Progressnotes - October/November 2012
- About MUSC Health
Proper growth and development have been the traditional concern of pediatricians. As pediatric obesity has more than tripled in the past 30 years, however, pediatricians have been more frequently confronted with a host of diseases more common in the adult population. An increasing number of obese children and adolescents are being diagnosed with hypertension, dyslipidemia and pre-diabetes, all part of the cluster of risk factors known as the metabolic syndrome, which increases the risk for coronary artery disease, stroke and type 2 diabetes. “We have to become more like internists and learn to treat high blood pressure, high lipids and diabetes,” noted Janice Key, M.D., Director of the Division of Adolescent Medicine at MUSC.
If the childhood obesity epidemic is radically changing what it means to be a pediatrician and blurring the lines between adult and pediatric medical care, then should physicians treat obese children just as they would obese adults?
The answer is a resounding no. Children are not little adults. Their bodies are not fully developed and are in a continual state of flux, making static weight and body mass index (BMI) guidelines developed for adults of little use. Although recognition is growing that the metabolic syndrome is present in the pediatric population, reaching consensus about how to define and treat it in the context of the developing child has remained elusive,1 partly because age and sex must be factored in when setting cutoffs for its various component risk factors. (For recently revised cutoffs, see the guidelines from the International Diabetes Federation2 and the American Heart Association3).
It should also be recognized that children do not have the same control over their environment and the same power of choice as adults, so meaningful efforts at prevention should focus on policy and environmental changes in addition to realigning individual and family behaviors.
Appropriately calculating and interpreting BMI is the first step in productively managing childhood overweight or obesity.
In children, obesity cannot be defined by an absolute BMI as in adults (BMI ≥30 mg/k2); instead, a child’s BMI is compared to the BMI of other children of the same age and sex and categorized by percentile (For more information, see http://www.cdc.gov/nccdphp/dnpa/growthcharts/training/modules/module1/text/ module1print.pdf ). Children whose BMI is at or above the 95th percentile are considered obese and those with a BMI between the 85th and 95th percentiles are considered overweight.
The Expert Committee Recommendations of the American Academy of Pediatrics (AAP) Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity4 encourage physicians to measure and plot BMI annually, obtain nutrition and activity histories and help identify and overcome barriers to healthy eating and adequate physical activity in all children older than two years. Anticipatory guidance that promotes healthy lifestyle behaviors should be provided during all well child visits. Parents should be encouraged to adopt and model positive lifestyle choices and healthy food- related behaviors, including portion control. The importance of reducing sedentary behaviors and increasing physical activity should also be addressed.
Recent guidelines endorsed by the AAP provide detailed algorithms on how to assess and treat children older than two years on the basis of their BMI status.5 For overweight and obese children, the guidelines recommend a staged approach. Physicians should begin by encouraging families to develop healthier food and mealtime habits (eg, eating a healthy breakfast, eating a meal together 5 times a week) and coach children to follow the 5-2-1-0 paradigm: 5 or more vegetables and fruits daily, less than 2 hours of screen time, at least one hour of physical activity and zero sugared beverages. If initial measures to modify lifestyle behaviors do not produce the desired results, treatment is stepped up, first to a more structured and supervised nutrition and activity regimen, then to referral to a multidisciplinary pediatric weight management team. For obese patients with significant comorbidities such as obstructive sleep apnea or type 2 diabetes, referral to a pediatric tertiary care facility should be considered.
Although the medical profession must continue to develop strategies for treating chronic diseases typical of an older population in the context of the developing child, its ultimate goal should be curtailing pediatric obesity through preventive measures.
As noted in a recent commentary in the Archives of Pediatric & Adolescent Medicine, pediatric obesity is a socially determined illness, meaning that “the childhood obesity epidemic is just one symptom of our way of living.”6 It reflects a culture that values quantity, speed, convenience and material success, sometimes at the expense of quality, leisure time and the rituals that bind relationships. Meals occur less often around kitchen tables and more frequently in front of televisions.
Fewer of those meals are prepared at home and there is greater reliance on processed, prepackaged foods. Children spend increasing amounts of time sitting in front of screens, playing video games, surfing the Internet and texting their friends— all sedentary activities. Although rampant in all populations, obesity hits hardest in low-income neighborhoods, where access to grocery stores and fresh vegetables can be even more limited. “With a problem like obesity that affects the majority of people, you can never make a change without also changing policy and the environment,” notes Dr. Key.
In South Carolina, there are almost 6 fast food outlets or convenience stores to each grocery story or produce market.7 In 2009, 68.0% of South Carolina residents reported no sidewalks in their neighborhood.7 As Dr. Key notes, “It’s one thing to say exercise more and it’s another thing to put in a sidewalk so that children can ride their bikes safely.”
MUSC Children’s Hospital’s Boeing Center for Promotion of Healthy Lifestyles in Children and Families, created in 2011 by merging a multidisciplinary obesity treatment program (Heart Health, directed by Melissa Henshaw, M.D.) and a successful childhood obesity prevention program (Lean Team, directed by Dr. Key), serves as a model for how to empower children and their families to develop healthy lifestyles and effective weight management practices and how to bring about needed environmental and policy change.
The Heart Health pediatric weight management and preventive cardiology program at MUSC Children’s Hospital (http://www. musckids.com/heart/health) provides child-centered, family- oriented treatment to overweight and obese patients aged 2 through 22 years, many of whom have multiple cardiovascular risk factors associated with the metabolic syndrome. Heart Health focuses on developing sustainable weight management behaviors and promotes healthy lifestyle choices associated with the reduction of cardiovascular risk.
Dr. Henshaw, founder and director of the Heart Health program, believes that meaningful lifestyle change is often not possible without parental involvement: “Many families struggle with a number of difficult factors that contribute to obesity, and a supportive multidisciplinary team approach is critical to their success.” The Heart Health program provides such an approach, offering individualized treatment plans that are developed within a common framework of one-on- one visits and group sessions. Sustainable lifestyle changes are encouraged through fitness training, nutrition education, and behavior modification. Teaching families to effectively improve nutrition- and activity-related lifestyle behaviors is possible, according to Dr. Henshaw, “through progressive goal setting coupled with positive reinforcement, particularly when parental role modeling and peer group support are combined with clinical expertise.”
MUSC’s Lean Team has worked with the Charleston County School District to create wellness committees and has encouraged physician participation on these committees through its Docs Adopt program. Of the 79 schools in the Charleston County School District, 53 (67%) now have active wellness committees and 75% have been adopted by a local physician. The Boeing Center provides $1000 incentive grants to schools with active wellness committees to fund future wellness projects. It has worked with schools to remove deep fryers, eliminate french fries, use whole wheat crust for pizza, substitute low-fat ranch dressing for the full- fat version, establish walking and yoga clubs and increase the amount of physical exercise children receive each day through “deskercises.”
With Boeing’s support, the Lean Team now plans to expand its efforts statewide, beginning with those areas where need is greatest or where a physician champion has been identified (see “How You As Physicians Can Help”). Physicians interested in adopting a school should sign up at the Lean Team’s website (www.musc.edu/leanteam), which also provides valuable resources to promote healthy change, including BMI calculators for children, a toolkit for recording and tracking students’ BMIs, videos demonstrating “deskercises” and lists of student-approved nutrition-rich recipes.
In the opinion of Dr. Key, “Doctors shouldn’t just be treating illness but should serve as the health resource for their community.” You can lead the charge against pediatric obesity by:
1 Pacifico L, Anania C, Martino F, et al. Management of metabolic syndrome in children and adolescents. Nutrition, Metabolism & Cardiovascular Disease. 2011; 21:455-466. doi:10.1016/j.numecd.2011.01.011
2 Zimmet P, Alberti KG, Kaufmann F, et al. The metabolic syndrome in children and adolescents—an IDF consensus report. Pediatr Diabetes. 2007;8:299-306.
3 Goodman E, Daniels SR, Meigs JB, Dolan LM. Instability in the diagnosis of metabolic syndrome in adolescents. Circulation. 2007;115:2316-2322.
4 Barlow SE, et al. Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report. Pediatrics. 2007,120:S164-S194.
5 Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: summary report. Pediatrics. 2011 Dec;128 Suppl 5:S213-56. Epub 2011 Nov 14.
6 The childhood obesity epidemic: lessons for preventing socially determined health conditions. Arch Pediatr Adolesc Med. Nov 2011. 165 (11): 973-975.
7 2011 SC Obesity Burden Report. South Carolina Department of Health and Environmental Control: Division of Nutrition, Physical Activity and Obesity. Available at http://www.scdhec.gov/health/ chcdp/obesity/data.htm. Accessed March 8, 2012
About BMI for children and teens. Centers for Disease Control and Prevention. Available at http://www.cdc.gov/healthyweight/assessing/bmi/childrens_BMI/about_childrens_BMI.html. Accessed March 8, 2012.
Child and teen BMI calculator. Centers for Disease Control and Prevention. Available at http://apps.nccd.cdc.gov/dnpabmi/Calculator.aspx. Accessed March 8, 2012.