High-Yield Care for Childhood Obesity: 10 Things Actually Worth Trying

Educational Objectives

The goals of this activity are to employ effective strategies in the management of weight and obesity in children. After hearing and assimilating this lecture, the clinician will be better able to:

1. Suggest interventions most likely to result in weight loss.

2. Perform a thorough diagnostic examination in obese children.

Summary

Challenges: patients may not return for follow-up or want to discuss obesity; managing obesity involves more than modifying lifestyle and behavior; genetic predisposition, medications (eg, atypical antipsychotic agents, medroxyprogesterone [Depo-Provera]), infection (eg, adenovirus), and environmental exposure (eg, bisphenol A [BPA]) also implicated; losing weight to achieve body mass index (BMI) <25 not always realistic; setting realistic goals (eg, stabilizing weight) reduces frustration

Reports of success: National Health and Nutrition Examination Survey — found obesity rates improved in early 2000s; decrease in rate for children aged 2 to 5 yr statistically significant; in children aged 6 to 11 yr, obesity peaked at ≈20% in 2007; speaker’s Adolescent Diabetes and OBEsity (ADOBE) clinic — treated >400 patients over 10 yr; goal of maintaining BMI met by 40%; weight lost by 40%

Prevention: in 2015, American Academy of Pediatrics (AAP) changed focus to prevention of obesity (including prenatal causes)

Reducing consumption of sugared beverages: single most effective intervention to lose weight; soda, juice, sweet tea, sports drinks, coffee drinks, and energy drinks have 100 to 200 cal per serving; compensating through exercise difficult (walking for 1 hr at 3 mph burns ≈150 cal); encourage patients to limit consumption to once weekly; diet soda — 10 yr ago, switching from regular to diet soda recommended; 2008 study found drinkers of diet soda gained more weight than drinkers of regular soda; reason unknown; artificially sweetened beverages may decrease levels of leptin (hormone that induces satiety) and thus increase hunger; changes in gut microbiome contribute to weight gain

Milk: in 2008, AAP recommended switching from whole milk to 2% or skim milk at 1 yr of age (adequate fat for brain development obtained from other foods)

5-4-3-2-1-0: daily recommendation 5 servings of fruits and vegetables, 4 glasses of water, 3 servings of calcium (usually milk), ≤2 hr screen time, 1 hr exercise, and 0 sugared beverages; Let’s Go! 5-2-1-0 program in Maine (Rogers et al 2013) — led to increase in consumption of fruits and vegetables and decrease in consumption of sugared beverages over 4 yr

Lean protein at breakfast: majority of adolescent boys and girls skip breakfast (lack of time most common reason); Leidy et al (2013) — late-adolescent girls ate 350-cal breakfast with differing protein content (13 g [1-2 turkey sausage links] or 35 g [3 sausage links and 2 egg whites]); found girls eating high-protein breakfast ate 400 fewer calories per day and had lower percentage of body fat

Smaller plates: evidence for usefulness found, particularly in younger children; empty plate may trigger satiety; effect may wear off by adolescence

Commercial programs: systematic review by Godzune et al found Jenny Craig program induced 4.9% greater weight loss; Weight Watchers 2.6% greater; programs provide support, methods, and accountability; not all programs accept minors (physician letters may be accepted); free online programs available

Exercise: focus on exercise alone without dietary changes usually ineffective (exercise important for other reasons)

Technology (eg, pedometers, apps, fitness trackers): systematic review by Bravata et al (2007) found pedometers potentially helpful (provide accountability) and inexpensive; 10,000 steps (5 mi/day) recommended; evidence for effectiveness of other devices lacking (eg, MyFitnessPal [aimed at adults]); use of devices may be helpful in motivated patients

Medications: none approved by US Food and Drug Administration for weight loss in children and adolescent boys and girls; sibutramine removed from market because of cardiac adverse effects; orlistat (Alli) approved for adults (adverse effect steatorrhea [off-putting for adolescent boys and girls]); metformin approved for type 2 diabetes mellitus (speaker has used it off-label); topiramate-phentermine approved for adults

Screening recommendations: determination of lipid levels (fasting or nonfasting) recommended for all children by 11 yr of age (helps detect familial hypercholesterolemia); 2015 American Diabetes Association guideline recommends screening overweight children with ≥2 risk factors (eg, family history, acanthosis nigricans, hypertension, dyslipidemia, polycystic ovary syndrome [PCOS]); check hemoglobin A1c level by age 10 yr; then every 3 yr; check blood pressure in all children ≥3 yr of age

Workup: all obese children — complete metabolic profile; lipid profile; levels of thyrotropin, hemoglobin A1c, and 25-hydroxy vitamin D; case-dependent tests — sleep study (if risk factors present); 24-hour urine test for free cortisol (if Cushing disease suspected [eg, very heavy younger child]); free and total testosterone levels; sleep apnea — ask about snoring; Epworth Sleepiness Scale useful (some insurance companies require score ≥10 to approve sleep study)

Vitamin D deficiency: vitamin D level in 80% of patients at ADOBE clinic <30 ng/mL; obese individuals at high risk for deficiency because of inadequate sun exposure, darker skin, insufficient dietary intake (best sources milk, mushrooms, and fatty fish), and dissolution (fat-soluble vitamin); Belenchia et al (2013) — found high-level supplementation for 6 mo improves fasting insulin levels and homeostatic model assessment of insulin resistance; Society for Adolescent Health and Medicine — recommends treating all adolescent boys and girls with ≥600 U vitamin D daily; if level insufficient (20-29 ng/mL), supplement with 1000 units vitamin D3 daily for 3 mo; then recheck; if deficient (<20 ng/mL), prescribe 50,000 U vitamin D2 weekly for 8 wk; maintenance dose for obese children 1000 U/day

Klinefelter syndrome (KS) and PCOS: incidence of PCOS in female patients ≤12% (eg, obesity, oligomenorrhea, hirsutism, acne); prevalence of KS 1 in 500 boys; despite image of tall thin individual, many adolescent boys with KS tall and overweight, with hypogonadism and behavioral issues; free and total testosterone levels elevated in PCOS and low in KS (in KS, use karyotyping)

Mental health: bullying and abuse — weight most common reason identified by teenagers for being bullied (100% of overweight and obese children teased or bullied); can lead to depression and anxiety; ≤50% of women in bariatric treatment centers report history of sexual abuse; eating disorders — incidence of binge-eating disorder (uncontrolled eating without purging) in obese adults ≈33%; of bulimia nervosa (binge eating with purging) lower; patients with bulimia may be overweight; refer for psychotherapy; start medication (or refer patient)

Readings

Belenchia AM et al: Correcting vitamin D insufficiency improves insulin sensitivity in obese adolescents: a randomized controlled trial. Am J Clin Nutr 2013 Apr;97(4):774-81; Bravata DM et al: Using pedometers to increase physical activity and improve health: a systematic review. JAMA 2007 Nov 21;298(19):2296-304; Briefel RR et al: Reducing calories and added sugars by improving children’s beverage choices. J Acad Nutr Diet 2013 Feb;113(2):269-75; Daniels SR et al: Committee on Nutrition: The role of the pediatrician in primary prevention of obesity. Pediatrics 2015 Jul;136(1):e275-92; Gudzune KA et al: Efficacy of commercial weight-loss programs: an updated systematic review. Ann Intern Med 2015 Apr 7;162(7):501-12; Jelalian E et al: Survey of physician attitudes and practices related to pediatric obesity. Clin Pediatr (Phila) 2003 Apr;42(3):235-45; Leidy HJ et al: Beneficial effects of a higher-protein breakfast on the appetite, hormonal, and neural signals controlling energy intake regulation in overweight/obese, “breakfast-skipping,” late-adolescent girls. Am J Clin Nutr 2013 Apr;97(4):677-88; Rogers VW et al: Impact of Let’s Go! 5-2-1-0: a community-based, multisetting childhood obesity prevention program. J Pediatr Psychol 2013 Oct;38(9):1010-20.

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, members of the faculty and planning committee reported nothing to disclose. In his lecture, Dr. Tosh presents information related to the off-label or investigational use of a therapy, product, or device.

Acknowledgements

Dr. Tosh was recorded at the 39th Annual Conference: Common Childhood Problems for the Practitioner Who Cares for Children — Managing Childhood Challenges From Head to Toe, presented by the Office of Continuing Medical Education and Physician Lifelong Learning, University of Missouri School of Medicine, Columbia, MO, and held May 19-20, 2017, in Columbia, MO. For information about upcoming CME conferences from the Office of Continuing Medical Education and Physician Lifelong Learning, University of Missouri School of Medicine, please visit www.musomcme.com. The Audio Digest Foundation thanks the speaker and sponsor for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

PD632902

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.