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Childhood Obesity in Practice
Robert D. Murray, MD, Professor of Pediatrics, Department of Human Nutrition, College of Education and Human Ecology, The Ohio State University, Columbus, OH
Samantha Anzeljc, BS, Department of Human Nutrition, College of Education and Human Ecology, The Ohio State University, Columbus, OH
Philip R. Fischer, MD, Professor of Pediatrics, Mayo Clinic, Rochester, MN
Obesity currently is the nation's greatest public health challenge. Serious chronic disorders are rising rapidly among children, teens, and young adults.1-5 Despite the urgency, many primary care clinicians have failed to engage their patients and parents around the topic of obesity. Yet in early childhood, no other health proponent has the access and influence to reshape the family's collective habits. National guidelines now exist to guide primary care clinicians through the evaluation and counseling process.
The prevalence of childhood obesity in the United States abruptly rose in the mid-1970s. Since then, rates steadily increased for nearly 30 years until the year 2000.6 In the first decade of the 21st century, rates of overweight seem to have plateaued, but at very high levels. Although obesity rates were 5% in the early 1960s, data collected by the National Health and Examination Survey (NHANES) through 2008 revealed that among all U.S. youth, 32% are overweight (above the 85th percentile body mass index [BMI]) and nearly 18% are obese (above the 95th percentile BMI). Examined by age group, the prevalence of obesity was 12.4%, 17.0%, and 17.6% for children ages 2-5 years, 6-11 years, and 12-19 years, respectively.7,8 This illustrates how early in life excess weight takes hold. Furthermore, the prevalence rates of extreme obesity, which is having a BMI > 97th percentile, was 8.5%, 11.4%, and 12.6% for children in those same age groups, respectively.
The Critical First Years
Of particular interest are the children in the first decade. This group continues to experience rising obesity rates of 1.2% to 2.1% in just the past 4 years alone.7,8 The highest risk factor for childhood obesity is parental obesity. Currently, more than two-thirds of U.S. adults are overweight and one-third are obese. The young adult parent of today represents the first wave of children caught in the obesity epidemic in the 1970s. This makes their children highly vulnerable to early and persistent excess weight.9-11 Being overweight in preschool raises by five-fold a child's risk of being overweight at age 12 years. Similarly, the child who is overweight or obese in the middle school years (10-14 years) has an 80% likelihood of being obese at age 25 years, compared with a mere 10% likelihood if normal weight.12 Collectively, the data indicate that the earlier the onset of obesity and the longer that it continues into the second decade, the greater the likelihood of maintaining obesity into adulthood.9-12
Primary Care is Front Line
Well-child visits to primary care providers offer the best public health opportunity to instill proper nutrition and physical activity habits in very young children. Nearly 95% of pediatricians obtain height and weight information on their patients during well-child visits; yet documentation of BMI and counseling are not commonly found on chart review.13-15 Only 12.5% and 13.3% of pediatricians and pediatric nurse practitioners, respectively, use BMI percentile to assess weight. The majority use their clinical impression.16 And another study showed that only 5% and 28% of overweight and obese children, respectively, had the diagnosis charted in their medical record.17 Following the trajectory of a child's rising BMI percentile can aid in an early recognition. Clinicians influence the parents' sense of urgency regarding the child's weight status by using the objective BMI information and a clear diagnosis of the problem. A recent sample of parents revealed that only 22% of patients with an obese child and 14% with an overweight child recalled the physician mentioning the child's abnormal weight.18
How to Discuss Weight
Many parents are overweight. Their experiences with weight may have been emotionally traumatic, so broaching obesity can be challenging. Physicians should focus on weight as a health issue. Making the child's BMI percentile a point of discussion during every well-child visit will heighten the family's sense of concern. Evidence of a changing BMI percentile can be useful to repeatedly raise awareness. If the child is already overweight or obese, the clinician can tie the BMI percentile with the family's health history to create a risk profile, linking the child's current and future health with diseases well known to the family.
A family's readiness to change its health-related behaviors can begin only once the parents recognize that a child is overweight. Parental recognition of obesity in their own child is poor.18-21 In a sample of parents attending well-child visits who were asked to select words to characterize their child's weight status, parents of overweight and obese children were more likely to perceive their child as "about the right weight" rather than "a little overweight or obese." However, parents of overweight and obese children also were more likely to select visual images of a heavier child than an image of an average or lighter weight child, indicating a disconnect between the words they used to describe their child's weight status and their image of the child's body.18 In another study population, 71% of parents of overweight children and 28% of parents of obese children perceived their child's weight as "about right" and 72% of parents of obese children perceived their child as "somewhat overweight." Only 25% of parents of overweight children and none of the parents of obese children accurately categorized their child's weight status.21 Parental misperception of their child's weight status may be influenced by the age and sex of the child. Parents were more likely to classify their sons incorrectly than their daughters. Also, the child's age can influence a parent's concern.18,21 Parents with children younger than 6 years old were less likely to recognize that their child was overweight, but were more likely to be concerned about their child's weight status when they did become aware of it, making this age group a prime target for intervention.18
The American Academy of Pediatrics (AAP) and 14 other collaborating organizations formed the Expert Committee on the Prevention, Identification, and Treatment of Childhood Obesity. In 2007, this group published its Expert Committee Recommendations (ECRs) to guide clinicians.22 (See Table 1.) These recommendations were rooted in scientific research and compiled to achieve optimal effectiveness in clinical practice. The primary behavioral targets included:
These messages can be delivered as anticipatory guidance for preventive purposes while children are younger, or they can be used as part of the intervention strategy when the child has been identified with a rising BMI or a BMI already exceeding the 85th percentile.
Toolkits, books, and programs have been developed to give clinicians resources for use in practice For example, see www.AAP.org for professional resources on obesity. (See Table 2.)
"An Ounce of Prevention" was developed in Ohio as a collaboration between medical and public health representatives and is available free to clinicians (see the Ohio Chapter of the American Academy of Pediatrics at www.OhioAAP.org). This series of visit-by-visit guides comprises a counseling process for obesity prevention, including resources that augment and amplify the basic recommendations of the Expert Committee. The materials are printed in English and acculturated Spanish. Parent handouts accompany each well-child visit and extend the physician's counseling on age-specific nutrition and activity behaviors. Figure 1 depicts the "Ounce of Prevention" handout for the 18-month well-child visit.
The BMI Charts
The BMI percentile is the most powerful tool for determining obesity. As a proxy for fat mass, it indicates whether the child is normal weight (or underweight) vs overweight (BMI 85th to 94th percentile) or obese (BMI greater than the 95th percentile).22 The Centers for Disease Control and Prevention (CDC) has provided many resources for clinicians about the BMI (available at www.CDC.gov). In 2006, the AAP, the CDC, and the National Institutes of Health convened to discuss the use of 2006 World Health Organization (WHO) growth charts in combination with the 2000 CDC growth charts. There were differences in the population of children studied and the methods used to create the CDC and WHO growths charts, and therefore, each growth chart describes growth in childhood from a different perspective.23 The CDC growth charts depict a snapshot of how a representative group of children were growing in a specific place and time. It is best used as a growth reference. For children younger than 24 months old, data were obtained from national vital statistics (for birth weights) and from Missouri and Wisconsin vital statistics (for birth lengths), the Pediatric Nutrition Surveillance Systems, and NHANES I, II, and III data, collectively. At least 50% of the infants included in the CDC charts were breastfed and 33% were breastfed until 3 months of age. Additionally, the CDC charts included infants and toddlers whose measurements reflected overweight.
The WHO charts, on the other hand, illustrate how healthy children thrived under the most favorable conditions, and therefore represent an optimal growth standard. The children included in the WHO growth charts were breastfed exclusively during the first 4 four months of life and continued breastfeeding until at least 12 months of age, meeting both the U.S. dietary reference intakes and the AAP's endorsement on breastfeeding. Additional selection criteria included low socioeconomic status, low altitude at birth, as well as inclusion of at least 20% of mothers who followed international feeding recommendations. Weight and length were measured weekly during the first 2 months of life, monthly until 12 months of age, and then bimonthly until the child was 24 months of age. For children 24-59 months of age, population demographics were similar. However, for children 24-59 months old, the WHO growth charts did not incorporate children whose weight was three standard deviations above the mean weight. Therefore, as a result, overweight children were not incorporated on the charts, even though these children were included as part of the study population.
Based on the different methodologies utilized, it has been recommended that the WHO growth charts be used for children less than 24 months old and the CDC growth charts for those above 24 months. If the WHO growth charts are utilized, physicians should use the 2nd and 98th percentiles to identify potential growth problems of under- or over-weight. The CDC charts not only provide physicians a well-researched screening method for children 2-19 years old, but also they incorporated overweight children in the study population. Physicians using the CDC charts were recommended to continue to use 5th, 85th, and 95th percentiles as indicators of unhealthy weight. But remember that the BMI is only a screening tool, not a diagnosis. Muscle mass or edema can contribute to BMI. So it is crucial that an abnormal BMI be followed by an examination to determine whether the child is at risk due to adiposity.
The Child at Risk
Once the clinician confirms that the child is either rapidly cutting across BMI percentile ranks or is already overweight or obese, the focus shifts to an assessment of the degree of health risk. There are four steps to assess health risk:
The family history includes an assessment of current behavioral risks that affect energy balance, such as sedentary time and physical activity behaviors, meal and snacking habits, daily schedule, and sleep time. In this aspect of the history, the clinician is seeking to identify modifiable behavioral risks that are contributing to the child's energy imbalance. Behavioral risks fall into two categories: traditional and non-traditional risk factors. Traditional risks are those dietary behaviors and physical activity behaviors directly related to calories in and calories out. Non-traditional risk factors include factors that comprise the structure of a child's daily life, including regular breakfast time, day care or school time, sleep and wake times, family meals, play time, and study time. The compilation of traditional and non-traditional risks will identify for the clinician where to begin when counseling the patient and family on weight management.
The identification of a child at risk mandates screening labs, according to the Expert Committee Recommendations. Depending on the age of the child and the extent of overweight, the blood tests will include some or all of the following: a lipid panel (for all overweight or obese children), fasting glucose, ALT, and AST (for all obese children or those who are overweight and above age 10 years). Labs screen for high triglycerides, LDL or VLDL cholesterol, a low HDL cholesterol, glucose intolerance or early type 2 diabetes, and evidence of non-alcoholic fatty liver disease. Chart evaluations of obese children in pediatric practices showed that orders for a lipid panel, fasting glucose, ALT, and AST were found in charts in only 57.8%, 29.0%, and 10.8% of cases, respectively. Only 15% of pediatricians consistently followed all the recommendations set by the Expert Committee in 2007.16 Only 25% of pediatricians collected a complete family history; the remaining assessed some aspect of the health history 85% asked about overweight family members, 90% assessed the child's family history for cardiovascular disease and hypertension, and 64% asked about diabetes mellitus and dyslipidemia.16 Identification of signs such as acanthosis nigricans, symptoms such as amenorrhea, or abnormal laboratory findings such as high cholesterol values, are critical tools that allow the clinician to frame the problem in terms of the child's health. These signs and symptoms form the rationale for repeated counseling visits.
A diagnosis of obesity will elicit a range of reactions from parents and caregivers. Many will be defensive. The most important determinant of successful weight management in a young child is the family's readiness to change. In one study evaluating parental attitudes, concern about excess weight (78%) was similar to that of their child experiencing multiple sunburns (76%) and only slightly higher than concern about watching too much television (67%).24 Parental lack of concern may relate to misperceptions about future problems associated with excess weight. Sixty-seven percent of parents believed that their overweight child was more likely than healthy weight children to be overweight as an adult; 74% believed that the child would have more difficulty with social relationships; and 76% believed that the child could develop diabetes.25
The starting point for health behavior change varies widely between patients. According to the Transtheoretical Process, there are five stages that categorize one's readiness to attempt behavior change: pre-contemplation, contemplation, preparation, action, and maintenance.26 The physician's role is to continue to express concern at each visit and encourage small, simple changes to get the family started. When the family has maintained a change in the child's health behavior for 6 or more months, the family is in the maintenance stage of change.27 Successful change builds upon itself. Particularly in obesity, relapses commonly occur. Rhee et al asked parents if they were thinking about making health behavior changes that would result in their child losing weight. Parents of obese children, compared with parents of overweight children, had an odds ratio of 4.5 for being in the preparation or action stage. This underscores the need for the physician to make families aware of their child's weight status. When parents believed that their child's weight posed a health risk, they had 16 times the odds of being in the preparation or action stage. There was increased odds for parents being in the preparation or action stage when they were overweight themselves, further supporting the need to raise the issue with families routinely.
Individually Based Risk
Despite a common assumption that obese patients share a common path to obesity, neither the causes of overweight, its development, nor the response to therapy are shared. Besides the child's familial genetic potential for obesity, race, ethnicity, and poverty are foremost contributors to risk.28-35 A study by Taveras et al illustrated ethnic differences. Hispanic and black children 2 years of age and older were more likely to have televisions in their bedrooms, to be consuming more fast food meals, and to be drinking more sugar-sweetened beverages than their white peers.28 Using the 2001 to 2003 Fragile Families and Child Wellbeing Study, Whitaker et al evaluated how race/ethnicity and several other socioeconomic indicators influenced the rates of obesity in preschool-aged children. Families were interviewed at the birth hospital (n = 4898), approximately 1 year after birth, and at 3 years of age (n = 2452).34 Despite their young age, the results were striking. Eighteen percent of children already were obese and 35.6% of children were at or above the 85th percentile for BMI. However, Hispanic children had an even higher prevalence of obesity of 25%, significantly higher than other groups. Interactions were not found between maternal education, income, or food security on the prevalence of obesity. Even with socioeconomic factors considered, Hispanic children had an 84%–104% higher risk than white children.
Obesity is fueled by genetics as well as by an individual's day-to-day life habits. A study of 4-year-old preschoolers by Anderson and Whitaker revealed that only 56.6%, 57.5%, and 40.4% ate meals with their families 6 or 7 days a week, slept an average 10.5 hours or more each night, or watched fewer than 2 hours of TV a day, respectively. Children were 23%–25% less likely to be obese if they displayed even one of those three behaviors. Cumulatively, a child further reduced the odds of being obese by 17% for each additional behavior manifested.29 This study brings attention to the benefits of encouraging structure in a child's life. Although not included in the ECRs as targeted behaviors, set sleep and wake times along with sleep duration have been independently associated with obesity in children. For instance, 7-year-old children were more likely to be obese if they fell into the lowest two quartiles for sleep duration when compared with children in the highest quartile for sleep duration, indicating that adequate sleep may reduce the risk of obesity.30
Clinicians report that treating obesity appears overwhelming, even though 78.1% and 89.1% of pediatricians thought that obesity warranted intervention.36 Pediatricians perceived lack of patient motivation (85.7%), lack of parent involvement (81.2%), lack of support services (60.0%) lack of clinician time (58.0%), and lack of treatment skills (45.0%) as barriers to treatment.36 In another study, physicians cited environmental, practice-based, and individual patient and family factors as barriers to effective treatment. Fast food and soft drink availability were noted by 97% and 95% of physicians, respectively, as ubiquitous environmental factors, while the most common practice-based barriers were lack of reimbursement for non-MD staff (51%), lack of on-site dietitian (51%), and lack of patient education materials (44%).37 Sixty-five percent of physicians felt that the caregiver's failure to perceive weight as a problem was the most common barrier to treatment. Pediatricians thought that treatment of childhood obesity was more complex than treatment of adults because it involved changes within the entire family.38 But pediatricians also expressed interest in learning behavioral management strategies, tips for resolving family conflicts, and guidance in parenting techniques. They would prefer to learn this information and acquire additional skill sets by referencing professional guidelines and taking continuing medical education courses.38 Of all the practice barriers cited by physicians, 96% of physicians expressed a need for better counseling tools to help them shape behavior changes in their patients.37
The clinician should set reasonable goals for counseling. The initial objective of counseling is not to induce weight loss, but to improve everyday habits, such as dietary choices and sedentary time. Increased physical activity and fitness are later goals to be achieved incrementally. In addition, evidence of a more structured daily schedule, improved family commitment and confidence, as well as a supportive network surrounding the child, are all fundamental foundations for weight management. So weight is not the sole, or even the most important, measure of success for the primary care counseling. Parents, especially mothers, are the most powerful agents of change for a young child.39,40 Thus, management of the child's weight should be viewed as a stepwise, incremental process, enacted through a series of office visits in a concentrated period of time by engaging the family in the process.41 The intervention goals should be individualized, designed in conjunction with the family, and initiated following the initial screening office visit.42 The simple guidelines outlined in Table 3 provide the foundation and basic framework for more intense counseling processes and resources that gradually should incorporate all nine of the Expert Committee Recommendations plus non-traditional risk factors. (See Table 4.)
Sequential Counseling Visits
In a self-reported survey on office visits with preschool-aged children, only 50% of pediatricians made recommendations for weight control, compared with school-aged children where 82% of pediatricians made such recommendations.43 However, pediatrician recommendations often were not specific, such as changing "eating patterns" or "limiting specific foods," and in physical activity "increase free play" or "decrease sedentary behaviors." Pediatrician concordance with the ECRs was approximately 40% for dietary behaviors and 80% for physical activity.43 A tool to bolster self-efficacy may include obesity counseling training sessions as a continuing medical education activity. These often include information on the topics of detecting unhealthy weight trajectories, communicating sensitive weight issues to parents, providing evidenced-based messages on diet and physical activity, and following up on counseling messages.44 Perrin et al provided physicians with ways to initiate discussions on weight management, using "Promoting Healthy Weight" counseling tools, BMI color-coded charts, and tools to assess parental readiness to change. Physicians who participated in this intervention experienced an increase in their ability to interpret BMI and identify risky eating and physical activity behaviors, and their skill to counsel on risky eating and physical activity behaviors.44
Parents of overweight children offered insight for clinicians on how they should approach and facilitate discussions on pediatric overweight.45 Parents felt that such discussions should begin with pediatricians classifying the child's weight status, referring to national standards and discussing the associated health risk of excess weight. Two of the Expert Committee Recommendations, those urging parents to limit sugar-sweetened beverages and limit screen time to 2 hours, were considered especially challenging. Sugar-sweetened beverages should be clearly defined to include fruit drinks (sweetened water with little real juice), energy drinks, sweet teas, soft drinks, sugary powders, and other sources of added sugar. Instead, clinicians should promote water for thirst along with important nutrient-dense alternatives, such as 100% fruit or vegetable juice, low-fat or non-fat milk, and flavored milk. Recommendations should include age-appropriate serving size and frequency of consumption. For instance, preschool-aged children should consume no more than one 4-6 ounce glass of 100% fruit juice per day and teens should only consume 8-12 ounces per day.46 See Table 5 for additional information on healthy serving sizes for children.
Parents expressed difficulty in limiting screen time during inclement weather or limiting screen time when they felt it was educational. Although challenging, pediatricians can recommend planned screen time and planned non-screen time to encourage structure.47,48
Clinician counseling has been shown to be effective. To start, a simple mnemonic device, the 5-2-1-0 recommendation has been championed within the AAP for anticipatory guidance (see AAP.org or BrightFutures.AAP.org). The behaviors targeted are restricted to: 1) eating five or more servings of fruits and vegetables each day, 2) limiting screen time to less than 2 hours per day, 3) being physically active for at least 1 hour each day, and 4) consuming little or no sugar-sweetened beverages.49 In the Delaware Initiative, health care professionals were offered training to support a range of staff within the primary care setting, including receptionists, nurses, nurse practitioners, and physicians. A similar primary care intervention, Keep ME HealthyThe Maine Youth Overweight Collaborative, pioneered the use of the 5-2-1-0 materials and physicians engaged in a quality collaborative. To improve the quality of obesity care, teams collected baseline data from 70 well-child visits charts to evaluate documentation of height, weight, BMI, BMI percentile, diagnosis of overweight or obesity, and blood pressure. Families seen during the collaborative were asked if they had heard the 5-2-1-0 messages at previous office visits and were asked to rate the counseling they received during current visits. Providers were surveyed before and during the collaborative to obtain their knowledge, self-efficacy, and practices around the 5-2-1-0 messages. There was a 64% increase in obtaining BMI percentile, a 56% increase in weight classification, and an 82% increase in the use of the 5-2-1-0 behavioral screening tool. Parents also indicated that physicians began to discuss the 5-2-1-0 messages and provided increased nutrition, physical activity, screen time, and sweetened beverage counseling. Providers reported increased self-efficacy to counsel patients on obesity. With time, clinicians can expand their counseling to encompass the range of Expert Committee Recommendations plus inclusion of non-traditional behavioral risks, as well as an acknowledgement of cultural, literacy, and language differences between families.50
Making the Messages Work
In The End of Overeating, David Kessler identifies the primary problem to be treated as "conditioned hypereating."51 This term clearly frames the aims of counseling. Dietary habits are the result of repeated exposure to powerful food stimuli, particularly to high-sugar, high-fat, and high-salt items. Counseling, then, requires the gradual disconnection of the triggers, represented by food stimuli, from the patient's habitual responses, along with the substitution of new, more healthful habits. Each success decreases the power of the stimulus to evoke a conditioned eating response. To accomplish this, a number of behavioral techniques that are utilized by weight management centers may be useful for the primary care clinician during counseling:
The primary clinician who cares for children and adolescents has a unique opportunity to shape everyday eating and activity patterns. The well-child visits are particularly powerful in the first years when lifelong habits are established. The fundamental behaviors that prevent and treat obesity are the same, but they need to be approached differently in practice. Using the BMI percentile allows the family to see how they are doing. When the child is becoming overweight or is already obese, the clinician's goals change. The BMI percentile is used to raise awareness of growth trajectory and the health implications for the child, given the family's health history. Screening lab tests, a targeted history, and physicals can help reinforce the clinician's concerns. The treatment involves gradual replacement of old habits with newer, healthful behaviors. Counseling tools and behavioral motivation techniques are available to aid the primary care clinician in mastering this crucial skill in practice.
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