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Paediatric Weight Management

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Ian Zenlea

on 29 October 2015

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Transcript of Paediatric Weight Management

The KidFit Health and Wellness Clinic
The KidFit Paediatric Weight Management Program is funded by the Ontario Ministry of Halth and Long-Term Care and in part by a philanthropic grant from the Medavie Health Foundation. Dr. Zenlea receives stipend support through this grant as well as through the Institute for Better health at Trillium Health Partners.
Disclosure of Potential Conflict of Interest and Commercial Support
What about Canada?
Recognize the scope of the paediatric obesity epidemic

Describe the components of a multidisciplinary paediatric weight management program

Reinforce knowledge of obesity-related co-morbidities

Introduce the KidFit Health and Wellness Clinic
Objectives
Paediatric Weight Management
The KidFit Health and Wellness Clinic
Small Steps. Lasting Change. Lifelong Wellness.
Ian S. Zenlea, MD, MPH

October 29, 2015
What about locally?
Ontario’s Response

Ontario’s Response cont.
Children’s Hospital of Eastern Ontario
The Hospital for Sick Children
McMaster Children’s Hospital, Hamilton Health Sciences Centre
Toronto East General Hospital
William Osler Health System
Thunder Bay Regional Health Sciences Centre
Health Sciences North
North York General Hospital
Children’s Hospital, London Health Sciences Centre
Holland Bloorview Kids Rehabilitation Hospital
Orillia Solder’s Memorial Hospital
Peterborough Regional Health Centre
The Scarborough Hospital/Rough Valley Health System
Trillium Health Partners
Paediatric Bariatric Network
Timely
access
to specialized obesity programs

Support
research
on causes of childhood overweight and obesity and effective interventions

Funding
to reduce childhood overweight and obesity, establishing public – private philanthropic investments in new programs and service
In January 2012, the Ontario Government set a bold target of reducing childhood obesity by 20% by 2018
Barlow SE. Pediatrics. 2007 Dec;120 Suppl 4:S164-92.
Paediatric Weight Management
Barlow SE. Pediatrics. 2007 Dec;120 Suppl 4:S164-92.
Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents; National Heart, Lung, and Blood Institute.Pediatrics. 2011 Dec;128 Suppl 5:S213-56.
Takes place in the office setting

Eating plan formulated by dietitian [e.g. Cardiovascular Health Integrated Lifestyle Diet (CHILD-1) & DASH]

Staff members with training in motivational interviewing and teaching of monitoring and reinforcement techniques

Access to counselor for help with parenting skills, resolution of family conflict, or motivation

Referral to exercise therapist

Monthly office visits are probably most appropriate at this level
Stage 2: Structured Weight Management
Langley GL, Moen R, Nolan KM, Nolan TW, Norman CL, Provost The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (2nd edition). San Francisco: Jossey-Bass Publishers; 2009.

Barlow SE. Pediatrics. 2007 Dec;120 Suppl 4:S164-92.
Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents; National Heart, Lung, and Blood Institute.Pediatrics. 2011 Dec;128 Suppl 5:S213-56.

Takes place in the office setting

National Physical Activity & Dietary Guidelines – reduced screen time, elimination of sugar-sweetened beverages, etc.

Follow-up visit frequency tailored to individual family, and motivational interviewing techniques may be useful to set the frequency

Physicians, advanced practice nurses, physician assistants, and office nurses, with appropriate training, can provide this level of treatment

Stage 1: Prevention Plus
Barlow SE. Pediatrics. 2007 Dec;120 Suppl 4:S164-92.
Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents; National Heart, Lung, and Blood Institute.Pediatrics. 2011 Dec;128 Suppl 5:S213-56.

A multidisciplinary team with experience in childhood obesity

Behavioral counselor

Dietitian

Exercise specialist

Primary care provider

Frequent office visits should be scheduled; weekly visits for a minimum of 8 to 12 weeks seem to be most efficacious

Subsequently, monthly visits can help maintain new behaviors
Stage 3: Comprehensive Multidisciplinary Intervention

Barlow SE. Pediatrics. 2007 Dec;120 Suppl 4:S164-92.
Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents; National Heart, Lung, and Blood Institute.Pediatrics. 2011 Dec;128 Suppl 5:S213-56.

Severely obese youth

Multidisciplinary team

Standard clinical protocols for patient selection, evaluation before, during, and after intervention

Focus on the physical and emotional effects of the treatment

Bariatric surgery
Stage 4: Tertiary Care Intervention
Network Working Groups
Performance Measurement and Evaluation Working Group

Resources Working Group

Professional Development Working Group
What Works?
Early intervention

Moderate intensity to high intensity intervention (26–75 hours) of sufficient duration (≥ 6 months)

Behavioral-based with exercise and dietary components

Parent-only, and parent-child group sessions

Structured exercise training

Follow-up contact during maintenance (monthly for 6 months)
But by how much?
BMI: -1.25 kg/m2 (95% CI: -2.18 to -0.32)
BMI z score: -0.10 (95% CI: -0.18 to -0.02)
LDL-C: -0.30 mmol/L (95% CI: -0.45 to -0.15)
TG: -0.15 mmol/L (95% CI: -0.24 to -0.07)
HDL-C: No change
Fasting insulin: -55.1 pmol/L (95% CI: -71.2 to -39.1)
Blood Pressure:
−1.69 mm Hg (95% CI: −3.15 to −0.24, study length < 6 months)
−3.72 mm Hg (95% CI: −4.74 to −2.69, study length 1 year)

Lifestyle vs. usual care:
Immediate: -1.30 kg/m2 (95% CI -1.58 to -1.03)
Post-treatment up to 1 year: -0.92 kg/m2 (95% CI -1.31 to -0.54)
Coppock JH. Curr Treat Options Cardiovasc Med. 2014 Nov;16(11):343.
Ho M. Pediatrics 2012; 130(6): e1647-1671.
Ho M. JAMA pediatrics 2013; 167(8): 759-768.
Whitlock EP. Pediatrics. 2010 Feb;125(2):e396-418.
Ho M. Pediatrics 2012; 130(6): e1647-1671.
27 – 73%

Family and demographic factors (e.g. race/ethnicity, insurance status, patient and parental BMI)

Program logistics and components (e.g. unfulfilled expectations, inconvenient appointment times)

Emotional and behavioral health problems (e.g. depression, low self-esteem)
Attrition
Barlow SE. Clin Pediatr (Phila). 2006 May;45(4):355-60.
Gaffka S. Child Obes. 2013 Oct;9(5):409-17.
Hampl S. Clin Pediatr (Phila). 2013 Jun;52(6):513-9.
Skelton JA. Obes Rev. 2011 May;12(5):e273-81.
Zeller M. J Pediatr. 2004 Apr;144(4):466-70.
Family-Based Behavioral Treatment & Parent-Only Behavioral Treatment

Clinical and community components

Produce small decreases or stabilize the rate of child and adolescent weight gain consistent with current recommendations for the treatment of paediatric obesity

Innovative and multifaceted; leveraging information technology and community-based resources

Patient/Family-centered, incorporate experience-based co-design

Preoccupation with quality and performance
The KidFit Clinic
KidFit Team
Paediatric Endocrinologist - Ian Zenlea

Registered Nurse/Project Coordinator - Carla Ulloa

Child Psychologist - Brooke Halpert

Social Worker - Erin Lipsitt

Dietician - Jennifer Green

Activity Therapist - Lisa Metzger

Project Manager - Alexandra Wills
Obese youth ages 2 – 17 years old

Priority given to youth with severe, complex obesity

Enrollment by referral from physician or self-referral
Referral Criteria
Medical Screening
1. Evaluate possible underlying diagnoses that may have contributed to the development of obesity

2. Identify physiological sequelae of obesity

3. Provide data for monitoring progress and response to treatment
Estrada E. Child Obes. 2014 Aug;10(4):304-17.
43% combined dyslipidemia - Low HDL-C, elevated TG +/- Low LDL-C

Children >2 y of age if BMI ≥ 85th percentile

1. Universal screening can be initiated with either:
a. Non-HDL-C: TC - HDL-C non-fasting
b. Fasting lipid panel

2. Abnormal levels should be confirmed with a repeated fasting test, especially for TG irregularities

Dyslipidemia
Irregular menses at least 2 years following menarche OR signs of hyperandrogenism (hirsutism, acne)

17-OH progesterone, total testosterone, free testosterone, LH, FSH, sex-hormone binding globulin, estradiol, prolactin, TSH
Polycystic Ovary Syndrome

Zacharia JP. Endocrinol Metab Clin North Am. 2014 Dec;43(4):981-92.
Undiagnosed type 2 diabetes (T2D) is very rare in the adolescent population

Targeted screening
Obesity (BMI ≥95th percentile for age and gender)
Member of a high-risk ethnic group (e.g. Aboriginal, African, Asian, Hispanic or South Asian descent)
Family history of type 2 diabetes and/or exposure to hyperglycemia in utero
Signs or symptoms of insulin resistance (including acanthosis nigricans)

Hemoglobin A1c or 2 hour OGTT


Type 2 diabetes
Estrada E. Child Obes. 2014 Aug;10(4):304-17.
Zeitler P. Pediatric Diabetes 2014: 15(Suppl. 20): 26–46.
Zeitler P. Pediatric Diabetes 2014: 15(Suppl. 20): 26–46.
Estrada E. Child Obes. 2014 Aug;10(4):304-17.
Information Session
Comprehensive Multidisciplinary Intake Assessment
KidFit Clinic (Credit Valley Hospital)
Duration of 3.5 hours in 2 appointments over 2 weeks

Medical

Behavioral and Mental Health

Dietary

Physical Activity and Sendentary Behavior

Individualized treatment and follow-up plans
Phase 1: Intensive Intervention
KidFit Community
10 - 12 weekly group sessions

2 - 3 month intervention

1.5 - 2 hour group sessions

Deliver curriculum – nutritional education, behavioral counseling, physical activity

Phase 2: Active Maintenance
KidFit Community
Bi-weekly group sessions

3-month intervention

1 – 1.5 hour group sessions

Engage families in long-term planning, problem-solving

Parenting skills to promote maintenance of diet and activity changes


Phase 3: Maintenance
KidFit Clinic & Community
Individual visits every 3 – 6 months

Community Partnerships (e.g. Peel Public Health, Parks & Recreation, Loblaws, YMCA)
Conclusions
Canada challenged by childhood overweight and obesity

Multidisciplinary weight management programs of moderate intensity to high intensity intervention (26–75 hours) of sufficient duration (≥ 6 months) with behavioral-based, exercise, and dietary components are the most effective

Consensus Guidelines exist for the screening and evaluation of obesity-related co-morbidities
Conclusions
Ontario is dedicating resources to combat obesity

Trillium Health Partners + Medavie Foundation + Ontario MOHLT = The KidFit Health and Wellness Clinic
Acknowledgements
Dr. Ann Bayliss
Dr. Dante Morra
KidFit Team

Trillium Health Partners Foundation

Medavie Health Foundation

Institute for Better Health

Ontario MOHLT
Huntington-Ashland-W.Va.-Ky.-Ohio
39.5% Obese
What about behavioral and mental health problems and psychosocial stressors?
Negative affect (depression, anxiety, stress and coping)
Body Image, self esteem
Peer influence (teasing, bullying, support)
Cognitive/Academic functioning (e.g., identified neurodevelopmental disorders)
School attendance and supports ( e.g., accommodations and/or modifications)
Financial stressors, food insecurity
Family stressors and functioning
Trauma, abuse and/or substance use histories
Therapeutic use of psychotropic medications (e.g., SSRIs)
Caregiver / parent / family mental health

Equitable
access

to timely, high quality, evidence-based, family-centred care
at the appropriate level for children and youth in Ontario as close to home as possible

Equitable
access to specialized services

Geographical networks
to support patient flow to provide the most appropriate level of care (including primary care), support the transition of patients to adult care

Leading
evidence-based practice
, standards of care to guide delivery of
quality
patient care in a
timely, safe, effective and efficient
manner
Data and information systems
to inform practice, policy, and promote accountability

Strategy-relevant
performance measurement
indicators and an accountability framework

A
human resource plan
to ensure sustainable delivery of paediatric obesity services

Provider
training
and continuing
education

Identifying or developing and
sharing resources
to build knowledge capacity and strengthen partnerships with community providers
Mission
Mission
Provincial Council for Maternal and Child Health’s Child and Youth Advisory Committee

Ontario Ministry of Health and Long-Term Care
Accountability
Comprehensive Paediatric Assessment
Medical and mental health history

Nutrition, physical activity, sleep and sedentary behaviours

Home environment, school functioning, family and peer relations

Bullying, body image and disordered eating symptoms

Identifiable strengths, supports, and readiness to change
Ebbling C. et al. Volume 360, No. 9331, p473–482, 10 August 2002
Ask
Ask for permission to discuss child’s weight, using a sensitive manner and being aware of weight bias and cultural influences

Be nonjudgmental while gauging readiness to change
Assess
Underlying cause and contributing factors
Ask about enablers and barriers in weight management

Conduct physical and mental health assessment to address complications
Advise
Agree
Provide information about obesity related risks, investigations and treatments

Stress importance of achieving behavioural and health -related improvements rather than focusing primarily on weight loss
Aim to have child and family choose behavioural goals themselves, with clinician or health care professional assistance

Assess confidence in achieving goals, use motivational interviewing techniques

Agree on small number of SMART (specific, measurable, achievable, realistic, timely) goals
Assist
Summarize management plan and propose solutions to address and mitigate

Provide additional available resources

Arrange for follow-up within a short time frame
Altman M. et al. Journal of Clinical Child & Adolescent Psychology,44(4), 521–537,2015
Altman M. et al. Journal of Clinical Child & Adolescent Psychology,44(4), 521–537,2015
SickKids Team Obesity Management Program (STOMP)
Mitigating Potential Bias
The content of this presentation is not influenced by the Medavie Health Foundation or Ministry of Health and Long-Term Care.
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