A seven-year-old boy presents with his mother for a routine well-child visit. He does not report any problems, his medical history is unremarkable, and he has no family history of heart disease or diabetes mellitus. During the physical examination, you note that he is obese, with a body mass index (BMI) in the 96th percentile for his age and sex.
1. The correct answer is D. The USPSTF recommends that children six years and older be screened for obesity (defined as an age- and gender-specific BMI at or above the 95th percentile). Children who are obese should be offered or referred for comprehensive, intensive behavioral interventions. The USPSTF found insufficient evidence for screening children younger than six years.
The USPSTF found adequate evidence that multi-component, moderate- to high-intensity behavioral interventions can yield short-term (up to 12 months) improvements in weight status in children and adolescents who are obese. Moderate- to high-intensity interventions are defined as involving more than 25 hours of contact with the child and/or the family over a six-month period.
There is limited evidence on the long-term (beyond 12 months) sustainability of absolute and/or relative decreases in BMI after interventions. Also, it is not known whether these interventions will result in similar improvements in children who are overweight but not obese.
2. The correct answer is C. The USPSTF found that interventions combining pharmacologic agents with behavioral interventions resulted in only modest short-term improvement in weight status in children 12 years and older. The magnitude of the harms of these drugs in children is uncertain. There are also no long-term data on the maintenance of improvement after discontinuation of medications.
Orlistat is a lipase inhibitor that has been approved for use in children 12 years and older. Sibutramine (Meridia), a centrally acting appetite suppressant, was withdrawn from the U.S. market in October 2010 because of clinical trial data indicating an increased risk of heart attack and stroke. Physicians should not prescribe this medication to their patients.
3. The correct answer is A. The USPSTF did not find evidence about appropriate intervals for screening for obesity in children and adolescents. Height and weight, which are used to calculate BMI, are routinely measured during health maintenance visits.
Posted on 9/01/09
Tommy V. is a 9-year-old boy with no significant medical history. His family history is significant for both parents being obese with co-morbid conditions of hypertension and diabetes. Tommy’s mother has a BMI of 35 and his father has a BMI of 37. On a recent visit to his pediatrician, Tommy was classified as obese, based on a BMI greater than the 90th percentile of the age- and gender-specific BMI chart, in accordance with the Centers for Disease Control and Prevention (CDC).
Tommy and his mother are covered as dependents under the father’s employer-based health plan. Through routine screening protocols tied to the system’s reimbursement codes, the health plan is alerted to Tommy’s new diagnosis. Fortunately, the system triages Tommy’s file to an intake coordinator in the health plan’s obesity disease management program. The coordinator contacts Tommy’s mother through a routine introductory phone call. Tommy’s mother is confused at first, not understanding why her husband’s insurance company would be calling about a “simple doctor’s visit for my son” and demands to know why the visit won’t be paid for. Once the coordinator assures Tommy’s mother that the purpose of the call is not to discuss money, but to identify resources available to her and her family, Tommy’s mother allows the call to continue.
The coordinator provides brief information about the obesity program available through the family’s disease management coverage and advises Tommy’s mother that her son’s pediatrician supports this patient and family resource. She identifies the opportunity for Tommy to be enrolled in this disease management program as a member benefit. Tommy’s mother informs the nurse that Tommy does not have a disease. “He’s just a little overweight; he’s not sick. It’s baby fat; he’ll grow out of it.” The coordinator proceeds to explain that obesity is a covered condition under the disease management program at the health plan, at which time Tommy’s mother hangs up.
Recognizing her limitations with this new referral, the coordinator turns the newly opened case over to a nurse case manager in the obesity disease management program. The case manager contacts Tommy’s mother via email. She provides a brief introduction about the obesity program, provides convenient call-back information, then outlines a few distinctly important facts about childhood obesity:
• Definition of overweight in children is defined as a BMI in the 85th to 95th percentile of the age- and gender-specific BMI charts developed by the CDC
• Obesity rates in children are increasing
• In the past 3 decades obesity rates have doubled in children 2 – 5 & 12 - 19 years of age
• In the past 3 decades obesity rates have tripled in children 6 – 11 years of age
• ~ 9 million children > 6 years of age are considered obese
• It is an international problem encompassing North America, Australia and other continents
• Obesity engenders a high psychosocial toll related to appearance (socially isolated, potential for eating disorders, anxiety and depression, discrimination, bullying, negative stereotyping, low self-esteem, negative body image, teasing, stigma)
• Genetics is a factor but not a cause. Having obese parents more than doubles a child’s risk of being obese
• Physical health consequences of obesity in children include:
* Orthopedic problems
* Sleep apnea
* Diabetes and glucose intolerance/insulin resistance
* Fatty liver
In less than 4 hours, the obesity disease manager receives a call from Tommy’s mother. The case manager’s strategy worked, as she anticipated that Tommy’s mother has the best interests of her son at heart. Once provided with factual information about the battery of health risks posed by obesity, she lowered her defense mechanism for her son.
The obesity disease manager is able to provide Tommy’s mother with printed pamphlets and materials aimed to educate both the parents and Tommy with age-appropriate literature and information. The educational materials outlined potential causes of obesity in young patients, and identified how these can be related to an adverse environment, including:
1. Decreased physical activities and walking;
2. Consumption of high caloric convenience foods used to decrease preparation time;
3. Reduced accessibility/affordability to nutritious foods, vegetables and fruit;
4. Reduced biking/walking to/from school, decreased physical activity opportunities at school or after school;
5. More sedentary activities such as television, playing computer/video games rather than playing outdoors
Recently published studies have shown that overweight children and adolescents are at greater risk for health problems during their youth and as adults, such as having risk factors associated with cardiovascular disease (eg, HTN, high cholesterol, and type 2 diabetes), than other children and adolescents. Overweight children are also more likely to become overweight adults, leading to additional cardiovascular risks and death.
Baker et al studied a cohort of children born between 1930 and 1975, through evaluation of mandatory annual health exams in Copenhagen schools. They evaluated the association between BMI in children aged 7 through 13 (n = 276,835) and coronary heart disease (CHD) as adults (aged ≥ 25 years of age), with and without adjustment for birth weight. Yearly height and weight were recorded through the Copenhagen School Registry Records. CHD events were obtained by linking to national registers. CHD events were classified as fatal or nonfatal. There were 10,235 men and 4,318 women for whom childhood BMI data were available and who received a CHD diagnosis or died of CHD as adults. The risk of any CHD event (fatal or nonfatal) positively correlated with BMI at 10 to 13 years of age for girls, and 7 to 13 years of age for boys. These relationships were linear at each age and showed that the CHD risk in adulthood was highest for boys with the highest BMI and lower for boys with the lowest BMI. The risk also increased as the age of the child increased. The results were similar for both genders. Adjustment for birth weight strengthened the results.
The authors of this study showed that higher BMI during childhood was associated with an increased risk of CHD in adulthood. They also noted that CHD risk factors such as dyslipidemia, impaired glucose intolerance, vascular abnormalities, and hypertension are already presenting factors in overweight children. Earlier education and intervention among this at-risk group could prevent potentially fatal or nonfatal CHD risks early on, rather than later when these children become adults.
In a second study, the effect of overweight adolescents on future adult CHD was estimated using computer simulation and modeling. US residents who were ≥ 35 years of age were used to project the annual excess incidence and prevalence of CHD, the total number of excess CHD events, and excess deaths from both CHD and other causes attributable to obesity. Effects of treating obesity-related increases in blood pressure and dyslipidemia were also evaluated. The authors noted that the prevalence of overweight adolescents in 2000 was 15.4% in girls and 16.7% in boys. In 2020, when these children become 35 year olds, there is an expected increase of 34% - 44% and 30% - 37% prevalence in women and men, respectively, along with the higher predicted prevalence of obesity. The annual excess of CHD incidence is expected to increase from 1,600 (in 2020) to 40,000 (in 2035), a 15% excess. The number of excess deaths is projected to increase from 59 (in 2020) to 3,600 (in 2035), an excess of 13%. CHD-related deaths are expected to be 26-84 (in 2020) and up to 1,500-5,000 (in 2035). Obesity-related deaths (but not CHD-related deaths) are expected to increase by 4% per year from 250 (in 2020) to 6,200 (in 2035). By 2035, it is estimated that the prevalence of CHD will increase by 5% - 16%, with > 100,000 obesity-related CHD-attributable excess cases. Significant morbidity and deaths are expected to be related to child/adolescent obesity. Increases in diabetes, other glucose metabolism, hyperlipidemia, and blood pressure effects are also expected as a consequence of continued overweight and obesity in this patient population. The authors conclude that although projecting out to 25 years or more into the future is subject to a number of uncertainties, extrapolating current data suggest that adolescent overweight will increase rates of CHD among future young and middle-aged adults, which will result in substantial morbidity and mortality.
In follow-up telephone conference calls with Tommy’s mother and one call with his father, the obesity disease manager is able to educate the parents about how to engage a healthier lifestyle. It is recommended that they monitor Tommy to increase his exercise, watch less television, eat healthier (more fruits, vegetables and less fried food and fast food) and initiate a fun and incentive-driven plan to track loss of excess weight. Tommy’s parents set a goal for him to receive a new bike once 15 pounds of weight are shed. The bicycle will provide wholesome outdoor exercise for Tommy, while encouraging him to make better eating choices. At the time of this writing, Tommy was bicycling his way to better health.
Bibbins-Domingo K, Coxson P, Fletcher MJ, et al. Adolescent overweight and future adults coronary heart disease. N Engl J Med. 2007;357:2371-2379.
Baker JL, Olsen LW, Sørenson TIA. Childhood body-mass index and the risk of coronary heart disease in adulthood. N Engl J Med. 2007;357:2329-2337.
Ludwig DS. Childhood obesity – the shape of things to come. N Engl J Med. 2007;357:2325-2327.
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