Ms K's adoptive parents are overweight, they too would benefit from increased exercise. As a family they could take up a new hobby such as swimming or cycling and workout together for a few days in a week. Currently, Ms K's only activity is walking a mile daily. Although her weight may inhibit her from going back to horse riding, she could increase the distance of her walks by a mile and further as her physical fitness increases. She would benefit physically and psychologically from increased physical activity (5). Although she does not watch much TV, she does spend time on the computer every night, having snacks at the same time. This sedentary behaviour tips the scale towards increased energy input and decreased energy output.
Ms K's mother is supportive of her goal of losing weight. She prepares meals at home and tries to keep Ms K from eating unhealthy snacks and desserts. Unfortunately, this effort has become a compulsion that leads to stress on the child and the parents. An alternative could be a revamp of Ms K's eating habits. First of all, she skips breakfast daily. Studies have shown that skipping breakfast leads to obesity, perhaps by the child eating more for lunch and dinner (6,7). As the saying goes: Eat like a king for breakfast, a prince for lunch and a pauper for dinner. Ms K should have a good breakfast daily, consisting of carbohydrates, protein and fiber, such as cereal with fruit and milk.
Secondly, Ms K's diet apparently contains very little fruits and vegetables. Other than the small salad she gets at school, there is little fiber in her diet. The snacks she considers "good junk food" are high carbohydrate foods such as crackers, chips and pasta. Ms K and her family should be educated on the composition of a healthy balanced diet, using the new food plate devised by the US Department of Agriculture, which emphasizes having fruits and vegetables fill half of your plate at every meal (8). Studies show that a diet high in fruits and vegetables is associated with reduced obesity rates (9,10).
Her parents would do better leading by example, eating healthy diets themselves, rather than being "food police". Grocery shopping lists need to be changed so that what is available for snacking at home is the healthy apple or carrot and not chips or crackers. This way, Ms K's parents do not need to keep watching what she is snacking on at home.
Thirdly, Ms K can learn to count calories and keep a calorie counter diary. That way she can keep track of how much energy she is taking in and how much she is expending. The aim should be to keep the numbers balanced and not tipped over to anorexia.
References: Rolland-Cachera MF. Childhood obesity: current definitions and recommendations for their use. Int J Pediatr Obes. 2011; 6:325-31.
Sorensen TI, Price RA, Stunkard AJ, Schulsinger F. Genetics of obesity in adult adoptees and their biological siblings. BMJ. 1989; 298:87 -90.
Daniels SR. Complications of obesity in children and adolescents. Int J Obes (Lond). 2009; 33:S60-5.
Neumark-Sztainer D, Wall M, Haines J, Story M, Eisenberg ME. Why does dieting predict weight gain in adolescents? Findings from project EAT-II: a 5-year longitudinal study. J Am Diet Assoc. 2007;107:448-55.
Ahn S, Fedewa AL. A meta-analysis of the relationship between children's physical activity and mental health. J Pediatr Psychol. 2011;36:385-97.
Timlin MT, Pereira MA, Story M, Neumark-Sztainer D. Breakfast eating and weight change in a 5-year prospective analysis of adolescents: Project EAT (Eating Among Teens). Pediatrics. 2008;121:e638-45.
Dubois L, Girard M, Potvin Kent M, Farmer A, Tatone-Tokuda F. Breakfast skipping is associated with differences in meal patterns, macronutrient intakes and overweight among pre-school children. Public Health Nutr. 2009;12:19-28.
2010 Dietary Guidelines. Updated recommendations put focus on obesity. Mayo Clin Womens Healthsource. 2010; 14:1-2.
Mozaffarian D, Hao T, Rimm EB, Willett WC, Hu FB. Changes in diet and lifestyle and long-term weight gain in women and men. N Engl J Med. 2011; 364:2392-404.
Balthazar EA, de Oliveira MR. Differences in dietary pattern between obese and eutrophic children. BMC Res Notes. 2011; 4:567.
Conflict of Interest:
None declared
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Childhood obesity: a crossroads for our society
Submit ResponseDear Editor,
The CDC reported that 17% of children and adolescents 2-19 years are obese (1). Childhood obesity is diagnosed by a body mass index above the 95th percentile, matched for age and sex (1). Obese children face disapproval, irony and abuse by peers and parents, and get stigmatized (2). They are not given equal opportunities to socialize, become members of peers groups, or create healthy interpersonal relations (3).
Unhealthy lifestyle habits are the leading cause of obesity and consist of increasing size in food portions, consuming processed foods and high sugar drinks, decrease in physical activity at school and home, increase in television viewing and video gaming hours and absence of healthy foods at school (1,4). Children eat unhealthy at home as well, because parents don't devote time for cooking or eating healthy themselves. During infancy, mothers give up breast feeding early on, increasing their children's future risk for obesity (5).
Unfortunately, during a doctor's visit all these issues cannot be addressed, because busy clinics don't allow adequate and frequent enough interaction with the entire family. This is a task for a multidisciplinary team, involving primary care physicians, dietitians, and psychologists with expertise in childhood and adolescence. Parents should be the focus of the whole approach, to prevent traumatizing the children. It should become clear that children need parental support and a safe home environment, because they are deprived of these elements during interaction with their peers. Participation in physical activities could help, but they should be fun and rewarding for the children and will yield better results, if the parents participate as well.
With regard to diet, it is best to avoid carrying unhealthy food at home, so that children do not get exposed to it. We should also focus on changing unhealthy habits in the parents' diet, creating positive reinforcement and role modeling for the children to follow. Radical changes in lifestyle require the entire care team involvement, including whole family and parents or children-only sessions, with the nutritionist or the psychologist. Ideally, the health care providers should initiate education of each patient on nutrition, weight management and physical activity, when they first access the health care system, long before they decide to create a family.
Medical treatments of childhood obesity are usually unsuccessful, or have a poor adverse reactions profile, causing high dropout rates, like a recent trial on orlistat showed (6). Metformin is FDA approved for treating type 2 diabetes in children over the age of 10, but the largest meta-analysis to date, failed to prove weight loss efficacy (7). Non FDA- regulated "natural" products should be avoided overall, unless clear evidence supporting their use arises. Surgical management is frequently successful, but could cause malabsorption of macro- and micronutrients and lead to severe nutritional deficiencies, restricting normal growth (8). The consensus is to consider bariatric surgery in children, only after they achieve Tanner IV stage of pubertal development, their bone age has reached 95% of predicted height (8) and their BMI is greater than 50kg/m2 (6).
1.CDC 2011 Report on childhood obesity. http://www.cdc.gov/obesity/index.html. Accessed January 27, 2012.
2. Thomas C, Hypponen E, Power C. Obesity and type 2 diabetes risk in midadult life: the role of childhood adversity. Pediatrics. May 2008;121(5):e1240-1249.
3. Cawley J, Spiess CK. Obesity and skill attainment in early childhood. Econ Hum Biol. Dec 2008;6(3):388-397.
4. Pabayo R, Spence JC, Cutumisu N, Casey L, Storey K. Sociodemographic, behavioural and environmental correlates of sweetened beverage consumption among pre-school children. Public Health Nutr. Jan 24 2012:1-9.
5. McPherson ME, Homer CJ. Policies to support obesity prevention for children: a focus on of early childhood policies. Pediatr Clin North Am. Dec 2011;58(6):1521-1541, xii.
6. Crocker MK, Yanovski JA. Pediatric obesity: etiology and treatment. Pediatr Clin North Am. Oct 2011;58(5):1217-1240, xi.
7. McGovern L, Johnson JN, Paulo R, et al. Clinical review: treatment of pediatric obesity: a systematic review and meta-analysis of randomized trials. J Clin Endocrinol Metab. Dec 2008;93(12):4600-4605.
8. Inge TH, Krebs NF, Garcia VF, et al. Bariatric surgery for severely overweight adolescents: concerns and recommendations. Pediatrics. Jul 2004;114(1):217-223.
Conflict of Interest:
None declared
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Treatment of pediatric obesity
Submit ResponseThe obesity phenotype and how to treat it is complex and challenging. There are several factors to consider and address. First, the patient must be motivated and supported by the family (1).
Ms. K's dietary habits and the parent-child relationship with food need to be addressed. She skips breakfast, which probably leads to overeating later in the day (2). She needs to understand the importance of breakfast and what should be eaten at breakfast. Counseling on the hunger scale and mindful eating is also warranted - the more she is connected to hunger signals, the more likely she will begin eating on a structured schedule and this should also counter the snacking. It should be determined if she can pack school lunch. She needs education on several nutritional concepts.
The snacking that occurs afterschool needs to be monitored. Where are the parents during this time? Is this boredom eating? If so, developing a list of activities to do instead of eating would be helpful. This time of day seems to be important for physical activity as well. Although she should be applauded for walking home from school and for not watching TV, it appears that once she arrives home from school she spends excessive time on the computer (while snacking). She should be encouraged to take 5 -10 minute activity breaks from the computer (3). Another option to improve the obesigenic behaviors that occur upon arriving home is getting her involved in afterschool activities.
Sleeping habits should also be assessed given the links between short sleep duration, appetite and obesity (4).
Another major issue around food is that she doesn't want to be asked about being on a diet. Parents putting limits on the food - being food police - seems to trigger her wanting more, and this needs to be addressed with the parents.
Besides the lifestyle behaviors, her psycho-social needs are significant. She should consider counseling immediately. Between being adopted, having stress from parents, and dealing with bullying and teasing at school, she has a tremendous amount of stress and anxiety that could be related to eating for comfort. The parents should be encouraged to continue counseling and encouraged to model all expected behaviors. They might also want to advocate on her behalf at school and develop a safety plan considering who can she go to with harassment issues and who are safe people for her be with.
She is adopted and there is no information on the biological mother or the maternal-fetal environment - the latter which has shown to be an important contributor to offspring obesity (5). Additionally, there may be attachment concerns. She may have an attachment to her food instead of her parents.
The clinician(s) should begin using motivation interviewing and empowering her to believe she is in control and sets her own course. She has "fallen off track" several times before and has tried to take the "quick solution route". It will be important to stress that patience and persistence towards goals will be necessary for long-term success.
1. Golan M, Crow S. Parents are key players in the prevention and treatment of weight-related problems. Nutr Rev. 2004 Jan;62(1):39-50
2. Leidy HJ, Racki EM. The addition of a protein-rich breakfast and its effects on acute appetite control and food intake in 'breakfast- skipping' adolescents. Int J Obes (Lond). 2010 Jul;34(7):1125-33. Epub 2010 Feb 2.
3. Healy GN, Dunstan DW, Salmon J, Cerin E, Shaw JE, Zimmet PZ, Owen N. Breaks in sedentary time: beneficial associations with metabolic risk. Diabetes Care. 2008 Apr;31(4):661-6
4. Taheri S, Lin L, Austin D, Young T, Mignot E. Short sleep duration is associated with reduced leptin, elevated ghrelin, and increased body mass index. PLoS Med. 2004 Dec;1(3):e62. Epub 2004 Dec 7.
5. Levin BE. Metabolic imprinting: critical impact of the perinatal environment on the regulation of energy homeostasis. Philos Trans R Soc Lond B Biol Sci. 2006 Jul 29;361(1471):1107-21
Conflict of Interest:
None declared
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Childhood Obesity: An Issue of Oversized Proportions for the United States
Submit ResponseWhat is the definition of childhood obesity?
Currently, one in three children are either obese or overweight(1) Children and adolescents aged 2 through 19 years at or above the 95th percentile of Body Mass Index (BMI) for age are labeled 'obese' and children between the 85th and 95th percentiles are labeled 'overweight'. (2) BMI interpretation is challenging because children and teens are still growing and it does not measure obesity directly. In children, BMI is correlated with adiposity and that correlation is higher at higher levels of BMI for age than at lower levels of BMI for age. (3)
What are the immediate medical and psychological consequences of obesity in children?
Medically, overweight or obese children are at higher risk for asthma, diabetes, dyslipidemias, gallstones, headaches, hypertension, liver disease, menstrual abnormalities, metabolic syndrome, pain in the back, knee, thigh or hips, skin infections, sleep apnea and psychological effects. (4) Immediately, Ms K is dealing with pain that limits her activity, thus decreasing her energy expenditure. Psychologically, overweight children may be labeled with negative attributes like lazy, unintelligent, and unmotivated. Very overweight children reported nearly a 6-fold higher poor self-esteem rating when compared to average weight peers. (5) Besides the medical and psychological costs, one should also address the ethical issues of childhood obesity - what are the responsibilities of parents to protect their children from obesity. Recently a 200-pound 8-year old boy was taken from his mother for not doing enough to control his weight.(6)
Why is childhood obesity so difficult to treat?
Public policy may hamper childhood obesity treatment. When the government is trying to determine if pizza or ketchup are vegetable options then we have larger issues to address.(7) Obesity is the product of disequilibrium in energy intake (food consumed) and expenditure (physical activity, metabolism, and growth and development). (8) Ms K is not able to expend as much energy due to occasional physical injuries. Moreover, behaviorally, Ms K appears to be in the contemplative phase of change and is being harassed by parents and classmates.
What are therapeutic options?
Therapeutic options to consider with Ms K are helping educate her about appropriate dietary intake, increasing non-weight bearing exercises like swimming or biking and making sure she gets the appropriate amount of sleep. Children that got less than nine hours of sleep at night were more likely to be overweight or obese.(3) Parents and children have to be interested in altering their current behavior and be ready to change. If both parents are overweight then the risk of an overweight child is 80% compared to only 7% for those families with neither overweight parent. (9) Half of a child's waking day is spent at school. Parents may also look to school-based interventions. A meta-analysis recently reported success by combining physical activity with classroom education. (10)
What parenting strategies can be used to promote long-term behavior change?
Parenting strategies should be supportive and be done jointly. Strategies should address the discrepancy between what Ms K is doing (e.g. skips snacks, no vegetables etc) and what she wants (e.g. lose weight). The success of long-term behavioral change is focusing on the positive behavioral components (e.g. 'I know this is something you can do'), and let Ms K save herself. (11)
References
1. Matthews VL, Wien M, Sabate J. The risk of child and adolescent overweight is related to types of food consumed. Nutr J. 2011 Jun 24;10:71.
2. Ogden CL, Carroll MD, Curtin LR, Lamb MM, Flegal KM. Prevalence of high body mass index is US children and adolescents, 2007-2008. JAMA 2010;303:242-9.
3. Juettner B. Childhood Obesity. San Diego, CA: Referencepoint PR Inc. 2009.
4. Hassink SG. American Academy of Pediatrics - A parent's guide to childhood obesity - a road map. Washington, DC: Library of Congress, 2006.
5. Sikorski C, Luppa M, Kaiser M, Glaesmer H, Schomerus G, Konig HH, Riedel-Heller SG. The stigma of obesity in the general public and its implications for public health - a systematic review. BMC Public Health. 2011;11:661.
6. Sheeran TJ. San Francisco Chronicle - Ohio officials take 200- pound boy from mother. November 29, 2011. http://www.sfgate.com/cgi- bin/article.cgi?f=/n/a/2011/11/28/national/a160710S40.DTL&type=science. Accessed November 29, 2011.
7. Simon R. Pizza a vegetable? Your government says so. November 18, 2011. The Columbus Dispatch. http://www.dispatch.com/content/stories/national_world/2011/11/18/pizza-a- vegetable-your-government-says-so.html Accessed November 19, 2011.
8. Ahmed AT, Oshiro CE, Loharuka S, Novotny R. Perceptions of middle school educators in Hawai'i about school-based gardening and child health. Hawai'I Med J. 2011;70:S11-15.
9. Perryman ML. Ethical family interventions for childhood obesity. Prev Chonic Dis 2011;8:1-3.
10. Gonzalez-Suarez C, Worley A, Grimmer-Somers K, Dones V. School- based interventions on childhood obesity: a meta-analysis. Am J Prev Med 2009;37:418-27.
11. Possidente CJ, Bucci KK, McClain WJ. Motivational interviewing: a tool to improve medication adherence? Am J Health-Syst Pharm 2005;62:1311 -4.
Conflict of Interest:
None declared
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Response to
Submit ResponseThe patient described in the article by Shipp 1 is very much like those seen in the Children's Center for Weight Management (CCWM) at Children's of Alabama. Located in Birmingham, Alabama it is comprised of a multidisciplinary team and a tertiary approach to provide assessment and education on nutrition, activity, medical obesity -related condition, psychological counseling, behavior management and bariatric surgery. Ms. K paints a typical picture of a family with differing ideas of weight, health and how to achieve an appropriate level of both.
DEFINITION OF CHILDHOOD OBESITY Obese children are identified as those at or above the 97th percentile of BMI-for age on growth charts and overweight at between the 85th and 95th percentiles. 2
IMMEDIATE MEDICAL AND PSYCHOLOGICAL CONSEQUENCES OF OBESITY IN CHILDREN The health problems associated with this disease are many. Metabolic disorders such as elevated liver function enzymes, insulin resistance, type II diabetes mellitus, and dyslipidemia are risk factors for hypertension, heart disease, stroke and liver disease.3 If acquired in childhood or adolescence, set-up the likelihood of increased risks of disease in adulthood with or without obesity. 4,5,3 Researchers have concluded that depressed adolescents have an increased risk of developing or maintaining obesity during adolescence. A number of factors may influence weight gain in depressed adolescents, perhaps the most observable being overeating in response to the negative emotions. Ms. K may have some unresolved anxiety related to being adopted. 6
DIFFICULTY IN TREATING CHILDHOOD OBESITY Causes of childhood obesity are numerous. Countless studies have been done on diet and exercise but many are now proposing that the reasons for the increase in obesity is multifactorial including such factors as parent perception of obesity, parental food choices, culture, fatigue, socioeconomic status, busy lifestyles, 7,8,9even coping mechanisms. 10,11
THERAPEUTIC OPTIONS Based on the evidence, the following methods are utilized in our clinic and could be applied to Ms. K and her family: - Setting realistic achievable goals that are in agreement with all members of the family - Assess sleep hygiene and rule out obstructive sleep apnea - Laboratory screening: CRP, fasting metabolic panel, lipid panel, and insulin and HgbA1C and thyroid screening - Evaluate any anxiety, emotional eating related to being adoptive, concern about her biological parents - Assess learning disabilities or cognitive/motor delays that may indicate need for genetic testing - Require daily food and activity logs - Nutrition, physical therapy and psychology consult - Parents/ Ms. K need information on bullying - Parents need to create an environment where the child can be successful; they need to be role models for healthy behaviors. - Summer weight loss camp: affordable camps are available - Eat meals as a family - School prescription for low fat lunch or take lunch to school
PARENTING STRATEGIES - Parent example: Role model healthy behaviors, join gym as a family, act as a team and support each other, - Allow child’s input and assistance with meal preparation, monitor portion sizes - Remove TV from bedroom, decrease screen time - Agreed upon bedtimes without cell phones/computers - Support child to complete any programs or team sports that he/she begins.
REFERENCES
1. Shipp, A. A 14-year-old struggling to lose weight. Journal of the American Medical Asociation. 2012;307(1): E1-E1.
2. Ogden, C. L., Carroll, M. D., Curtin, L. R., Lamb, M. M., Flegal, K. M. Prevalence of high body mass index in US children and adolescents, 2007-2008. JAMA. 2010; 303(3): 242-249. doi: 2009.2012 [pii]
3. Daniels, S. R. The consequences of childhood overweight and obesity. The Future of Children.2006; 16(1): 47-68.
4. Biro, F. M., & Wien, M. Childhood obesity and adult morbidities 5. The American journal of clinical nutrition. 2010; 91(5): 1499S-1505S. doi: 10.3945/ajcn.2010.28701B
6. Caprio, S. Treating child obesity and associated medical conditions. The Future of Children.2006; 16(1): 209(216).
7. Talking to you teen about being adopted. Retrieved from http://www.aap.org/. Retrieved 1/27/12.
8. Sealy, Y. M. Parents' food choices: obesity among minority parents and children. Journal of Community Health Nursing,(2010) 27(1), 1-11. doi: 10.1080/07370010903466072
9. Strasburger, V. C. (2011). Children, adolescents, obesity, and the media. Pediatrics, 128(1), 201-208. doi: Thompson, J. L., Jago, R., Brockman, R., et al. Physically active families - de-bunking the myth? A qualitative study of family participation in physical activity. Child: Care, Health & Development. 2010; 36(2), 265-274. doi: 10.1111/j.1365- 2214.2009.01051.x
10. 1 Anderson, P. M., & Butcher, K. F. Childhood obesity: trends and potential causes.(child care). The Future of Children. 2006; 16(1): 19-27.
11. Chen, J. L.; Kennedy, C. Cultural variations in children's coping behaviour, TV viewing time, and family functioning. International nursing review.2005; 52(3): 186-195. doi: 10.1111/j.1466-7657.2005.00419.x
Conflict of Interest:
None declared
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A 14-Year-Old Struggling to Lose Weight.
Submit ResponseMs. K presents severe obesity (defined as body weight above the 99 percentile) (1) and acanthosis nigricans, both highly associated with several metabolic disorders, including type 2 diabetes mellitus (1,2,3). Taken into account her current clinical signs, it is possible that she presents the metabolic syndrome. In order to confirm this diagnosis, it is necessary to assess the presence of three out of five characteristics: abdominal obesity, defined by anthropometric measurements (waist circumference or waist to hip ratio or waist to height ratios), impaired glucose tolerance, hypertension and/or dyslipidemia (1,2,3).
Ms. K also presented blood pressure levels that suggest the diagnosis of prehypertension (4). This clinical sign warrants follow up with proper measurements of blood pressure and if necessary, the performance of ambulatory monitoring of the blood pressure to finally establish the diagnosis of systemic hypertension (4).
Ms. K's medical history suggests that she presented precocious sexual development given the report of menarche at age 11 (5). She also suffers emotional distress due to bullying behavior towards her (3,6). Both findings are frequently reported in childhood and adolescence obesity.
Obstructive sleep apnea is another comorbidity associated with obesity and it could be suspected if Ms. K snores, pauses her breath during sleep, presents behavior changes (e.g irritability, decrease in school performance etc) and/or diurnal somnolence. If one or more of these symptoms are present, the performance of polysomnography would be recommended (1,3).
Based on the current guidelines for children and adolescence with obesity, Ms. K is eligible for laboratorial blood measurements of glucose (and depending upon the results, oral tolerance test would be required), cholesterol, triglycerides and hepatic transaminases, AST and ALT (for the diagnosis of non-alcoholic fat liver disease, another comorbidity associated with obesity) (3,6).
It is important to distinguish between primary and secondary causes of obesity in order to prescribe the appropriate treatment. According to Ms. K's history and physical examination, secondary cause of obesity is slim because she does not present any phenotypical features or retardation of sexual development and growth that suggest genetic or other causes of obesity (7). Most probably her obesity stems on the interaction between inheritance and environmental factors, such as inadequate behaviors (meal skipping, snacking frequently, eating before the computer, no portion control) and poor quality of food containing high-fat and low-fiber contents.
The goal of her treatment is to achieve BMI z-score less than 2 in a period of 6 months (3,7). A family-based program of weight management that focus on individualized behavioral and lifestyle modifications associated with a more intensive and tailored physical activity might be effective.
Ms. K presents some features believed to be keys to success of any intervention to manage weight and its associated comorbidities: motivation and support of her parents. However, if after 6 months of supervised intervention, the treatment fails to control her weight and comorbidities, additional treatment would be required such as pharmacological intervention (metformin, sibutramine or orlistat) and ultimately bariatric surgery (1,8,9,10).
References
1. Sweeting HN. Measurement and definitions of obesity in childhood and adolescence: a field guide for the uninitiated. Nutr J. 2007 Oct 26;6:32.
2. Abraham C, Rozmus CL. Is Acanthosis Nigricans a Reliable Indicator for Risk of Type 2 Diabetes in Obese Children and Adolescents? A Systematic Review. J Sch Nurs. 2011 Dec 16. [Epub ahead of print]
3. Speiser PW, Rudolf MC, Anhalt H, Camacho-Hubner C, Chiarelli F, Eliakim A, Freemark M, Gruters A, Hershkovitz E, Iughetti L, Krude H, Latzer Y, Lustig RH, Pescovitz OH, Pinhas-Hamiel O, Rogol AD, Shalitin S, Sultan C, Stein D, Vardi P, Werther GA, Zadik Z, Zuckerman-Levin N, Hochberg Z; Obesity Consensus Working Group. Childhood obesity. J Clin Endocrinol Metab. 2005 Mar;90(3):1871-87. Epub 2004 Dec 14.
4. National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics. 2004 Aug;114(2 Suppl 4th Report):555-76.
5. Ahmed ML, Ong KK, Dunger DB. Childhood obesity and the timing of puberty. Trends Endocrinol Metab. 2009 Jul;20(5):237-42. Epub 2009 Jun 21.
6. Daniels SR, Jacobson MS, McCrindle BW, Eckel RH, Sanner BM. American Heart Association Childhood Obesity Summit: executive summary. Circulation. 2009 Apr 21;119(15):2114-23. Epub 2009 Mar 30.
7. Kramer RE, Daniels SR. Evaluation of a child for secondary causes of obesity and comorbidities. Nat Rev Endocrinol. 2009 Apr;5(4):227-32.
8. Hesketh KD, Campbell KJ. Interventions to prevent obesity in 0-5 years olds: an updated systematic review of the literature. Obesity (Silver Spring). 2010 Feb;18 Suppl 1:S27-35.
9. Epstein LH, Wrotniak BH. Future directions for pediatric obesity treatment. Obesity (Silver Spring). 2010 Feb;18 Suppl 1:S8-12.
10. Obesity: preventing and managing the global epidemic. Report of a WHO consultation. World Health Organ Tech Rep Ser. 2000;894:i-xii, 1-253.
Conflict of Interest:
None declared
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"Supershrink Me"
Submit ResponseDefinition of Childhood Obesity
"While no single body fat value...clearly distinguishes health from disease or risk of disease...BMI is a useful tool and elevations predict future adiposity, as well as future morbidity and death. BMI between the 85th and 94th percentile is termed overweight and at or above the 95th percentile termed obese." [1]
Immediate Medical and Psychological Consequences
Medical consequences include: hypertension, sleep apnea, liver dysfunction, dermatologic disorders, pre-disposition to type II diabetes and cardiovascular disease (metabolic syndrome)[2], polycystic ovarian disease (PCOS), dyslipidemia, left ventricular hypertrophy and dysfunction, pseudotumor cerebri, symptomatic shortness of breath and decreased exercise capacity, orthopedic complications..
Psychosocial problems (which are the most common consequences) [3], include: diminished domains of self-esteem [4], impaired quality of life [5], and specific psychiatric disorders[6], such as depression, oppositional disorder, and ADHD. Weight bias as a social consequence of obesity can lead to emotional distress and peer rejection.[7]
Difficult to Treat
Numerous biological, psychological, and societal factors compromise childhood obesity treatment. Biologically, there is a strong genetic disposition for adiposity and the disease progresses in a slow, insidious manner. Early metabolic disturbances and a set point process involve a decreased metabolic rate with increased metabolic efficiency. Biological and psychosocial elements merge in the obesogenic family. Limited nutritional awareness in families, faulty early feeding patterns, and problematic parenting styles[8] also compromise treatment effectiveness. Psychologically, "emotional eating" is intrinsically rewarding for children, as is the sedentary, semi-addictive nature of electronic entertainment, eclipsing much physical activity. These obstacles occur within the context of powerful societal forces including: the toxic food environment ,[9] the cultural acceptability of overeating, the media marketing of calorie dense, low nutrient food to children and a built environment which is not conducive to safe, outdoor physical recreation.
Therapeutic Options
Given its resistance to treatment, the best strategy for childhood obesity is prevention. Nutritional counseling and exercise combined with family-based behavior modification is considered the most effective outpatient treatment.[10] Intensive interventions involve the controlled environment of an inpatient service, specialized summer camp, and residential school. Last options for obese adolescents include: weight- reduction medications and bariatric surgeries. For weight-related emotional distress, psychotherapy and group therapy may be beneficial.
Parenting Strategies for Long-Term Behavior Change
The general parenting strategies for healthy childrearing provide the environment for preventing or parenting overweight and obesity in families. These well-established concepts include: providing warmth, consistency, support and flexibility, as well as promoting independence and responsibility, and clear, respectful communication.
Methods for promoting long-term weight-related changes include: encouraging moderation and balance in eating and exercise behavior, modeling these healthy patterns, early recognition and consistent help- seeking, modifying obesity-related parenting styles [8] and eliminating family weight bias in the forms of blaming or teasing.[7]
References
1.Barlow S. Expert committee recommendations regarding the prevention, assessment and treatment of child and adolescent overweight and obesity: summary report. Pediatrics.2007; 120: S164.
2.MacLean PS, Higgins JA, Johnson GC, Fleming-Elder BK, Donahoo WT, Melanson EL,Hill JO. Enhanced metabolic efficiency contributes to weight regain after weight loss in obesity-prone rats. Amer J Physiology. 2004; 287(6) R1306 - R1 315.
3.Heinberg LJ, Thompson JK. Preface. IN: Heinberg LJ, Thompson JK (eds). Obesity in Youth: Causes, Consequences and Cures. Washington, DC: American Psychological Association: 2009.
4.French SA, Story M, Perry CL. Self-esteem and obesity in children and adolescents: a literature review. Obes. Res. 1995; 3(5): 479-490.
5.Reilly JJ, Methven E, McDowell ZC, et al. Health consequences of obesity. Arch Dis Child. 2003; 88(9): 748-752.
6. Panzer BM. Obesity and the Dual diagnosis child: exploring the dynamics of co-morbid psychiatric disorders. Submitted 2012.
7.Latner JD, Schwartz MB. Weight bias in a child's world. In: Brownel K, et al (eds).Weight bias: nature, consequences, and remedies. New York: Guilford Press: 2005 .
8.Rhee KE, Lumeng JC, Appugliese DP, Kaciroti N, Bradley RH. Parenting styles and overweight status in first grade. Pediatrics. 2006; 117(6): 2047-2054.
9.Brownell KD, Horgen KG. Food Fight: The Inside Story of the Food Industry, America's Obesity Crisis and What We Can Do About It. Chicago, IL: Contemporary Books; 2004.
10.Faith MS, Saelens BE, Wilfley DE, Allison DB. Behavioral treatment of childhood and adolescent obesity: Current status, challenges and future directions. In: Thompson JK, Smolak L (eds.). Body image, eating disorders and obesity in youth: Assessment, prevention, and treatment. Washington, DC: American Psychological Association;2001: 313-340.
Conflict of Interest:
None declared
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Pediatric Obesity Treatment Recommendations
Submit ResponseThe complexity of treating childhood and adolescent obesity requires a multidisciplinary and multifaceted response. This is particularly relevant for Ms. K, as described in the Clinical Crossroads presentation, given her BMI of 40 at age 14, which suggests that she would benefit from a Stage 3 comprehensive level of obesity care. As noted in the Expert Committee recommendations in 2007 [1], a multidisciplinary team with experience in childhood obesity should include a mental health provider (e.g., psychologist or social worker), registered dietitian, exercise specialist, and primary care provider. Each team member has a unique role in patient care and provides the opportunity for the family and child/adolescent to develop an individually tailored treatment plan.
Model pediatric obesity treatment programs also focus on the family at a system level and encourage all caregivers to participate in treatment. Family based treatment programs have been supported in the literature [2] and avoid the view of the child/adolescent as "the patient" by engaging the family as a whole [3]. Targeting the entire family is especially important if parents, in addition to children, are overweight [4].
Given this framework, we would recommend the following steps. First, Ms. K would benefit from a comprehensive history, physical, and laboratory screening in order to make an assessment of the primary chief complaint of abnormal weight gain and of the presence of possible comorbid obesity- related medical problems (e.g.,type 2 diabetes mellitus, hyperlipidemia, , nonalcoholic fatty liver disease, polycystic ovarian syndrome and respiratory problems), especially with the noted initial elevated blood pressure in office and presence of acanthosis nigricans on physical exam. Identification and communication of a patient's obesity and obesity related medical conditions may help to motivate Ms. K and her family and may serve to improve adherence with treatment options that are tailored to the severity of the patient's disease. The above would best be done by an experienced clinician in treating childhood obesity.
Second, we would recommend an initial psychological consultation to determine whether emotional, social, and family factors are negatively impacting Ms. K's functioning, as well as her ability to make lasting behavioral changes toward a healthier lifestyle. Immediate psychological comorbidities that should be assessed include depression, anxiety, binge eating, and low self esteem. While psychological symptoms were not directly indicated in the case presentation, it seems that Ms. K has experienced episodes of bullying that could lead to a decreased desire to attend school and to withdraw from her peer group. Additionally, it appears that concerns with regard to weight and eating have resulted in increased parent child conflict. Therefore, it would be beneficial to assess Ms. K's view of her relationship with her adoptive parents and the emotional environment in the home. Discussion between Ms. K and her parents should also focus around the food environment in the home, given that her parents seem to closely monitor and criticize Ms. K’s food choices and portions (suggesting the accessibility of unhealthy food options). Rather than "backing off" as was suggested by Ms. K's parents' counselor, it may be helpful for Ms. K and her parents to discuss ways in which her parents could positively support lifestyle changes and to discuss current barriers that promote unhealthy eating habits. Should these or similar concerns arise in the context of the initial consultation, a combination of family and individual psychotherapy would be an important next step in treatment.
With regard to the approach taken related to dietary and exercise habits, we would recommend that the focus be on improving lifestyle and health with small, sustainable changes. It seems that in the past, Ms. K has tried various dietary changes for a very short period of time (e.g., 3 days). Thus, the importance of long term approaches would be a necessary discussion point for the family, as well as education regarding the chronic nature of obesity. We recommend that Ms. K and her family meet with a dietitian to help identify eating habits that may be leading to continued weight gain. Areas of focus may include, but are not limited to, eating breakfast regularly, decreasing the amount of snacks, and increasing fruit and vegetable consumption. For help with increasing physical activity, Ms. K would likely benefit from meeting with an exercise specialist to determine her current level of physical fitness and to identify strategies for promoting physical activity. We recommend using a strength-based approach to determine activities that she inherently enjoys (e.g., horseback riding) and to encourage participation of both parents in physical activity with Ms. K.
Ongoing care is an essential part of the management of any chronic disease. We recommend that obesity follow-up visits focus on adherence with treatment recommendations, barriers to adherence, and measurements of physiological change. Short term weight loss with family based therapy is often modest but clinically important. Long term outcomes will depend on Ms. K and her family's ability to create and value healthier habits and environments that promote sustained lifestyle change.
1. Barlow, S. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: Summary report. Ped. 2007;120:S164-S192.
2. Nowicka P,Flodmark, CE. Family in pediatric obesity management: A literature review. Int J Ped Obes. 2008;3;44-50.
3. Golan M, Weizman A, Apter A, Fainaru M. Parents as the exclusive agents of change in the treatment of childhood obesity. Am J Clin Nutr. 1998; 67:1130-1135.
4. Epstein LH, Valoski A, Wing RR, McCurley J. Ten-year outcomes of behavioral family-based treatment of childhood obesity. Health Psych; 13:373-383.
Conflict of Interest:
None declared
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Diet is a four letter word!
Submit ResponseWhile extreme, Ms K's presentation is typical, both for children and adults. The focus on short-term weight management, the use of meal skipping in an attempt to reduce caloric intake, the added family and social stress related to her obesity, and lack of sustained physical activity. But how should Ms K. and her parents be advised?
First, the term diet, that is strageties aimed at rapid, short-term weight loss, should be eliminated from the discussion. Significant, rapid weight loss leads to psychological and biological adaptations intended to minimize the loss of energy stores. Perhaps the most famous study was performed by Ancel Keys during WWII which demonstrated increased fixation on food, reduced satiety upon eating, increased anxiety and symptoms of depression, and disordered eating behaviors among men who under went substantial caloric restriction[1]. Other studies have shown that rapid weight loss leads to sustained changes in homrones related to satiety, making it difficult to sustain the caloric intake necessary to sustain the weight loss[2].
As for the obesity per se., she should be advised to start eating a nutrient rich breakfast. Several studies have shown that meal skipping leads to increased caloric intake upon the next meal. K.S. Stote and colleagues reported that meal skipping leads to increased hunger before meals, increased desire to eat, fixation on food, reduced satiety upon eating[3]. Not only should Ms K eat more, but she and her parents should slow down at meal time. Several years ago Andrade reported that increased extended mealtime led to increased satiety and lower caloric intake[4]. Peptide YY and GLP-1, hormones related to satiety, are increased in people who consume a meal in 30 minutes compared to 10 minutes[5]. So sit down and enjoy breakfast and dinner together, and mom and dad should be encouraged to stop focusing on their daughter's body weight.
While childhood obesity is an independent risk factor for adult obesity, diabetes, heart disease and some forms of cancer, the abject failure of weight loss programs to produce long-term weight loss has nudged clinicians, dietitians, and physiologists to focus more on healthy behaviors that will improve metabolic and cardiovascular health independent of body mass. At the most recent meeting of the American College of Sports Medicine a symposium was held addressing this issue titled "Does Weight Loss as a Primary Outcome Undermine Obesity Treatment Programs?". The consensus recommendation was to focus on over-all health outcomes - reduced cholesterol, sympathetic activity, blood glucose and increased aerobic capacity, arterial compliance, and skeletal muscle mass. All these factors can be improved with little change in body mass while improving the overall risk of cardiovascular and metabolic disease as an adult.
While not mentioned, sleep may be an important factor to consider. There are substantial increases in human growth hormone, important for maintaining lean body mass and decreases in cortisol, important for the storage of energy as adipose. As much as we would like to increase her physical activity, adequate sleep is an important factor in weight management.
Lastly, we need to applaud and encourage Ms K for her attempts to be physically active - walking home from school and playing field hockey. These types of activities need to be encouraged. Not so much to lose weight, but to improve her psychological function (reduced symptoms of depression from which she likely suffers) and her cardiovascular and metabolic health. While exercise has not been shown to be a successful strategy for long-term weight loss, it is an important part of a broad- based weight management plan as stated in the ACSM position stand on the "Appropriate Physical Activity Intervention Strategies for Weight Loss and Prevention of Weight Regain for Adults"[6].
In summary, Ms K and her family should be encouraged to stop thinking about short-term weight loss. In fact, Ms K. should be encouraged to eat appetizing, nutrient dense foods more regularly, and to slow down and enjoy the experience. Emphasis should be placed on improved cardiovascular and metabolic fitness rather than body weight. Physical activity should be included as part of her plan, but not to lose weight. More social forms of physical activity/play might be preferable as often times social support plays a key role in compliance.
1. Kalm LM, Semba RD. They starved so that others be better fed: remembering Ancel Keys and the Minnesota experiment. J Nutr. Jun 2005;135(6):1347-1352. 2. Sumithran P, Prendergast LA, Delbridge E, et al. Long-term persistence of hormonal adaptations to weight loss. N Engl J Med. Oct 27;365(17):1597- 1604. 3. Stote KS, Baer DJ, Spears K, et al. A controlled trial of reduced meal frequency without caloric restriction in healthy, normal-weight, middle- aged adults. Am J Clin Nutr. Apr 2007;85(4):981-988. 4. Andrade AM, Greene GW, Melanson KJ. Eating slowly led to decreases in energy intake within meals in healthy women. J Am Diet Assoc. Jul 2008;108(7):1186-1191. 5. Kokkinos A, le Roux CW, Alexiadou K, et al. Eating slowly increases the postprandial response of the anorexigenic gut hormones, peptide YY and glucagon-like peptide-1. J Clin Endocrinol Metab. Jan;95(1):333-337. 6. Donnelly JE, Blair SN, Jakicic JM, Manore MM, Rankin JW, Smith BK. American College of Sports Medicine Position Stand. Appropriate physical activity intervention strategies for weight loss and prevention of weight regain for adults. Med Sci Sports Exerc. Feb 2009;41(2):459-471.
Conflict of Interest:
None declared
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OCCUPATIONAL HIV EXPOSURE & POST-EXPOSURE PROPHYLAXIS PROTOCOLS
Submit ResponseThe true incidence of occupationally acquired HIV is unknown, and may be under- reported. The risk for HIV transmission after a percutaneous exposure to HIV-infected blood has been estimated to be 0.3% and after a mucous membrane exposure approximately 0.09%, whereas it is estimated to be up to 100 times greater for hepatitis B virus (30%) and could be up to 10% for hepatitis C virus.[1,2,3]
Needle stick injury prevention, must be multimodal; institutions must ensure universal precautions, safe disposal of sharps, education of hospital staff & well-defined prophylaxis protocols[4]. Two hand recapping and distraction while working should be discouraged. All cuts/ abrasions should be covered with waterproof dressings[3].
In case of exposure one should: encourage bleeding of wound, avoid panic, check baseline HIV status of worker and patient, evaluate the hepatitis B surface antigen status of the source and vaccination with vaccine-response status of the exposed [2], seek consultation with appropriate authority and start anti-retroviral prophylaxis.
Postexposure prophylaxis (PEP) with hepatitis B immune globulin (HBIG) and/or hepatitis B vaccine to any susceptible, unvaccinated person who sustains an occupational blood or body fluid exposure is recommended2.
A full 4-week regimen HIV post exposure prophylaxis (PEP) is recommended, however, malaise, nausea and side effects often hinder completion[5]. It is recommended to counsel the exposed about expected PEP adverse effects and that PEP may not be 100% effective in preventing sero- conversion[6]. Determining how many of which agents to use or when to alter a PEP regimen is primarily empiric[7] . In theory, a combination of drugs with activity at different stages in the viral replication cycle may offer higher preventive effects, and use of three- (or more) drug regimens might be justified for high risk of transmission exposures. Whether the potential added toxicity of a third or fourth drug is justified for lower-risk exposures is uncertain, in the absence of supportive data in the context of occupational PEP. Offering a two-drug regimen is a viable option, because the benefit of completing a full course of this regimen exceeds the benefit of adding the third agent and risking non-completion. In addition, the total body burden of HIV is substantially lower in exposed HCP than among persons with established HIV infection.
Thus, recommendations provide guidance for two- and three- (or more) drug PEP regimens on the basis of the level of risk for HIV transmission represented by the exposure[4,6]. Dr J's needlestick injury was managed well by his supervising resident and hospital team. Dr J himself demonstrated responsible behavior by reporting the injury, handing over to another resident, rinsing the wound and seeking treatment. He also introspected into what he could have done differently to prevent the injury, which is praiseworthy. The obvious lacunae that can be drawn in management of Dr J's case is lack of patient-friendly information as part of the hospital's needlestick protocol and thorough counseling, a lack of repeat serology for Hepatitis B & C to avoid their window periods and also a lack of resources (regular needle drivers in the CCU) for suturing or lack of Dr J's training in the use of a curved hemostat.
REFERENCES: 1.Canadian Center for Occupational Health and Safety: http://www.ccohs.ca/oshanswers/diseases/needlestick_injuries.html 2.http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5011a1.htm 3.http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5409a1.htm#tab3 4.http://www.hpa.org.uk/Publications/InfectiousDiseases/BloodBorneInfections/0503OcctransmissionHIVsummaryofreports/ 5.Young TN, Arens FJ, Kennedy GE, Laurie JW, Rutherford G. Antiretroviral post-exposure prophylaxis (PEP) for occupational HIV exposure. Cochrane Database Syst Rev. 2007 Jan 24;(1):CD002835. 6.Gerberding JL. Occupational exposure to HIV in health care settings. N Engl J Med 2003;348:826--33.
Conflict of Interest:
None declared
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