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Obesity Prevention and Treatment

Overview

Screening

Prevention

General Information

References

Advisory Committee

Publication Information

OVERVIEW

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Patients with these conditions are potentially at high risk for overweight/obesity:

Other important risk factors

  • Excess calorie intake/inadequate physical activity
  • Hypothyroidism
  • Atypical antipsychotic medication (especially clozapine or olanzapine)
  • Race/ethnicity

 

SCREENING PATIENTS WITH DEVELOPMENTAL DISORDERS FOR OVERWEIGHT AND OBESITY

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For adults 21 and over, overweight is defined as a body mass index (BMI – weight/height2 [kg/m2]) of 25.0-29.9. Obesity (class 1) is defined as a BMI 30.0-34.9, obesity (class 2) is defined as BMI 35-39.9, and extreme obesity (class 3) is defined as a BMI ¡Ý40.

From birth to 2 years of age, weight-for-length is plotted on gender-specific Centers for Disease Control and Prevention (CDC) growth charts. Weight-for-length >95th percentile is defined as overweight.

For children 2-20 years old, BMI is plotted on gender-specific CDC BMI-for-age growth charts. BMI-for-age between the 85th-94th percentile is defined as at risk for overweight and BMI-for-age >95th percentile is defined as overweight.

The CDC growth charts for birth to 20 years of age were developed using data from a nationally representative sample, but they are not specific for children with developmental disorders. Children with developmental disorders may have altered growth patterns compared to children without developmental disorders. The CDC recommends, however, that the CDC growth charts be used to examine growth patterns over time for all children.

Condition-specific growth charts are available for these conditions:

Down syndrome (chart 1 [UK/Ireland], chart 2 [Sweden])

The use of these charts should be carefully considered. They are limited by the fact that they are developed from small sample sizes and homogenous populations (little ethnic/geographic diversity). It is also unclear in many cases if consistent measuring techniques were used and if nutritional status/secondary medical conditions were taken into account when constructing these charts.

Height measurements

It may be difficult to measure height in children with the inability to stand, contractures, scoliosis, lack of head and trunk control, and the need to wear braces. There are some alternative measurements that can be used to assess linear growth (specific description/pictures for techniques):

  • Crown-rump length and sitting height
  • Arm span (not appropriate if child cannot fully extend arms)
  • Upper arm length: recommended for children who are unable to stand or stretch out on a length board (i.e. children with spina bifida who are bedridden or wheelchair bound)
  • Lower leg length: recommended for children 6-18 years who have contractures

All of these measurements can be plotted on the CDC stature-for-age or length-for-age charts to establish a growth pattern over time (even if measurements are <5th percentile).

Weight measurements

If children are unable to stand, chair scales, bucket scales, wheelchair scales, or bed scales can be used. If only standing scales are available, weigh an adult holding the child, then weight the adult alone and subtract his/her weight from the original measurement. If a child requires braces to be able to stand, the braces can be weighed separately and subtracted from the child’s weight measurements.

Skinfold measurements

If children with developmental disorders have decreased muscle mass or differences in bone size, they may have increased body fat (conferring increased health risks) without a BMI-for-age in the at risk/overweight percentile range. Mita et al. found that children with spina bifida were more likely than age matched controls to have increased percent body fat after age 6. Skinfold measurements can be useful in monitoring changes in a child’s body composition (more information on skinfold measurements).

Practice Resources

2000 CDC Growth Charts: United States

http://www.cdc.gov/growthcharts/

CDC BMI Calculator

http://www.cdc.gov/nccdphp/dnpa/bmi/calc-bmi.htm

Continuing Medical Education

Centers for Disease Control and Prevention

Course Title: CDC Growth Chart Training

http://www.cdc.gov/nccdphp/dnpa/growthcharts/training/modules/index.htm

Health Resources and Services Administration: Maternal and Child Health Bureau

Course Title: The CDC Growth Charts for Children with Special Health Care Needs

http://depts.washington.edu/growth/cshcn/text/intro.htm

PREVENTING OVERWEIGHT/OBESITY IN INDIVIDUALS WITH DEVELOPMENTAL DISORDERS

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Individuals with developmental disorders may have altered energy intake needs compared to patients without developmental disorders because of eating patterns, hypotonia, short stature, and limited mobility/physical activity. Rubin et al. found that individuals with Down syndrome who live in family settings are at higher risk for overweight and obesity compared with individuals living in group home or institutional settings. Therefore family counseling about nutrition and physical activity is important.

Nutrition

Condition-specific equations for estimating daily energy requirements (Children with Special Health Care Needs: Nutrition Care Handbook):

Down syndrome (children ages 5-11)

  • Girls: 14.3 kcal/cm
  • Boys: 16.1 kcal/cm

Spina bifida (minimally active children >8 years)

  • 9-11 kcal/cm to maintain weight
  • 7 kcal/cm to promote weight loss

Prader-Willi Syndrome (all children and adolescents)

  • 10-11 kcal/cm to maintain current growth trajectory
  • 8.5 kcal/cm to promote weight loss

Example recommendations for decreasing calorie intake include increasing fruits, vegetables and whole grains and limiting fruit drinks/juices and sodas in the diet. For assessment of caloric intake and development of a calorie-appropriate eating plan, refer patients to a registered dietitian. Find a dietitian.

Physical activity

Bandini et al. analyzed NHANES 1999-2002 data and found that children with physical activity limitations had a 20% higher risk of being at risk for overweight and a 14% higher risk of being overweight compared to children without physical activity limitations. The CDC currently recommends that children and adolescents participate in at least 60 minutes of moderate intensity physical activity on most days of the week, preferably daily.

You can help parents and caregivers to reduce weight gain due to decreased physical activity by promoting appropriate, adaptive physical activities for individuals with developmental disorders:

  • The National Center on Physical Activity and Disability has information on how to develop appropriate physical activity programs for individuals with disabilities, including video clips of exercises (i.e. adapted yoga for children with cerebral palsy, strength training for people with intellectual disabilities, etc.).
  • The Special Olympics provides individuals with intellectual disabilities with the opportunity to participate in year-round sports training and athletic competition.

In addition, recommend that parents and caregivers reduce television time.

Practice Resource

American Academy of Pediatrics Policy Statement: Prevention of Pediatric Overweight and Obesity

http://aappolicy.aappublications.org/cgi/reprint/pediatrics;112/2/424.pdf

Bright Future in Practice: Physical Activity, Children with Special Needs

http://www.brightfutures.org/physicalactivity/issues_concerns/5.html

Continuing Medical Education

University of Tennessee, Boling Center for Developmental Disabilities
Course Title: Interdisciplinary Leadership Training in Overweight Prevention and Intervention for Children with Special Health Care Needs

http://anywhere.tennessee.edu/boling/

GENERAL INFORMATION ON OVERWEIGHT/OBESITY

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Ongoing management

Children

Assessment of potential complications of overweight

  • Slipped capital femoral epiphysis (hip/knee pain, limited hip range of motion)
  • Blount’s disease and osteoarthritis
  • Sleep apnea or obesity hypoventilation syndrome (daytime somnolence, breathing difficulty during sleep)
  • Pseudotumor cerebri (severe headaches, blurred margins of the optic disks)
  • Gall bladder disease (abdominal pain, tenderness)
  • Polycystic ovary disease (oligomenorrhea, amenorrhea and hirsutism)
  • Type 2 diabetes
  • Hypertension
  • Dyslipidemias
  • Congestive heart failure

Medical goals

  • Improvement/resolution of secondary complications
  • Children 2-7 years old
    • BMI 85th-94th percentile: weight maintenance (gradual decline in BMI as height increases)
    • BMI ≥ 95th percentile. If no secondary complications, weight maintenance. If secondary compliations exists, consider weight loss strategies (~1 pound/month).
  • Children >7 years old
    • BMI 85th-94th percentile. If no secondary complications, weight maintenance. If secondary compliations exists, consider weight loss strategies (~1 pound/month).
    • BMI ≥ 95th percentile: weight loss (~1 pound/month).

General principles

  • Start family-based interventions early ¨C as children get older, the risk of persistent obesity increases and habits become harder to change
  • Eating/physical activity behavior changes should be made at the family/caregiver level if possible to provide support and prevent the child from feeling singled out
  • Drastic diets/exercise programs aimed at rapid weight loss are not appropriate for children
  • Registered dietitians can help children and families develop appropriate eating goals
  • School physical education teachers and physical therapists can help children and families develop appropriate physical activity goals and programs
  • Social workers and psychologists can work with families to achieve behavior change goals

Pharmacotherapy

  • Haqq et al. found that growth hormone (0.043 mg/kg x d) had positive impacts on body composition, REE, sleep quality and pulmonary function in children with Prader-Willi syndrome

Practice resource

Maternal and Child Health Bureau, Health Resources and Services Administration, the Department of Health and Human Services

Obesity Evaluation and Treatment: Expert Committee Recommendations (children/adolescents)

http://pediatrics.aappublications.org/cgi/reprint/102/3/e29

American Medical Association

Adolescent Health: Nutrition and physical fitness

http://www.ama-assn.org/ama/pub/category/2282.html

Adults

Assessment of potential complications

  • Waist circumference measurement (wcm): men with wcm >40 inches and women with wcm >35 inches at high risk of diabetes, dyslipidemia, hypertension, cardiovascular disease
  • Comorbidities/risk factors that place patients at high absolute risk for mortality
    • Coronary heart disease and other atherosclerotic diseases
    • Type 2 diabetes
    • Sleep apnea
    • Three or more of the following: hypertension, cigarette smoking, high LDL cholesterol, low HDL cholesterol, impaired fasting glucose, family history of early cardiovascular disease, age (males ≥45 years and females ≥55 years)
  • Comorbidities/risk factors that should be treated but generally do not increase mortality risk: osteoarthritis, gallstones, stress incontinence, gynecological abnormalities (amenorrhea, menorrhagia), medical goals/management.
  • Patients with BMI ≥30; patients with BMI 25-29.9 and ≥2 risk factors or comorbidities; patients with high waist circumference and ≥2 risk factors or comorbidities. Prevent further weight gain. Weight loss of 10% of body weight over 6 months (weight loss rate 1-2 pounds/week). Maintain weight loss.
  • Dietary therapy

Referral to a registered dietitian may help patients to achieve their dietary goals Reduce calorie intake by 500-1000 calories per day (but not below 800 total calories). General calorie guidelines for weight loss: Women <165 pounds, sedentary women: 1000-1200 calories/day; Men, women ≥165 pounds, women who exercise: 1200-1600 calories/day.

  • Physical Activity: Referral to an athletic trainer or physical therapist may help patients achieve physical activity goals. Encourage patients to gradually increase physical activity to meet these goals:
    • To reduce risk of chronic disease: at least 30 minutes of moderate-intensity physical activity, above usual activity, at work or home on most days of the week
    • To manage weight and prevent weight gain: 60 minutes of moderate-to-vigorous-intensity activity on most days of the week
    • To sustain weight loss: at least 60 to 90 minutes of daily moderate-intensity physical activity
  • Behavior Therapy: Referral to a psychologist or social worker may help patients achieve behavioral goals such as: self-monitoring, stress management, stimulus control, problem-solving, contingency management, cognitive restructuring, social support.
  • Pharmacotherapy should be used in context of treatment program including diet and physical activity changes and behavior therapy. It is generally indicated for patients with BMI ≥ 30 or patients with BMI ≥ 27 with obesity-related risk factors/diseases. If a patient has not lost at least 4.4 pounds after 4 weeks, the patient is unlikely to benefit from the drug. Drugs approved by the FDA for long-term use in weight loss: sibutramine (Meridia) and orlistat (Xenical)
  • Weight loss surgery (vertical banded gastroplasty or Roux-en-Y gastric bypass) generally leads to sustained weight loss for 5 years post-surgery in most patients. Potentially indicated when other means of treatment have been unsuccessful and patients have clinically severe obesity (BMI ≥ 40) or BMI ≥ 35 with serious comorbidities. Mortality rates range from 1% (young patients without comorbidities with a BMI < 50) to 2-4% (patients with a BMI > 60 and diabetes/hypertension/cardiopulmonary failure). Patients should be provided with diet, physical activity, and psychosocial counseling before and after surgery

Practice Resource

National Heart, Lung, and Blood Institute: Obesity Education Initiative

  • Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults (http://www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns.htm)
  • The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults (http://www.nhlbi.nih.gov/guidelines/obesity/practgde.htm)

REFERENCES

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Peer-reviewed Journal Articles/Academies

Acosta, P.B. et al. (2003). Nutrient Intakes and Physical Growth of Children with Phenylketonuria Undergoing Nutrition Therapy. Journal of the American Dietetic Association, 103(9), 1167-1173.

Bandini, L.G., Curtin, C., Hamad, C., Tybor, D.J., Must, A. (2005). Prevalence of Overweight in Children with Developmental Disorders in the Continuous National Health and Nutrition Examination Survey (NHANES 1999-2002). The Journal Pediatrics, 146, 738-43.

Cronk, C., Crocker, A.C., Pueschel, S.M. et al. (1998). Growth Charts for Children with Down Syndrome: 1 Month to 18 Years of Age. Pediatrics, 81(1), 102-110.

Curtin, C., Bandini, L.G., Perrin, E.C., Tybor, .DJ., Must, A. (2005). Prevalence of Overweight in Children and Adolescents with Attention Deficit Hyperactivity Disorder and Autism Spectrum Disorders: A Chart Review. BMC Pediatrics, 5, 48.

http://www.biomedcentral.com/content/pdf/1471-2431-5-48.pdf

Haqq, A.M., Stadler, D.D., Jackson, R.H., Rosenfeld, R.G., Purnell, J.Q., LaFranchi, S.H. (2003). Effects of Growth Hormone on Pulmonary Function, Sleep Quality, Behavior, Cognition, Growth Velocity, Body Composition and Resting Energy Expenditure in Prader-Willi Syndrome. Journal of Clinical Endocrinology and Metabolism, 88(5), 2206-2212.

Havercamp, S.M., Scandlin, D., Roth, M. (2004). Health Disparities Among Adults with Developmental Disabilities, Adults with Other Disabilities, and Adults Not Reporting Disability in North Carolina. Public Health Reports, 119(4), 418-426.

Holm, V.A. (1995). Growth Charts for Prader-Willi Syndrome. In Greenswag L.R. & Alexander, R.C. (Eds.) Management of Prader-Willi Syndrome 2nd ed., New York: Springer-Verlag.

Horton, W.A., Rotter, J.I., Rimoin, D.L., et al. (1978). Standard Growth Curves for Achondroplasia. The Journal of Pediatrics, 93(3), 435-438.

Kline, A.D., Barr, M., Jackson, L.G. (1993). Growth Manifestations in the Brachmann-DeLange Syndrome. American Journal of Medical Genetics, 47(7), 1042-1049.

Krick, J., Murphy-Miller, P., Zeger, S., Wright, E. (1996).  Pattern of Growth in Children with Cerebral Palsy. Journal of the American Dietetic Association. 96, 680-685.

Lyon, A.F., Preece, M.A., Grant, D.B. (1985). Growth Curves for Girls with Turner Syndrome. Archive of Disease in Children, 60(10), 932-935.

Mita, K., Akataki, K., Itoh, K., Ono, Y., Ishida, N., Oki, T. (1993). Assessment of Obesity of Children with Spina Bifida. Developmental Medicine and Children Neurology, 35(4), 305-11.

Morris, C.A,. Demsey, S.A, Leonard, C.O,. et al. (1998). Natural history of Williams syndrome: Physical Characteristics. The Journal of Pediatrics, 113(2), 318-326.

Myrelid, A. et al. (2002). Growth Charts for Downs Syndrome from Birth to 18 Years of Age. Archive of Disease in Children, 87, 97-103.

Position of the American Dietetic Association: (2004). Providing Nutritional Services for Infants, Children, and Adults with Developmental Disabilities and Special Health Care Needs. Journal of the American Dietetic Association, 104(1), 97-107.

Ranke, M.B., Pfluger, H., Rosendahl, W., et al. (1983). Turner Syndrome: Spontaneous Growth in 150 Cases and Review of the Literature. European Journal of Pediatrics, 141(2), 81-88.

Rimmer, J.H., Braddock, D., Marks, B. (1995). Health Characteristics and Behaviors of Adults with Mental Retardation Residing in Three Living Arrangements. Research in Developmental Disabilities, 16(6), 489-499.

Rubin, S.S., Rimmer, J.H., Chicoine, B., Braddock, D., McGuire, D.E, (1998). Overweight Prevalence in Persons with Down Syndrome. Mental Retardation, 36(3), 175-181.

Stevens, C.A., Hennekam, R.C., Blackburn, B.L. (1990). Growth in the Rubinstein-Taybi Syndrome. American Journal of Medical Genetics, 6, 51-55.

Styles, M,E,, Cole, T.J., Dennis, J., Preece, M.A. (2002).  New Cross Sectional Stature, Weight, and Head Circumference References for Down’s Syndrome in the UK and Republic of Ireland. Archive of Disease in Children, 87, 104-108.

Government

California Obesity Prevention Initiative

http://www.dhs.ca.gov/ps/cdic/copi/html/Taking%20Action.htm

Centers for Disease Control and Prevention (CDC), National Center for Chronic Disease Prevention and Health Promotion, Division of Nutrition and Physical Activity

http://www.cdc.gov/nccdphp/dnpa/obesity/

Executive Office of the President and the Department of Health and Human Services (DHHS)

http://www.healthierus.gov/

United States Department of Agriculture

MyPyramid: http://www.mypyramid.gov/

Nutrition information clearinghouse: http://www.nutrition.gov/

Dietary Guidelines for Americans 2005

http://www.healthierus.gov/dietaryguidelines/

The President’s Council on Physical Fitness and Sports

http://www.fitness.gov/

The President’s Challenge Physical Activity and Fitness Awards Program

http://www.presidentschallenge.org/

DHHS Healthy Lifestyles Campaign

http://www.smallstep.gov/

National Cancer Institute 5-to-9 a Day Campaign

http://www.5aday.gov/

CDC VERB Campaign (fitness for children ages 9-13)

http://www.cdc.gov/youthcampaign/

CDC BAM! Campaign (nutrition and fitness for adolescents)

http://www.bam.gov/

Federal Land Management Agencies

http://www.recreation.gov

Special Interest Groups/Other Publications

American Obesity Association

http://www.obesity.org/

Holm V. In: Greenswag LR, Alexander RC, (Eds.) (1995). Management of Prader-Willi Syndrome. 2nd ed. New York: Springer-Verlag, 1995.

Pediatric Nutrition Practice Group and Dietetics in Developmental and Psychiatric Disorders. (2004). Children with Special Health Care Needs: Nutrition Care Handbook. Ed. Lucas BL. Chicago: American Dietetic Association,

ADVISORY COMMITTEE

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Mary Ann Lewis, Dr.P.H., R.N., F.A.A.N.

Theodore A. Kastner, M.D., M.S.

Felice Weber Parisi, M.D., M.P.H.

Sam Yang, M.D.

Larry Yin, M.D., M.S.P.H., F.A.A.P.

PUBLICATION INFORMATION

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Funded by a grant from the California Department of Developmental Services

For more information, contact:

Center for Health Improvement

1330 21st Street, Suite 100

Sacramento, CA 95814

(916) 901-9645

This document does not provide advice regarding medical diagnosis or treatment for any individual case, and any opinions or statements contained in this document are not intended to serve as a standard of medical care. Physicians are encouraged to view the considerations presented in this document in light of evolving scientific information. This document is not intended for use by the layperson. Reproduction of this document may be done with proper credit given to California Department of Developmental Services and the Center for Health Improvement.