Dr. Rena LaFrance Medical Clinical Lead Pediatric Centre For Weight And Health Psychiatric Consultant PCWH Stollery Misericordia Site Quote This generation of children will be the first to live shorter lives than their parents... Schwartz and Brownell 2007 What is Overweight/Obesity? Many definitions- Excess of calories leading of the deposition of adiposity BMI above 25 in adults(overweight)30 (obese) Children whose weight is above the 85 th percentile (overweight) Children whose weight is above the 95 th percentile - obesity
What is Obesity? It is a chronic disease once acquired of multiple complex etiologies It is a multifactorial disease which can be conceptualized in a biopsychosocial mannerism Example bio psycho social Family history diabetes Evidence of binge eating Financial Multiple members of family obese Premature death from cardiovascular disease Evidence of emotional eating Resilient coping style in child Child being bullied at school Stigma Child has Obstructive Sleep Apnea Evidence of depression Comorbidities
Why is this an important disease to treat? It is because by treating this one disease you can eliminate or diminish the onset of a number of other diseases How many other disease processes can you say that about? Key concepts The single most important factor in successful treatment is the motivation to change Precontemplation Contemplation Preparation Motivational Action Interviewing Maintenance Relapse Key concepts Multiple psychiatric co morbidities All treatment modalities (lifestyle, medication, surgery) involve a mental health component In pediatrics you are always treating the whole family Behavioural and cognitive behavioural therapy are the 2 most studied therapies in this population
Key Concepts Not one treatment size fits all Looking for small improvements over long term Treatment 3 Main categories Behavioural family based programming involving nutrition and exercise Medication Surgery Treatment Comprehensive interventions that include behavioural therapy along with changes in nutrition and physical activity are the most closely studied and seem to be the most successful approaches to improving long term weight and health status Jelalian et al. 1999
Evidence based nutritional guidelines Canada s Food Guide Understood as a guide for appropriate eating (in and of itself is not a weight loss tool) No evidence to support any specific or macronutrient diet strategy (example high carb low protein) Pediatric nutrition guidelines American Academy of Pediatrics Limit consumption of sugar sweetened beverages Encourage appropriate intake of fruits and vegetables Eat breakfast daily Limit eating out especially fast food Encourage family meals Follow appropriate portion size guidelines Traffic light diet (Epstein et al. 1990) Evidence based Physical Activity Guidelines Part of the energy expenditure equation Only directly modifiable piece (resting metabolic rate not as easily modifiable) Increasing physical activity has potential to improve weight loss and weight maintenance
Physical Activity Physical activity less of a factor than dietary modification (But still very important) Why? Easier to decrease calories than exercise to an equivalent amount Risk of physical inactivity We know that sedentary children lead to sedentary adults Large amount of literature supporting this link Sedentary lifestyle increases the risk of DM CA HTN CAD dyslipidemia... Health Canada Recommendations 90 minutes per day moderate activity for children and youth 30 to 60 minutes for adults Ways to increase Physical Activity Active living ( take the stairs) Recreation (bowling) Focused exercise ( skating class)
Expert Recommendations American Academy of Pediatrics No TV for children under age of 2 No more then 2 hours per day screen time for children 2 and over Remove TV from sleeping area Vigorous activity recommended Therapies Multiple behavioural techniques to encourage healthy living increased activity and weight loss in some cases Removing unhealthy foods from home Food diaries and activity diaries Goal setting for energy consumption /physical activity Rewards for positive change and behaviour (not food!) Parent skills training Evidence for CBT Emphasis on cognitive restructuring and cognitive distortions as they apply to obesity Evidence in literature to indicate that it may be helpful Downside labour intensive, requires a great deal of motivation More studies needed Van Dorsten and Lindley Dec 2008
Evidence therapies Clear evidence that behavioural techniques added to exercise and diet provide better treatment then exercise and nutritional counselling alone Eliakem et al 2008 Evidence behavioural therapies Who to target for change? Epstein and colleagues demonstrated in children 8 to 12 yrs targeting children and parents superior to children alone (Epstein 1990,1994) Golan and colleagues showed targeting parents exclusively superior to targeting children exclusively (ages 6 to 11)Targeting parents to lose weight also improved outcomes. (Golan 1998) Therapies More and more evidence of a social ecological focus on healthy weight achievement Influence of peer group in especially older children Using community, school, family, friends as supports in order to achieve goals. More studies to be done
Social Ecological Model Can treating obesity increase the prevalence of eating disorders? Potential benefits of dieting outweigh the risks (National Task Force on the Prevention and Treatment of Obesity 2000) In literature 15 years ago concerns about the emergence of eating disorders from dieting They did not use RCTs prior to 1995 in this subject area Recent studies indicate increase in longevity with moderate calorie restriction -Ottinger 2004 Recent data shows only small minority susceptible to increased psychiatric co morbidity ( Fairburn 2005) Recent RCTs show no indication that calorie restriction associated with increase in ED (Williamson et al 2008)
Medication Sibutramine Appetite suppressant Non selective reuptake inhibitor Blocks NA,SE,DA Cytochrome p450 3a4 FDA approved 16 yr older 2yr usage only Sibutramine Contraindications: Arrhythmia History of stroke CAD Serotonin syndrome Side effects major increased heart rate increased bp, anticholinergic Sibutramine 12 month RCT trial 498 participants Behaviour therapy plus 10 to 15 mg sibutramine or placebo Measured BMI, waist circumference, weight, lipid glycemic variables, safety and tolerability
Sibutramine Results (children all greater than 95 th ) Sibutramine group decreased BMI (2.9),weight (8.4 kg) Statistically significant vs. placebo Greater improvement in labs Greater increase in heart rate then placebo Overall conclusion statistically and clinical significance (Berkowitz 2006) Orlistat Reversible lipase inhibitor Binds lipase in the lumen of stomach and intestine Lipase therefore can not hydrolyse dietary fats Triglycerides and cholesterol pass unchanged out of gut Health Canada and FDA approved 12 to 16 yrs Orlistat Standard dose 120 mg tid Restrict fat intake to less than 30 % overall calories Multivitamin daily (fat soluble ADEK) Side effect tolerability poor Oily bowel movements Flatus with discharge Oily spotting on underwear Abdominal pain
Orlistat RCT in adolescents Multicenter 54 week trial 539 adolescents 120 mg tid, or placebo in addition of 30% fat diet exercise and behavioural therapy Results BMI decreased by.55 compared to increase of.33 in placebo group (Chanoin 2005) Metformin Biguanide oral hypoglycemic agent Evidence of weight reduction vs. placebo Studies very small Children all hyperinsulinemic GI side effects noted nausea, diarrhea Children with diabetes lose more weight (Kay et al. 2001),(Freemark et al 2001),(Snirivasin 2006),(Desillets et al 2008) Metformin Use in obese adolescents is currently off label if they do not have diabetes Not the standard of care in Edmonton to prescribe this medication for this population (Endocrinology) However we are seeing more and more children presenting on it! More studies, larger trials necessary.
Surgery More interest in the bariatric medicine community in this modality Limited studies evaluating surgical intervention 3 main surgical interventions Roux en Y (only FDA approved in adolescents) Gastric banding (2 to 3 yrs off approval) Gastric sleeve resection (nowhere near approval!) Roux en Y Gastric banding
Gastric Sleeve Resection Expert Panel Recommendations Pratt et al. 2005 Patients physically mature BMI>50 BMI>40 with co morbidities Expert Panel Recommendations Pratt et al 2008 (presented Phoenix ) BMI >40 BMI>35 with co morbidities
Surgery Reasons stated for decrease higher incidence of Death at higher weight Concerns Requires intensive evaluation for physical maturity, psychological readiness Proof of ability to adhere to lifestyle change Or weight WILL BE REGAINED Surgery Contraindications Medically correctable cause Medical, Psychiatric, Cognitive disability that impairs adherence Inability or unwillingness of family to understand procedure or consequences Ref. Inge 2008, Obesity Society Meeting Phoenix Overall Behaviour lifestyle modification -3-5 % reduction in weight Medication add in 5-10% reduction in weight Surgery add in -20-30 % reduction in weight
Psychiatric Co morbidities Clinical evidence of large range of co morbidities including axis 1, axis 2 and axis 3 disorders Evidence of quality of life impact self esteem, bullying etc. Evidence of stigma Binge Eating disorder Still research criteria 2 days a week for 6 months Eating large quantities of food at one sitting Loss of control the hallmark BED in adults 1-2% Binge eating 5-10% adults Treatment binge eating CBT IPT Behavioural weight loss therapy Pharmacotherapy antidepressants, sibutramine, orlistat Calls to reclassify eating disorders to include binge eating as a separate category (Williamson et al.2005)
Reclassification Night Eating Syndrome Recognised 1955 by Stunkard Proposed new DSM diagnosis Daily pattern of eating demonstrates increased intake in evening or night time as manifested as one or both of the following 25% of intake consumed after evening meal 2 episodes of nocturnal eating/week Night Eating Syndrome Clinical A) lack of desire to eat in am breakfast omitted 4 mornings/week B) presence of strong urge to eat between dinner and sleep onset and or during night C) sleep onset or sleep maintenance insomnia present 4 or more nights / week D) Belief one must eat in order to sleep E) Mood frequently depressed or worsens in evening
Night Eating Syndrome Awareness and recall of event Significant distress impairment 3 month minimum Not secondary to GMC, medication or another psychiatric disorder (Allison 2008 Obesity society conference Phoenix) Treatment Adult Phototherapy ( light lamps) Sertraline small study but significant results in diminishing night eating and some weight loss weight Topirimate small study increased somnolence associated with decrease in eating. Evidence of weight loss with topirimate in general CBT Requires much greater study (O Reardon 2005) Antipsychotics and Weight Gain Unpublished data in dogs from Dr. Marilyn Adler University of Southern California Phoenix conference Mechanism of metabolic dysfunction studying olanzapine 3 mechanisms Intake increase/movement decrease Insulin resistance within the liver Dysfunctional beta cells unable to compensate by increasing secretion of insulin
Pediatric population Prescribed for many reasons-psychosis,odd, anxiety, bipolar and more Many neuroleptic naive This population vulnerable to weight gain Management of antipsychotic weight gain Recognize problem Choice of initial medication- use of ziprasidone Additive effects of medication Continuous monitoring Medication switch if necessary Lifestyle interventions for weight reduction Management Non Pharmacologic Review of 10 RCTs in adults No statistically significant difference between CBT and nutritional counselling Individual or group All were effective in aiding some weight management (Alvarez-Jimenez 2008)
Pharmacologic intervention Sibutramine and orlistat may be helpful. No studies in pediatric population One study adults for Zyprexa (sibutramine) induced weight reduction on average of 4.6 kg Metformin 2 studies both open label Demonstrated no weight gain or demonstrated weight loss when compared to placebo Pharmacologic intervention Topirimate some evidence in adult population of benefit in combination with zyprexa Amantadine-(dopamine agonist anti parkonsonian)- counteracts antipsychotic likely mechanism! Other drugs looked at in adults-modafanil, betahistine, axokine, prozac Edmonton s Programs Pediatric Regional program 2 Sites PCWH- Stollery and Misericordia Partnership between Stollery Children s Hospital Misericordia Community Hospital, Weight Wise, AHS and Covenant Health and Department of Pediatrics Multidisciplinary intervention-psychiatry, Pediatrics, Dietician, Exercise Specialist, Nursing, Psychology
Edmonton s Programs Referral of children over 8 years old to central access (link) Initial visit 2 screens (Pediatric and Mental Health) Combination of educational classes, one on one intervention and groups Ongoing follow-up program no less than 2 years Edmonton s Programs All children have access to specialists at both sites Psychiatry Endocrinology Respirology and more Edmonton s Programs Emphasis on family centred care Chronic disease paradigm Motivation to change Lifestyle modification (not restriction) Partnership with community resources
Edmonton s Programs Behavioural lifestyle change Emphasis on stability in order to exact change If any red flags come up on initial screen family may have to treat those things before obtaining active treatment Families in precontemplation/contemplation are given opportunity to move forward Edmonton s Programs Future planning Emphasis on research and innovation Further intensification of services Partnership with PCN s and the community Access to remote areas telehealth Further education of health professionals Evaluation of the role of medication and surgery Questions