How do I approach treatment for an adolescent with a body mass index (BMI) greater than 95% for age and gender?
What specific lifestyle changes are likely to be most effective?
How would I address lifestyle change in terms of family and patient strengths and barriers?
How do the principles of the Chronic Care Model (CCM) apply to treatment of obesity?
How do I know when to “step-up or step-down” treatment?
This chapter will address the following American College of Graduate Medical Education competencies: patient care, interpersonal and communication skills, and systems-based practice.
Patient Care: In order to effectively care for a child with obesity the pediatric health care provider must be proficient in using the CCM (www.improvingchroniccare.org) applied to weight management. This chapter will review the salient points of this model.
Interpersonal and Communication Skills: This chapter will help the pediatric health care provider incorporate motivational interviewing into their practice as a core competency essential for caring for a child with obesity and their family.
Systems-Based Practice: This chapter will help the health care provider use systems-based practice to coordinate the care of children with obesity among the many practitioners and programs outside the physician office which are needed for successful treatment.
Obesity is a chronic disease, similar to asthma and diabetes, which responds best to regular, ongoing care over a prolonged period of time in an office prepared to offer effective treatment. Once a child is diagnosed with overweight or obesity, shifting the care model from acute disease treatment to chronic disease management offers potential for improving health outcomes. Some children will experience improvement in their obesity and potentially go into remission. Others may experience worsening over time and develop complications, such as hypertension, diabetes, dyslipidemia, sleep apnea, or depression. These children will need more intensive services over time to support them and their families in learning how to manage their obesity and its complications
Care of the child with overweight or obesity in the primary care setting can seem daunting, leading to frustration for both the pediatric health care provider and the family. While it is true that most evidence for interventions in the primary care setting show only small improvements in BMI1, 2, 3, 4, 5 except in very intensive interventions,6, 7, 8 improvements in healthy behaviors are possible over time. Further, an office setting and staff, using a systematic approach that begins with the promotion of healthy weight for all children and then offers targeted care for those who develop obesity, may have the best opportunity to produce significant improvements in the population of families they serve. The CCM9 offers an integrated structure to improve patient care and medical outcomes.
Obesity is a chronic disease that is complex and requires the patient and family to learn a set of skills to manage the disease independently.10 The CCM advocates a change in the interaction of health care and patient to more appropriately address chronic conditions. Chronic conditions require patients to be active in self-care and self-monitoring, to change behavior, to manage multiple problems, and to identify and use resources outside the health care office. To support patients with chronic conditions, the CCM proposes that health care offices develop new systems: creation of a delivery design in which providers and staff reallocate patient care responsibilities, decision support using technology to prompt appropriate prevention and intervention in complex conditions, development of tools to help patients better manage their conditions, and linkage of patients to community resources and programs.9 The CCM applied to obesity in children offers a framework to set up an office, staff, and the processes to create a space for families to make changes together to improve the health of each family member. For more detail on the CCM, see Chapter 21.
Just as parents’ modeling of healthy behaviors is essential to successful and sustainable behavior change in children, the pediatric health care provider’s office and staff have the potential to be sources of encouragement and modeling around the healthy changes they are promoting. Using the CCM as a guide, delivery system design needs a systematic, team-based approach with clear division of responsibility and planned management of obesity. Each step in the office visit can be an opportunity to promote healthy weight, and each member of the health care team can support the family and maximize the effectiveness of the patient visit.
The waiting room can promote play and relaxation, and also be a site for education on health topics to be covered in the visit. Furniture to accommodate patients and family members of different sizes, posters inviting discussion of weight and healthy lifestyle, and staff visibly engaged in healthy habits are all helpful to prepare families for a discussion with the physician. During intake and vital signs procedures, some offices give a checklist of health behaviors11 to identify topics families are interested in discussing. Once in the examination room, the health care provider can interpret the BMI and use this information to offer guidance for healthy changes based on topics of interest to the family. At checkout, staff can ensure the patients schedule the recommended follow-up and provide information to schedule necessary referrals. Each team member has a specific role in addressing the needs of a family.
Policies within the office setting can create a healthy environment for patients. Experience from smoking bans can inform the process of healthy policies around food and drink consumed in the office in view of patients. Just because it is now culturally acceptable to limit smoking to dedicated smoking areas or eliminate it entirely, consumption of soda and unhealthy foods can also be confined to certain locations, out of sight of patients working hard to eliminate these food items from their family diets. Many children’s hospitals have set the precedent of removing sugar-sweetened beverages from their campuses in an effort to improve the environment in the hospital.12 What we do ourselves speaks louder than words.
Examples of staff engaging in and encouraging healthy behaviors speak to the commitment and expertise of the office in healthy behaviors, and assist in the development of readiness for patients. Some health care providers have used social media postings to demonstrate personal involvement with physical activity, healthy recipes, and community programs promoting health. Different from other areas of health care delivery, promotion of healthy weight asks the health care team to look into their personal beliefs and behaviors around eating and exercise.
The foundation of the 2007 Expert Committee recommendations10 for the prevention and treatment of overweight and obesity centers around promotion of healthy behaviors and thereby healthy weight in all pediatric patients regardless of current weight status and risk factors. For all patients, the recommendations lay out a staged approach, beginning with medical assessment and brief counseling in the primary care office and progressing as needed to more intensive approaches that may engage community programs or health care specialists, especially for those children identified to have overweight or obesity.
The most common barriers cited in primary care offices for not addressing obesity are practice based, including concerns for lack of reimbursement and not feeling adequately equipped with the tools and personnel needed to work with families.13 Using the Expert Committee recommendations, a clear stepwise plan for addressing healthy weight by each member of the health care team in each visit regardless of weight status can improve prevention, diagnosis, and earlier treatment of children with overweight and obesity.
The Expert Committee recommendations suggest that all children are at risk for obesity, and that prevention should be universal. Attention to high-risk nutrition and activity behaviors, as well as sleep habits, effective parenting, and routines can be applied to all families and children. Many practitioners use the mnemonic of 5-2-1-0 (5 fruits and vegetables, no more than 2 hours of screen time, 1 hour of physical activity, and 0 sugar-sweetened beverages) as a quick review for families and children, and a doorway into discussion of healthy eating and active living. The www.letsgo.org Web site has an excellent list of resources to guide office interventions around 5-2-1-0 and other basic healthy lifestyle topics. Assessment of BMI in addition to other parameters at each visit allows prevention efforts at all visits and early identification of overweight and obesity.
Brief counseling in the primary care office to guide families toward healthy behaviors is a feasible approach and has been well accepted by parents and health care providers.1 The first stage (see Table 12-1) of treating patients with overweight or obesity (BMI > 85% for age and gender) is to focus on healthy lifestyle activities and eating habits and physical activity that are also obesity prevention strategies. The role of the health care provider and office staff in Stage 1 is to provide basic education for families regarding healthy habits that promote weight maintenance and return toward a healthy BMI over time. Entry into this stage occurs when a health care provider identifies the child as having overweight and discusses this diagnosis with the family. In an ideal situation, this conversation would build on previous conversations about healthy lifestyles and use motivational interviewing techniques to help the family self-identify areas for increased attention, with a focus now on attaining a healthy weight.
| Prevention Plus | |
|---|---|
| What | How |
Family-based change 5-9 fruits and vegetables No sugar-sweetened beverages Structured eating behavior ≤ 2 h screen time ≥ 1 h physical activity Adequate sleep Additional behaviors that may emerge from literature | Primary care office based Trained office support Roles for all staff (MD, NP/PA, RN, MA) Support materials Ability to link patients to community resources Scheduled monthly follow-up visits Advance to next stage in 3 to 6 months, if needed |
The strength-based approach begins by identifying assets in the family and then uses shared decision-making to address concerns about food choices and other healthy behaviors.14 An office that actively recognizes what families are doing right will find the families more open to new, healthier behaviors. Mastery, belonging, generosity, and independent decision-making are assets to emphasize as health care providers support development of parenting skills, which are the means for parents to foster development of healthy behaviors in the family.14, 15, 16 A menu of behavior changes that are likely to lead to healthier weight provides families with choices and allows an approach tailored to the needs, capacities, and priorities of the individual family. The American Academy of Pediatrics (AAP) Healthy Active Living for Families: Right from the Start program (HALF) resources are tools to assist pediatric health care providers in preventing obesity in young children.14
After the assessment interview, a clinician will have information about readiness to change and areas in need of improvement. Allowing the patient and their family to identify target goals is an important step for successful weight management. However, some families may not recognize a problem or may not feel ready to implement a change in behavior. The goal of health care providers in these situations is to assist the family moving toward understanding the problem of obesity and potential complications, based on a family’s readiness to change (see Chapter 15 for more information).
When a family is in the precontemplation stage, not recognizing the child’s weight as a problem, they will not likely be ready to implement a change in behavior. When a family is in this stage or in the contemplation stage (recognizing the problem but not planning any change), cognitive strategies can increase knowledge and change attitudes. When in action or maintenance stages, families will benefit from behavioral strategies to support healthy changes.17
Most families will be in different stages for different behaviors; some health behaviors will be in maintenance while others are in precontemplation. For those areas where families are ready to make changes, the provider can help them select initial goals and note other areas needing attention to address at subsequent visits. Key target areas in need of assessment and likely improvement include food and drink, sedentary time, physical activity, and sleep. In addition, further investigation of typical daily routines, eating schedule, sleeping patterns, and parenting skills can be helpful. For many families, unhealthy lifestyle results from disorganized household routines; parenting techniques can be tools to correct irregular eating and sleep habits and lack of time for physical activity that may lead to energy imbalance.
A healthy home food environment will make it easier to achieve healthy eating. Pediatric health care providers can counsel families that children eat whatever foods are brought into the home; therefore, families should buy only foods they desire to have the family eating.
Healthy tips include:
Think of a snack as a mini meal which always includes a fruit or vegetable, only adding a healthy protein when still hungry.
Remove unhealthy snack foods from the home to decrease battles over food.
“We do not have any,” versus “No, you cannot eat that.”
Plan so that a desired snack can be eaten in the right portion and with decreased frequency.
Place vegetables on the table to munch before dinner to increase vegetable intake and decrease portions at dinner. Patients can be referred to www.choosemyplate.gov for education regarding what constitutes a serving of fruits or vegetables.18
The consumption of sugar-sweetened beverages is strongly correlated with increased risk for development of overweight and obesity in both children and adults.19 Sweetened beverages including fruit juice, sodas, and sports drinks are low in nutrients and high in calories. Sodas, sports drinks, and fruit drinks in combination can provide an estimated 10.7 tablespoons of added sugar to a child’s diet.20 Even 100% juice has sugar content similar to soda. Sugar-sweetened beverages increase the daily calorie intake in a way that is not always recognized by patients compared to the satiety they receive when eating a calorically equivalent amount of food.21 In other words, sugar-sweetened beverages may not make individuals feel full. Removing or reducing sugar-sweetened beverages from the diet can have a great impact on lowering total daily calorie intake without significant alterations in behavior but may require a stepwise weaning process to increase likelihood of success. Developing a specific plan with the patient and family is important to guide this process.
Artificial sweeteners may be an option to use in moderation to aid in weaning from sweetened beverages and to reduce calories in beverages or products that are typically sweetened. The Food and Drug Administration (FDA) has currently approved 5 artificial sweeteners for human consumption.21a The American Diabetes Association has recommended artificial sweeteners as an alternative to sugar to manage overweight and obesity (see http://www.diabetes.org/food-and-fitness/food/what-can-i-eat/understanding-carbohydrates/artificial-sweeteners/). Due to limited studies in children, the AAP has no official recommendations regarding the use of noncaloric sweeteners.21b
Healthy tips include:
Artificially sweetened beverages are not an appropriate substitute for water or milk.
If families are drinking artificially sweetened beverages help them think of them as transitional drinks, and develop a plan with families and children to move from these beverages to water.
Among children, skipping breakfast is associated with higher levels of obesity22,23 and adult breakfast consumers are less likely to have obesity.24 In adult weight loss maintainers in the National Weight Control Registry, 78% report eating breakfast 7 days per week and less than 5% report skipping breakfast daily.25 Breakfast consumption in children may improve energy balance and children who consume daily breakfast are more likely to make good food choices throughout the day.23 Breakfast skipping is associated with increased snacking, frequently of more high-fat snacks.26,27
The frequency of family meals is associated with improved nutritional health in children and adolescents. At least 3 family meals per week have been shown to reduce the odds of overweight, eating unhealthy foods, and disordered eating behaviors.28 Preparing meals at home allows more control over ingredients, preparation methods, and portions. Children should be allowed to contribute to meal planning and preparation. For families that do not have background knowledge in healthy meal preparation, community-based cooking demonstrations or web classes can be a valuable resource. In some communities, these may be offered through the local branch of the state university extension office or the local food bank.
Parents are responsible for presenting a balanced group of foods at the meal or snack; the child decides what and how much of each food to eat.29 In Stage 1, the portions of carbohydrates, animal-based proteins, and fats consumed by the child need to be limited to what is appropriate for the age of the child due to their increased calorie density. To accomplish this goal while still allowing the child to self-regulate, the caregivers can offer 1 protein serving and 1 starch serving at a meal, cooked in amounts just enough for each family member to have 1 serving without leftovers. Fruits and nonstarchy vegetables without added sauces or fat can be offered in unlimited portions. The Hand Model is a practical method to estimate portion sizes.30 Another method is for the caregiver to plate the food using the healthy plate model and then allow seconds of fruits and vegetables.31 When using this method, any additional carbohydrate or meat can be put away, even in the freezer, for a different meal.
Healthy tips include:
Meals
Limit the preparation of protein and starches to 1 serving per person per meal.
Use a 6-in plate for children age 8 and younger and a 9-in plate for age 9 through adult.
Allow unlimited access to fresh fruits and nonstarchy vegetables; avoid corn or potatoes.
Snacks
Fruit or vegetable.
Protein when still hungry.
Water.
Avoid carbohydrates, typical snack foods, and sweetened beverages.
Teaching families to better identify which foods should be most prevalent in the diet and those that should be limited is an important step. A common technique is the We Can! Go, Slow, Whoa program.32 This tool helps parents and children begin to look at foods not in a dichotomous manner—bad or good, or unhealthy or healthy—but as a continuum that is adaptable to any eating situation. Families can work together to balance their eating toward green Go foods and small amounts of red Whoa foods with high fat or calorie content and low nutrient density. Once this method is understood, it becomes easier over time to substitute Whoa foods with Slow or Go options, to track eating, and to improve balance in the diet.
More time spent in front of a television is associated with increased weight gain.33 The major effect of screen time in promoting weight gain is through exposure to unhealthy eating practices via advertisements, an average of 4400 to 7000 per year, or programming on television and other screen activities.34 Web sites and apps are now designed by food producers to advertise their products to children.35,36 Screen time takes up the majority of waking time in children, an average of 7 hours per day; therefore, concern arises that screen time displaces both physical activity and sleep.34 Other ways for children to get screen time include through a computer or other electronic devices. Eating while focused on entertaining stimuli can lead to a decreased awareness of intake and a decreased hunger for a more nutritious meal. Watching television during meals is associated with less consumption of fruits and vegetables and more consumption of pizza, salty snacks, and sodas.37
The current recommendation for amount of screen time is age-based. Children younger than 2 years should have no screen time; children older than 2 years should limit screen time to no more than 1 to 2 hours daily.38 Reducing television time has proven to be difficult, likely because of the appeal of programs targeted toward younger audiences and the freedom it gives parents. At this time, no interventions have been specifically proven to be effective at reducing screen time in an outpatient setting.39 Some strategies that have been suggested include classroom-based interventions,34 family-based interventions,40 or using an electronic allowance box or monitored television.40,41 Classroom-based interventions teach children media literacy, offering tools to avoid the negative influence of unhealthy food advertising and negative body images.34 In addition, removing television from the bedroom significantly reduces the amount of screen time. Children who have a television in their bedroom average 11 hours per day of screen time compared with 7 hours per day for children without televisions in their rooms.34
Children and adolescents should get at least 60 minutes of physical activity each day.42 It is very important to identify age-appropriate activities that the child is able to enjoy. The types of physical activity best for the child are based on developmental and cognitive abilities. Preschool-aged children (ages 4-6 years) should be encouraged to have supervised free play in a safe environment. Examples of activities include playing with wagons and other wheeled toys, or playing tag, hide-and-seek, and other games. Elementary school children (ages 7-9 years) with improved motor skills and balance can be encouraged to participate in some organized sports, jumping rope, or longer walks with family members. Middle school–aged children (ages 10-12 years) are better able to play complex sports and have a better understanding of rules and team dynamics. They may also begin a well-supervised weight training program.42 Adolescents (age ≥ 13 years) are more influenced by their peers and may benefit from activities that they can participate in with friends, such as organized sports, dance, biking, or hiking.42 For more information, see Chapter 7.
A sedentary child is unlikely to go from 0 activity to 60 minutes per day. The health care provider should set smaller, stepwise goals for physical activity, increasing with time until an age-appropriate goal is reached. Also, encouraging activities that typically can be continued into adulthood can be helpful for those families not involved in current physical activity. Walking and going to the park are often the most easily adopted outdoor activities. An indoor option is also necessary to ensure regular daily exercise. Dancing, cleaning with music, playing chase, climbing stairs, exercise videos, and active video games can be good indoor options for the whole family.
The recommended 60 minutes a day does not have to be a continuous block of time, but it should not be divided to the extent that the child is unable to get their heart rate up during exercise. Very short bursts of activity in the range of 5 to 10 minutes contribute to the baseline level of activity a child receives on a daily basis, but the longer sessions of 15 minutes or more allow more intense cardiovascular activity that builds muscles and improves overall conditioning and fitness.42 Working with the child and family to identify activities they can enjoy is important to reach the goal activity and sustain this intensity over time. For more information, see Chapter 7.
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