Teaching materials for this week:
- Case and discussion
- AAP Institute for Healthy Childhood Weight resources– see the Professional Education section for Change Talk app for Motivational Interviewing skills, podcasts, and the Clinical Supports section for the 2023 Clinical Practice Guidelines, algorithms, and other tools for child obesity assessment and management
- ACT! program information and referrals
- Child Wellness Clinic resources at SCH
Take-home points for this week:
- What’s the epidemiology of child obesity? While some progress was being made pre-pandemic, with promising data on declines among preschool youth, obesity rates have risen to 1 in 5 children with a BMI >=95th percentile, 1 in 3 including overweight (BMI>=85th percentile). Unfortunately, the CDC reported the rate of BMI increase nearly doubled among youth during COVID. Etiology of obesity is multifactorial including important genetic and environmental contributors that are affected by social determinants, which were exacerbated by COVID. We must acknowledge the equity issues reflected in higher rates of obesity among those affected by racism and social disadvantages including low-income families, and Hispanic, African American and American Indian youth.
- What focused messages can we share in clinic? Focusing on behaviors/ environments that support healthy weight starts from infancy. Teach responsive feeding with the Division of Responsibility for feeding; or “parents provide, and child decides.” The parent is responsible for what, where, and when food is served, and the child is responsible for how much to eat. We can use Let’s Go! 5210 goals to help guide healthy behaviors: 5 fruits and veggies per day, watch no more than 2 hours of screen time, get 1 hour or more of physical activity, and have 0 sugary drinks. Limiting processed foods and having family meals are 2 other important nutrition approaches families can take. Families should choose their own goals through motivational interviewing, which has been shown in randomized trials in pediatrics to work in improving weight trajectories.
- How can we address this sensitive topic and avoid weight stigma in our practice? Bias about weight is among the strongest biases, even among children, and bullying and stigma are major problems for those living in larger bodies. We must be aware of our own biases as we treat patients and adopt inclusive, non-judgmental language, as recommended by Health at Every Size (HAES), which seeks to promote health-affirming behaviors and diversity of size, and to decrease weight stigma and emphasis. It’s helpful to acknowledge there are a lot of things outside the control of families (genes, community environment, societal stigma, etc), while also supporting specific behaviors to promote well-being and health (and advocating for changes at the societal level). I like to hold these concepts as a dialectic of both/and: acknowledging that obesity/high BMI can be (though not always) an individual and public health challenge associated with medical complications, and also that an over-focus on weight/BMI is highly problematic, may contribute to unhealthy behaviors such as disordered eating, increased weight bias, and other harms.
- What are the approaches for overweight and obese? The clinical practice guidelines algorithm and Key Action Statements recommends BMI screening and blood pressure for all youth. Starting at age 10, all youth with BMI >85th percentile (overweight) who have risk factors, and BMI> 95th percentile (obese) should have screening labs for metabolic risk factors (lipid panel, liver enzymes and A1c and/or glucose). Labs may be considered in ages 2-9 if severe obesity and/or risk factors. To promote healthy behaviors, the guidelines recommend intensive health behavior and lifestyle treatment (IHBLT). In our area, this would include referral to resources like the YMCA ACT! program, the SCH Wellness Clinic for multidisciplinary weight management from age 2 through 11. When metabolic problems are identified, see this article on treating comorbidities.
- What is the role of physical activity? For children of all body sizes, regular physical activity reduces the likelihood of comorbidities, including psychological ones, with or without changes in BMI. It’s important for us to emphasize helping kids and parents find ways to be active and enjoy movement, no matter their body type.