Pediatric Obesity: A Multi-Disciplinary Approach to a Multi-Faceted Problem

Transcription

1 Pediatric Obesity: A Multi-Disciplinary Approach to a Multi-Faceted Problem Sharon A. Martino, PT, MS, PhD Associate Director Post Professional DPT Program Clinical Assistant Professor School of Heath, Technology and Management Division of Rehabilitation Science/ Department of Physical Therapy Stony Brook University Sharon.Martino@stonybrook.edu Objectives: 1) Discuss related medical problems 2) Assessment of the obese / overweight child 3) Describe Fit Kids for Life 4) Review case studies 5) Talk about future research directions Percent Overweight and Obese Children in the United States 20% 16% 12% 8% 4% 0% 17% 17.6% 12.4% 11.3% 10.5% 5% 6.1% 4% 5% 6.5% 5% 7.2% Aged 2-5 Aged 6-11 Aged Obesity Rates: ADULTS 1

2 Complications of Childhood Overweight / Obesity Taylor, et al, (2006).Orthopedic Complications of Overweight in Children and Adolescents. Pediatrics, 117(6), Pediatric Obesity is a Multiple Organ System Problem Musculoskeletal: Fractures Posture, mineral density, LBP Overweight : 8% less bone mineral Obese : 12-13% less bone mineral SCFE Stovitz, Pardee, Vazquez, Duval, & Schwimmer. Acta Pædiatrica : Musculoskeletal: Pain Musculoskeletal Musculoskeletal Blount s Disease 2

3 Pes Planus, Foot Pain,... Musculoskeletal Cardiometabolic Risk Factors Metabolic Syndrome: Insulin resistance Dyslipidemia Hypertension Abdominal Obesity Systemic inflammation Cardiovascular Hypertension Several studies show association between obesity and HTN in children (Berenson, et al., 1998; McGill, et al. 2000). Rates have increased with Obesity epidemic 3x more prevalent in obese compared to non-obese (Sorof et al, 2002). Cardiovascular Dyslipidemia Triglyceride concentrations of > 150 mg/dl (AHA) HDL concentrations of < 35 mg/dl (AHA) Total cholesterol > 200 mg/dl (Daniels, 2008) LDL level > 130 mg/dl (De Ferranti, 2011, UptoDate, Inc. Cardiovascular Other Findings... Young adults who had elevations in non-hdl cholesterol, LDL-C, and the ratio of TC/HDL-C as children (5 to 17 years of age) are more likely to have increased intima-media thickness in adulthood 16 to 19 years later (Bogalusa Heart Study, Pediatrics, 2008) Approximately half of the children with abnormal serum lipoprotein values will continue to have dyslipidemia on followup into adulthood, 4 to 15 years later (Haney, et al., 2007). Cardiovascular Obstructive Sleep Apnea (OSA)- 2% of children (Rosen et al., 2003). snoring apneic episodes hypoxemia sleep disruption daytime sleepiness cognitive / behavioral effects Relationship to BMI Relationship to adenotonsillar hypertrophy Pulmonary: Sleep Apnea 3

4 Asthma From 1980 through 1996, the prevalence of ADULT self-reported asthma increased 73.9%. (Centers for Disease Control and Prevention. Surveillance for asthma United States, MMWR 51 SS-1 (1998), pp ) Pediatric literature not as conclusive (Ford, ES, 2005). Pulmonary: Asthma Bullying Sadness / Low Self Esteem Depression- People who are obese are at increased risk of becoming depressed, and people who are depressed are at increased risk of becoming obese (Luppino, FS, et al., 2010). Lack of Motivation Psychosocial Aspects Assessment of the Overweight / Obese Child / Adolescent Assessing the Overweight / Obese Child : Ht, Wt, BMI Skin folds, ADP (Bod Pod), BIA, DXA Cardio: Blood pressure Waist Circumference Total Cholesterol Hemoglobin A1c Fitness: Flexibility Strength Mm Endurance Agility / Coordination Psychosocial: Impact of Weight on QOL- Parent and kid versions Piers Harris self concept Assessing the Overweight / Obese Child -Height -Weight -BMI 4

5 Skin Fold Thickness Pros? Air Displacement Plethysmography (ADP) Cons? Bioelectrical Impedance Assessment (BIA) DEXA An Alternative Outcome Measure Muscle holds water. The greater the amount of water in a person's body, the easier it is for the current to pass through it. Fat is resistant to the current (poor conductor) Pros: BIA is safe; does not hurt. Cons: Reliability Issues Hologic QDR 4500/A DXA system Muscle Mass: 88.7kg Fat Mass: 13.8kg Bone Mass: 3.8kg Body Fat: Muscle Mass:69.5kg Fat Mass: 25.8kg Bone Mass: 2.8kg Body Fat: 5

6 Classification Women (% fat) Athletes Fitness 14-20% 21-24% Percent Body Fat Men (% fat) 5-13% 14-17% Children (AGE??)?? Acceptable 25-31% 18-25%?? Obese 32%+ 26%+ Risk Factors for CVD Family History Age Gender Nutrition / diet Physical Inactivity Tobacco exposure Overweight/ obesity Blood Pressure HTN in childhood is defined as systolic and/or diastolic BP that is 95 th percentile for age, gender and height. Pre-hypertension = >90 th percentile, but <95 th As with adults, adolescents with BP levels 120/80 mm Hg should be considered prehypertensive. Appropriate Cuff Size By convention, an appropriate cuff size is a cuff with an inflatable bladder width that is at least 40% of the arm circumference at a point midway between the olecranon and the acromion Waist Circumference Waist Circumference Proper Technique 6

7 Fernández JR, Redden DT, Pietrobelli A, Allison DB. J Pediatr 2004;145: Blood Panel Total cholesterol Hemoglobin A1c Fasting Glucose ECG Echocardiogram Stress Testing When to refer out? Go back to Risk Factors for CVD Family History Age Gender Nutrition / diet Physical Inactivity Tobacco exposure Overweight/ obesity Blood Pressure referrals Fitness Measures Push ups Sit ups T-Test Muscle Endurance: Push ups and sit ups Flexibility: sit and reach Agility / Coordination T agility test Strength: HHD for upper and lower extremities Cardiovascular Endurance: 6MWT Sit and Reach Strength 6 minute walk test (Geiger, et al., 2006) ACSM s Guidelines for Exercise Testing and Prescription 7 th ed. ACSM s Guidelines for Exercise Testing and Prescription 7 th ed. Assessment: Fitness Assessment: Fitness Assessment: Fitness 7

8 Quality of Life Impact of Weight on QOL: IWQOL Parent and kid versions 27 Items / 4 domains Physical Comfort Social Life Body Esteem Family Relations The Presidential Physical Fitness Award (This represents the 85th percentile.) The National Physical Fitness Award (This represents the 50th percentile.) Assessment: Psychosocial ICC: 0.88 to 0.95 Convergent validity:(r = 0.76, p < ) Self Esteem Piers Harris Self Concept Scale 1-physical appearance and attributes 2-intellectual and school status 3-happiness and satisfaction 4-freedom from anxiety 5-behavioral adjustment 6-popularity Fit Kids for Life Fit Kids for Life Department of Pediatrics Department of Division of Pediatric Physical Therapy: Cardiology Sharon Martino, Peter Morelli, MD PT, PhD PT / Medical Department of Students Pediatrics Division of Pediatric Cardiology Department of Marybeth Heyden, NP Psychology Department of Behavioral Pediatrics Psychologists Registered Dieticians Assessment: Psychosocial A Team Approach! 8

9 Standardization of Fit Kids for Life Screening Motivational Interviewing ! BMI plotted annually At least one CV risk factor: BMI 95th %; 30 kg/m2 (Obese) BMI 85th-94th Percentile (Overweight) HTN Dyslipidemia Type 2 Diabetes Metabolic Syndrome Frequency Guidelines = 1 hour per day. FKFL= 2x per week for 10 weeks (each session ~2 hours) Nutritional Education Exercise Program Behavioral Modification Family Involvement Family history /obesity risks 2 lean parents = 9% chance of becoming obese 2 obese parents = 60-68% chance Overweight adolescents have a 70 percent chance of becoming overweight or obese adults, which increases to 80 percent if one or more parent is overweight or obese (Torgan, 2002). Cardio Corner Child chooses three machines Each machine for 5 minutes = total of 15 minutes RHR and HR after ex; PCERT 1.5 mile walk, jog, run Machine Madness 2 sets of 12 reps Initial wt based upon 1 RM /Wt adjusted weekly as tolerated Average of 7-10 machines in 15 minute period Core on the Floor Set routine of exercises Use of body weight, Thera bands, dumb bells Step wise progression Fit Kids for Life Clinical Guidelines for Prevention and Treatment of Childhood Overweight and Obesity PCERT Fitness Trainers 30+ Medical, PT, OT and ATC students Sustainability Class credit Mandatory Training Session 1:1 ratio Fit Kids for Life: Results 9

10 Sit and reach cm 6MWT Meters 1/12/2012 Enrollment Assessed for eligibility (n=58) Matched by age and BMI then randomized (n=48) Excluded (n=10) Not meeting criteria (n=3) Declined study participation (n=7) Children Became Stronger Allocation Allocated to Intervention (n=24) Allocated to wait list control group (n=24) Lost to one of three f/u visits (n=4) Lost to one of three f/u visits (n=7) Follow-up [moved away, n=1; family illness, n=1; refused final DXA, n=2] [moved away, n=1; family illness n=2; refused final DXA, n=2] Discontinued intervention (n=0) Discontinued intervention (n=0) NIH General Clinical Research Center Grant # M01RR Flexibility Improved p<.05 Baseline 10 weeks 20 weeks Muscular Endurance Improved Push ups Sit ups Baseline 10 weeks 20 weeks Baseline 10 weeks 20 weeks Baseline 10 weeks 20 weeks p<.05 Cardiovascular Endurance Improved p= Baseline 10 weeks 20 weeks 10

11 Seconds 1/12/ Agility Improved Improved BMI Remained Stable 13.5 Baseline 10 weeks 20 weeks p<.05 Case Studies Future Directions for Fit Kids for Life Role of Physical Activity in the Treatment of Child Obesity Pedometers Exercise Journals (self report) Heart Rate Monitors FUSION Award: Development and validation of a wireless activity and heart rate monitor in overweight and obese children. Collaborative and Translational Research Study Current Collaboration with CEWIT, Computer Science, and Sensor CAT 11

12 Family, Facebook, or Fortitude: A Biopsychosocial Study of Sleep and Resilience in Pediatrics Combining retrospective and prospective data with polysomnography studies Virtual Reality Technologies for Research and Education in Obesity and Diabetes Run for Good Grant: First annual Fit Kids for Life 5K Run to raise awareness about childhood overweight and obesity. Current Collaboration with Pediatrics, SB Sleep Disorders Center, Respiratory Therapy, Health Care Policy & Management, SB Survey Center Future collaboration with Computer Science, CEWIT Children who are overweight and obese are developing ADULT like diseases. But remember, children are not small adults! Pediatric Overweight / Obesity is a multi-faceted problem...affecting many Americans young and old! Will take a multi-disciplinary approach to tackle this problem! Lack of Universal protocols for assessment tools and lack of normative data in this population What assessment tools / outcome measures do we have? What do we need to develop? 12

13 Why don t more PTs measure body composition? as WHO the defines Primary obesity as a Goal! condition of excess fat accrual in adipose tissue to a degree that health may be impaired. Therefore, a primary goal indicative of success is an improvement in body composition, as defined as a reduction in body fat (Goran, 1998, Tsiros et al., 2008) Maintenance of BMI should be reviewed as a success! (Nemet, et al, 2005). Pediatric Obesity: A Multi-Disciplinary Approach to a Multi-Faceted Problem Sharon A. Martino, PT, MS, PhD Associate Director Post Professional DPT Program Clinical Assistant Professor School of Heath, Technology and Management Division of Rehabilitation Science/ Department of Physical Therapy Stony Brook University Sharon.Martino@stonybrook.edu QUESTIONS?? 13