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Surveillance, prevention and intervention

5 Year Well Child Check


A five year 11 month male presents with increased usage of albuterol inhaler. In general symptoms are induced by exercise, but also with URI illness. He is an active, playful boy and has recently been using his inhaler every 4 hours. His mother believes he is poorly controlled. She is also concerned because the school will not give him his inhaler at school.

She has begun to restrict his activity in order to try and prevent symptoms. Mom has noticed that he has begun gaining a good deal of weight.

Past Medical History: Past 35 weeker, Asthma diagnosed at age one, Eczema Family History: Father with Asthma, mother with environmental allergies, - for hypercholesterolemia, - for diabetes Social History: He lives with his mother, mothers boyfriend and attends kindergaarten

Vitals: Weight 34.6kg, Height- not recorded, Temperature 97.3 General: Overweight, NAD HEENT: NCAT, no conjunctival irritation or exudate, no congestion, no lymphadenopathy Ears: canals clear, TMs nml bilaterally Chest: CTAB; mild expiratory wheeze with forced expiration after deep inhalation CV: RRR without murmurs Abdomen: obese, NABS, no TTP Skin: without rashes

BMI is widely used to define overweight and obesity because it uses commonly derived data and correlates well with more accurate measures of body fatness. Definitions: Overweight is defined (by the CDC) as a BMI at or above the 85th percentile and lower than the 95th percentile for children of the same age and sex. Obesity is defined as a BMI at or above the 95th percentile for children of the same age and sex.

Obesity rates among children in the United States


Approximately 17% (or 12.5 million) of children and adolescents aged 219 years are obese. Since 1980, obesity prevalence among children and adolescents has almost tripled. During the last 10 years the rate has begun to plateau, but the heaviest are getting heavier. There are significant racial and ethnic disparities in obesity prevalence among U.S. children and adolescents. In 20072008, Hispanic boys, aged 2 to 19 years,were significantly more likely to be obese than nonHispanic white boys, and non-Hispanic black girls were significantly more likely to be obese than non-Hispanic white girls.

Consequences of childhood obesity? Health risks now Childhood obesity can have a harmful effect on the body in a variety of ways. Obese children are more likely to have
High blood pressure and high cholesterol, which are risk factors for cardiovascular disease (CVD). In one study, 70% of obese children had at least one CVD risk factor, and 39% had two or more. Increased risk of impaired glucose tolerance, insulin resistance and type 2 diabetes. * Breathing problems, such as sleep apnea, and asthma. Joint problems and musculoskeletal discomfort. Fatty liver disease, gallstones, and gastro-esophageal reflux.

Obese children and adolescents have a greater risk of social and psychological problems, such as discrimination and poor self-esteem, which can continue into adulthood.

Health risks later Obese children are more likely to become obese adults; 80 percent of children who were overweight at 10 to 15 years old were obese at 25. Adult obesity is associated with a number of serious health conditions including heart disease, diabetes, and some cancers. If children are overweight, obesity in adulthood is likely to be more severe.
Although prevalence has remained flat in the last several years, costs of obesity have risen substantially. One study showed 9% of all healthcare costs were obesity related in 2008, almost double ten years earlier, equally $147 billion.

Between 1988-1994 and 2007-2008 the prevalence of obesity increased From 11.6% to 16.7% among non-Hispanic white boys. From 10.7% to 19.8% among non-Hispanic black boys. From 14.1% to 26.8% among Mexican-American boys.

2009 State Prevalence Among Low-Income Children Aged 2 to 4 Years

More than half of Utah adults are overweight or obese (60.1%, Utah BRFSS 2008). Over one in three of those are obese (24.0% Utah BRFSS 2008). Utah is only doing slightly better than the US where 63.1% of adults are overweight or obese and 26.6% are obese (US BRFSS 2008). The percentage of obese adults in Utah has more than doubled (a 128% increase) since 1989. Significantly more men (67.5%) were overweight or obese in Utah than women (52.4%, Utah BRFSS 2008). Over one in five elementary-age Utah children are overweight or obese (21.5%, Utah child height and weight study 2008). Over one in five high school-age Utah children are overweight or obese (20.4%) and 8.7% are obese (2007 YRBSS).

Identification of effective interventions requires understanding the underlying cause of the increase in prevalence. Shifts in food consumption Decreases in physical activity levels Higher levels of TV watching and video game time (with further inactivity) Marketing of food to children

Intervention and Prevention


Breastfeeding has been shown to reduce risk of childhood obesity
Breastfeeding should be encouraged for at least the 1st 6 months of life Work places must be encouraged to make breastfeeding easier for mothers Other interventions: Decreased availability and consumption of high energy-density foods Increased consumption of fruits and vegetables Decrease consumption of sugar-sweetened beverages Increased Physical activity* Decreasing screen time, TV and video game time Consequently reducing exposure to food based marketing to children

Research has shown that for maximal population impact strategies to alter food consumption and physical activity must focus on places were people live, learn, work, play and worship. Those that focus on a single behavior are unlikely to be successful Encouraging healthy foods alone is not enough The US Dept of Agriculture stated that 23.5 million people live in Food Deserts, low income areas without access to healthy food

Programs
In Philadelphia a program working with 4th, 5th, and 6th graders emphasizing reduced TV time, increased physical activity and increased intake of fruits and veggies resulted in a 50% reduction in incidence of overweight and a 10% reduction in prevalence of overweight after 2 years. The Maine Youth Overweight Collaborative developed the 5-2-1-0 message for health professionals in 2004 Two years later The Lets Go! Project was developed which incorporated the message into schools, childcare, communities, workplaces and local businesses, and has since spread nationally Lets Move is the First Ladys initiative aiming to empower parents, encourage healthier foods in schools, increase physical activity and quality phys ed in schools, and increase access to affordable healthy foods

Policy can aid in eliminating the availability of sugarbased drinks and calorie dense foods in schools, increasing the availability of fresh water in public parks, improving the built environment to increase safe walkable and bikeable routes, increase public parks and public safety The Healthy Food Financing Initiative combined money from the Dept of Agriculture, Health and Human Services and Treasury to supply money for grants, loans and tax credits to projects that aim to improve access to healthy foods

Prevention In the Office:


Surveillance: Measure height, weight and calculate and record BMI at every visit. Track BMI on growth charts and evaluate for trends at every visit; intervene before child is significantly overweight. Likely that this will be more successful than interventions after. Diet history at all WCC Discussions/education to raise parental awareness about eating habits, obesity and its consequences at every well visit in non-judgemental manner. Emphasize healthy habits over focusing on habits to avoid.

Provider and office tools available at www.letsgo.org Including patient handouts and guides for effective communication with family

5 or more fruits & vegetables 2 hours or less recreational screen


time* 1 hour or more of physical activity 0 sugary drinks, more water & low fat milk

Prevention Plus is for children between the 85th - 94th percentiles BMI. Specifically encourage 5 servings of fruits and vegetables/day, 2 hours or less of screen time, 1 hour or more of physical activity and 0 sugared drinks. Also discuss the importance of family meal time, limiting eating out, consuming a healthy breakfast, preparing your own foods, and promotion of breastfeeding. Structured Weight Management is used if prevention plus has not been effective and BMI is between 95th - 98th percentiles. This approach combines more frequent follow-up with written diet and exercise plans. Comprehensive Multidisciplinary Intervention is used when 3 - 6 months of structured weight management has failed to achieve targets. This approach combines more frequent visits with an MD and a dietician and could also include exercise and behavioral specialists. Tertiary Care Intervention is for patients with BMI 99th percentile or greater and with associated comorbidities or for those who structured weight management and comprehensive multidisciplinary intervention were not effective. This approach consists of all that is contained in the previous delivered interventions plus consideration of more aggressive therapies including meal replacements, pharmacotherapy, and even bariatric surgery in selected adolescents.

As pediatricians and, often, community leaders we are in a position to advocate for change in other arenas as well: Increase activities levels, via programs in schools, childcare and afterschool programs that emphasize daily activities for personal fitness. Advocate for reduction in energy dense foods in these settings with replacement with nutrient rich foods, along with elimination of sugar sweetened beverages. Increasing access to healthy food for low income children: advocate for community gardens, Farmers markets Advocate for policy reducing advertising and promoting energy-dense, nutrient poor food to children

AAP Policy Statement : prevention of Pediatric Overweight and Obesity CDC Grand Rounds: Childhood Obesity in the United http://health.utah.gov/obesity http://www.letsgo.org/
National, state and local disparities in childhood obesity, Health Affairs, March 2010

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