The Latest Treatment Advances in Childhood Obesity Denise E.
Wilfley, Ph.D. Scott Rudolph University Professor of Psychiatry,
Medicine, Pediatrics and Psychology Washington University in St.
Louis April 21, 2015
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Overview Highlight the impact of obesity on youth Discuss
importance of early intervention Define the gold standard treatment
for children with obesity Propose ideas for how to implement
treatment in community settings
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Childhood Obesity in Missouri Obesity Among Low-Income Children
Ages 2-4 National Center for Chronic Disease Prevention and Health
Promotion, 2012; Pediatric Nutrition Surveillance System Altman et
al., in process 2015 28% of children in Missouri (more than
400,000) are overweight or obese 12.9% of low-income 2-4 year olds
are obese Up to 40% of middle school students in parts of MOsuch as
Bransonare overweight or obese
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The Impact of Obesity and Stigma on Children Quality of life
rated as low as young cancer patients on chemotherapy Schwimmer et
al., JAMA 2003; Williams et al., JAMA 2005
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OBESITY IS FOUND TO GAIN ITS HOLD IN EARLIEST YEARS For many
obese adults, the die was cast by the time they were 5 years old.
70-80% will track obesity into adulthood Efforts must start much
earlier and focus more on the children at greatest risk.
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Early Identification and Intervention is Crucial Prevents
harmful effects Harnesses parental support Fosters healthy habits
Small weight losses can make a big impact Age at the start of
treatment has a strong impact on treatment outcome Treatment is
more efficacious at a younger age Adolescents have more difficulty
losing clinically-significant amounts of weight Danielsson et al.,
Arch Pediatr Adolesc Med, 2012; Danielsson et al., Obes Facts,
2012; Reinehr et al., Am J Clin Nutr, 2010; Reinehr et al.,
Obesity, 2009; Sabin et al., J Clin Eval Clin Prac, 2007
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A grandmother, Diane, called into KMOXa St. Louis based radio
stationto find resources for her granddaughterwho was told she was
obese by her pediatrician. Mother is distraught and does not know
where to turn or how to help. Access to effective care for children
with obesity is scarce. Pediatricians could provide resources and
serve as gatekeepers to effective care. Providing Resources to
Parents
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Discussing Child Weight with Parents Explain growth charts
Inform parent of potential health consequences Avoid blame language
Use non-stigmatizing language that will motivate Recent data
suggests perceived negative judgment from provider leads to patient
mistrust Emphasize lifestyle change, not number on scale Discuss
change in a family-context Keep the child in the room to facilitate
conversation between parent and child Puhl et al., Pediatrics,
2011; Wilfley, et al, Pediatric Clin North Am, 2011; Eneli et al.,
Clin Pediatrics, 2007; Gudzune, et al., Patient Education and
Counseling, 2014
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The Energy-Balance Equation: Its Not Enough Running for 3.5
hours Energy Intake (Calories) Energy Output (Physical
Activity)
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Multiple Meta-Analyses Document Significance of Lifestyle
Interventions Young et al., Clin Psychol Rev; Altman et al. JCCAP,
2014; Hayes et al., Curr Cardio Rep 2015; Wilfley et al., Health
Psych, 2007; Sung-Chan, et al. Obes Rev, 2013; Ho et al., JAMA
Pediatrics, 2013 Adding a family component stressing parental
involvement to behavioral lifestyle interventions increases their
effectiveness and parents should be targeted along with children to
achieve the greatest reduction in child overweight A recent
systematic review suggests even further that family based
interventions including individual family sessions achieve greater
magnitude weight loss than group sessions alone for children with
obesity.
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Family-based Behavioral Intervention First line of treatment
for children and adolescents Targets reduction in energy intake and
increase in energy expenditure in both youth and caregivers
Recognizes that knowledge alone is not sufficient Focuses on
successive changes using family support Core strategies include:
self-monitoring, reinforcement, stimulus control, goal setting,
contingency management Shown to impact: weight status, psychosocial
health, and health- related parameters (e.g., blood pressure,
cholesterol, insulin sensitivity) This treatment has shown to have
long-sustained effects that improve weight maintenance Jelalian et
al., J Pediatr, 2010; Kalarchian et al., Pediatrics, 2009; Epstein
et al., Childhood Obesity, 2014; McGovern et al., J Clin Endocrinol
Metab, 2008; Altman et al., JCCAP, 2014; Ho et al., Pediatrics,
2013
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The Ripple Effect FBT can impact not only the child involved,
but the participating parent and even other siblings within the
household Providing treatment for one child who is overweight/obese
in the family has the potential to impact others inside and outside
the family (effect will vary based on sex, age) FBT more
cost-effective for weight loss Epstein et al., Childhood Obesity,
2014; Epstein et al., Obes Res, 2001; Golan et al., Am J Clin Nutr,
1998; Golan et al., Int J Obes Relat Metab Disord, 1998; Wrotniak
et al., Obes Res, 2005; Golan et al., 2006, 2009; Gorin et al.,
2008.
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Engineer the Environment to Support Health
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Parent and Peer Support Are Key
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Jazmyne and her mother enrolled in the TODAY trial for
management of Jazmynes Type 2 Diabetes : The St. Louis American,
January 22, 2010; TODAY Study Group Diabetes Care, 2013; Ebbeling
et al., Lancet 2002 At 14, she started feeling really bad
headaches, nauseated, fatigue [], her mother said. When she went
for her checkup before school, the doctor was alarmed.
Post-treatment: Jazmynes headaches got better and her mood swings
improved. Together, daughter and mother made significant lifestyle
changes. We could prevent future medical costs by providing
targeted intervention in infancy, childhood, and adolescence. Call
for Early Intervention Diagnosis of type 2 diabetes often brings
emotional isolation, lifetime of medication, hypertension,
nephropathy, dyslipidemia, chronic inflammation, nonalcoholic fatty
liver disease
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Future DirectionsThe Medical Home Consists of a variety of
specialists housed within primary care practices to provide
coordinated care for the patients Individuals prefer to first see
their primary care physician A gatekeeper for specialist
recommendations Medical home model can help improve coordination of
primary care services Demonstration project with Missouri
Department of Mental Health (DMH) and the Missouri Coalition for
Community Behavioral Health Care American Academy of Pediatrics.
The Medical Home. Peds, 2004; Grumbach K, Selby JV et al.,
JAMA,1999
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Call to Action Ensure that every child and family engages in
healthy eating and weight management practices. Advocate for
insurance coverage for treatment Add your voice to a cooperative
effort for reimbursement Establishment of a certification system
for training individuals to deliver evidence-based care Explore and
recommend local options for initiating and sustaining healthy
habits Integrate intervention across multiple levels of care
Collaborative partnerships: It takes a village Wilfley et al.,
Pediatr Clin N Am, 2011
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Work Together to Optimize Health for Children, Families, and
Communities