Obesity screening recommended for kids

On January 25, 2010, in Uncategorized, by Andrea

It’s a sad fact — and one that as a parent I must accept — that our kids are becoming obese at a rate that is outpacing even our expectations as an obese nation.

I imagine that some screening is already in place by some pediatricians.  I know that our normal pedi doesn’t do blood pressure checks, but our specialist pediatrican’s office (we go to a GI and allergist) does do BP checks.  Perhaps this should be done by a general pedi as well?

What about A1c and cholesterol screening?  At what point does cost outweigh risk factors?

From Medscape:

USPSTF Recommends Obesity Screening for Children Ages 6 to 18 Years

Laurie Barclay, MD

January 22, 2010 — The US Preventive Services Task Force (USPSTF) recommends that clinicians screen children ages 6 to 18 years for obesity and refer as appropriate to programs to improve their weight status, according to evidence-based guidelines posted online January 18 and to be published in the February print issue of Pediatrics. The statement, which is an update of the 2005 USPSTF statement about screening for overweight in children and adolescents, is accompanied by a supporting systematic review and commentary.

“Since the 1970s, childhood and adolescent obesity has increased three- to sixfold,” write chair Ned Calonge, MD, MPH, from the Colorado Department of Public Health and Environment in Denver, and colleagues from the USPSTF. “Approximately 12% to 18% of 2- to 19-year-old children and adolescents are obese (defined as having an age- and gender-specific BMI [body mass index] at >95th percentile)….Previously, the USPSTF found adequate evidence that BMI was an acceptable measure for identifying children and adolescents with excess weight.”

The USPSTF evaluated evidence for the efficacy of pediatric weight management interventions that are feasible in primary care or referable from primary care. The task force also considered the evidence for the magnitude of potential harms of treatment in children and adolescents.

This evidence led the USPSTF to issue a grade B recommendation that clinicians screen children 6 years and older for obesity and provide obese children with intensive counseling and behavioral interventions designed to improve weight status, or that they refer them for such counseling and interventions.

During health maintenance visits, height and weight are routinely measured, allowing calculation of BMI. Based on a review of 20 clinical trials of behavioral and pharmacologic interventions for obesity, the task force concluded that evidence was adequate that comprehensive, moderate- to high-intensity interventions effectively improve BMI in children.

“Over the past several years, research into weight management in obese children and adolescents has improved in quality and quantity,” write Evelyn P. Whitlock, MD, MPH, from the Center for Health Research, Kaiser Permanente in Portland, Oregon, and colleagues. “Despite important gaps, available research supports at least short-term benefits of comprehensive medium- to high-intensity behavioral interventions in obese children and adolescents.”

Moderate- to high-intensity programs are defined as those in which there are more than 25 hours of contact with the child and/or family during a 6-month period. Low-intensity interventions were not associated with significant improvement in weight status.

Three components needed for effective, comprehensive programs are counseling regarding healthy diet and/or weight loss; counseling regarding physical activity recommendations or a physical activity program; and behavioral management techniques including setting goals and self monitoring.

Families seeking treatment for obese children should therefore consider comprehensive programs targeting weight control through healthy food choices, physical exercise, and building behavioral skills.

The task force also concluded that evidence is adequate that the harms of behavioral interventions are no greater than small, and that there is moderate certainty that the net benefit is moderate for screening for obesity in children at least 6 years old and for offering or referring children to moderate- to high-intensity interventions to improve weight status. The USPSTF did not find sufficient evidence for screening children younger than 6 years.

Although interventions that combined pharmacotherapy (sibutramine or orlistat) with behavioral interventions were associated with modest short-term improvement in weight status in children at least 12 years old, there were no long-term data on maintenance of improvement after medications were discontinued. The magnitude of the harms of these medications in children could not be estimated with certainty, but known adverse effects include elevated heart rate and blood pressure and adverse gastrointestinal tract effects.

“Areas for further research include investigations to determine the specific effective components of behavioral interventions,” the task force concludes. “Longer-term follow-up of participants in behavioral or multicomponent trials is needed to confirm maintenance of treatment effect and to assess longer-term risks and harms. Investigation is needed of more efficient, primary care–feasible interventions that use allied health professionals. More studies are needed that address weight management in minority children and adolescents, behavioral interventions in younger children (aged <5 years), and behavioral interventions in children who are overweight but not obese.”

In an accompanying commentary, pediatrician and American Academy of Pediatrics Board of Directors member Sandra Hassink, MD, FAAP, from A. I. Dupont Hospital for Children in Wilmington, Delaware notes that the American Academy of Pediatrics supports the USPSTF recommendations but also recommends routine obesity screening of children beginning at age 2 years.

“Recognition that screening is the first step to individual evaluation and counseling for obesity prevention and treatment should be standard in practice now,” Dr. Hassink writes. “Working with families to screen for high-risk nutrition and activity behaviors that contribute to obesity in early childhood must be part of that task. With that said, the current USPSTF report is significant because it provides evidence that obesity treatment can be effective and extend beyond the immediate intervention and that pediatricians in the context of a medical home model that supports multidisciplinary care, with the appropriate supports of training and reimbursement, can provide effective obesity prevention and treatment for the families and children in their care.”

The statement, review, and commentary authors have disclosed no relevant financial relationships.

Pediatrics. Published online January 18, 2010.

Cholesterol high in kids

On January 21, 2010, in Uncategorized, by Andrea

Not good.  I mean, what else can I say?  Really not good?  Horrible, tragic news?

Not surprising, I suppose.


1 in 5 teens has unhealthy cholesterol levels

Even 14 percent of teens with normal weight have poor levels, CDC says

WASHINGTON – One in five American teens has unhealthy cholesterol levels, a major risk factor for heart disease in adults, the U.S. Centers for Disease Control and Prevention said on Thursday.

The heavier teens were, the more likely they were to have high cholesterol but even 14 percent of teens with normal body weight were found to have unhealthy cholesterol levels, the CDC said.

CDC researchers studied data on 3,125 teens collected from the National Health and Nutrition Examination Survey for 1999 through 2006.

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They found that 20.3 percent of young people aged 12 to 19 and more boys than girls had unhealthy cholesterol levels.

The study found that, based on American Academy of Pediatrics guidelines, a third of teens would be eligible for cholesterol screening based on a family history of high cholesterol or premature heart disease.

The researchers analyzed measurements of low-density lipoprotein — LDL or so-called bad cholesterol; high-density lipoprotein, the HDL or “good,” cholesterol; and triglycerides.

Bad cholesterol can help clog arteries while good cholesterol carries away the bad stuff. People should aim for low LDL and triglycerides and high HDL.

Ashleigh May of the CDC, who led the study, said the results were “very concerning.”

“It’s a large proportion of the youth that have at least one abnormal lipid level. That is concerning given the long term implications for heart disease,” May said in a telephone interview.

Unhealthy cholesterol levels, which often begin during childhood and adolescence, are a big risk factor in heart disease, the No. 1 cause of death among adults in the United States.

“We really want to make sure that clinicians are aware of lipid screening guidelines and lifestyle interventions that are recommended, for youth, especially overweight and obese youth,” May said.

“For all youth, healthy eating habits and physical activity are good ways to reduce their risk for abnormal lipids and heart disease in the long term.”

Non-surgical treatment for kids

On January 18, 2010, in Uncategorized, by Andrea

Kids need help.  Badly.  Pediatric obesity is not on the rise — it’s reaching epidemic levels.  And given that many that are affected are low-income, there needs to be options for those families to afford treatment.  Treatment should not be relegated just to those who can afford it.

From MSNBC.com:

Obesity treatment for kids works, panel says

Advice could transform how doctors deal with overweight children

CHICAGO – An influential advisory panel says school-aged youngsters and teens should be screened for obesity and sent to intensive behavior treatment if they need to lose weight — a move that could transform how doctors deal with overweight children.

Treating obese kids can help them lose weight, the panel of doctors said in issuing new guidelines Monday. But that’s only if it involves rigorous diet, activity and behavior counseling.

Just five years ago, the same panel — the U.S. Preventive Services Task Force — found few benefits from pediatric obesity programs. Since then, the task force said, studies have shown success. But that has only come with treatment that is costly, hard to find and hard to follow.

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The good news is, “you don’t have to throw your arms up and say you can’t do anything,” said task force chairman Dr. Ned Calonge. “This is a recommendation that says there are things that work.”

Calonge said the panel recognizes that most pediatricians are not equipped to offer the necessary kind of treatment, and that it may be hard to find, or afford, places that do. The recommendations merely highlight scientific evidence showing what type of programs work — “not whether or not those services are currently available,” he said.

The new advice, published online in the journal Pediatrics, could serve as a template for creating obesity programs. It also might remove one important cost barrier: Calonge said insurers will no longer be able to argue that they won’t provide coverage because treatment programs don’t work.

Evidence the panel evaluated shows intensive treatment can help children lose several pounds — enough for obese kids to drop into the “overweight” category, making them less prone to diabetes and other health problems. The treatment requires appointments at least once or twice a week for six months or more.

The recommendations follow government reports last week that showed obesity rates in kids and adults have held steady for about five years. Almost one-third of kids are at least overweight; about 17 percent are obese.

The task force is the same group of government-appointed but independent experts whose new mammogram advice startled many women in November. That guidance — that most women don’t need routine mammograms until age 50 — is at odds with the American Cancer Society and several doctor groups.

Costly programs
In this case, the task force advice mirrors that of the American Academy of Pediatrics. Many pediatricians already measure their young patients’ height, weight and body mass index at yearly checkups.

Task force recommendations in 2005 said there wasn’t enough evidence to encourage routine obesity screening and treatment. The update is based on a review of 20 studies, most published since 2005, involving more than 1,000 children.

The review excluded studies on obesity surgery, which is only done in extreme cases.

The panel stopped short of recommending two diet drugs approved for use in older children, Xenical and Meridia, because of potential side effects including elevated heart rate, and no evidence that they result in lasting weight loss.

Calonge, chief medical officer for Colorado’s public health department, said evidence is lacking on effective treatment for very young children, so the recommendations apply to ages 6 to 18.

The most effective treatment often involves counseling parents along with kids, group therapy and other programs that some insurers won’t cover. But adequate reimbursement “would be critical” to implementing these programs, Dr. Sandra Hassink, a member of the American Academy of Pediatrics’ board of directors, said in a Pediatrics editorial.

Dr. Helen Binns, who runs a nutrition clinic at Chicago’s Children’s Memorial Hospital, says such programs are scarce partly because they’re so costly. Her own hospital — a large institution in one of Chicago’s wealthiest neighborhoods — doesn’t have one.

Many families with obese or overweight children can’t afford that type of treatment. And it’s not just cost. Many aren’t willing to make the necessary lifestyle changes, she said.

“It requires a big commitment factor on the part of the parent, because they need to want to change themselves, and change family behavior,” Binns said.

Great!  Lovely!  This stuff is in tons of things marketed to our kids.  I’d know — I have two of them running around.  Well, not right now as it’s after 11pm.  But I would if I were doing this during a sane hour.

Increase in triglycerides, blood pressure, and lowered good cholesterol levels.  That’s quite the trifecta there.

From Medscape:

High Fructose Intake Linked to Metabolic Syndrome, Kidney Disease

Anthony J. Brown, MD

January 15, 2010 — Excessive intake of fructose, a common sweetener in soft drinks, can induce features of metabolic syndrome and may be a risk factor for chronic kidney disease, according to the findings from two studies.

The results of both studies suggest that these adverse effects are mediated, at least in part, through elevations in uric acid levels.

“Excessive fructose intake causes metabolic syndrome in animals and can be partially prevented by lowering the uric acid level,” Dr. S. E. Perez-Pozo, lead author of the first study, and colleagues note. “We tested the hypothesis that fructose might induce features of metabolic syndrome in adult men and whether that is protected by allopurinol.”

The researchers’ study, reported in the December 22nd online issue of the International Journal of Obesity, featured 74 adult men who were randomized to receive 200 g fructose daily for 2 weeks without or without allopurinol. Primary endpoints included changes in ambulatory blood pressure, lipid levels, glucose and insulin, homeostatic model assessment (HOMA) index, body mass index, and criteria for metabolic syndrome.

Fructose intake was associated with an average increase in systolic and diastolic blood pressure of 7 and 5 mm Hg, respectively (p < 0.004 and p < 0.007, respectively), Dr. Perez-Pozo, from Son Llatzer Hospital–Palm of Majorca, Spain, and colleagues report.

Mean fasting triglyceride levels rose by 0.62 mmol/L (p < 0.002), while high-density lipoprotein cholesterol levels fell by 0.06 mmol/L (p < 0.001).

Although plasma glucose levels did not change, a significant increase in fasting insulin and HOMA indices was observed. Depending on the criteria used, the prevalence of metabolic syndrome increased by 25% to 33%.

Allopurinol treatment reduced uric acid levels and prevented the increase in blood pressure. In addition, it reduced levels of low-density lipoprotein cholesterol. Although allopurinol did not reduce HOMA or fasting triglyceride levels, it did help stave off newly diagnosed metabolic syndrome (p = 0.009).

The results “suggest that the primary effect of lowering the uric acid level on the metabolic syndrome induced by fructose is to reduce the blood pressure elevation,” the authors conclude. “It remains possible that the lowering of uric acid level might be beneficial on lipids and insulin resistance if postprandial levels were targeted as opposed to fasting levels,” they add.

In the second study, published in the December 23rd online issue of Kidney International, Dr. Andrew S. Bomback, from Columbia University College of Physicians and Surgeons, New York, and colleagues assessed the impact of sugar-sweetened soda intake on the risk of hyperuricemia and reduced kidney function. They analyzed data from 15,745 patients in the Atherosclerosis Risk in Communities Study who completed dietary questionnaires at baseline and had levels of creatinine and uric acid measured.

On cross-sectional analysis, consumption of more than 1 soda per day increased the odds of hyperuricemia by 31% relative to intake of less than 1 soda per day. Likewise, such intake was associated with 46% increased risk of chronic kidney disease, defined as an estimated glomerular filtration rate of <60 mL/min per 1.73 meters-squared. In subjects with uric acid levels over 9.0 mg/dL, intake of more than 1 soda per day increased the risk of kidney disease by 159%.

By contrast, on longitudinal analysis, high soda intake was not linked with hyperuricemia or chronic kidney disease at either 3 years or 9 years, the findings indicate.

Given that only the cross-sectional analysis showed a significant association between soda intake and hyperuricemia/chronic kidney disease, “our findings add to but in no way close the heated discussion over the potential dangers of sugar-sweetened soda,” the authors conclude.

Int J Obesity. Published online December 22, 2009.

Kidney Int. Published online December 23, 2009.

Controversial surgical center for teens

On January 15, 2010, in Uncategorized, by Andrea

I’m of two minds of this.

At 17, I would not have been ready for a life-altering event like this.  At times, I don’t think I was really ready at 25.  At 17, I would not have been ready for the responsibility of the vitamin regimen for RNY.  Maybe a non-malabsorptive surgical option like VSG or AGB — but not DS or RNY.  But I know there has to be an option for those that ARE.

From the Denver Post:

Surgical hope for obese teens

Rose opens the first bariatric program for youths in Colorado &mdash; amid controversy

Kat Borst tried low-carb and no-carb and South Beach and Weight Watchers and so many other diets she “can’t even list them all.” None worked.

So at 17 years old and 280 pounds, Borst underwent surgery to squeeze her stomach smaller. She’s lost 54 pounds since June and now hits the gym with her dad, even though she couldn’t climb a flight of stairs without wheezing before.

Borst’s weight loss, and the success of other teens who’ve had Lap-Band or gastric-bypass surgery at Rose Medical Center in Denver, have led the hospital to open a new bariatric program for teens — the first of its kind in Colorado.

The new center comes as childhood obesity has reached epic levels — about 17 percent of American children and teens are considered obese — but also as controversy looms about the safety of bariatric surgery for adolescents.

The program at Rose is tailored to teens, with several weeks of pre- and post-surgery sessions on nutrition, psychology and behavioral changes.

“Being 17 is really hard,” said Dr. Michael A. Snyder, a bariatric surgeon who will direct the center. “Being a teen with bariatric surgery is very difficult. Being a morbidly obese teen is a total nightmare.”

Snyder, who has done more than 2,800 bariatric surgeries and developed a special high-nutrition food for his patients, said he makes sure teens “are ready for a life-long commitment” before he performs surgery, which costs about $9,500 and is only sometimes covered by insurance. For most adolescents, Snyder places a Lap-Band, which is gradually tightened to reduce stomach capacity to about 10 to 20 percent of its original space.

It should take about 4 ounces of protein — a chicken breast about as big as a computer mouse, for example — to make a patient with a Lap-Band feel “Thanksgiving full” for two or three hours, Snyder said. The bariatric center counsels teens not to waste calories on frappachinos or sodas or really anything without protein — otherwise they don’t lose the weight and could suffer from malnutrition.

Doctors disagree on rules

Snyder, one of few bariatric surgeons in the state who will operate on people younger than 18, said the ideal patient is at least 100 pounds overweight and has tried dieting and exercise without success. The doctor cites studies showing a less than 3 percent chance that a morbidly obese person will lose the excess weight and keep it off on their own.

“It’s the safest bet in Vegas,” he said. “If you are morbidly obese, the rules are different for you.”

But other physicians argue Lap-Band and gastric-bypass surgery on adolescents is irresponsible and unsafe.

“I am so disgusted with this,” said Dr. Wendy Scinta, a pediatric bariatrician on the board of the American Society of Bariatric Physicians. “In children, it’s still considered experimental.”

Scinta, who runs a medical weight-loss clinic for children and teens in Syracuse, N.Y., said adolescents who have bariatric surgery could end up with severe vitamin deficiencies and require surgery later to remove “elephant skin,” the kind that hangs off the body when weight loss happens too quickly without maintaining muscle mass.

“It’s kind of young to be going through something so drastic,” she said. “We’re at the point where the obesity epidemic is happening faster than we can get our arms around it, but especially with children, we do

have some time. We need to give them a shot at doing something less aggressive at first.”At Scinta’s clinic, kids take medication to control their insulin levels, they learn — with their parents — to change the family diet to five small meals per day, and they are hooked up with pedometers and an exercise program. Childhood obesity often is caused by family or medical problems, Scinta said.

“Kids are easy,” she said. “You really give them their life back or give them a life if they have never had one.”

Scinta said she would recommend bariatric surgery — and she never has for a child or teen — only for a kid who weighed 600 or 700 pounds, couldn’t get out of bed and was “truly on death’s door.”

Doctors said it’s often difficult to discern the parents’ desires from the child’s when considering bariatric surgery for an adolescent.

“The hardest thing in the pediatric population is determining who is deciding they should have surgery,” said Dr. Scott Fisher, director of bariatrics at Penrose-St. Francis Health Services in Colorado Springs. “Is it society? Is it the parents who are embarrassed of their child’s weight? For 40-year-olds, it is because they are choosing themselves to make themselves healthier.”

The Penrose bariatric surgery center has operated on only 10 to 15 teens in the last eight years, Fisher said.

Diet still a challenge

Borst, who is 18 now and working toward her goal weight of 145 pounds, wishes she would have had her Lap-Band surgery sooner in life. She struggled with her weight since age 4, was ridiculed throughout elementary school and left high school for an online program because of all the teasing.

Now she’s planning on college next fall.

“I’m getting more confident,” she said. “It’s not fully built up yet because I’m still pretty big.”

Still, Borst’s life is different now. Before her surgery she “was feeling like absolute death.” Now she enjoys hopping on a treadmill or stationary bike and playing badminton. Her clothes, she said, are “falling off.”

Changing her diet has been the biggest challenge.

“I’m not going to lie; I have a lot of spells where I lose my determination,” she said. “I get disappointed in myself. Every teenager that goes into this has to know it’s not easy.”

Jennifer Brown: 303-954-1593 or jenbrown@denverpost.com

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