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Managing Adolescent Obesity in an Urban Clinic
- 1. Caring for Adolescents with Obesity in an Urban Clinic Julia Joseph-Di Caprio, M.D., M.P.H. HCMC Chief of Pediatrics
- 2. I have nothing to disclose.
- 3. Objectives Upon completion of this session, participants should be better able to: • Discuss an adolescent’s obesity with them and their parent. • Develop plans with adolescents from diverse backgrounds and their parents for the management of the adolescents’ obesity (plans that have a chance of working).
- 4. Clinical Pearls • Clinicians should talk about an adolescent’s weight with them, but the focus should be on healthy living, not dieting. • Parents should not talk about weight with their adolescent, but modeling healthy behaviors is recommended. • Most youth will not take part in intensive weight loss programs, but clinicians can use diet and exercise recommendations, community programs, and new media technologies to manage an adolescent’s obesity with them and their parents.
- 6. Adolescent Obesity in the U.S. Percentage of high school students who were obese* — selected U.S. states, Youth Risk Behavior Survey, 2003
- 7. Adolescent Obesity in the U.S. Percentage of high school students who were obese* — selected U.S. states, Youth Risk Behavior Survey, 2005
- 8. Adolescent Obesity in the U.S. Percentage of high school students who were obese* — selected U.S. states, Youth Risk Behavior Survey, 2007
- 9. Adolescent Obesity in the U.S. Percentage of high school students who were obese* — selected U.S. states, Youth Risk Behavior Survey, 2009
- 10. Adolescent Obesity in the U.S. Percentage of high school students who were obese* — selected U.S. states, Youth Risk Behavior Survey, 2011
- 11. Adolescent Obesity in the U.S. American Heart Association. Circulation, 2011
- 12. Adolescent Obesity in the U.S. Ogden CL, et al. JAMA. 2012 Prevalence of Obesity and Trends in Body Mass Index Among US Children and Adolescents, 1999-2010
- 13. Adolescent Obesity in the U.S. Ogden CL, et al. JAMA. 2012
- 14. Adolescent Obesity in Minnesota Minnesota Student Survey Trends Report 2010
- 15. Adolescent Obesity in Minnesota Minnesota Student Survey Trends Report 2010
- 16. Adolescent Obesity in Minnesota Minnesota Student Survey Trends Report 2010
- 17. Adolescent Obesity in Hennepin County
- 18. Adolescent Obesity in Hennepin County
- 19. Mental health and overweight BeLue, et al. Pediatrics, 2008
- 20. Objectives Upon completion of this session, participants should be better able to: • Discuss an adolescent’s obesity with them and their parent. • Develop plans with adolescents from diverse backgrounds and their parents for the management of the adolescents’ obesity (plans that have a chance of working).
- 21. How to talk about weight Puhl, et al, Pediatrics 2011
- 22. How to talk about weight Puhl, et al, Pediatrics 2011
- 23. Neumark-Sztainer, et al. Pediatrics, 2008
- 25. Objectives Upon completion of this session, participants should be better able to: • Discuss an adolescent’s obesity with them and their parent. • Develop plans with adolescents from diverse backgrounds and their parents for the management of the adolescents’ obesity (plans that have a chance of working).
- 26. The twenty minute office visit evaluation/intervention • Labs, family history-the “hook”? • Diet review with recommendations • Exercise and media review with recommendations
- 30. You need to drop a few pounds • Nutrition • Psychology • Medications • Bariatric surgery • Community programs Taking Steps Together Youth Determined to Succeed • Apps and other new technology solutions
- 31. You need to drop a few pounds Chanoine, et al. JAMA, 2005
- 32. You need to drop a few pounds Srinivasan, et al. J Clin Endocrinol Metab, 2006
- 33. You need to drop a few pounds O’Brien PE, et al. JAMA, 2010
- 34. You need to drop a few pounds • Nutrition • Psychology • Medications • Bariatric surgery • Community programs Taking Steps Together Youth Determined to Succeed • Apps and other new technology solutions
- 36. YDS focus groups • 6 males and 8 females • 13-18 years • Grades: 8th to college • Social media used:Instagram, Twitter, Snap Chat, Tumblr, Facebook, You Tube, Pinterest, Gmail, Facetime, Skype, text messages • To get YDS message out: Facebook and Twitter • Twitter: must be inspiring tweets, don’t retweet, don’t recycle tweets, no more than 3-12 tweets per day • Use Instagram for before and after pictures • Use You Tube for training videos, PSAs
- 38. You need to drop a few pounds
- 39. You need to drop a few pounds www.drj4teenhealth.com @DrJ4TeenHealth
- 41. Clinical Pearls • Clinicians should talk about an adolescent’s weight with them, but the focus should be on healthy living, not dieting. • Parents should not talk about weight with their adolescent, but modeling healthy behaviors is recommended. • Most youth will not take part in intensive weight loss programs, but clinicians can use diet and exercise recommendations, community programs, and new media technologies to manage an adolescent’s obesity with them and their parents.
Notas del editor
- Hello,I’m Julia Joseph-Di Caprio. I’m the Chief of Pediatrics at HCMC and it’s my pleasure to speak about “Caring for Adolescents with Obesity in and Urban Clinic.”
- I have nothing to disclose.
- List Objectives
- List Clinical Pearls.
- In addition to being the Chief of Pediatrics at HCMC, I practice adolescent medicine with a smattering of general pediatrics added in at the always busy HCMC hospital and our community clinics. As such, I see many youth and families that are struggling with childhood and adolescent overweight and obesity. This is a challenge for me and many other clinicians because over one-third of 12-19 year olds in the United States have a body mass index greater than or equal to the 85th %, that is they are overweight. About 18% of 12-19 year olds are obese, that is their BMI is greater than the 95th %.
- These maps using the CDC Youth Risk Behavior Survey data from 2003 through 2011, show the increasing challenge obesity poses for U.S. high school students. Some states, like Minnesota, have no data because they do not participate in the YRBS. Minnesota administers it’s own survey, the Minnesota Student Survey. I will talk about that data in a moment. These maps from the YRBS demonstrate that more states have 10 or more percent of high school students with obesity.
- But what is obvious from this slide is that, yes the prevalence of obesity has significantly increased in youth from the 1970s to now, but since 2003 the rise in the percent of youth with obesity appears to slowed.Trends in the prevalence of obesity among US children and adolescents by age and survey year (National Health and Nutrition Examination Survey: 1971–1974, 1976–1980, 1988–1994, 1999–2002, 2003–2006 and 2007–2010). Data derived from Health, United States, 2011 (National Center for Health Statistics).AHA Statistical UpdateHeart Disease and Stroke Statistics—2013 UpdateA Report From the American Heart AssociationCirculation. 2013; 127: e6-e
- This data from National Health and Nutrition Examination Survey 2009-2010, which is a representative, cross-sectional survey of birth to 19 year olds, illustrates this plateau. The overall prevalence of obesity in children and adolescents (2-19 year olds) is 16.9% which was unchanged from 2007-2008. Boys were more obese than girls and the BMI for boys continues to increase while that for girls as decreased. Further, there are disparities by ethnicity, with non-Hispanic youth having higher BMIs, but they have significantly lower levels of body fat than Mexican-American youth and non-Hispanic white children at the same BMI. The trend is important however, and these graphs indicate increases for non-Hispanic black boys, high prevalence in Mexican American boys, and non Hispanic black girls. I see these higher rates of obesity in my patients at HCMC because more than two-thirds of adolescents who seek care at HCMC are insured by public programs, and almost 90% self identify as African-American, Latino, Somali, Native American, or Hmong.
- Significant differences in obesity prevalence by race/ethnicity were found. In 2009-2010, 21.2% (95% CI, 19.5%-23.0%) of Hispanic children and adolescents and 24.3% (95% CI, 20.5%-28.6%) of non-Hispanic black children and adolescents were obese compared with 14.0% (95% CI, 11.7%-16.7%) of non-Hispanic white children and adolescents.So overall, during the past 12 years (1999-2010), the odds of being obese were significantly higher for non-Hispanic black males (OR, 1.27; 95% CI, 1.09-1.48) and females (OR, 1.99; 95% CI, 1.69-2.35) and Mexican American males (OR, 1.81; 95% CI, 1.56-2.09) and females (OR, 1.47; 95% CI, 1.23-1.76) compared with both non-Hispanic white males and females after controlling for age and survey period.When combining all survey years together, children aged 2 through 5 years had a lower odds of obesity (males: OR, 0.58; 95% CI, 0.48-0.70; females: OR, 0.62; 95% CI, 0.51-0.74) compared with adolescents aged 12 through 19 years after adjusting for survey period and race/ethnicity. The odds of obesity were not significantly different for children aged 6 through 11 years compared with adolescents aged 12 through 19 years (males: OR, 1.02; 95% CI, 0.90-1.15; females: OR, 0.95; 95% CI, 0.82-1.08).
- In Minnesota, the Minnesota Student Survey is administered every 3 years to 6th, 9th, and 12th graders. The 2010 MSS reveals that overall the number of youth who feel they are overweight has not changed mush since the 1990s.
- Here’s the data for boys.
- Here’s the data for girls. Nevertheless, despite plateauing the percentage is too high.
- One can get data on overweight in Hennepin County by looking at the Survey of the Health of All the Population and Environment or SHAPE survey which is conducted every 4 years in Hennepin County and collects data on health status and factors that affect residents’ health. The last survey was conducted in 2012 and included a child survey. One child in a household was selected from randomly sampled households. The survey was completed by the adult most knowledgeable about the selected child. Overall, 6% reported that of the 0-17 year old selected a health professional had told them that the child weighed too much. This seems to be an underreporting. The highest prevalence was in 14-17 year olds, over 25%, with over one quarter of adults reporting that no professional had ever said anything about the child’s weight. Almost 1 in 3 18-24 year olds in Minneapolis consider themselves overweight, perhaps a more accurate reporting.
- Most adults reported that they felt that the child was at the right weight, with only about 6.0% feeling the child was overweight. Does it matter that these parents seem to be underreporting their child’s overweight? I’ll talk about this in a moment. But, first, I’ll touch on overweight and mental health problem in youth.
- In my practice it is important to recognize the association between overweight and mental health problems because youth with mental health problems may not be able to initiate or maintain the lifestyle changes needed to achieve a healthy weight. To get sense of the number of youth this involves—a study published in 2009 using data for 12-17 year olds in the National Survey of Children’s Health, found that reports of mental health problems increased with increasing BMI; that is overweight youth are more likely to have a mental health problem, like anxiety and depression, versus youth of normal weight. This study did not determine causality, but I see youth struggling with both mental health issues and overweight often in my practice.
- How should a clinician discuss weight with a parent and youth? Well, parents of 2-18 year olds were surveyed in 2010 (data published in 2011), found that parents preferred the terms “weight” or “unhealthy weight” as opposed to “fat,” “extremely obese,” and “obese.” These 3 terms were found to be the most stigmatizing and blaming by parents and the least likely to motivate weight loss. The study found the terms “unhealthy weight,” “weight problem,” or “overweight” to be the most motivating.
- If stigmatizing terms were used, 68% of the parents said that they would encourage the child to lose weight and 36% said that they would put the child on a strict diet. For these reasons, I use the diagnosis, overweight, BMI >85th %.
- So the language clinicians use when discussing a teens weight with a caregiver is important and I mentioned that adults in Hennepin County may underreport a child’s overweight/obesity? Is it important for parents to correctly report or view their teen as overweight or obese? Should we work to get parents to view their teen as overweight and obese when the youth is overweight or obese? The answer is “no.” The rationale for this can be found from the Project EAT (Eating Amongst Teens) study conducted right here in the Minneapolis and St. Paul Public Schools (reported in 2008). This study found that approximately half of parents of adolescent girls who were overweight viewed the teens weight as about right. For the overweight adolescent boys, 60% of their parents viewed their weight as about right. Further, there was no difference in healthy nutrition habits (increased family meals, greater availability of fruits and vegetables at home, fewer soft drinks at home, and parental encouragement to make healthy food choices or be physically active) between parents who correctly classify their teen as overweight and those who did not. Unfortunately, parents who did identify the youth as overweight were more likely to encourage the young person to diet for weight control purposes than parents who did not perceive their child as overweight. Did this encouragement lead to the youth no longer being overweight? No. When reassessed 5 years later, these youth were slightly more likely to persist in being overweight compared to those whose parents did not encourage them to diet.
- Because of these and other studies that found that weight-related talk does not lead to healthier weights, and because there is weight-related teasing in many homes which also results in weight gain in many youth—it has been recommended that parents not discuss a youth’s weight with them. I ask parents to model healthy behavior instead. Keep healthy foods at home and let youth see you eat it. Make a point of being more active, like taking a walk.
- I have developed several techniques to get the most out of every clinic visit. Initially, for many of my patients I need a “hook,” something tangible that youth and caregivers can see and grasp as something we are working on together. Yes, weight change and improved health for the youth is the goal, but this can be too amorphous and big for a youth and their parent to agree to work on. Plus, there is a limit how much I can do in the first visit, especially if the youth is in clinic for something unrelated to weight—but their overweight is identified. But, a low Vitamin D level or slightly high cholesterol or insulin level-it is interesting how often youth and families agree to return for f/u of these issues. I can then establish a relationship with them and learn more about the context in which they live. After this we can begin work on more difficult changes. I do begin a discussion of diet changes right away if the youth is there for a well visit. I ask whether they eat breakfast, ask about whether they eat school lunches, and discuss consumption of sugar drinks, including sports drinks. I also ask about unhealthy snacking—like Hot Cheetos, and emphasize that practically anything prepared at home is better for them than eating at restaurants.
- Many parents do not know that school food is much healthier than it has ever been. I tell families that if I ate school lunches I would be eating well because school lunches have gotten healthier. The USDA has changed the school lunch nutrition standards so that they contain more fruits and vegetables with less fat, sodium and calories. I also refer families to the school nutrition services websites so they can see the menus. Many parents only hear from their children that school food is “nasty.” I use the school food sites to debunk this myth and to encourage students to eat the healthy school foods that are offered.
- I also ask what the young people like to do for fun and try to encourage the parents who are wary about letting the youth do sports at school to allow their participation. The parents particularly of some Somali and Latina youth are afraid to let them stay after school and participate in sports.
- Media use by teens is increasing. Total media use by 8-18 year olds increased by more than 2 hours from 2005-2009 to 8.5 hours per day. How is this possible? Adolescents multitask, they use more than one form of media at a time. I do ask about media use not because I need verification of the substantial amount of media a youth is using, but because I provide support to parents who are trying to get a youth up and out of the house, or who are trying to get a teen to go to bed instead of staying up texting or surfing Facebook. I think it is still a question as to when and how much we need to moderate an adolescent’s media use and whether this will make any difference in weight management.
- So, my intervention begins the moment I identify overweight in a youth. But, my work with them in my clinic may not be enough. I do try to get youth to return for visits with a nutritionist. I also try to get the adolescent and their parents to begin to be seen by a counselor to help with the substantial behavior changes many overweight and obese youth and their families need to make. Of course, if I identify any mental health problems, which are often present, I involve psychology and psychiatry as well if needed. I support in-home therapy or therapy as close to home as possible. The more accessible the therapy the more likely the youth and family are to continue with it.
- I occasionally, and very occasionally because many of my patients are unlikely to take medications as recommended, use medications like orlistat or Metformin. In a study of over 500 12-16 year olds with obesity randomized to orlistat or placebo, with both groups eating a low calorie diet, receiving behavior modification therapy, and exercise counseling, both had a decrease in BMI, with the orlistat group never returning to baseline.
- With respect to metformin, in a small study of 9-18 year olds who had obesity and insulin resistance, metformin had a significant effect on weight, BMI, waist circumference and fasting insulin. This same effect was seen in a larger study of 8-18 year olds. I have had some success with metformin and orlistat with some youth, however medication adherence is challenging for a number of my patients.
- I have had very few patients who have been able to follow through with the process required before having bariatric surgery. These patients have done very well so far. This type of success with bariatric surgery has been demonstrated in some randomized studies. This study of 14-18 year olds found that the patients who had bariatric surgery had lost a mean of 35 kg at 2 years versus 3 kg for those who received a lifestyle program that consisted of individualized diet plans, a structured exercise schedule and behavior modification. Families were included as much as possible in the lifestyle program.
- Less invasive than bariatric surgery are community based, intensive, nutrition and exercise programs. These programs, including 2 I am involved with, have shown some success in knowledge of healthy behaviors and improvement in the health of the participants.
- Taking Steps Together is a program we offer through my department at HCMC at 2 community sites. It is a program that works with the families of youth and children with unhealthy weights and helps families learn about healthy eating, healthy weight and being active. The program is 16 weeks and involves a 2 hour class once a week. Many of the participants are Latinos. As adjuncts to TST, we offer Sporty Saturdays (Sabados Deportivos!)-a drop-in one hour activity and game program Saturdays from 2-3, and a Garden Club. Youth Determined to Succeed is North Minneapolis organization founded by Melvin Anderson, an ex pro football player, to address the problem of obesity among urban youth. It has several components now-Kids $ Health (nutrition, exercise, lifestyle program for youth with unhealthy weights and their families), Brooklyn Center Institute ( a similar program at Brooklyn Center HS Recreational Center), a leadership program, Youth Leaders of Change, and Track Minnesota (an elite track program).
- I have a small project with YDS to implement a youth-derives social media strategy. The potential of new media technologies like social media to address adolescent health issues is exciting, because new media technology use by youth is substantial and youth do use these technologies to get health information. The young people of YDS recommended how Facebook and Twitter can be used to get the messages of YDS to more youth.
- More than ¾’s of youth have cell phones and increasing numbers have smart phones. This is why apps have the potential to reach many youth. Lifecast is one I am advising on with University of Minnesota graphic designers. This study has a number of elements, but essentially the app allows parents to see hoe their child will look with various diet and exercise choices.
- I found this app, Figure Facts Teen Nutrition, which helps teens track what they eat, drink and how much they exercise. This app is only $0.99 and can be used on iPhones, iPads, and iPod touches. One of my most favorite parts of the app is that it can let a young person know whether they have had enough water everyday.
- I offer information about apps and many other adolescent health related topics on my blog, www.drj4teenhealth.com. I also tweet everyday, @DrJ4TeenHealth. By the way, I have placed this presentation on my blog.
- Finally, the power of the bully pulpit is substantial. The First Lady’s Let’s Move campaign uses many tools, including videos to solve the problem of childhood obesity within a generation, no there’s a big audacious goal, and to raise healthier children. Beyonce made a dance video for Let’s Move and it is an example of how one health improvement vidoe, highly produced, has been seen by so many—over 26 million times, and spawned hundreds, perhaps thousand of “flash mob” dancers, like these. I refer my patients to things like this-to get them up and going. Don’t you want to give this a try? http://youtu.be/PyxcTU_yJm8
- So thanks. List Clinical Pearls.