Working with children who are overweight is a challenge for the pediatrician. Obesity is a chronic disease that requires frequent office visits, reinforcement, and encouragement for the patient and family. Because of the poor success rate and prognosis, frustration is common.

The first step in treating children with obesity is to recognize the problem and take the time to address the problem with the patient and family. It is recommended to screen for obesity at  6 years of age. If the physician is not prepared to care for these individuals, referral to other physicians and helpers is recommended.

The incidence of childhood obesity is approximately 17% (equal incidence in boys and girls) in the United States and about 30% of adults who are obese have a history of childhood obesity.  Childhood obesity becomes more of a predictor of adult obesity as the child gets older. 

Most cases of obesity are identified by the appearance of the child. The Body Mass Index (BMI) has been used in adolescents and adults to define obesity. It is calculated by the formula of weight in kg./length in meters squared. Simple growth charts are available for calculaiing BMI in children 2-20 years of age. Values over the 95% are considered to be indicative of with a strong liklihood that the child will have persistence of obesity into adulthood. These children should have a complete medical assessment to identify any underlying syndromes and secondary complications. 85%-95% range should be evaluated for complications of obesity.

Etiology of Obesity

1. Excessive intake of food will lead to increase in body stores of fat when intake of energy exceeds expenditure.
2. Medical Conditions associated with Obesity
1. Endocrinopathies
1. Hypothyroid- decrease linear growth
2. Cushing's syndrome- hirsutism, striae, truncal obesity
3. Hyperinsulinism
4. Hypothalamic conditions
2. Psychological
1. eating disorders
2. Depression
3. Syndromes
1. Prader Willi
2. Laurence Moon Biedl
3. Stein-Leventhal Syndrome
4. Turner's syndrome

1. Sleep apnea
2. Pichwickean Syndrome
3. Slipped Capital Femoral Epiphysis
4. Blounts disease
5. Cardiovascular problems
1. Hypertension
2. Dyslipedemias
6. Gall Bladder disease
7. Pseudotumor cerebri

1. Intervention should begin early. The risk of adult obesity increases with the child's age. Adolescent changes are quite difficult.
2. Overcome the child's feeling of embarrassment and involve them in conversations
3. Acknowledge that obesity is a chronic disease that requires treatment. Emphasize the medical complication and risks. 
4. Encouragement
5. Establish readiness and desire to institute change. If the family and child are not ready, stop.
6. Involve outside caregivers such as grandparents, babysitters, daycare facilities.
7. Obtain a complete diet history
1. Attention to eating outside the house
2. Discuss quality and quantity of food intake
3. Number of meals per day
   
8. Exercise history
1. Television watching/video games, computer time/day
   
2. Be aware of the difficulties of some children playing outside (safe environment)
   
3. Encourage sports, dancing, involvement in chores around the house, walking, using stairs
9. Emphasize that this is a long term plan and involves life style changes. Other family members may benefit from joining the "program"
10. Small changes at a time. Minor adjustments in food intake and exercise may have large benefit.  Eliminating empty calories such as pop and juices.
    
11. Monitor linear growth
12. Use outside help such as nutritionists, psychotherapists, exercise trainers, Weight Watcher type groups

1. In most instances, maintenance of weight will be adequate because as linear growth continues, the BMI will decrease
2. If there are medical complications, weight loss may be necessary.  Exercise ad dietary changes arre recommended first.  The approved medications for treatment of obesity in adolexcents include Orlistat and Sibutramine.  Most OTC weight loss preparations are not recommended.
   
3. Follow-up frequently, every 2 weeks, to monitor progress, encourage, reinforce success, and ensure linear growth.

With limited time and diagnostic resources available to the students, residents and attendings taking care of patients at the Washington Park Clinic, the goal of most interactions is to address the immediate need of the patient (usually a physical or pre-participation clearance form, lead testing, and/or immunizations) and to refer the patient to a true medical home for continuity of care.  Consequently, there are a limited number of conditions that can be appropriately tackled during a typical clinic visit, especially during the busier fall and early summer months.

Although it has received increasing attention in the national media, obesity statistics demand repeating:

In 1985, no state had an obesity prevalence greater than 15%; by 2009, no state had an obesity prevalence less than 15%, with only Colorado and the District of Columbia having rates less than 20%.

How obesity is defined

A patient may be considered obese using one of several approaches.  A functional approach is the weight at which a person experiences a negative impact on health and the ability to perform activities of daily living.  While such an approach is not easily quantifiable, it has the benefit of relating obesity to a measure the patient can relate to (unlike the more technical or epidemiological approaches below).

A more technical approach is to use either weight or body mass index (BMI).  One common threshold is thirty pounds over ideal body weight for age, height and sex.  As ideal body weight is a difficult statistic to define, BMI (weight in kilograms per the square of height in meters, a rough estimate of weight per surface area) has become widely adopted.  Commonly, a BMI of 30 or more is considered obese.

From a epidemiologic perspective, obesity has been defined as a body weight greater than the 95^th percentile for age, height, and sex.  This measure is rarely used clinically for adults, but is the standard for children in order to account for the shifting proportions of children’s bodies from head-dominant to thorax-dominant as they age.  Normal weight is between the 5^th and 85^th percentiles.

The effects of obesity

By the end of their third year, most medical students can list the health effects of obesity without hesitation.  This is because almost all of the prevalent health problems a medical student will see have been shown to at the very least be exacerbated by obesity.

Some of the common health consequences include:

·       Hypertension

·       Diabetes

·       Hypercholesterolemia

·       Apnea (which in turn leads to hypertension)

·       Stroke

·       Coronary artery disease

·       Breast and endometrial cancer

·       Reproductive dysfunction including dysmenorrhea, infertility, and precocious puberty

·       Cholelithiasis

·       Musculoskeletal dysfunction and chronic pain

These conditions have been estimated to place a greater than $100 billion burden upon the medical and insurance systems annually in the United States alone.

Why obesity?

Food access: This is exemplified by the phenomenon of “food deserts”, regions of urban centers devoid of healthy eating options.  The Washington Park neighborhood has five fast food restaurants and no grocery options apart from convenient stores (compare that with the over 20 restaurants, 2 grocery stores, and farmers’ market in Hyde Park).  Additionally, for the entire South Side, there are only three major grocery chains between the South Loop and 79^th street, an area that is home to hundreds of thousands of people.  61% of people surveyed in the Englewood Community Nutrition and Physical Activity Survey shop at “Food-4-Less”.

Activity access: Even for residents desiring to maintain a healthy and active lifestyle, there are many obstacles to doing so, especially for children.

·       Only 52% of Englewood parents feeling safe allowing their children to play outside

·       Several areas on the South Side have 2-3 times the violent crime of North Side neighborhoods

·       Only 37% of Englewood children meet CDC guidelines for activity

·       Children spend a median 5 hours of screen time daily

Education: One of the largest obstacles to fighting obesity is misinformation among the patients.

·       91% of Englewood respondents were at least “somewhat satisfied” with their food options

·       92% of parents of overweight children and 65% of parents of obese children identified their child’s weight as “about right”

Furthermore, the Englewood Survey noted that while 31% of teenagers are overweight or obese, of children aged 2-5 years old, 5% are overweight and 76% are already obese, suggesting a demographic crisis in less than a decade.

Approach to weight in the clinic

Weigh and plot all of your pediatric patients.  Plotting is critical for several reasons.

·       As noted above, pediatric obesity is defined according to percentile BMI adjusted for age and sex.  Only by using the appropriate CDC growth chart (or the SonneWheel from the Children’s Hospital Boston) can your patient’s BMI be meaningfully interpreted.  Remember, a BMI of 17 in an adult is considered dangerously underweight; for a 4 year-old, it is considered obese.

·       Plotting serial BMIs (and other growth parameters) will allow monitoring for changes in growth trajectory that may indicate underlying pathology or socioeconomic stressors that may not have been volunteered as part of the history.

Knowing the patient’s BMI percentile is also important for understanding their vital signs.  In the pediatric patient, the normal ranges of the vital signs, specifically blood pressure, are defined according to age and BMI.  This is important to always remember, as a pressure that is normal in an adult may be grossly inappropriate in a child or infant.

Questions to ask parents and patients

Unfortunately, no good screening tool exists to identify children at risk for becoming obese.  Instead, active surveillance using CDC growth charts remains the mainstay for identifying early obesity as childhood obesity is the strongest predictor of later obesity.

from the Mayo Clinic staff

Counseling

As mentioned above, there are several measures of obesity and it is certainly appropriate to use them to help your patient find a target weight to obtain or maintain.  However, pursuing a specific weight is a long-term goal.  In the more immediate term, it is important to set functional goals for your patients.  A good rule of thumb for patients is the ideal weight is the “weight at which your body responds to you.”

One general nutritional and lifestyle approach is the 5-4-3-2-1-Go! program:

These simple approaches will help the patient to make concrete changes that will help them to obtain and maintain a healthy weight.

Be sure to consult the referrals resources for different community resources that patients can use to achieve a healthy lifestyle (e.g., cooking classes, sources of healthy foods, simple activities, etc.).  Referral allows us to use the strength of Washington Park (its referral network) to help our patients confront a long-standing chronic issue within the confines of a limited visit.

CPS programs

CPS has several ongoing programs designed to fight obesity and promote healthy lifestyles.  The schools offer breakfasts and lunches meant to be nutritious with a goal of teaching students the basics of healthy eating.  Additionally, students may qualify for free or reduced (40¢ per meal) lunches; breakfast is free for all students.  There is an application process, and not all parents are aware of this program.  The school district has also established a snack vending approved product list to ensure an appropriate nutritional environment.

The Nutritional Support Services at CPS has lead to the elimination of all but skim milk in the school, eliminated fryers, and has increased student exposure to healthy eating by increasing enrollment in the various meal options available to CPS students.

References

Becker, Adam B., Joyce Brown, Gay Chisum, Anne Clancy, Sunday Davis, Doris Jones, Orrin Williams. “Englewood Community Nutrition & Physical Activity Survey.” Spring, 2010.

Center for Neighborhood Technology/CLOCC Seed Grant. “Measuring Community Walkability for Children.” 2004.

Cristoffel, Katherine K.. “Early Early Factors in Childhood Obesity.” 2009; CLOCC Quarterly Meeting.

Kipping, Ruth R., Russell Jago, Debbie A. Lawlor.  “Obesity in children. Part 1: Epidemiology, measurement, risk factors, and screening.”  British Medical Journal.  2008; 337:a1824.

Nader, Philip R., Marion O'Brien, Renate Houts, Robert Bradley, Jay Belsky, Robert Crosnoe, Sarah Friedman, Zuguo Mei, Elizabeth J. Susman.  “Identifying Risk for Obesity in Early Childhood.”  Pediatrics.  2006; 118(3):e594-e601.

Whitlock, Evelyn P., Selvi B. Williams, Rachel Gold, Paula R. Smith, Scott A. Shipman. “Screening and Interventions for Childhood Overweight: A Summary of Evidence for the US Preventive Services Task Force.”  Pediatrics. 2005; 116(1):e125-e144.

For More Information:

Centers for Disease Control

http://www.cdc.gov/obesity/childhood/index.html

Let’s Move Initiative

http://www.letsmove.org

Chicago Family Health Center

http://www.chicagofamilyhealth.org/

Health Leads Chicago

http://www.healthleadsusa.org/our-locations/localchicago/

Consortium to Lower Obesity in Chicago Children

http://www.clocc.net

South Side Health and Vitality Studies: Resource Mapping

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