2018-19 TOW #26: Childhood Obesity

As the new year begins, we can harness the season’s focus on wellness to offer families encouragement with healthy behaviors. Obesity prevention and intervention is a topic close to my heart, so I am excited to highlight our great local resources. We have many wonderful obesity research experts in our clinics, including Drs. Lenna Liu, Jay Mendoza, and Pooja Tandon. A big thanks to Dr. Allison LaRoche for her help updating materials for this topic. Feel free to email any of us with questions!

Teaching materials for this week:

Take-home points for this week:

  1. What’s the epidemiology of child obesity?: While some progress is being made, with promising data on declines among preschool youth, overweight/obesity rates remain high at 1 in 3 children with a BMI at or above the 85th percentile. Etiology of obesity is multifactorial including important environmental contributors that are affected by social determinants. As pediatricians, we should acknowledge the equity issues reflected in higher rates of obesity among those with more social disadvantage including low-income families, and Hispanic, African American and American Indian youth.
  2. What focused messages can we share in clinic? Focusing on behaviors/ environments that support healthy weight starts from infancy. Teach the Division of Responsibility for feeding in which “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 5210 goals to help guide healthy weight 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. The Let’s Go! 5210 campaign was started by a pediatrician in Maine, and they have some great resources like Phrases that Help and Hinder. Families should choose their own goals through motivational interviewing, which has been shown in randomized trials in pediatrics to work in improving weight trajectories.
  3. How can we address this sensitive topic and avoid weight stigma in our practice? Recognize that obesity is highly stigmatizing and bias for weight is among the strongest biases culturally, even among children. 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, etc), while also supporting specific behaviors that make a difference for health.
  4. What are the approaches for overweight and obese? For youth with BMI >85th percentile (overweight), and BMI> 95th percentile (obese), follow weight trajectory and family history to assess risk. Screening labs for metabolic risk factors (lipid panel, liver enzymes and A1c and/or glucose) are recommended starting at age 10 if obese (or overweight+risk factors). To promote healthy behaviors, refer to resources like the YMCA ACT! program – ACT! programs are enrolling this winter for 8-14 year olds around our area. We can also refer to SCH Wellness Clinics for multidisciplinary weight management from age 2 through adolescence. When metabolic problems are identified, see this article on treating comorbidities.
  5. What is the role of physical activity? For children at all weights, regular physical activity reduces the likelihood of comorbidities, even without decreasing BMI. It’s important for us to emphasize helping kids and parents find ways to be active and enjoy movement, no matter their body size.

2018-19 TOW #13: Newborn screening

Newborn screening has helped revolutionize our ability to detect metabolic and hematologic diseases in infants. While the vast majority of screens are normal, when we catch those rare diseases before any symptoms start, we are reminded just how remarkable this process is (as per my experience in clinic last week). Two of our program graduates contributed to the materials for this topic, Drs Dave Higgins and Beth Tarini MD MPH, a national expert.

Materials to review:

Key points in newborn screening:

  1. When did it start and how is it done? The first sensitive, inexpensive, and easily performed newborn screening test was developed by Dr. Robert Guthrie in 1962. Prior to Guthrie’s assay for hyperphenyalaninemia, infants with suspected phenylketonuria (PKU) were diagnosed at 6-8 weeks of age. Within 10 years the testing was used nationwide. Now many diseases can be detected with tandem mass spectrometry technique (we screen for about 30 on our state screening). Key criteria for screening is which diseases have accurate, safe, effective testing and follow-up treatment available.
  2. What are the most common diseases detected? Congenital hypothyroidism, hemoglobinopathies, congenital adrenal hyperplasia, CF, and galactosemia. In WA each year 174,000 specimens from about 86,000 newborns are tested. Approximately 170 – 200 infants have one of the conditions. A one-time fee ($69.00 in 2014) for each baby screened funds this testing.
  3. What’s the reliability of screening tests? Sensitivity is approaching 99% for most disorders. However, false-positives remain a big problem, particularly for endocrinopathies: one study found as many as 50 false-positives for 1 true-positive. Studies have shown that up to 20% of families maintain some concern about the health of their child after false-positive screening results, so reviewing this information with families is key.
  4. Why a 2nd screening? A 2nd screening between 7-14 days of life is recommended (though not required in our state), primarily to detect congenital hypothyroidism. About 15% of hypothyroidism cases are missed on the first screen.
  5. What to do when a test is positive? Key information we should review with parents includes basic description of the disease process in question, that there are false positives, especially for some diseases, and next steps in evaluation and treatment (e.g., repeat testing on same sample, speaking to a specialist early in the evaluation process). Refer to the WA state newborn screening website for more guidance.