Bonnie A. Spear

Recommendations for Treatment of Child and Adolescent Overweight and Obesity

In this article, we review evidence about the treatment of obesity that may have applications in primary care, community, and tertiary care settings. We examine current information about eating behaviors, physical activity behaviors, and sedentary behaviors that may affect weight in children and adolescents. We also review studies of multidisciplinary behavior-based obesity treatment programs and information about more aggressive forms of treatment. The writing group has drawn from the available evidence to propose a comprehensive 4-step or staged-care approach for weight management that includes the following stages: (1) Prevention Plus; (2) structured weight management; (3) comprehensive multidisciplinary intervention; and (4) tertiary care intervention. We suggest that providers encourage healthy behaviors while using techniques to motivate patients and families, and interventions should be tailored to the individual child and family. Although more intense treatment stages will generally occur outside the typical office setting, offices can implement less intense intervention strategies. We not ony address specific patient behavior goals but also encourage practices to modify office systems to streamline office-based care and to prepare to coordinate with professionals and programs outside the office for more intensive interventions.

Consensus Statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition Indicators Recommended for the Identification and Documentation of Pediatric Malnutrition (Undernutrition)

The Academy of Nutrition and Dietetics (the Academy) and the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), utilizing an evidence-informed, consensus-derived process, recommend that a standardized set of diagnostic indicators be used to identify and document pediatric malnutrition (undernutrition) in routine clinical practice. The recommended indicators include z scores for weight-for-height/length, body mass index-for-age, or length/height-for-age or mid-upper arm circumference when a single data point is available. When 2 or more data points are available, indicators may also include weight gain velocity (<2 years of age), weight loss (2-20 years of age), deceleration in weight for length/height z score, and inadequate nutrient intake. The purpose of this consensus statement is to identify a basic set of indicators that can be used to diagnose and document undernutrition in the pediatric population ages 1 month to 18 years. The indicators are intended for use in multiple settings (eg, acute, ambulatory care/outpatient, residential care). Several screening tools have been developed for use in hospitalized children. However, identifying criteria for use in screening for nutritional risk is not the purpose of this paper. Clinicians should use as many data points as available to identify and document the presence of malnutrition. The universal use of a single set of diagnostic parameters will expedite the recognition of pediatric undernutrition, lead to the development of more accurate estimates of its prevalence and incidence, direct interventions, and promote improved outcomes. A standardized diagnostic approach will also inform the prediction of the human and financial responsibilities and costs associated with the prevention and treatment of undernutrition in this vulnerable population and help to further ensure the provision of high-quality, cost-effective nutritional care.

Adolescence as a Critical Stage in the MCH Life Course Model: Commentary for the Leadership Education in Adolescent Health (LEAH) Interdisciplinary Training Program Projects

The Life Course Perspective (LCP), or Model, is now a guiding framework in Maternal and Child Health (MCH) activities, including training, supported by the Health Resources and Services Administration’s Maternal and Child Health Bureau. As generally applied, the LCP tends to focus on pre- through post-natal stages, infancy and early childhood, with less attention paid to adolescents as either the “maternal” or “child” elements of MCH discourse. Adolescence is a distinct developmental period with unique opportunities for the development of health, competence and capacity and not merely a transitional phase between childhood and adulthood. Adequately addressing adolescents’ emergent and ongoing health needs requires well-trained and specialized professionals who recognize the unique role of this developmental period in the LCP.

Obesity and Nutrition

Obesity in America has reached epidemic proportions. It has been called a major health care crisis. In little over a decade, between 1971–1980 and 1988–1991, the prevalence of significantly overweight adults in the United States rose by 33%, far from the decrease of 23% targeted by the US Public Health Service. Currently, 20% of adolescent children and approximately one third of all adults in America are defined as obese. Minority populations, especially minority women, are disproportionately affected; nearly 50% of African-American women are overweight. Overweight and obese adults are at increased risk for morbidity and mortality associated with acute and chronic medical conditions including hypertension, elevated serum lipid levels, coronary artery disease, diabetes mellitus, respiratory disease, certain types of cancer, gout, and arthritis (American Dietetic Association, 1997).

Incorporating the life course model into MCH nutrition leadership education and training programs.

Life course perspective, social determinants of health, and health equity have been combined into one comprehensive model, the life course model (LCM), for strategic planning by US Health Resources and Services Administration’s Maternal and Child Health Bureau. The purpose of this project was to describe a faculty development process; identify strategies for incorporation of the LCM into nutrition leadership education and training at the graduate and professional levels; and suggest broader implications for training, research, and practice. Nineteen representatives from 6 MCHB-funded nutrition leadership education and training programs and 10 federal partners participated in a one-day session that began with an overview of the models and concluded with guided small group discussions on how to incorporate them into maternal and child health (MCH) leadership training using obesity as an example. Written notes from group discussions were compiled and coded emergently. Content analysis determined the most salient themes about incorporating the models into training. Four major LCM-related themes emerged, three of which were about training: (1) incorporation by training grants through LCM-framed coursework and experiences for trainees, and similarly framed continuing education and skills development for professionals; (2) incorporation through collaboration with other training programs and state and community partners, and through advocacy; and (3) incorporation by others at the federal and local levels through policy, political, and prevention efforts. The fourth theme focused on anticipated challenges of incorporating the model in training. Multiple methods for incorporating the LCM into MCH training and practice are warranted. Challenges to incorporating include the need for research and related policy development.

148 ASSESSMENT AND TREATMENT OF OBESITY IN A PRIMARY CARE ADOLESCENT PRACTICE.

Purpose The purpose of this study was to determine the rate of assessment and treatment of adolescent patients greater than the 85th percentile BMI in a primary care adolescent clinic. This study will provide baseline data to develop a screening and intervention program for overweight/obese adolescents. Methods All adolescents (11-18 yrs) who had primary care visits and were seen in a 3 mo period were eligible for inclusion in the study. Of the 367 reviewed charts only 261 had well-child visits and were included in the study. Results 78.9% female, 40.6% had BMIs > 85th percentile, with 27.2% > 95th percentile. Only 30.3% had BMIs calculated and only 16.5% BMIs plotted with 41% of those in the > 95th percentile category. Of the teens between 85th and 95th BMI, only 29% received counseling (22% from MD and 78% from RD). Only 45% who were > 95th percentile BMI received counseling (28% from MD and 72% from RD). Since the majority were female we also looked at contraceptive use. There were no significant differences in BMI found between those using contraceptive (OCPs, patch or Depo) and those not using contraceptive. Forty-seven percent of those with > 95th percentile BMI had BP > 95th percentile for age and height. The frequency of symptoms were asthma, 19.5%; joint pain, 16.1%; acanthosis nigricans, 6.5%; PCOS, 2.3%; sleep apnea symptoms, 1.1%. Conclusions Despite a high number of overweight/obese patients (40.6%) routine screening with BMI was limited and few were counseled for weight loss despite other comorbidities (BP > 95th percentile and physical symptoms). Improvements in BMI screening are needed as well as the development of a practical screening and intervention tool, which would greatly enhance care for this population.

149 ADOLESCENT WEIGHT PERCEPTIONS, CONCERNS, AND MANAGEMENT PRACTICES.

Background Adolescents at risk for overweight, who would benefit from long-term lifestyle changes, may resist weight management counseling if they consider their weight to be healthy or are not concerned about their weight. The purpose of this study was to examine the self-perceptions and concerns of adolescents related to their weight and weight management. Methods We surveyed 100 adolescent health-fair participants, 14-19 years old, in an urban minority community. This sample was primarily African American (95%) and female (74%). Participants completed a one-page survey consisting of questions about height, weight, family history of obesity-related conditions, self-description of their weight, and methods to manage their weight. Results Calculated from self-reported heights and weights, 40% of the adolescents had a body mass index (BMI)

255 LEVEL OF PHYSICAL ACTIVITY, DIETARY HABITS AND BODY MASS INDEX IN RURAL YOUTH PARTICIPATING IN 2003 NATIONAL YOUTH SPORTS PROGRAM

85thpercentile for age, gender, and height, though only 27% of the population described themselves as overweight. Diabetes (58%) and hypertension (62%) were the most prevalent conditions reported by family history. The most popular methods for weight management were increasing physical activity (58%) and eating more fruits and vegetables (55%). Although 58% of the youth considered themselves to have a healthy weight, the 70% of the sample were trying to do something about their weight. Adolescents in the overweight category (BMI

Adolescent growth and development.

85th percentile), as compared to those in the normal weight category, were more likely to report a family history of high cholesterol (p = .029), described themselves as overweight (p = .001), described their weight as unhealthy (p = .034), were concerned about their weight (p = .015), were trying to do something about their weight (p = .0001), and used eating less sweets as a method of weight control (p = .01). Conclusions Our findings suggest that overweight and normal weight youth are concerned about their weight and using weight management strategies, although those at risk for overweight do not perceive themselves to have this risk. Health care professionals can educate youth about their personal health risks related to overweight, encourage already existing healthful weight management methods, and point adolescents toward other healthy lifestyle changes in counseling adolescents regarding weight management practices.

Does dieting increase the risk for obesity and eating disorders

Purpose To determine the prevalence of youth who have a body mass index (BMI) ≥ 85th percentile and related characteristics (elevated blood pressures, dietary and physical habits) among rural participants. Methods Cross-sectional assessment of adolescents (ages 10 to 14 years) participating in the 2003 National Youth Sports Program (NYSP) in a rural southeastern US city was done. Heights, weights, and blood pressures were collected during pre-participation examinations. BMIs and percentiles were calculated based on gender standards. During the first week of the 2003 NYSP, a questionnaire regarding dietary habits and physical activities was administrated. Descriptive and bivariate analyses were performed using SPSS software. Results 236 youth (mean age 11.9 years) had pre-participation examinations; 8 were excluded for invalid variables, resulting in 228 analyzable participants. The mean BMI percentile was at the 70th (range 1-99th). 42% (N = 99) of the youth had a BMI ≥ 85th percentile for their age and gender. Having an elevated systolic or diastolic blood pressure (greater than 90th percentile for height and gender) was significantly associated with having a BMI ≥ 85th percentile (p = .015 and p = .022 respectively). Of those who received medical assessments, 124 youth had completed questionnaires. 85% of respondents reported both eating less than 4 fruits and vegetables per day; 78% had 2 or more sodas per day, and 50% drank milk one time or less per day. Fast food was eaten more than twice per week by 81% of participants and 59% visited the convenience store more than twice per week for snacks. 61% stated that they ate breakfast five times or less per week. From the questions regarding physical activity, 78% and 57% of youth respectively watched TV or played computer/video games more than 3 hours per day. 68% stated that there was not a park near their house, with 71% stating that they did not feel safe getting physical activity at a park. Nearly half (48%) did not participate in a sport team after school. No significant associations between having a BMI ≥ 85th percentile and these dietary or physical activity habits were found. Conclusions The study demonstrated the need for interventions to promote healthy eating and physical activities in rural NYSP participants. Programs targeting obesity prevention and intervention as well as blood pressure control are feasible in this setting. The NYSP, often implemented through venues at historically black universities/colleges, is attended by over 50,000 disadvantaged youth annually.