The Quarterly Consult is a quarterly publication highlighting pediatric clinical expertise. If you would like to submit questions for a specialist at Children's to address in the Quarterly Consult, contact Kim Arthur, editor.
October 2012: Managing Overweight and Obesity
Dr. Lenna Liu, physician with Seattle Children's Obesity Program and primary care pediatrician at Odessa Brown Children's Clinic, addresses questions about managing patients who are overweight or obese. Thank you to Dr. Wendy Sue Swanson, a pediatrician at The Everett Clinic in Mill Creek and member of Children's medical staff, for submitting these questions.
Q. What is the current data on best practices for notifying and talking with children and teens who are at risk, overweight or obese? I use the term "unhealthy weight" a lot. What else can we do to have a conversation without stigmatizing and upsetting children and teens?
A. These are challenging issues. First of all, it's key to build a trusting relationship with a child and family before discussing this issue. You may want to ask permission first. You can ask, "Is it OK if we talk about your child's growth and weight today?" It may also be easier to have an open discussion without the child in the room.
I agree with your choice of "unhealthy weight" rather than "obese." I think these terms (overweight or obese) are useful for practitioners but can certainly affect a child's self-esteem. It's important to start counseling early. Obesity research has found a predisposition for obesity at young ages and even in utero. Excessive maternal weight gain during pregnancy can predispose an infant to developing obesity.
I start counseling about respecting hunger and fullness cues in early infancy and talk to parents about normal changes in growth in the first few years. Much of the anticipatory guidance we give in infancy, toddler and preschool years supports obesity prevention.
I review a child's growth chart with parents at every visit from birth on and emphasize that children should grow along their percentile lines. When they are gaining weight too quickly or their body mass index (BMI) rises earlier than expected for age according to the BMI growth chart (e.g., an early adiposity rebound), we can have a preventative discussion about addressing eating and activity at younger ages when it is easier to change.
For children of all ages, it's helpful to shift the focus of the conversation from weight to health behaviors that can be modified, such as increasing physical activity and reducing screen time and consumption of sugary drinks.
Q. Which overweight or obese children need a lipid panel, glucose level, liver function tests (LFTs) or a HA1C? What are your recommendations for intervals of screening labs - every year, every two years, at age 11 and 17?
A. The American Academy of Pediatrics and American Medical Association recommend fasting glucose, lipid panel, aspartate aminotransferase (AST) and alanine aminotransferase (ALT) beginning at age 8 for children who are overweight (85th to 94th percentile) with risk factors (e.g., minority race or ethnicity, family history of diabetes or obesity-related comorbidity, acanthosis nigricans or other evidence of insulin resistance, etc.) or obese (95th percentile or greater). These screening labs are recommended every two years.
Q. Most of us have overweight or obese patients whom we see year after year without improvement. Some children don't make progress even with referrals to the ACT! (Actively Changing Together!) program, nutrition referrals and ongoing motivational interviewing in the office. Do you have any tips for the best research-driven next steps?
A. Thanks for integrating nutrition, motivational interviewing and referrals to the ACT! program into your practice! It is true that many families find it hard to change, even with support. Change is very difficult. Our culture doesn't readily support families who want to make these changes. Furthermore, these issues are often not the most pressing for a family and they are not ready to address them yet.
I think it is our role to be patient and supportive, keep the issue on their radar screen and let them know that we are available to help when they are ready.
In terms of changes that make a big difference, I'd say sugar-sweetened beverages are the largest contributor at all ages. Reducing consumption of sugary drinks and soda can really help us meet U.S. federal goals for reducing obesity rates.
By 2020, children in the United States need to eliminate an average of 64 excess calories per day to meet federal goals (Gortmaker et al. 2012). That's less than half the calories in one can of soda!
In fact, Seattle Children's has just implemented a new initiative to eliminate all sugar-sweetened beverages and offer healthier food choices in the hospital cafeteria and vending machines at all locations.
It's also helpful to encourage families to do activities they enjoy, including family activities like cooking together. I recommend making changes as a whole family, rather than trying to make changes for one person in the family. It's a good idea to start small. Small changes add up.
Q. At what intervals do you think it is best to follow children with overweight or obesity? Should they return to recheck body mass index, stats and weight and receive ongoing care every three to six months or just annually?
A. It is recommended that we follow up with these children more regularly. However, in practice it depends on their motivation. If there is no motivation, we can bring them back for counseling, but often they will not show up. Motivational interviewing can help build readiness.
Once a family is motivated, having frequent visits is key. Visit frequency can be tailored to the degree of support that a family needs.
More frequent visits for nutrition counseling can be very helpful. Our dietitians at Seattle Children's Child Wellness Clinic see parents every two weeks for four months when they are motivated. The dietitians work to support parents in making changes and monitor their progress every few weeks.
Q. How often do you recommend teens weigh themselves? Is there any data to back up recommendations?
A. In general I don't think teens should weigh themselves regularly. Our society is much too focused on weight in an unhealthy way.
According to a five-year observational study involving 2,500 teens, females who self-weighed had a higher association with disordered eating. No association was found for males (Neumark-Sztainer et al. 2006). Among younger teen females, weight increased over time among those with frequent self-weighing.
On the other hand, a smaller study showed that overweight teens who weighed themselves at least once a week were more likely to engage in other healthy weight behaviors than teens who weighed themselves less frequently (Alm et al. 2009).
The research is still out on this issue. In the end, it probably depends on the teen and if they are managing their weight in a healthy way or not.
Alm ME, et al. Self-weighing and weight control behaviors among adolescents with a history of overweight. J Adolesc Health. 2009 May;44 (5):424-30.
Wang YC, Orleans CT, Gortmaker SL. Reaching the healthy people goals for reducing childhood obesity: closing the energy gap. Am J Prev Med. 2012 May;42 (5):437-44.
Neumark-Sztainer D, van den Berg P, Hannan PJ, Story M. Self-weighing in adolescents: helpful or harmful? Longitudinal associations with body weight changes and disordered eating. J Adolesc Health. 2006 Dec;39 (6):811-8.