WHS PR Symposium - Management of Childhood and Adolescent Obesity

8/21/2019 WHS PR Symposium - Management of Childhood and Adolescent Obesity

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MANAGEMENT OF

November 15th, 2014Marriot Hotel, San Juan

Francisco Nieves Rivera, MD, FAA

Childhood &Adolescent Obesity


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Disclosure!he s"ea#er has no con$lict to %isclose&


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Objectives

' De$ine over(ei)ht*obesit+ severe obesit+

' Revie( success$ul evi%ence-base% mo%el $or

chil%hoo%*a%olescent (ei)ht interventions&

' resent the role o$ sur)er+ in a%%ressin)

"e%iatric obesit+


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Management o !ediatric Obesity

.n "e%iatric "rimar+ care, the tra%itional visit mo%el (or#s(ell $or acute me%ical issues/ ho(ever, com"le chronicillnesses such as obesit+ reuire a %i$$erent a""roach&

Cygan_J Pediatr Health Care2014_p429-437


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More than 1* o$ chil%ren

currentl+ are re"orte% to be

over(ei)ht 36 or obese

376&

Severe 7 7M. 85940 :)*m2

D;uria J& ei)hin) .n< revention o$

chil%hoo% over(ei)ht an% obesit+& Journal of

Pediatric Health Care& 2011, 253=6


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>n%ocrine Ne(s Jul+ 2014


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!revalence o Childhood Obesity in the "#$ %' ( )


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Childhood Obesity E*idemic+ !,

' ?ross-sectional stu%+ 9 1=@, 12-+ear-ol% chil%ren $rom 4

"ublic schools locate% in the San Juan area

' ariables< socio-%emo)ra"hic characteristics, social

environment, "h+sical activit+, (ei)ht, hei)ht, 7M., an%

24-hr %ietar+ recall %iar+

' =4B (ere health+ (ei)ht' =B (ere *7 31=&CB 1&B 76

Serrano M, !orres R Ere ?M, alacios ?& Social environment $actors, %iet ualit+, an% bo%+(ei)ht in 12-+ear-ol% chil%ren $rom $our "ublic schools in R& PR Health Sci J2014, 326


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' A (orrisome tren% hasemer)e% in the $orm o$severe "e%iatric obesit+ asthe $astest-)ro(in)

subcate)or+ o$ obesit+ inchil%ren an% a%olescents&

' Severe obesit+ a$$lictsbet(een 4B an% =B o$ all

+outh in the GS an% hasboth imme%iate an% lon)-term health conseuences&

:ell+ AS, 7arlo( S>, Rao , et al& Severe obesit+ in chil%ren an% a%olescents&Circulation201/ 12@


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' Severe obesit+ in chil%ren I2 +ears o$ a)e an% ina%olescents be %e$ine% as havin) a 7M. I120B o$ the5th"ercentile or an absolute 7M. I5 #)*m2, (hicheveris lo(er base% on a)e an% se&

' !he inclusion o$ an absolute 7M. threshol% 35 #)*m26ali)ns the "e%iatric %e$inition (ith class .. obesit+ ina%ults, a hi)h-ris# cate)or+ o$ obesit+ associate% (ithearl+ mortalit+ in a%ults&

:ell+ AS, 7arlo( S>, Rao , et al& Severe obesit+

in chil%ren an% a%olescents& Circulation201/12@


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O-.O/More

calories less activit+

7iolo)ical

ris# $actors

herechil%ren

live "la+ >arl+

$ee%in)"ractices

Foo%"olicies Famil+ li$e


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?o""oc# JH, Ri%ol$i DR, Ha+es JF, aul MSt, il$le+ D>& ?urrent a""roaches to the manaCurr Treat Options Cardio Met2014/ 1=


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!he most recent NHAN>S %ata sho(

that class 2 obesit+ 38120 B o$ 5th

"ercentile6 has risen $rom &@ B in 1-

2000 to 5& B in 2011- 12 an% class

obesit+ 38140 B o$ 5th"ercentile6 has

increase% $rom 0& B to 2&1 B in this

same time s"an&

?o""oc# JH, Ri%ol$i DR, Ha+es JF, aul MSt, il$le+ D>& ?urrent a""roaches to themana)ement o$ "e%iatric obesit+& Curr Treat Options Cardio Met2014/ 1=


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' !his rise has le% toven maintainin) (ei)ht an% "reventin) (ei)ht )ain in

)ro(in) chil%ren im"roves car%iovascular ris# $actors&



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' >arl+ chil%hoo% intervention also allo(s health+ eatin)an% "h+sical activit+ habits to be establishe% be$orechil%ren become entrenche% in obeso)enic "atterns&

' !hus, "revention an% earl+ intervention are critical to"romote a health+ (ei)ht an% car%iovascular health ina%ulthoo%&



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' Famil+ "h+sicians an% "e%iatricians have the o""ortunit+

$or earl+ i%enti$ication o$ over(ei)ht an% obesit+ throu)h

routine "h+sical eaminations&

' Ho(ever, at "resent, the evi%ence su))ests that "rimar+

care-base% treatment (ithout interventionist su""ort is

not su$$icient to mana)e "e%iatric obesit+&



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rovi%ers are o$ten limite% to a sin)le visit to a%%ress the"roblem, but even a stu%+ involvin) $our "h+sicianconsultations re)ar%in) %ietar+ an% "h+sical activit+behaviors over 12 months %i% not "ro%uce sustaine% 7M.

re%uction relative to control&



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' rimar+ care base% interventions ma+ be more e$$ective

i$ im"lemente% at a hi)her intensit+ b+ a traine%

interventionist&

' A%olescent $emales "artici"atin) in (ee#l+ )rou"

sessions $or months $ollo(e% b+ bi-(ee#l+ sessions $or

t(o months %ecrease% mo%estl+, but si)ni$icantl+, in -

score 7M. units com"are% to usual care control )rou"&



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Another intensive stu%+ com"lete% in"rimar+ care that $ocuse% on %iet an%"h+sical activit+ behavior chan)e in both"reschoolers an% "arents %emonstrate%

)reater (ei)ht loss com"are% to control&



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' !hus, an+ treatment %elivere% in

"rimar+ care must be o$ hi)h intensit+

to be e$$ective&

' ?onsistent screenin) $or over(ei)ht

an% obesit+ an% re$erral to evi%ence-

base% care o$$ere% (ithin or outsi%e the

clinic ma+ be an o"timal role o$ the

"rimar+ care "rovi%er&



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' Ki$est+le interventions& ?urrent a""roaches to the

mana)ement o$ "e%iatric obesit+& Curr Treat Options Cardio Met2014/ 1=


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Family(based 0iestyle 1ntervention

As a result, the GS reventive Services !as# Forcerecommen%s that "e%iatricians an% "rimar+ care "h+siciansscreen $or obesit+ in all chil%ren over =-+ears-ol%, an% re$erchil%ren over =-+ears-ol% "resentin) (ith over(ei)ht an%obesit+ to intensive li$est+le interventions an% counselin)that tar)ets %iet, "h+sical activit+, an% behavior chan)e&


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Diet and !hysical Activity

Follo(in) AHA )ui%elines $orchil%ren over t(o +ears o$ a)e,%ietar+ mo%i$ication shoul%em"hasie increase%consum"tion o$ $ruits an%ve)etables, (hole )rains, lo(-$atan% non-$at %air+ "ro%ucts, beans,

an% $ish an% lean meats&

?o""oc# JH, Ri%ol$i DR, Ha+es JF, aul MSt, il$le+ D>& ?urrent a""roaches to the



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' !reatment shoul% $ocus onre%ucin) hi)h-$at an% hi)hcalorie $oo%s, an% re%ucin) or

eliminatin) su)ar s(eetene%bevera)es such as so$t %rin#san% $ruit %rin#s&

' .n a%%ition, mil% caloric

restriction is both sa$e an%e$$ective&




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' !ra$$ic Ki)ht lan

' a metho% o$ attainin) a caloric %e$icit b+ %ecreasin) hi)h ener)+

%ensit+ $oo%s 3hi)h calorie, lo( volume6 an% increasin) lo( ener)+

%ensit+ $oo%s 3lo( calorie, hi)h volume6&

' !his "ro)ram classi$ies $oo%s as )reen3lo( ener)+ %ensit+,

increase consum"tion6, +ello(3mo%erate ener)+ %ensit+, eat

in mo%eration6, an% re%3hi)h ener)+ %ensit+, sto" an% thin#

be$ore eatin)6&




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!hese cate)ories are %esi)ne% to hel" chil%ren )ra%uall+%ecrease their $at an% calorie inta#e, (hile a%o"tin)healthier eatin) "atterns&




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!hysical Activity

' !reatment shoul% tar)et )ra%uall+ increasin) the chil%Ls"h+sical activit+ to at least =0 minutes*%a+ on all or most%a+s o$ the (ee#, in line (ith ?D? recommen%ations&

' h+sical activit+ shoul% be %evelo"mentall+ a""ro"riate,an% es"eciall+ at +oun)er a)es, shoul% be $ocuse% onintermittent, unstructure% "la+ rather than structure%car%iovascular eercise&

?o""oc# JH, Ri%ol$i DR, Ha+es JF, aul MSt, il$le+ D>&

Curr Treat Options Cardio Met2014/ 1=


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!hysical Activity

' !he )oal o$ "h+sical activit+ shoul% not ust be calorice"en%iture, but also $osterin) an eno+ment o$ "h+sicalactivit+, motor s#ill im"rovement, an% increase% sel$-

e$$icac+ $or "h+sical activit+&

' !hese tar)ets are necessar+ to $orm sustainable "h+sicalactivit+ habits&


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!arental 1nvolvement

Famil+-base% behavioral treatment 3F7!6, a

multicom"onent li$est+le intervention that

tar)ets the behaviors o$ both the chil% an% the

"arent, has consistentl+ "roven to be the most

robust intervention $or "e%iatric obesit+&




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Management o !ediatric

Obesity

!arental 1nvolvement

' Stu%ies eaminin) F7! have %emonstrate% both a lar)e

e$$ect sie an% lon)-term maintenance o$ (ei)ht loss (ith

chil%ren %ecreasin) "ercent over(ei)ht b+ 20 B, an%

e$$ects still si)ni$icant at ten +ears "ost-treatment&

' .nclusion o$ "arents as tar)ets is critical as "arentsuccess is %irectl+ correlate% (ith chil% success&




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' F7! aims to mo%i$+ eatin) an% activit+ behaviors o$ both

the chil% an% "arent (ith successive chan)es to the

home environment, utiliin) the "arents as a)ents o$

chan)e&

' !reatment is $ocuse% on buil%in) s#ills in sel$-monitorin),

"arental "raise an% "ositive rein$orcement, stimulus

control, an% "roblem solvin), alon) (ith "arentin) s#ills

such as limit settin)&


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.n or%er to achieve o"timal results, F7! must be %elivere%(ith me%ium to hi)h intensit+ 32=-C5 hours o$ contact6, (ithsu$$icient %uration 3si months $or initial (ei)ht loss "hase6,an% have a stron) $amil+ com"onent&




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#ocio(environmental

Conte2t

hile man+ behavioraltreatments can "ro%uce

clinicall+ meanin)$ul resultsin the short term,maintenance reuires acom"rehensive a""roach

that s"ans socio-environmental contets&




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#ocio(environmental Conte2t

Social $acilitation maintenance treatment 3SFM6 to buil% on

strate)ies learne% in F7! an% e"an% the reach o$ behavior

chan)es across social contets to enhance "arent an% "eer

su""ort, im"rove bo%+ ima)e, an% hel" chil%ren res"on% to

teasin), ultimatel+ "romotin) health+ eatin) an% activit+

behaviors be+on% treatment cessation&




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#ocio(environmental Conte2t

' 7asic behavioral research has %emonstrate% that

"reviousl+ learne% behaviors are not re"lace% b+ ne(l+

learne% behaviors, but rather coeist (ith them&

' !hese ne(l+ learne% behaviors are also less

)eneraliable, an% ol% learnin) is susce"tible tocontetual cues $or activation&


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#ocio(environmental

Conte2t

!hus, usin) a socio-environmental a""roach,

SFM tar)ets learnin) an%"racticin) ne( behaviorsacross multi"le contets to$irml+ establish ne( health+

habits&




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1mmersion

' .mmersion treatment has been %evelo"e% as an intensivethera"+ that moves a chil% $rom the obeso)enicenvironment into a thera"eutic environment that ensures

health+ (ei)ht loss behaviors&' ith a structure similar to summer cam", these "ro)rams

ensure a restricte% %iet an% at least = %a+s*(ee# o$"h+sical activit+, an% the most e$$ective "ro)rams are

those that inclu%e a co)nitive behavioral thera"+com"onent&




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1mmersion

' A meta-anal+sis o$ 22 immersion treatments

%emonstrate% an avera)e re%uction in "ercent o$

2& B "ost-treatment an% 20&= B at $ollo(-u"&

' hile such treatments can achieve %ramatic results, the+

are costl+ 3 O P1,000*(ee#6 an% shoul%, thus be reserve%

$or more severe cases o$ obesit+&




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Medical & !harmacological Treatment

hile severel+ obese +oun) chil%ren can bene$it $rom

behavioral li$est+le interventions, severel+ obese ol%er

chil%ren an% a%olescents o$ten reuire intensive

intervention in or%er to achieve clinicall+ si)ni$icant (ei)ht

loss&


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' At "resent, rlistat is the onl+ (ei)ht loss me%icationa""rove% b+ the FDA $or use in a%olescents&

' oole% anal+ses o$ orlistat trials have re"orte% re%uctionsin 7M. ran)in) $rom 0&C to 0&@ #)*m2&




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Management o !ediatric

Obesity


hile (ei)ht loss sur)er+ is )enerall+ consi%ere% sa$e,e"erts recommen% that a%olescents shoul% onl+ be

consi%ere% $or bariatric sur)er+ i$ the+ are ver+ severel+obese 37M.I406, are at least 1-+ears-ol% $or )irls an% 15-+ears-ol% $or bo+s in or%er to ensure maimum s#eletalmaturit+, have serious me%ical comorbi%ities associate%

(ith their obesit+, an% have $aile% at least si months o$ astructure% (ei)ht loss "ro)ram&




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#urgery

' iven the limite% e$$ectiveness o$ li$est+le an%"harmacolo)ical interventions an% the severe %e)ree o$obesit+ in man+ "atients, sur)ical "roce%ures that have

"roven health bene$its $or a%ults are more commonl+bein) consi%ere% $or severel+ obese a%olescents&

' ver the "ast %eca%e, bariatric sur)er+ has become amore broa%l+ acce"te% a""roach to treatment o$ hi)hl+

selecte% a%olescents (ho are su$$erin) $rom the healthan% "s+chosocial e$$ects o$ severe obesit+&

:ell+ AS, 7arlo( S>, Rao , et al& Severe obesit+ in chil%ren an% a%olescents&

Circulation201/ 12@


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Types of Bariatric Surgery

' 7ariatric sur)er+ re$ers to a variet+ o$ %i$$erent"roce%ures that anatomicall+ alter the . tract an% resultin restriction o$ stomach ca"acit+, inter$erence (ith

"ro)ression o$ a meal, or %iversion o$ in)este% contents&' 7+ $ar, the most common "roce%ures use% $or

a%olescents (ith severe obesit+ inclu%e roux en Y)astricb+"ass 3RQ76, a%ustable )astric ban%in) 3A76, an%

the more recentl+ intro%uce% vertical sleeve )astrectom+3S6, (hich is bein) use% (ith increasin) $reuenc+&


Circulation201/ 12@


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Ty*es o /ariatric #urgery


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Types of Bariatric Surgery' .n )eneral, "ublishe% e"erience (ith bariatric

"roce%ures su))ests that (ei)ht loss outcomes,comorbi%it+ outcomes, an% "atient sa$et+ are com"arable

or better $or a%olescents than those seen in a%ults&


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Roux en Y Gastric Bypass

' Gse o$ RQ7 $or (ei)ht

loss in the Gnite% States

%ates bac# to the 1=0s

$or a%ults an% the 1C0s

$or a%olescents&


Circulation201/ 12@


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' Similar to a%ult stu%ies, a%olescent RQ7 t+"icall+

resulte% in a si)ni$icant 5B - CB re%uction in 7M. b+ 1

+ear a$ter sur)er+, (ith the maorit+ o$ this (ei)ht loss

occurrin) in the $irst = months a$ter sur)er+&

' 7+ contrast, onl+ a B 7M. re%uction (as $oun% (hen

similarl+ obese 3mean 7M. 4C #)*m26 a%olescents (ere

treate% in a behaviorall+ base% (ei)ht mana)ement

"ro)ram&


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' Kon)-term %urabilit+ 3814 +ears6 o$ clinicall+ si)ni$icant

(ei)ht re%uction in a%olescents has been reveale% b+

onl+ 1 retros"ective stu%+ thus $ar but the $in%in)s are

consistent (ith the lar)er a%ult literature that

%emonstrates the %urabilit+ o$ sur)er+&

' A$ter RQ7, no %eaths have been re"orte% in the

"erio"erative 3(ithin 0 %a+s o$ o"eration6 "erio%


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' !he t+"ical com"lications o$ maor )astrointestinalsur)er+ have been seen a$ter RQ7 in a%olescents,inclu%in) anastomotic stricture, lea#, (oun% in$ection,bo(el obstruction, blee%in), ulceration, "neumonia,

vitamin %e$icienc+, an% venous thromboembolism&' !(ice as man+ a%ults as a%olescents reuire% a

"osto"erative intensive care unit sta+ 314B versus CB,P0&056, an% a%ults ha% hi)her 0-%a+ morbi%it+ rates

3&@B versus 5&5B, P0&056, (hich su))ests thata%olescents ma+ tolerate bariatric "roce%ures better thana%ults&


Circulation201/ 12@


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!hus, base% on current literature, RQ7 a""ears to be a

sa$e an% e$$ective o"eration in a%olescents, (ith outcomes

similar to, i$ not more $avorable than, those observe% in

a%ults, "rovi%e% measures are ta#en to "revent vitamin,

iron, an% calcium %e$icienc+, (hich can have %eleterious

e$$ects i$ uncorrecte%&


Circulation201/ 12@


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Adjustable Gastric Banding

' !he a%ustable )astric ban%, a%evice that creates a small )astric"ouch in the "roimal stomach, (as

a""rove% b+ the FDA $or a%ults 810+ears a)o but has not +et beena""rove% $or use in "atients 1@+ears o$ a)e&


Circulation201/ 12@


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Circulation201/ 12@


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!he literature re"ortin) a%olescent outcomes o$ the A7has continue% to )ro( %es"ite lac# o$ FDA a""roval, inlar)e "art because use o$ this %evice %oes not involveirreversible chan)e in the )astrointestinal tract, the earl+

sa$et+ "ro$ile %emonstrate% $e(er li$e-threatenin) ris#s, an%there are $e(er nutritional ris#s in the lon)-term&


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' A recent com"arison o$ earl+ ris#s amon) 40 RQ7

a%olescent "atients 3mean $ollo(-u" o$ 1@ months6 an%

10= (ho un%er(ent A7 3mean $ollo(-u" 12 months6

$oun% lon)er hos"ital sta+s a$ter RQ7 32& versus 0&=

%a+s6 an% %emonstrate% no mortalit+ in either )rou"&

' !here (ere no statisticall+ si)ni$icant %i$$erences in

com"lication rates bet(een a%olescents un%er)oin)

RQ7 an% A7&


Circulation201/ 12@


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' verall, %ata su))est that bariatric sur)er+ ma+ be themost e$$ective treatment $or severe obesit+ ina%olescents&

' >vi%ence %emonstrates that sur)ical "roce%ures result in

20B to 5B initial (ei)ht loss over at least the $irst 2+ears/ sustainabilit+ o$ (ei)ht loss $or 81 %eca%e has alsobeen sho(n&

' Data on com"lications to be e"ecte% (ith these

interventions a""ear to sho( such com"lications to beless severe in a%olescents than in a%ults&


Circulation201/ 12@


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Access to care

' hile Famil+-base% behavioral treatment has "roven tobe e$$ective $or treatment o$ chil%hoo% obesit+, access toa""ro"riate care remains a challen)e&

' 7arriers inclu%e time an% cost o$ trainin) "rovi%ers in F7!%eliver+, lac# o$ reimbursement $or treatment, an% limite%s"ecialt+ clinics to (hich "rovi%ers can re$er their"atients&

' >"erts recommen% that the treatment selecte% betailore% to the nee%s o$ the in%ivi%ual&




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' Ho(ever, (ei)ht loss an% 7M. re%uction in behavioral(ei)ht mana)ement "ro)rams t+"icall+ are mo%est,ran)in) $rom 5B to 20B o$ ecess bo%+ (ei)ht or 1 to Go$ 7M. an% relativel+ hi)h attrition rates have been

observe%&' Moreover, because baseline 7M. values are o$ten so hi)h,

man+ (ill remain severel+ obese even a$ter success$ulT37M. re%uction o$ a $e( units6 li$est+le mo%i$ication

thera"+&' .n man+ communities, intensive behavior-base% "ro)ramsare not o$$ere% or are e"ensive an% not covere% b+insurance&


Circulation201/ 12@


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' ?onsi%ere% to)ether, the behavioral stu%ies con%ucte%amon) +outh (ith severe obesit+ to %ate su))est thatli$est+le mo%i$ication thera"+ alone results in mo%estre%uctions in 7M. an% bo%+ $at an% some im"rovement in

car%iometabolic ris# $actors but that the bene$its are not%urable over time&

' utcomes ma+ be better (hen li$est+le mo%i$icationthera"+ is institute% earl+ in chil%hoo%&

' Alternative a""roaches, such as in"atient treatment an%meal re"lacements, have also been assesse%&


Circulation201/ 12@


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?o""oc# JH, Ri%ol$i DR, Ha+es JF, aul MSt, il$le+ D>& ?urrent a""roaches to the manaCurr Treat Options Cardio Met2014/ 1=


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The solution+

an all(out(eort rom cells(to(society


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#"MMA,3

' reventin) ecess (ei)ht )ain $rom an earl+ a)e is"erha"s the most reliable "ath to health+ (ei)ht, astreatment can be challen)in) re)ar%less o$ the a""roach&

' >arl+ intervention, as earl+ as the $etal sta)e, ma+ be

"articularl+ im"ortant $or "revention&' revention e$$orts involve tar)etin) behaviors that have

been associate% (ith increase% (ei)ht in chil%ren an%a%olescents, (ith a "articular $ocus on hi)h-ris# "e%iatric

"o"ulations&


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#"MMA,3

' 7reast $e% in$ants %emonstrate mo%eratel+ lo(er o%%s o$%evelo"in) over(ei)ht as chil%ren, su))estin) thatbreast$ee%in) coul% be a "reventative measure&

' Most "e%iatric "rimar+ care "rovi%ers currentl+ lac# the

tools necessar+ to em"lo+ an% im"lement )ui%elines toa%%ress *7 in the clinical settin)&

' For +oun)er chil%ren $or (hom me%ication or sur)er+ (ill)enerall+ be ina""ro"riate, e"loration o$ intensive

"ro)rams $or $amilies, inclu%in) home-base% thera"+ orshort term resi%ential "ro)rams $or $amilies&


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#"MMA,3' e nee% $or better characteriation o$ the ori)in o$ severe

obesit+ an% i%enti$ication o$ %istinct behavioral, )enetic,"atho"h+siolo)ical, an% environmental $actors associate% (ithsevere obesit+, as o""ose% to over(ei)ht or obesit+, to %esi)nnovel treatment a""roaches&

' Severe obesit+ in +outh rarel+ res"on%s to lo(-intensit+ ormo%eratel+ intensive thera"+&&

' .n li)ht o$ the limite% e$$ectiveness o$ li$est+le mo%i$ication an%me%ical thera"+ sho(n to %ate $or severe obesit+, sur)ical

"roce%ures that have an evi%ence base that su""orts theire$$icac+ an% sa$et+ shoul% be consi%ere% $or "atients (ho%emonstrate me%ical necessit+ an% "s+chosocial rea%iness&


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#"MMA,3

' 7ariatric sur)er+ is the most e$$ective treatment $or severeobesit+ in a%olescents/ ho(ever, sur)er+ is a""ro"riatean% available $or onl+ some a%olescents (ith severeobesit+, an% broa%enin) availabilit+ (ill %e"en% on the

results o$ lon)-term outcome stu%ies, currentl+ in"ro)ress&

' !he tas# ahea% (ill be ar%uous an% com"licate%, but thehi)h "revalence an% serious conseuences o$ severe

obesit+ reuire us to commit time, intellectual ca"ital, an%$inancial resources to a%%ress it&

Documents

WHS PR Symposium - Management of Childhood and Adolescent Obesity