Transcript Barwon Division G4K launch - Barwon Division of General

Management of child and adolescent
obesity
Barwon Division
9th November 2008
Speaker: Dr Colin Bell, Program Director, Good for Kids. Good for Life
Acknowledgement
Louise A Baur
Discipline of Paediatrics & Child Health, Univ. Sydney;
NSW Centre for Overweight & Obesity
The Children’s Hospital at Westmead
Email: [email protected]
Obesity
• One of today’s most blatantly visible – yet most
neglected – public health problems
• The public health equivalent of climate change
• The Millennium Disease
WHO; www.who.int/nut/obs.htm; Laing & Rayner, Obesity Reviews 2007; www.iotf.org
Obesity
One of the most common
chronic diseases in
childhood and adolescence
1:4 school-aged children are overweight or obese
Are these children presenting
to general practice?
Yes
But in even higher numbers
than for the general population
And NOT for the problem of
overweight or obesity
In Australia, of every 200 children presenting to their GP, 60 are
overweight or obese (23 obese) – and 1 is offered weight management
intervention
BEACH data set, Annual national random survey of 1000 GP surgeries
2002-2006, Children aged 2- 17 years, Self-reported heights & weights
Cretikos M et al, Medical Care, 2008, in press.
What GPs say are the barriers to management of paediatric obesity in
general practice
•
•
•
•
•
•
•
•
Lack of time
Lack of reimbursement
Lack of parent / patient motivation
Lack of effective interventions
Lack of support services
Complex, difficult problem
Inadequate training
Parent / child sensitivity
Results of focus groups held with NSW GPs.
King L et al. British Journal of General Practice. 2007; 57:124-129.
So, what can be done
in general practice?
Case 1: Katie – 6 years of age
• Chinese ethnic origin; only child of busy parents
(father has two jobs; mother works as a cleaner)
• Mother brings her to you with an intercurrent
illness (URTI) which is simply managed
• But you note incidentally that Katie looks quite
plump for her age
How do you confirm your impression
that Katie is overweight?
How do you confirm your impression
that Katie is overweight?
Measure height & weight
Calculate BMI
Plot on BMI for age chart
Clinical example of Katie
Girl aged 6 years
Weight 33 kg
Height 120 cm
BMI 22.9 kg/m2
Overweight or obese?
Normal weight?
Unsure?
Katie
Girl aged 6 years
Weight 33 kg
Height 120 cm
BMI 22.9 kg/m2
(>>97th centile for age;
obese range)
You’ve confirmed your clinical impression
that Katie’s BMI is in the obese range
Would you raise this issue
with Katie’s mother?
If so: why?
If not: why not?
Factors to consider
• Health risks for Katie
– Severity of obesity
– Associated co-morbidities
– Family history of obesity, diabetes and related
disorders
• Approach to raising the issue
–
–
–
–
Avoid stigmatising
Avoid blaming
Solution-focussed
Supportive
What would you ask about
in the family history?
Are there high-risk ethnic groups?
High risk family history & ethnicity
• Enquire re F/H of obesity and type 2 diabetes:
– Obesity, type 2 diabetes, premature heart disease,
obstructive sleep apnoea, hypertension,
dyslipidaemia
• Enquire re parental eating disorders & bariatric
surgery
• Ethnic groups at higher risk of diabetes etc
– Indian sub-continent, Mediterranean/MiddleEastern, Maori & Pacific Islander, Aboriginal &
Torres Strait Islander, probably east Asian
Katie’s family history
• Family history:
– Obesity – maternal grandmother
– Type 2 diabetes – maternal grandmother
• Chinese ethnic origin
Katie’s medical assessment
• Mild teasing by classmate at school
• No other co-morbidities suggested by history
or physical examination
How would you raise this issue
with Katie’s mother?
Little direct evidence to guide approach
but the following may be useful
• Regular assessment of growth and plotting of BMI
allows the issue of growth and weight to be raised
• Be non-judgmental and sensitive
• Example of an introduction:
– “I notice that Katie’s weight (or weight adjusted for
height) is high for her age. Is that something
you’ve been concerned about? ….. Would you
like to discuss it at some stage?”
Katie’s mother is interested in talking further about
this issue, as she knows that Katie has been
teased about her weight.
Obesity is not the original reason
for today’s consultation ….
and your waiting room is crowded!
What would your next steps be?
Next steps
• Acknowledge the importance of dealing with the issue
• Make another appointment – with Katie’s mother (+/other carers) - to start discussions re weight
management intervention
• Do not include Katie in the weight management
intervention – she’s only 6 years of age!
Weight status of children in the Parents-only vs. Parents + Child
treatments
Overweight Percentage
65
(Golan. Int J Pediatr Obes 2006)
Parents + child
Parents-only
a
55
b
45
35
45.0 43
45.5
Baseline
6 months
41.6
25
32
15
*
**
BMI +0.32
5
Change within each group * p=0.003 ** p=0.001
Change between groups
a p=0.02 b p<0.05
31.8
BMI -1.09
BMI -1.28
12 months
Be developmentally sensitive
• For younger, pre-adolescent children: Focus
on parents as the agents of change. Consider
excluding the child from the consultations
• For adolescents:
Include some adolescent-only sessions
Katie’s mother returns a week later when
Katie is at school, in order to discuss
strategies for weight management.
What approach would you use?
What strategies might you discuss?
The basics
• Family focus
• Developmentally appropriate approach
• Long-term behaviour change
• Both sides of the energy balance equation need to be
addressed
• Set small, achievable goals
• Regular follow-up and support
The Big Five
(CHW Program)
1.
Choose water as your main drink
2.
Eat breakfast each day
3.
Eat together once a day as a family without the TV
being on
4.
Spend at least 60 minutes outside every day
(playing or being physically active)
5.
Limit screen time to less than 2 hours per day (TV,
electronic games, DVDs, computer, Ipod, MP3 or videos etc)
The first law of thermodynamics
Energy is conserved
Energy in = energy out
Practical tips regarding food - 1
• The person who buys the food and who cooks it needs
to be engaged in the treatment approach
• Regular meals – especially breakfast
• Water as the main beverage
– limit soft drinks, fruit juice, cordial
• Eat together as a family
– Make a ritual of meal-times
– No TV or other distractions
Practical tips regarding food - 2
• Store healthy snacks – for morning & afternoon teas
• One approach for the whole family
• What foods are in the cupboards? These will
invariably be eaten!
• Check serve sizes – are these appropriate for a
child?
TV viewing and a screen-friendly lifestyle
• Look at TV, video game and
computer usage - for the whole
family
• How many TVs are there in the
house? Is there one in Katie’s
bedroom? Who turns the TV on or
off?
• Explore alternatives
• Parental overview vital
Practical tips regarding activity - 1
• Family approach to television, video-games,
computer use
– Plan TV viewing with the TV Guide
– Limit to <2 hours per day
– No TV on during meals
• Transport to/from school
– Walking instead?
– Dropping off at a distance from the school gate?
• Use of the family car. Is it needed for short trips?
Practical tips regarding activity - 2
• For most, organised activity is less important than
increased opportunities for incidental activity
• “Mucking around” outside is vital:
– balls, skipping ropes, swings, trampolines …
– backyards?, parks?, other playgrounds?
• Whole-family opportunities for physical activity?
• Role-modelling of parents
Different “exercise” programs
(Epstein, 1996)
% Change in Overweight
15
10
Calisthenics
5
Gym-aerobics
0
Lifestyle
-5
-10
-15
-20
-25
0
5
Time (y)
10
% change in overweight
Targeting sedentary behaviour (Epstein, 1996)
0
-5
Exercise
-10
Combined
Sedentary
-15
-20
0
0
4
Time (months)
12
14
What happened with Katie?
• Mother identified the following as issues
she’d like to change:
– Soft drink intake (evening meal and afternoon tea
in particular)
– TV viewing (accompanies mother while she does
her cleaning jobs – mother turns on TV to act as
child-minder for Katie; TV on while eating at
home)
– School lunch “treats”
What happened with Katie?
• Strategies
– Only water offered at meal-times
– TV viewing – colouring in equipment, books and
games brought so that Katie is occupied while
mother works; some extra support for childminding from neighbour; TV turned off when the
family eats
– Katie booked in to After School Care three days a
week
– School lunch box – no more packets of crisps!
Katie’s anthropometry
6 months later
Weight unchanged
Height 123 cm (  3 cm)
What has happened to
BMI?
Katie’s anthropometry
6 months later
Weight unchanged
Height 123 cm (  3 cm)
BMI 21.8 kg/m2
In what circumstances would you
organise further investigations?
If so – what ones?
Further investigations – when?
• Age: adolescents > younger children
• Severe obesity (esp. central obesity)
• High risk family history:
– 1st and 2nd degree relatives with heart disease, type
2 diabetes (incl. GDM), dyslipidaemia, sleep apnoea
etc
• High risk ethnic group:
– Indian sub-continent, Mediterranean & MiddleEastern, Maori & Pacific Islander, Aboriginal & Torres
Strait Islander, probably east Asian
• Clinical suggestion of co-morbidities
Further investigations – what ones?
• Initial fasting blood tests (others dependent upon
results*):
• Glucose
• LFTs (ALT, AST)
• Lipids (TG, HDL cholesterol, LDL cholesterol)
• Insulin
• ?TSH???
• Consider referral for sleep assessment
• Other investigations that MAY be warranted: OGTT,
liver ultrasound
When would you refer on?
When to refer on?
• Will depend upon your expertise and the
resources available
• Paediatrician referral:
– Severe obesity
– Presence of co-morbidities
– Strong family history of co-morbidities
• Mental health unit referral:
– Significant psychosocial distress
When to refer on?
• To other health professionals eg
–
–
–
–
–
Dietitian
Nurse (Early Childhood nurse, community nurse)
Clinical psychologist
Physiotherapist
Exercise scientist etc
• Ideally for all patients, but hampered by cost &
availability
How often should the
patient/parent be seen in follow-up?
Frequency of follow-up?
• Frequent follow-up is important in the first few weeks
and months in order to aid behaviour change
• CHW practice:
– 3 fortnightly consultations,
– Then progressively less frequent thereafter
• Consider shared care with other health professionals
Good for Kids
• To mainstream healthy eating and
physical activity for children (up to 15
yrs) and their families in the Hunter New
England region
– ↓ sweetened drink consumption ↑ nonsweetened drinks
– ↓ energy dense foods ↑ fruit and vegetables
– ↑ physical activity (sport, play, leisure)
– ↓ time spent in small screen recreation (TV,
video games)
Three key messages – reinforced in
all settings
• Step 1: Get active, get out and play
– Kids need at least one hour a day of physical
activity
– Kids should not spend more than 2 hours a day
watching TV/computer games
• Step 2: Drink H20- think water first
– Kids should drink water instead of juice or soft
drinks
• Step 3: Eat more fruit and vegies
– Kids should also limit less healthy snack foods
Combined overweight & obesity in
the HNE region 2007
25%
20%
15%
10%
B&G
5%
0%
2-5
ye a rs
Yrs
Yrs 8 / 1 0 Ove ra ll
K/ 2 / 4 / 6
c hild re n
2 - 1 5 yrs
Nutrition and physical activity in the
HNE region 2007
90%
80%
70%
60%
50%
40%
Chn 2 - 1 5 yrs
30%
20%
10%
0%
Wa te r
S o ft
d rink
EDNP
SSR
PA
Television in bedroom
60
Prevalence (%)
50
40
30
20
10
0
Child
Care
K
2
4
6
School Year
8
10
A role for General Practice
1. Find opportunities to reinforce program
messages – build on brand and message
recognition
2. Participate in Medicare Healthy Kids Check
•
97% parents agreed ‘I would feel
comfortable with a GP measuring my child’s
height and weight, and discussing their
weight status with me (letting me know
whether he/she is underweight, healthy
weight, or above healthy weight)’
Building on the Healthy Kids
Check
• Assess
– 4 year old weight status
– Other ages opportunistically
• Advise
– Drink H20, think water first
– Get active, get out and play
– Eat more fruit and veges
• Manage/refer
– those who are above a healthy weight eg HIKUPs
Healthy Kids Check
• Height and weight are mandatory.
– Opportunity to assess BMI and introduce it as a
tool to monitor growth over time
• Brief prevention messages at a time when life
long behaviours are being defined
– Use resources to reinforce program messages,
relevant for all kids/families
• Messages for whole family not just the 4 year
old
• Option to manage/refer children ‘above
healthy weight’
• Financial incentive for General Practice
Resources to help with advice
• Get Set for Life (Commonwealth parent
resource)
• Good for Kids posters, general program
brochures
• G4K Healthy Families checklist
– Can use at 4 year old check and
opportunistically with other ages
– 15 child and family behaviours – encourage
small changes for whole family
Healthy Families Checklist
Healthy Kids Check overview
1.
2.
3.
4.
5.
6.
Weigh & measure child along with other
components of check
Calculate BMI and plot on BMI chart
Show parent chart –’raise the issue’
Offer ‘brief advice’ – use handouts (including
Healthy Families checklist if not done prior)
Provide parent with materials to reinforce
If child ‘above healthy weight’ encourage parent to
make another appointment to manage weight status
or consider referral
Thank you
Further Resources
• BMI for age charts:
www.cdc.gov/growthcharts/
• NHMRC Clinical Practice
Guidelines for the Management
of O&O:
http://www.obesityguidelines.go
v.au
• CHW Fact Sheets:
http://www.chw.edu.au/parents/f
actsheets/