Pediatric Primary Care Case Studies, 1st Ed.

Chapter 7. The Overweight Preschooler

Margaret A. Brady

Childhood overweight is an increasing health problem that the primary healthcare provider (PCP) often faces on a daily basis when seeing pediatric patients. Rarely do parents of young children bring their child to the PCP for either sick or well child visits with expressed concerns of overweight. Typically, parents think in terms of “baby fat” that will magically disappear as the child grows or believe that comorbidities linked to obesity are issues seen only during adulthood. Because childhood overweight often becomes a chronic problem, the PCP must be vigilant in identifying risk factors and in assessing weight, nutrition, and physical activity issues when caring for children. The PCP must also remember that nutrition and weight are likely culturally bound. Therefore, a family-centered approach is needed because the child typically is not the only obese member of the family unit.

Educational Objectives

1.  Describe how genetic inheritance and environmental factors impact the development of obesity in young children.

2.  Explain the diagnostic criteria used to determine whether a child is at risk for overweight or obesity.

3.  Describe the common clinical manifestations and comorbidities associated with pediatric obesity.

4.  Apply physical activity and nutrition management guidelines for prevention of overweight and obesity to a toddler who is at the 85th percentile for BMI.

5.  Integrate knowledge of culture, development, nutrition, physical activity, and behavioral approaches to develop a treatment plan for the toddler who is obese.

  Case Presentation and Discussion

Maria Smith is a 3-year-old girl who is brought in by her mother, Margarita Smith, for her 3-year-old health supervision examination. Mrs. Smith says that the family just moved from out of state and that Maria and her younger 22-month-old brother, Bobby, are now going to be receiving care at your clinic. Mrs. Smith says that Maria has been a healthy child and she has no real concerns at this time except that Maria needs to see a dentist because she has lots of cavities. Mrs. Smith pauses and then says, “Maria’s preschool teacher says Maria needs to go on a diet because she is too fat.” You acknowledge that it is important for Maria to see a dentist and that her growth and development are important issues that you will be discussing with Mrs. Smith as part of this health supervision visit.

The Health Supervision Visit and Areas of Concern Identified by the Mother

The Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents (Hagan, Shaw, & Duncan, 2008) outlines 10 themes that should be promoted when children are seen for health supervision visits: the promotion of family support, child development, mental health, healthy weight, healthy nutrition, physical activity, oral health, healthy sexual development and sexuality, safety and injury prevention, and community relationships and resources.

Mrs. Smith has already identified issues related to oral health and healthy weight. You decide that you need some introductory family background and then will investigate these oral health and healthy weight issues next because they are the concerns she has listed as her priority items.

What questions should you ask Mrs. Smith about family support and mental health issues? image

You begin by asking general questions about the family and learn the following. Mrs. Smith is married to Maria’s father, who was recently discharged from the Army and now works as an auto mechanic. She proudly tells you that they bought their first home and are happy to have two healthy children, Maria and her 22-month-old brother, Bobby. The maternal grandmother, grandfather, and 18-year-old uncle live around the corner from them. The grandparents watch the children 2 days a week while Mrs. Smith works at a fast food restaurant during the day. Money is tight but they are doing OK and are happy to now have health insurance through Mr. Smith’s job. Mrs. Smith smiles and tells you that her husband is very loving with the children and loves to read to them before bedtime. The children and Mr. Smith like to go to the local park on the weekends so Maria and Bobby can play on the swings with the other neighborhood children. Mrs. Smith is Hispanic and Mr. Smith is African American. Mrs. Smith said that she and her husband are happy in their marriage. While they were dating, it was a tense situation for both families at first because of their different ethnicities, but their respective families now like each other.

During the visit, you note that Mrs. Smith communicates in a loving manner with the children and gives them appropriate choices. When either one of them misbehaves (e.g., when Maria reached for a tongue blade), her response was appropriate.

Developmental Surveillance and Promotion of Safety and Injury Prevention

Your clinic routinely uses a developmental screening checklist for all health supervision examinations. The list was developed from Bright Futures materials.

Maria does well in all areas (social-emotional, communicative, cognitive, and physical development), and Mrs. Smith is pleased. She reports that Maria is toilet trained for bladder and bowel during the day and wet her bed only once this past month. Maria has been attending Head Start for the past 6 weeks and “is doing well” socializing with the other children.

After asking Mrs. Smith questions about car safety seats, pedestrian safety, fall risks, and guns, you are comfortable that both Maria and her brother are well supervised and the appropriate safety precautions have been implemented to prevent unintentional injuries in the home and car environment.

Oral Health

Maria has not yet seen a dentist despite obvious caries in her frontal incisors. Mrs. Smith says that she was told by her last primary care provider that the cavities were from drinking too many bottles of milk. She says, “I was so tired with two babies that I let Maria have a bottle of milk to carry around the house. I feel badly now because that is why she has all those cavities. I know that I need to take her to the dentist.” Upon further questioning, you are told that Mrs. Smith took the bottle away from Maria at 22 months of age and that she often had 50 ounces of whole milk a day when she was a toddler. She has not had a bottle for the past 10 months and drinks 24 ounces of whole milk a day from a cup and only with her meals and snacks. Mrs. Smith brushes Maria’s teeth with a soft toothbrush and toothpaste twice a day, “but it is a struggle.” Maria drinks tap water daily; their water has the recommended amount of fluoride.

Healthful Nutrition, Physical Activity, and Healthy Weight

Culture and food are often interconnected, so you start off by asking questions about Maria’s typical eating pattern—number of meals, snacks, portion sizes, and food preferences.

You are told that Maria eats three meals and two snacks daily. Maria likes cheese but isn’t good about eating vegetables. She also likes apples and strawberries. She prefers the “kids’ meals” from the fast food restaurant that mom works in and eats them four times a week. The Smiths enjoy a family meal on Saturdays and Sundays at either the maternal or paternal grandparents’ home, having either Mexican food or “soul” food depending on the relative they are visiting. Maria’s favorite vegetable is a “french fry”; she has sodas about three times a week as a treat and has about 12 ounces of juice a day. The grandparents like to give Maria and Bobby candy treats on the weekends, but Mrs. Smith doesn’t give them candy otherwise.

You ask about the physical activities Maria likes to do. Mrs. Smith says, “Maria loves to draw her pictures,” and she prefers interacting with other children by sitting down as she “isn’t a runner.” You also ask Maria what she likes to do best with the other children at preschool or home. She says, “I like to color and play with my dolls.” You ask Maria how fast she can run, what her favorite games are, and whether she likes to play inside or outside. She replies, “I can’t run as fast as the other kids. I like to stay inside with teacher and watch videos. I like The Little Mermaid.” When asked how long Maria watches videos, TV, or participates in other screen time activities on a daily basis, Mrs. Smith says, “about 3 hours, but more like 5 hours when grandma is babysitting.”

You ask whether Mrs. Smith remembers being shown Maria’s growth grids or given information about her height and weight during her prior health supervision visits. She said, “Yes, Maria has been over the 95th percentile in height and weight since she was 6 months old. But our families are big people.”

Here is some information about the problem of obesity in children that you need to consider as you continue your data collection.

Obesity in Children

Epidemiology of Obesity

The rapidly increasing prevalence of childhood obesity has become an escalating problem and is considered a major public health issue in the United States. The National Health and Nutrition Examination Survey (NHANES) reported that 14% of children ages 2–5 years were overweight (National Center for Health Statistics, 2007), and in 2006 17% of children ages 6 to 17 in the United States were overweight (Federal Interagency Forum, 2008). A national study of 3-year-olds reported that 35% of the children in this study were overweight and that Hispanic children were twice as likely as black or white children to be overweight or obese (Kimbro, Brooks-Gunn, & McLanahan, 2007).

Etiology

Simply stated, obesity results when energy intake from food exceeds energy expenditure. Factors that cause this imbalance are numerous and influence both the prevalence and severity of overweight in an individual (Anderson & Butcher, 2006). Genetic inheritance factors are estimated to account for anywhere from 16% to 85% of body mass index (BMI) and from 35% to 63% of body fat percentage (Yang, Kelly, & He, 2007); however, the exact mechanism of how genes contribute to the prevalence and severity of obesity is unknown. All ethnic minorities in the United States are at higher risk for overweight than whites regardless of socioeconomic status (Freedman et al., 2008). Gene regulation involved in energy homeostasis, thermogenesis, adipogenesis, leptin, insulin levels, or a combination of these factors is thought to contribute to obesity (Lagou et al., 2008; Yang et al., 2007).

Genes interact with diet via digestion and absorption of nutrients to regulate energy metabolism and cellular growth. Genes also affect expenditure of energy through physical activity by regulating cellular maximal oxygen uptake and skeletal muscle metabolism. Thus, some individuals perform better in their athletic activities because of their genetic inheritance. However, the impetus to become involved in physical activity and the level of involvement largely occur through positive rewards for performance, which is a significant factor. In contrast, engaging in sedentary activities (watching television, excessive screen time activities) is associated with energy conservation with low metabolic demands. Television or screen time activities combined with food intake are particularly problematic. This hypothesis is now supported by studies demonstrating that excessive energy consumption with television viewing may be a greater problem than the lack of activity per se (Epstein et al., 2008; Matheson, Killen, Wang, Varady, & Robinson, 2004).

Intrauterine environment is now viewed as one of the most potent factors in determining risk for future overweight and obesity based on studies with large and small for gestational weight infants (Gillman, Rifas-Shiman, Berkey, Field, & Colditz, 2003; Simmons, 2004). An overly nutrient-rich intrauterine environment appears to impact fetal metabolism, which puts the child at risk for later overweight by creating demand for excessive energy intake after birth (Rasmussen & Kjolhede, 2008). Hence, maternal preconception overweight and excessive weight gain during pregnancy are issues associated with childhood overweight. The converse to this is the small for gestational age infant who is now thought to be programmed by a nutrient-poor environment to function with a “thrifty gene” that may forever alter the child’s level of nutrient needs. Overfeeding such a child is also problematic.

Certain environmental and lifestyle changes are directly linked to the increasing prevalence of childhood obesity in almost every part of the world; these result in children being raised in an obesogenic environment. When meals are not prepared at home and fast food is the meal of choice, there is a significantly greater risk for childhood overweight (Larson et al., 2008; Pereira et al., 2005). Likewise, the lack of neighborhood safety for outdoor play, increased sedentary screen time activities (> 2 hours per day) as part of a child’s everyday life events, and the reduction of physical education in schools are factors that reduce the opportunities of children to perform physical activities. Larger proportions of food servings, increased consumption of foods higher in total fat and saturated fats, decreased consumption of fruits and vegetables, and increased sweetened beverage intake are related to unhealthful food choices and eating patterns that are now more often the norm than not.

Parents provide both the genetic and environmental factors which are important to the weight of their children. Strong predictors of childhood overweight that continues throughout childhood are having either one or both parents overweight and low income status (Danielzik, 2004; Dorosty, Emmett, Reilly, & ALSPAC, 2000; Gahagan, 2004; Sothern & Gordon, 2003; Whitaker, Wright, Pepe, Seidel, & Dierz, 1997).

Diagnostic Criteria for Childhood Obesity

The American Academy of Pediatrics (AAP) Expert Committee (Barlow & Expert Committee, 2007) and the Centers for Disease Control and Prevention (CDC) use body mass index (BMI) percentile classification based on age and gender to define childhood overweight and obesity. BMI measurements are used beginning at age 2 years. If a child’s BMI is equal to or greater than the 95th percentile for age and gender, the child is considered obese. A child is termed overweight if the BMI is at the 85th to less than the 95th percentile. The AAP and CDC recommend the use of weight-for-length in children younger than 2 years, with values above the 95th percentile indicating overweight. Although the BMI is not a perfect measure, it is currently considered the measurement of choice to determine overweight in children (Krebs et al., 2007; Kuczmarski et al., 2002).

Comorbidities Linked to Childhood Obesity

The problems associated with childhood obesity are numerous and include hypertension; lipid profile abnormalities; polycystic ovary syndrome; fatty plaque development within the arterial intima; type 2 diabetes mellitus (Libman & Arslanian, 2007), which occurs more commonly after 10 years of age; asthma (Glazebrook et al., 2006); more fractures and musculoskeletal conditions (Taylor et al., 2006); nonalcoholic fatty liver disease (Riley, Bass, Rosenthal, & Merriman, 2005); sleep-disordered breathing and obstructive sleep apnea (Muzumdar & Rao, 2006); and academic performance and social/emotional well-being issues (Gable, Britt-Rankin, & Krull, 2008). The pathophysiologic consequences of childhood obesity related to the comorbid conditions just identified are linked to such underlying processes as metabolic overwork due to insulin resistance, hyperglycemia, excessive adipose tissues, stress on bones, and negative self-esteem.

From the above review, what additional questions should you ask? image

What other areas do you want to explore in the history which might be related to the obesity problem? image

History

Pregnancy, Labor, and Delivery

Mrs. Smith reports that she had high blood pressure during her last 4 months of pregnancy with both of her children and was on insulin for gestational diabetes. She was induced at 38 weeks with Maria because of her hypertension and diabetes. Maria weighed 8 pounds 15 ounces at birth, had no problems, and went home with mom on day 2.

Family Medical History

You ask about the weight status of other family members, cardiovascular risk factors (heart attacks before the age of 50 years, hypertension, hyperlipidemia), and diabetes.

Mrs. Smith tells you that Maria’s maternal and paternal grandmothers have type 2 diabetes and her paternal grandfather had a heart attack at age 52. Mrs. Smith relates that both sets of grandparents are very overweight with blood pressure and cholesterol problems. She tries to watch her own weight and considers herself to be a little overweight, wearing “large women” clothes. She ends by saying, “I come from big boned people.” Mrs. Smith said that her blood sugars have gone back to normal after both of her pregnancies. She says, “I don’t want to get diabetes like my mom and dad.” She reports that her husband has maintained his army weight since his discharge 3 months ago because he exercises a lot.

Additional Nutrition Questions

You start out by saying, “Let’s talk about what Maria ate yesterday for her meals and snacks.”

Mrs. Smith relates that Maria had a large bowl of sugar puffs for breakfast with milk and a piece of toast and fruit juice (6 ounces). For lunch, she ate at the fast food restaurant where mom works and had a kid’s meal—cheeseburger, fries, a yogurt, and a regular soda as a treat (because she was a good girl). Grandma cooked cheese enchiladas for the family dinner, and Maria had one, and a scoop of ice cream for dessert. She thinks Maria had her usual glass of whole milk (about 8 ounces) but doesn’t know for sure because her mom fed the kids because she had to work until 8 p.m. Her snacks were apple slices around 10 a.m. and a chocolate chip cookie before bed with 8 ounces of whole milk.

  You note to yourself that her diet is high in carbohydrates and Maria’s portion sizes are excessive.

Past Medical Problems and Review of Systems

image  Illnesses: Maria has been healthy but was diagnosed with “low iron” anemia at age 15 months. She was treated with iron and was told to limit her milk intake. Maria has never been hospitalized or taken to the emergency room for illnesses or injuries and has no known allergies to foods or medications.

image  Sleep: A review of systems is positive for loud snoring at night and some restlessness with sleep. However, Maria does not seem sleepy during the day and takes an occasional 20- to 30-minute nap. She sleeps about 10 to 11 hours a night.

image  Immunization history: A review of Maria’s immunization history reveals that she is up to date with all required immunizations for a child of 3 years.

image  Physical activity: You ask about the type of physical and play activities Maria did yesterday. Mrs. Smith took the kids for a walk around the block before she went to work and then grandma babysat. Maria told her mom that she and her brother and grandma watched her grandma’s “soaps,” played with their toys and dolls, and then watched her favorite videos in the afternoon until her dad picked the children up. Maria and her dad played his favorite video games after they went home from grandma’s house at 7 p.m. Mrs. Smith got off from work at 8 p.m.

Psychosocial History

image  School adjustment: Maria seems happy at school and is doing well. The only issue has been that some of the kids call her “fatso,” which prompted the teacher to call Mrs. Smith and talk to her about Maria’s weight.

image  Discipline: You ask Mrs. Smith how she disciplines Maria when her behavior is not appropriate and how she rewards Maria for good behavior. Mrs. Smith says that Maria has a short time-out in her room and that she rewards Maria with praise. When asked whether she uses food as a reward, Mrs. Smith said, “I try not to reward her with candy like her grandparents do, but I’ve been giving her a piece of chocolate every day that she doesn’t fight with her baby brother. That seems to be the only way to control the fighting between Maria and Bobby.”

What aspects of the physical examination will be important in this case? image

A developmentally appropriate approach to conducting the physical examination of a 3-year-old such as Maria involves approaching her slowly and keeping her mother close to her, gaining her involvement in the examination process, and giving attention to issues of modesty that may now surface as an area of concern for some preschoolers. A complete physical examination is needed, with the primary care provider being diligent to investigate for signs of secondary complications associated with obesity (e.g., obstructive sleep apnea, hypertension, orthopedic issues, etc.).

Physical Examination

Maria is in the 75th percentile in height and well above the 95th percentile in weight. Her BMI places her in the 97th percentile; her BP is normal for age, sex, and height percentile. Her general appearance is that of a happy but noticeably overweight preschooler. The general physical examination is within normal limits for age with the following positive findings: multiple caries involving the upper incisors and lower molars, and purple striae on her thighs. Chafing marks of her inner thighs are noted, and her vulvar area is erythematous, but without discharge. Inspection for acanthosis nigricans is negative.

The cardiovascular examination is within normal limits for age and reveals a normal S1 and S2 with no murmurs noted. She has full range of motion in all joints with bilateral symmetry and good strength in all extremities. A waddling gait is noted when she walks back and forth in the room. The EENT (eyes, ears, nose, and throat) exam is normal for age with 3+ tonsils bilaterally.

Making the Diagnosis

Do you need to do anything else, such as laboratory studies, to confirm the diagnosis? image

Routine urine and hemoglobin screening is a standard practice in your clinic at the 3-year health supervision visit. Maria’s urine dip is negative for glucose and ketones and all other urine parameters are negative. Her hemoglobin is 11 g/dL, which is normal for her age. These results provide baseline data to help you rule out anemia as well as glucosuria and ketonuria. A baseline fasting lipid profile for triglycerides, total serum cholesterol was ordered because of the paternal grandfather’s history of a heart attack at age 52 years. In addition, a thyroid screen was ordered because Mrs. Smith wanted reassurance that Maria’s overweight was not due to hypothyroidism. Otherwise, thyroid testing is not necessary at this age if the only symptom is overweight with no other symptoms such as goiter, brittle hair, stunted growth, or fatigue consistent with hypothyroidism present (Libman, Sun, Foley, & Becker, 2008). Although type 2 diabetes in children is predominantly seen after 10 years of age, you order a fasting blood glucose because Maria is at high risk due to her family history and ethnic background.

What are your diagnoses? image

Maria’s Hispanic/African American ethnic status puts her in a high risk category for obesity. Her history and physical examination with a BMI > 95th percentile are consistent with the diagnosis of obesity due to poor nutritional practices and an inactive lifestyle. Obesity is a family issue that must also be addressed. She has multiple caries. In addition, the possibility of obstructive sleep apnea needs further assessment and monitoring of symptoms. You will await the results of her lipid, thyroid, and fasting glucose readings to determine whether additional problems are identified. Maria’s cognitive, gross and fine motor skills, and language development are appropriate for age. Her thigh and vulvar skin irritation can be easily treated with topical barrier agents. In summary, your diagnoses are:

•  Obesity with a BMI at the 97th percentile

•  Normal cognitive, language, social, and fine and gross motor development for age

•  Caries

•  Thigh and vulvar skin irritation secondary to obesity

Management

Overview of Nutrition and Physical Activitiy Guidelines

The U.S. Department of Agriculture provides guidelines and recommendations for structuring a healthy diet for children 2 years of age or older at http://www.mypyramid.gov/KIDS/. The healthy diet emphasizes fruits, vegetables, whole grains, and fat-free or low-fat milk and milk products and is low in saturated fats, trans fats, cholesterol, sodium, and added sugars. Appropriate food portion size for age is stressed. This Web site contains information about developing personal MyPryamid goals and planning meals. Another important point to stress with parents of young children is the need to limit fruit juice to ≤ 4 ounces per day at any age (Spear et al., 2007), excessive milk intake, and sweetened beverage intake.

Sixty minutes or more of daily moderate to vigorous intense physical activity is recommended to maintain weight. For preschool children, this is interpreted as active play. The benefits of moderate and intense levels of physical activity also include improved mood and attention (Berkey, Rockett, Gillman, & Colditz, 2003) and reduction of cardiovascular risk factors, whether or not weight loss occurs (McGavok, Sellers, & Dean, 2007; McMurray, Harrell, Creighton, Wang, & Bangdiwala, 2008). Limiting a child’s daily screen time to no more than 2 hours is important. Sedentary activities are often a way of life for obese children or adults who may find physical activity difficult. Thus, the obese child will need to start with shorter periods of moderate to vigorous physical activity and gradually increase to these recommended levels over time. To lose weight, at least 90 minutes of vigorous daily physical activity are needed.

Culture has a significant impact on attitudes about foods, food choices, and eating practices and must be addressed as part of the management plan (Lumeng, 2008). The goal is to work within the culture to adopt culturally-appropriate healthier eating habits. Because the obese child is part of a family unit with other members who typically also have weight management issues, changes to more healthful nutrition and physical activity practices should focus on both the child and the family; family meals and healthier eating practices should be emphasized for all members of the unit. Likewise, physical activities should be encouraged for all members of the family, with physical activities scheduled as a family unit together whenever possible.

A Staged Treatment for Obesity

Using an evidence-based approach to the management of childhood obesity provides guidance to help children, adolescents, and their family to return to healthier nutrition and physical activity practices. In addition, the treatment of secondary complications (e.g., type 2 diabetes and obstructive sleep apnea) that are now more commonly found in younger obese children and adolescents also becomes an area that requires attention in order to avoid resulting negative personal and societal consequences. The AAP Expert Committee (Barlow & Expert Committee, 2007) recommends a four-stage approach for the prevention and management of overweight. Highlights of these stages are identified by Gottesman et al. (2010):

•  Stage 1: Prevention Plus: The goal of this stage is to move the child’s BMI to the 85th percentile; it will take 3–6 months for a noticeable change in BMI. Key concepts are to encourage family meals, eating at the table, adding more daily servings of fruits and vegetables, daily breakfast, and no sweetened beverages. Vigorous physical activity daily for ≥ 60 minutes needs to be planned with ≤ 2 hours of daily screen time per day allowed for the child. The provider should see the patient every 3 to 6 months. The goal of this stage is to increase physical activity, decrease physical inactivity, and improve the nutrition quality of the child’s meals and snacks and develop better eating practices (e.g., not eating in front of television or grazing on food throughout the day).

•  Stage 2: Structured Weight Management: Stage 2 includes all components of stage 1 with the addition of behavioral counseling. The key components of healthy eating in this stage are to emphasize foods with low calorie density, structured meals with one to two healthy snacks, and no sweetened beverages. The child should have 60 minutes of planned and supervised daily physical activity, and screen time should be limited to ≤ 60 minutes daily. A daily recording of physical activity and TV time, with a 3-day food log between visits, should be submitted for review. The parent or child should identify and use planned reinforcements which are not food related for desired behaviors. Schedule monthly visits to the PCP, and use of the services of multidisciplinary team members should be considered including referrals to family counseling, dietitian, physical therapy, and/or exercise therapist.

•  Stage 3: Comprehensive, Multidisciplinary Intervention: The strategies for stage 3 include those listed in stages 1 and 2 plus a diet and daily physical activity plan to achieve a negative energy balance for weight loss. A multidisciplinary team approach is essential for both the child and family. More frequent follow-up visits are needed, with visits scheduled every 2 to 3 weeks. If comorbid medical issues are present, they must be monitored closely.

•  Stage 4: Tertiary Care Intervention: Older children and adolescents who are severely obese and have failed stage 3 need to be referred to a pediatric obesity expert for stage 4 intervention. Management strategies may include very low calorie meal and snack plans, pharmacotherapy (e.g., Sibutramine or Orlistat), and/or bariatric surgery. A multidisciplinary team approach is essential.

Prevention

Prevention of overweight and obesity is of paramount importance, and every pediatric health supervision visit beginning at birth should provide anticipatory guidance about healthful nutrition practice, a healthy weight, and the promotion of age-appropriate physical activities and goals. When a child is found to be at risk for overweight or is obese, management of this problem and secondary complications, if present, become the focus of treatment to get the child “back on track.” Once obesity is established it is difficult to reverse. Therefore, the prevention of childhood overweight must focus on health promotion and anticipatory guidance activities that emphasize healthful nutrition and optimal feeding and eating behaviors. The National Association of Pediatric Nurse Practitioners in their Healthy Eating and Activity Together (HEAT) Initiative developed clinical practice guidelines entitled Identifying and Preventing Overweight in Childhood; these can be accessed via the National Guideline Clearinghouse at http://www.guideline.gov. They are an excellent resource for PCPs.

Strengthening Parenting Skills and Family Motivation for Change

Strengthening parenting skills and family motivation to embrace healthful nutrition practices and inclusion of physical activity into a daily life plan are strategies the PCP must employ for both the prevention and treatment of obesity. The tenets of motivational interviewing techniques stress the need for self-management of healthcare problems and/or a return to healthier lifestyles and choices. The steps of motivational interviewing include assessing the importance, confidence (using a scale of 0–10 to rate confidence in the ability to change), and readiness for change; exploring the importance of making a behavior change; building confidence in the ability to change; and planning for change. For children, motivational interviewing requires the healthcare provider to work with the child and/or parents, who are the ones who determine what practices and interventions for change can be implemented in their lives. The emphasis is on patient values and preferences rather than telling the child or parent exactly what they “must do” (Gance-Cleveland, 2007). Information about motivational interviewing can be found at http://www.motivationalinterview.org.

Therapeutic Plan: What will you do therapeutically to manage this child? image

Maria’s BMI is at the 97th percentile, which requires stage 1 weight management—prevention plus—as identified for this category. Reducing Maria’s sedentary activities by decreasing her daily screen time, increasing her daily physical activities through increased opportunities for active play, and providing more healthful meals and snacks with appropriate portions as identified in http://Mypyramid.gov/KIDS/are the three areas to address with Mrs. Smith. Because Maria has been teased about her weight by her preschool friends, you address the problem of negative self-esteem, which could become an issue for her. Furthermore, Mrs. Smith has indicated a readiness for change regarding nutrition and physical activity for her whole family. Building Mrs. Smith’s confidence that she can identify changes that will work considering her family’s lifestyle and personal preferences is essential.

Mrs. Smith identified the following plan for Maria. She will be allowed only 2 hours of screen time per day, and they will walk to preschool and the grandparents’ home rather than going in the car. She will encourage more play time. Mrs. Smith is going to talk with the grandparents about providing Maria with more nutritious snacks and will also discuss with her husband ways they can increase the entire family’s physical activity time together. Mrs. Smith says that she is going to try to reduce the number of times Maria has fast foods and will reduce Maria’s soda drinking to two half-cans per week. She is also going to talk with Maria about her schoolmates calling her “fatso” and how best to respond to them.

Caries

A dental referral is initiated for Maria, and you provide her mother with pamphlets and teaching about healthy dental practices including daily brushing, fluoride sealants, and dental visits.

Skin Issues

You recommend a topical over-the-counter barrier cream to be applied twice a day.

When do you want to see this patient back again? image

You want to initially see Maria back in a month to 6 weeks. You will review the laboratory studies that were ordered, discuss the effectiveness of the treatment plan, and support the family in the new treatment management at this time. As the family develops self-care skills, further appointments can be spread further apart.

How should you close today’s visit? image

You end by saying that Maria will be scheduled for a follow-up visit in 6 weeks to check her weight and review how Maria and her family are doing with the increased emphasis on healthy food choices and practices and increasing their daily activity. You ask Mrs. Smith to tell you how comfortable she is with implementing some of the suggestions that either you have given her or she has identified on her own to increase Maria’s daily physical activity and to promote more healthful nutrition practices for her daughter. You write the plan down in Maria’s chart and identify that, on a scale of 1 to 10, Mrs. Smith is a 5 in her comfort level that this plan will help both Maria and her family. You praise Mrs. Smith for her willingness to address the family’s issue of being overweight and provide Mrs. Smith with a list of local community recreational programs that focus on increasing physical activities for young children and their parents.

The Follow-Up Visit

Maria and her mother return in 6 weeks for a weight recheck and follow-up counseling regarding nutrition and physical activity. Her weight is a ½ pound lower and she has seen the dentist and begun dental treatment for her multiple caries. You review her laboratory results. Her fasting blood glucose is 90 mg/dL (normal) and her thyroid and lipid panels are also within normal limits for age. Mrs. Smith is pleased with Maria’s normal laboratory results.

Mrs. Smith says that the entire family is walking twice every day for a total of 30 to 45 minutes. The grandparents have also been receptive to reducing the portion sizes they give Maria when they provide her meals and are giving her healthier food choices by providing more fruits and vegetables. Maria still asks for candy rewards but Mrs. Smith is limiting this to only once a week as compared to five or six times, which she had done in the past.

You decide to wait to order polysomnography based on the data that Maria’s loud snoring has not worsened and she remains awake and cheerful during the day.

Key Points from the Case

1. Obesity results when there is an imbalance between energy intake from food and energy expenditure from physical activity. Therefore, healthful nutrition practices and behaviors such as improved nutrition quality, appropriate portions, daily breakfast, and a daily plan of physical activity are key elements in the prevention and treatment of childhood obesity.

2. Heritability is a critical correlate regarding the prevalence and severity of obesity, with ethnic minorities at higher risk for overweight.

3. An obesogenic environment starting during prenatal development has a significant impact on the development of childhood obesity.

4. The primary care provider should address nutrition and physical activity at every well child visit by consistently monitoring growth parameters (height and weight percentiles) starting at birth and charting BMI beginning at age 2 years.

5. Childhood overweight and obesity typically do not occur as a single family member issue, but rather also as a health issue for other family members. Thus, a family-centered approach is needed as part of the management plan.

6. Motivational interviewing is a technique that establishes a collaborative relationship in the prevention, treatment, and management of a health problem. Offering management options and involving the caregiver and older child with decisions related to types of physical activity to engage in and adopting more healthful food choices encourages the practice of self-care management of the child’s overweight problem.

7. Excessive screen time and food portions, lack of daily physical activity, fast food consumption, and using food as a reward are unhealthful behaviors that should be discussed with parents.

8. The emotional toll of childhood overweight and obesity, such as poor self-esteem and victimization by bullying, should also be addressed.

9. Some parents do not believe their child is overweight or at risk for comorbidities that they erroneously believe are adult onset problems.

10. Because of the increased prevalence of childhood overweight and obesity, primary care providers must assume an active role in the prevention and management of childhood obesity.

REFERENCES

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