LOSE WEIGHT FOR KIDS

LEARN TO DETERMINATION OF THE LEVEL OF OBESITY

noreply@blogger.com (mesothelioma.abestos.lawyers) — Thu, 30 Aug 2012 07:23:00 +0000

confirm the slightly of obesity, weight and height, you ought to be measured connected to scale calibration. then you might want to confirm the bmi percentile bmi-sds and / or. calculation graphics functions are actually in receipt on your knowledge based mostly on german education by the internet ( http ://www. aga. de ) 3. previously, a lot of youth 15 years, the pattern of distribution of fat often is distinguished within the whole middle regarding overweight and obesity. it's so the measurement on your waist circumference center on your lower rib and also the iliac crest. hips , measured horizontally, along at the prime on your bigger trochanter. waist-hip ratio in adult girls ? zero. 85, whr of adult men ? 1. 0 what's an indicator on your central distribution of unwanted fat. there's presently no standard the price on your whr of young individuals, from young youngsters and elderly, but
adult reference, you might want to by the basis of classification.

TIPS ON RATIONAL CLINICAL DIAGNOSTIC MEDICAL EVALUATION OF CHILDREN AND ADOLESCENTS

noreply@blogger.com (mesothelioma.abestos.lawyers) — Wed, 29 Aug 2012 07:20:00 +0000

Incremental medical analysis of children youth will certainly be displayed with suspected obesity ( see additionally table 1 ). where within your case, all steps can lead to firmly additional diagnostic method described in the very first stage of screening is to firmly classify the excess. weight. preferred clinical measures of body mass index ( bmi ). obesity in childhood and adolescence, according to firmly national guidelines that will be defined being a bmi ? percentile on your specific ninety-seven, kids and adolescents to firmly age and sex and 97 percentile values of bmi and between the very first ninety, are thought of obese 1. you'll be able to reference information of international bmi values and policy application within the presence on your country of reference 2. in patients with extra risk factors ought to thought of obese they usually have additional contributed to firmly the diagnosis and fastidiously. particularly in, bmi positive family history of obesity within the parent ( ( 2 kg/m2 per year ? crossing from step upward percentile, of bmi ) of bmi gain acceleration ? heart attack and stroke ( early onset of atherosclerosis ) or 30 kg / m 2 insult ? ought to lead to firmly fifty five of the very first or second degree a similar diagnostic procedures in patients with obesity. if there can be no extra risk factors name ought to be accessible, patient and family to firmly accompany, to firmly follow up at 12 months. a additional examination of youngsters and adolescents with obesity and obesity patients with extra risk factors for more than one of these following three the most purpose : to firmly verify the somewhat of obesity ( 1 ) ; removal on your underlying primary disease ( 2 ), and individual analysis ( 3 ) comorbidity ( eg, endocrine, metabolic, and orthopedic risk issue profile, respiratory, dermatology, psychiatry complications ).

Determinants of physical fitness in children with asthma

noreply@blogger.com (mesothelioma.abestos.lawyers) — Wed, 29 Aug 2012 04:43:00 +0000

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and blood pressure on left ventricular growth in children and young adults in the Bogalusa
Heart Study. Circulation 1995; 91(9):2400–2406.
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cardiovascular deconditioning, high prevalence of cardiovascular risk factors, diabetes mellitus/
hyperinsulinemia, and respiratory compromise. J Ped 2004;144(6):766–769.
17. Friberg P, Allansdotter-Johnsson A, Ambring A, Ahl R, Arheden H, Framme J et al. Increased left
ventricular mass in obese adolescents. Euro Heart J 2004; 25(11):987–992.
18. Giordano U, Ciampalini P, Turchetta A, Santilli A, Calzolari F, Crino A et al. Cardiovascular hemodynamics:
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19. Mensah GA, Treiber FA, Kapuku GK, Davis H, Barnes VA, Strong WB. Patterns of body fat deposition
in youth and their relation to left ventricular markers of adverse cardiovascular prognosis. Am J Cardo
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of blood pressure. Hypertension 1996; 28(1):37–41.
21. Rowland T, Bhargava R, Parslow D, Heptulla RA. Cardiac response to progressive cycle exercise in
moderately obese adolescent females. J Adolesc Health 2003; 32(6):422–427.
22. Humphries MC, Gutin B, Barbeau P, Vemulapalli S, Allison J, Owens S. Relations of adiposity and
effects of training on the left ventricle in obese youths. Med Sci sports Exer 2002; 34(9):1428–1435.
23. Uwaifo GI, Fallon EM, Calis KA, Drinkard B, McDuffie JR, Yanovski JA. Improvement in hypertrophic
cardiomyopathy after significant weight loss: case report. So Med J 2003; 96(6):626–631.
24. Reinehr T, Kiess W, Kapellen T, Andler W. Insulin sensitivity among obese children and adolescents,
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metabolic syndrome in children and adolescents. NE J med 2004; 350(23):2362–2374.
27. Reaven G, Abbasi F, McLaughlin T. Obesity, insulin resistance, and cardiovascular disease. Recent
Prog Horm Res 2004; 59:207–223.
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2003; 30(4):697–710.
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prevents progression from precocious pubarche to polycystic ovary syndrome. J Ped 2004;144(1):23–29.
30. Pinhas-Hamiel O, Dolan LM, Daniels SR et al. Increased incidence of non-insulin-dependent diabetes
mellitus among adolescents. J Ped 1996; 128:608–615.
31. Festi D, Colecchia A, Orsini M, Sangermano A, Sottili S, Simoni P et al. Gallbladder motility and
gallstone formation in obese patients following very low calorie diets. Use it (fat) to lose it (well).
International Journal of Obesity and Related Metabolic Disorders 1998;Jun;22(6):592–600.
32. Chan DF, Li AM, Chu WC, Chan MH, Wong EM, Liu EK et al. Hepatic steatosis in obese Chinese
children. Int J Obes Rel Metabol Disord 2004; 28(10):1257–1263.
33. Li AM, Chan D, Wong E, Yin J, Nelson EA, Fok TF. The effects of obesity on pulmonary function.
Arch Dis Child 2003; 88(4):361–363.
34. Lazarus R, Colditz G, Berkey CS, Speizer FE. Effects of body fat on ventilatory function in children
and adolescents: cross-sectional findings from a random population sample of school children. Ped
Pulmonol 1997; 24(3):187–194.
35. Pianosi PT, Davis HT. Determinants of physical fitness in children with asthma. Pediatrics 2004;
113:e225–e229.
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Research Group. Association of body mass with pulmonary function in the Childhood Asthma
Management Program (CAMP). Thorax 2003; 58(12):1036–1041.
37. Rosen CL. Clinical features of obstructive sleep apnea hypoventilation syndrome in otherwise healthy
children. Ped Pulmonol 1999; 27(6):403–409.
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39. Loder RT, Aronson DD, Greenfield ML. The epidemiology of bilateral slipped capital femoral epiphysis.
A study of children in Michigan. J Bone Joint Surg 1993;75:1141–1147.

DEFINITION ORTHOPEDIC

noreply@blogger.com (mesothelioma.abestos.lawyers) — Wed, 29 Aug 2012 04:42:00 +0000

Two orthopedic conditions are of particular importance in pediatric obesity — Blount disease and
slipped capital femoral epiphysis. Both occur primarily in younger adolescents and preteens, and
both are disorders of the lower extremity. Both conditions may lead to a vicious cycle of overweight
making the orthopedic condition worse, while the raised barrier to physical activity that theconditions present then make the overweight condition worse, and so on. Both should be considered
orthopedic emergencies requiring surgical consultation because they can be crippling.
Blount disease (also known as Tibia vera, or Genu varum) presents as a bowing of the leg with
or without pain and limp. It consists of an abnormality in the growth of the medial portion of the
proximal tibia. It is unclear whether this abnormality is caused by excess weight placed on the
joint at a critical stage in development or whether it is an underlying condition that is aggravated
by the excess weight. Plain anterior–posterior x-rays of the leg characteristically show irregularity
of the growth of the proximal medial tibial physis, with beaking or a triangulation of the metaphysis.
Surgical correction is by osteotomy.
Slipped capital femoral epiphysis occurs when the epiphysis of the proximal femur slips off
the metaphysis posteriorly and medially secondary to increased weight on the cartilaginous growth
plate of the hip [39]. The classic patient is an overweight, hypogonadal boy with delayed bone age.
Symptoms include limp, hip or knee pain, and the typical antalgic gate, with the leg externally
rotated and abducted.

DEFINITION NEUROLOGICAL

noreply@blogger.com (mesothelioma.abestos.lawyers) — Wed, 29 Aug 2012 04:41:00 +0000

Pseudotumor cerebri (benign intracranial hypertension) presents with headache, dizziness, diploplia,
and mild unsteadiness. It generally has a gradual onset and does not show localizing neurological
signs. If symptoms begin acutely, or if focal signs are present, other sources of raised intracranial
pressure must be sought. Phillips et al. studied the 10-year incidence of this disorder in a hospitalbased
series of children up to 18 years of age [38]. Obesity was associated with one-third of cases.
There was no gender predilection. One third of patients demonstrated some optic atrophy at follow
up [38]. Weight loss is recognized as the best treatment.

DEFINITION OBSTRUCTIVE SLEEP APNEA HYPOVENTILATION SYNDROME

noreply@blogger.com (mesothelioma.abestos.lawyers) — Wed, 29 Aug 2012 04:41:00 +0000

Obstructive sleep apnea hypoventilation syndrome is associated with obesity in adults. It is characterized
by snoring, irregular breathing with long pauses during sleep, and daytime tiredness. In
children, it can be confused with attention deficit disorder and other learning problems, as well as
depression. Rosen studied a group of 326 children who were referred for sleep studies and found
that although obesity was not the only cause of pediatric obstructive sleep apnea hypoventilation
syndrome, high BMI was twice as prevalent as expected (28%) in this population [37].

DEFINITION ASTHMA

noreply@blogger.com (mesothelioma.abestos.lawyers) — Wed, 29 Aug 2012 04:41:00 +0000

Pianosi and Davis studied the pulmonary functions of children with asthma and found that overweight
and obese children were more likely to be overmedicated despite similar asthma severity
because of their perceived exercise intolerance [35]. The authors concluded that efforts should be
directed at understanding the reasons responsible for reduced exercise tolerance before escalating
pharmacologic treatment for asthma among the overweight [35]. Tantisira et al. studied pulmonary
function in a group of children with asthma and found that the ratio of forced expiratory volume
in 1 second to the forced vital capacity was inversely associated with BMI, but that other measures
of asthma severity were not independently associated with severity of overweight [36].

DEFINITION PULMONARY COMPLICATIONS OF OBESITY GENERAL ALTERATIONS IN PULMONARY FUNCTION

noreply@blogger.com (mesothelioma.abestos.lawyers) — Wed, 29 Aug 2012 04:40:00 +0000

The findings of impaired pulmonary function in overweight children highlight an important concern
that decreased lung capacity leads to decreased exercise capacity, followed by decrease in physical
activities, leading to a vicious cycle of impaired lifestyle and overweight. Li et al. found reduction
in functional residual capacity and diffusion impairment were the most common abnormalities in
a cohort of obese patients. Reduction in static lung volume was correlated with the degree of obesity
[33]. Lazarus et al., in a randomized population sample of 2500 Australian adolescents, found
decreased pulmonary function with increasing adiposity [34]. Because the fall in pulmonary function
was severe in obese boys and these falls were correlated with body mass index and skinfolds,
it is concluded that diagnosis and management may improve aerobic exercise performance and
participation in obese children.

DEFINITION HEPATIC STEATOSIS (FATTY LIVER)

noreply@blogger.com (mesothelioma.abestos.lawyers) — Wed, 29 Aug 2012 04:40:00 +0000

Interest in hepatic disorders in obesity has increased as the epidemic of obesity has progressed. As
the patients are usually asymptomatic, liver abnormalities are found on routine blood tests of liver
enzymes. The concern is that the excess fat storage within the liver will lead to chronic inflammation
and eventual cirrhosis, fibrosis, end-stage liver disease, and hepatic failure. The early stage of this
problem, known as nonalcoholic fatty liver disease, is associated with the degree of obesity,
hypertriglyceridemia, and insulin resistance. It is diagnosed on imaging studies such as ultrasound
or computed tomography by evidence of fatty infiltration. Hepatic steatosis is thought to occur
initially, through hepatic and peripheral insulin resistance, which leads to altered glucose and free
fatty acid metabolism. As much as 77% of pediatric referrals for obesity may have evidence of
nonalcoholic fatty liver disease [32]. When the disease progresses, serum chemistries, particularly
alanine aminotransferase (ALT) and aspartate aminotransferase (AST), become elevated, showing
evidence of inflammation, and the condition becomes known as nonalcoholic steatohepatitis, which
has been reported in 5 to 10% of pediatric obesity referrals. The progression, prognosis, and
treatment of nonalcoholic fatty liver disease and nonalcoholic steatohepatitis are under active
investigation. The work-up for nonalcoholic steatohepatitis should include antibody studies to rule
out infectious causes of hepatitis, and enzymes should be monitored during weight management.
Drug usage to treat insulin resistance and antioxidant vitamins to reduce inflammation are areas
of active investigation.

DEFINITION CHOLELITHIASIS (GALLSTONES)

noreply@blogger.com (mesothelioma.abestos.lawyers) — Wed, 29 Aug 2012 04:39:00 +0000

GASTROINTESTINAL SYSTEM
CHOLELITHIASIS (GALLSTONES)
Obesity is a major risk factor for the formation of gallstones, cholecystitis, and cholecystectomy.
Any obese child with classic symptoms of right upper quadrant abdominal pain with or without
fever, nausea, and vomiting should be carefully evaluated and surgical consultation sought. It is
seen mostly in females (70%) and after age 10 years. Cholelithiasis can also be seen following
rapid weight loss, particularly on very low calorie diets, as a result of lack of motility of the
gallbladder. This can be avoided if sufficient fat is included in the dietary regimen [31].

DEFINITION TYPE 2 DIABETES MELLITUS

noreply@blogger.com (mesothelioma.abestos.lawyers) — Wed, 29 Aug 2012 04:39:00 +0000

Type 2 diabetes mellitus, a disease not previously seen in pediatrics, is now recognized as a major
concern. It has become common in pediatric diabetes programs in the last decade [30]. The
prevalence of this disease is a result of the epidemic of severe obesity and presents a major ongoing
challenge to the health care system. It is of so recent an onset that long-term follow-up studies are
not available to determine outcome, but most experts are fearful that complications of this epidemic
will be formidable. Although routine screening of all overweight children is not indicated, the
American Academy of Pediatrics and the American Diabetes Association have guidlines for screening
those age 10 years and above who are at high risk by virtue of being overweight and having
at least two of the following three findings: family history of diabetes mellitus, signs of insulin
resistance, or certain ethnic backgrounds (Native American, African American, Asian-Pacific
Islander, Hispanic). The recommended screening test is a fasting glucose or an oral 2-hour glucose
tolerance test.

DEFINITION POLYCYSTIC OVARIAN SYNDROME

noreply@blogger.com (mesothelioma.abestos.lawyers) — Wed, 29 Aug 2012 04:38:00 +0000

Polycystic ovarian syndrome consists of hyperinsulinemic hyperandrogenism with anovulation. It
is strongly associated with abdominal adiposity, oligomenorrhea, hirsutism, and infertility. These
young women can have psychological effects from the constellation of symptoms and signs that
often begin during adolescence, when body image concerns are paramount [28]. Risk for diabetes,
glucose intolerance, hyperlipidemia, endometrial cancer, infertility, and coronary heart disease are
also elevated. One recent study indicates that some young girls at increased risk may be identified
and prophylactically treated with insulin-sensitizing agents to prevent polycystic ovarian syndrome.
The significant risk factors identified were low birth weight and precocious puberty [29].

DEFINITION METABOLIC SYNDROME OR SYNDROME X

noreply@blogger.com (mesothelioma.abestos.lawyers) — Wed, 29 Aug 2012 04:38:00 +0000

The Adult Treatment Panel III ([25]) has recently defined the metabolic syndrome (or syndrome X,
originally described by Reaven, three decades ago) as having three or more of the following five
factors: high BMI (males > 29 kg/m2, females > 25 kg/m2), high glucose (>110 mg/dL), high
triglycerides (>150 mg/dL), low high-density lipoprotein cholesterol (males < 40 mg/dL, females
< 50 mg/dL), or hypertension (blood pressure > 130/85 mmHg). The importance of diagnosing
this syndrome is that it confers a significant burden of cardiovascular disease risk and, for many
individuals, is a precursor to type 2 diabetes mellitus.
In a study of 439 obese adolescents, Weiss et al. used three out of the following five items as
criteria to diagnose metabolic syndrome: BMI greater than 97th percentile for age and sex, triglycerides
greater than 95th percentile, high-density lipoprotein cholesterol below the 5th percentile,
systolic or diastolic blood pressure above the 95th percentile, and impaired glucose tolerance. By
these criteria, the researchers found metabolic syndrome in 39% of moderately obese adolescents
(BMI > 95th percentile) and in 48% of severely obese adolescents (BMI > 2.5 standard deviations
above the mean) [26]. The relative risk of metabolic syndrome in that study was increased 1.55 times
for each 0.5-unit increase in BMI z score. It is important to realize that although BMI and insulin
resistance are related, they are not synonymous. They make independent and different contributions
to increasing cardiovascular disease (CVD) risk [27].

DEFINITION INSULIN RESISTANCE SYNDROMES

noreply@blogger.com (mesothelioma.abestos.lawyers) — Wed, 29 Aug 2012 04:37:00 +0000

The relative ability of a given amount of insulin secretion to dispose of serum glucose varies as
much as sixfold among apparently healthy adults. The highest third of individuals are referred to as
insulin resistant, and this resistance is associated with a number of disease states, including cardiovascular
disease, hypertension, stroke, type 2 diabetes, nonalcoholic fatty liver disease, and polycystic
ovarian syndrome. One fourth to one third of the variance in insulin resistance is related to being
overweight, and particularly to abdominal pattern obesity. Although most of the data about the insulin
resistance syndromes have been obtained from adults, it is increasingly clear that insulin resistance
is present in obese children and adolescents, and that the consequences are increasingly being seen
in the pediatric age group. Reinehr et al. were able to show improvement in insulin resistance in 6-
to 14-year-old patients over 1 year if treatment resulted in at least a 0.5 decrease in BMI z score [24].

DEFINITION CARDIOVASCULAR COMPLICATIONS LIPID DISORDERS

noreply@blogger.com (mesothelioma.abestos.lawyers) — Wed, 29 Aug 2012 04:37:00 +0000

The lipid disorders associated with pediatric obesity are among the most frequent, best understood,
and most described metabolic abnormalities seen. It has been clear since the beginning of pediatric
lipid studies that obesity is associated with lipid abnormalities [6,7]. Recently, with the advent of
Centers for Disease Control and Prevention reference data for BMI (body mass index) percentiles,
it has become clear that BMI greater than the 95th percentile is a major determinant of hyperlipidemia
and dyslipidemia in children [8]. Furthermore, the autopsy data from the PDAY study
and from Bogalusa have proved that abnormal lipid patterns in youth are associated with premature
atherosclerosis, as measured by fibrous plaque accumulation in aorta and coronary arteries [9,10].
In clinical practice, it has become clear that obesity is the most frequent determinant of abnormal
lipids, and in the past decade obesity has become a more common cause than either heterozygous
familial hypercholesterolemia or familial combined hyperlipidemia.
Differential diagnosis of lipid disorders in the overweight child includes both primary and
secondary causes. They are listed in Table 3.1. Familial hypercholesterolemia is found in 1 in 500
children in the United States and is caused by defects in number or function of the cell surface
low-density lipoprotein (LDL) receptors, resulting in impaired LDL clearance and increased intracellular
cholesterol synthesis. Associated features of familial hypercholesterolemia include familial
history of premature atherosclerosis and findings of peripheral cholesterol deposition, such as
tendinous xanthomas, xanthelasma, and corneal arcus in the child or in first-degree relatives.
Familial combined hyperlipidemia is found in 1 in 200 to 400 children in the United States. It is
caused by hereditary defects in hepatic very low density lipoprotein (VLDL) synthesis and metabolism
and is characterized by variable hyperlipidemia patterns in the same family. Children with
familial combined hyperlipidemia present with modest elevations of cholesterol and triglycerides,
VLDL, and LDL and with depressed levels of high-density lipoprotein cholesterol for age and sex.
Mixed environmental–genetic hyperlipidemia is an imprecise but widely used term that attempts
to describe the majority of hyperlipidemia seen in children and adults. These children may or may
not initially present as overweight, but they will have no clearly defined genetic abnormality of
lipid metabolism. They are more susceptible to raised lipids when they eat diets high in saturated
fats or simple carbohydrates. Some of the genetic patterns associated with this type of hyperlipidemia,
such as variation in the frequency of apo E isoforms, are well described, but most are not.
Excessive adiposity itself is a risk factor for hyperlipidemia in children, as shown most clearly in
the Bogalusa data [8]. It is clear though that certain individuals are more susceptible to dietaryinduced
hyperlipidemia than others and that change in diet and weight loss are sufficient to improve
or normalize their lipid patterns.
Secondary causes of lipid abnormalities in the overweight child can be ruled out with a careful
history, a physical examination, and a few simple laboratory tests. Hypothyroidism has been
discussed above, under endocrinopathies. Nephrotic syndrome is characterized by edema and
proteinuria, as well as hypercholesterolemia. Hepatitis can be a mild, flulike illness in children and
may not demonstrate jaundice; therefore, routine hepatic enzyme testing is warranted. Connective
tissue diseases have familial combined hyperlipidemia-like patterns that can be exacerbated by
corticosteroid therapy [11,12]. The child treated with prolonged systemic corticosteroids who
becomes Cushingoid will present with both elevated cholesterol and triglycerides.
Hypertension is commonly seen in overweight children. Unlike in adults, where the definition
and severity of hypertension is independent of age and height, in children, diagnosis of hypertension
is based on percentiles adjusted for age, gender, and height percentile. Therefore, it is important
to have available up-to-date reference data tables when assessing blood pressure in children [13].
Proper baseline conditions are critical in obtaining accurate and reliable measurement of blood
pressure. The child or adolescent should be seated at rest 10 minutes, and an appropriate size cuff
should be applied to the right arm. Cuff size is determined by a bladder width that is approximately
40% of the arm circumference, midway between the olecranon and the acromion processes of the
humerus. A larger, rather than a smaller, cuff should be chosen if neither is exactly correct. Systolic
pressure is recorded as the first sound, and diastolic as the disappearance point, or fifth sound. The
average of two measurements is better than one alone.
When an overweight child has been diagnosed with prehypertension or stage 1 hypertension,
it is prudent to attempt weight management before pharmacotherapy. If stage 2 hypertension is
diagnosed, a pediatric nephrologist should be consulted. There are no data to help us determine
how long to prescribe weight management alone before instituting specific antihypertensive therapy;
therefore, clinical judgment of whether therapy is working to control weight, as well as twicemonthly
measurement of blood pressure, is needed. If stage 1 hypertension persists despite significant
weight loss, consultation with a pediatric nephrologist for a renal workup is indicated.
CARDIAC STRUCTURE AND FUNCTION
It is apparent that a variety of adaptations or alterations in cardiac structure and function occur as
excessive adiposity accumulates, even in the absence of comorbidities. When these changes
progress, clinical disease ensues. Findings such as left ventricular dilatation, increased wall stress,
compensatory left ventricular hypertrophy, and diastolic dysfunction are common [14]. These
changes may also occur on the right, where they are associated with sleep apnea, pulmonary
hypertension, and hypoventilation. When obesity is longstanding and severe, progressive congestive
heart failure and sudden death may result from these hemodynamic alterations. Most of the available
pediatric data are from adolescents. Urbina et al. studied 160 healthy 9- to 22-year-old patients
from the Bogalusa population to understand the role of weight gain on cardiac structural development
[15]. The researchers found that excess weight gain was associated with increased left
ventricular mass and systolic blood pressure [15].
Gidding et al. investigated 48 boys and girls aged 8 to 17 with BMI > 40kg/m2 on a graded
cycle exercise test [16]. Only 2 had normal fitness. The remainder had various combinations of
deconditioning (37/48), upper airway obstruction (7/48), small airway disease (35/48) and left
ventricular hypertrophy (8/48). Friberg et al. found left ventricular mass was 16% greater in obese
compared with lean adolescents [17]. Giordano et al. found a significant relation of blood pressure,
insulin resistance, and left ventricular mass in 24 obese adolescent males compared with controls
[18]. Mensah et al. studied 225 adolescents with a family history of hypertension and found that
anthropometric indexes of fat mass were significantly correlated measures with left ventricular
markers of dysfunction and adverse prognosis [19]. Daniels et al. studied 201 6- to 17-year-old
subjects to further understand the relationship of fat and lean mass to hemodynamic determinants
of blood pressure [20]. They concluded that lean mass is a more important correlate of blood
pressure than fat mass, and that sex and race have significant independent effects on blood pressure
in adolescents. Rowland et al. studied adolescent females’ (BMI 30 to 40 kg/m2) response to
maximal cycle testing. They found that depressed peak VO2 and limited endurance were not
associated with decreased cardiac functional capacity [21].
Whether the cardiac changes seen in obesity are reversible was questioned by Humphries et al.
[22]. These researchers studied the effect of 4 months of physical training on body composition
and left ventricular mass in obese adolescents and found no effect of training on cardiac mass
despite a significant reduction in percentage body fat and visceral fat, as measured by magnetic
resonance imaging [22]. On a more hopeful note, Uwaifo et al. from the National Institutes of
Health reported a case of a 17-year-old obese boy with familial apical hypertrophic cardiomyopathy.
After a 1-year program that resulted in a 49-kg weight loss (BMI reduced from 43.6 to 28.1 kg/m2),
the patient showed striking improvement in cardiac functional indices [23].

DEFINITION GROWTH HORMONE DEFICIENCY

noreply@blogger.com (mesothelioma.abestos.lawyers) — Wed, 29 Aug 2012 04:36:00 +0000

HYPOTHYROIDISM
Congenital hypothyroidism is screened for at birth, but the acquired forms can occur at any age.
When it is insidious in onset, it may present as only obesity with hypercholesterolemia. Often the
typical growth, metabolic, and intellectual function abnormalities classically described in this
condition present subtly, resulting in delayed diagnosis. Screening is therefore warranted, but the
specific laboratory investigations for screening should be discussed with a local pediatric endocrinologist
because clinical lab specificity and sensitivity may vary considerably from center to center.
In our center we screen with a thyroid-stimulating hormone for hypothyroidism among children
presenting with short stature or delayed growth, obesity, and hypercholesterolemia [4].
GROWTH HORMONE DEFICIENCY
Growth hormone–deficient children, in addition to presenting with reduced growth velocity and
short stature, have reduced fat-free mass. The metabolic abnormalities in leptin and ghrelin are
corrected by growth hormone treatment, but insulin resistance may ensue. Primary growth hormone
deficiency is not likely to present as obesity, but growth velocity measures can easily differentiate
the two conditions, as in obesity, growth velocity is normal or high.
Hypercortisolism can be either central (adrenocorticotropic hormone [ACTH] excess or Cushing
disease), peripheral (ACTH-producing tumor or adrenal adenoma), or iatrogenic in origin. The
excess cortisol results in hypertension, glucose intolerance, dyslipidemia, moon facies, decreased
muscle mass, broad violaceous stria, visceral adiposity, and poor growth [5]. When history and
physical exam warrant screening, an 8 A.M. plasma cortisol test or 24-hour urinary cortisol is indicated.

DEFINITION ENDOCRINE DISORDERS

noreply@blogger.com (mesothelioma.abestos.lawyers) — Wed, 29 Aug 2012 04:36:00 +0000

Taken individually, endocrine disorders are rare causes of obesity in pediatric practice, but as a
group they make up an important reversible cause of obesity and have significant morbidity and
potential mortality. Recognizing the signs and symptoms is thus important. A general rule is that
any child who presents as overweight and is below the 50th percentile of height for age should be
screened for an underlying endocrinologic etiology. The yield of endocrine screening tests in taller
children will be very low, and without other signs and symptoms, testing should not be done. In
the shorter group, it will still be less than 0.5 to 1% in our clinical experience, but high enough to
warrant a raised index of suspicion.

DEFINITION GENETIC SYNDROMES ASSOCIATED WITH CHILDHOOD OBESITY

noreply@blogger.com (mesothelioma.abestos.lawyers) — Wed, 29 Aug 2012 04:35:00 +0000

These conditions are rare and are usually associated with an abnormality evident on physical exam,
developmental delay, or mental retardation. Many, such as the dysmorphic syndromes, Turner’s,
and Beckwith–Wiedeman, are generally identified during infancy before the development of obesity.
Prader–Willi Syndrome is the best described and most frequent of these syndromes and is associated
with hypotonia, poor linear growth, dysmorphic features such as small hands and feet, hypogonadotropic
hypogonadism, and developmental delay. It is caused by the loss of paternally expressed
genes, including small nuclear ribonucleoprotein, within the critical region of chromosome 15q.
The striking hyperphagia associated with high ghrelin levels noted in this syndrome is the syndrome’s
most difficult management challenge [3]. The Bardet–Biedl syndrome is characterized by
mental retardation, retinitis pigmentosa, hypogonadism, and polydactyly. Several chromosome
regions have been identified as involved [3]. Pseudohypoparathyroidism, which is so named because
of its phenotypic similarity to the features of hypoparathyroidism without the low parathyroid
function, consists of short stature, short neck, rounded facies, hypocalcemia, and mental retardation.
These syndromes are important to be aware of in the differential diagnosis of pediatric obesity and
are more thoroughly

TIPS Motivating the obese child to move

noreply@blogger.com (mesothelioma.abestos.lawyers) — Wed, 29 Aug 2012 04:34:00 +0000

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obese child to move: the role of structured exercise in pediatric weight management. South Med J.
92:577–584, 1999.

LEARN TO EVALUATING A HEALTH PROMOTION PROGRAM EVALUATION APPROACHES

noreply@blogger.com (mesothelioma.abestos.lawyers) — Wed, 29 Aug 2012 04:33:00 +0000

There are several ways to approach the evaluation of your pediatric weight management program.
Process evaluation will measure variables associated with the delivery of the intervention such as
program times, speakers, and participant attendance and approval ratings [27]. Data gathered will
enable the interventionist to assess program compliance and participant adherence and satisfaction.
Impact evaluation data measure knowledge, awareness, attitudes, and behaviors. Many of the
psychological parameters that are outlined in Chapter 9 by Johnson and von Almen fall into this
category (see Appendix 2.5). Outcome evaluation is the most commonly used evaluation in the
clinical management of pediatric obesity. This type of evaluation measures the variables that answer
the primary goal of the program. Variables typically include morbidity or mortality, vital signs and
symptoms, and physiologic and metabolic parameters. Because the primary goal of pediatric weight
management is the achievement of a healthy body weight, height and weight indices and anthropometry
best determine program success (Appendix 2). By using the baseline and quarterly evaluation
results, it is possible to perform simple analyses to determine successful outcome.
RESULTS AND REPORTING
Data collection, analysis, and reporting are time-consuming, tedious tasks. However, the information
gathered from these processes is vital to maintaining a successful program. A sample spreadsheet
that can be used to extract data from clinical files is located in Appendix A1.23. This information
can easily be transferred to a data management system for further analysis. Many modern computer
programs are equipped with systems that can transfer this data into visual presentations for marketing
and promotions (Figure 2.2).
SUMMARY
The business of pediatric weight management, although complex, is doable. The economic effect
of reversing obesity during childhood is unknown. However, current costs to treat pediatric obesity–
related illness are over $100 million. The cost to provide treatment of pediatric obesity varies, but
the short-term positive results of programs using family-based, multidisciplinary approaches are
consistent. The task then is to apply sound design principles, health promotion models and theories,
and implementation strategies to specific populations and locations. This process requires careful
research into the needs of the target audience, the specific health problems surrounding obesity,
and the development of goals and objectives. The program must then be organized and structured.
Medical, legal, and financial concerns must be addressed. Once this is accomplished, step-by-step
implementation will ensure successful outcome, and ongoing program evaluation will maintain
program quality.

Assign Participants to the Appropriate Treatment

noreply@blogger.com (mesothelioma.abestos.lawyers) — Wed, 29 Aug 2012 04:33:00 +0000

Using the Weight Level Form (Table 2.8) and the calculations made by the clinic dietitian of percent
overweight (refer to the BMI percentile in the Patient File), the child is assigned to a class roster
form in the appropriate level. The receptionist will then mail the parents a letter and telephone
them to give the date and the time of the clinic meeting.
Orientation
The orientation meeting is attended by all the weight management staff members, the patients, and
their families. Patients’ files should be available. The receptionist should prepare extra patient files
and information packets with registration forms for late registrants. Educational materials are
handed to each family as they arrive and sign in, provided they are registered and have paid the
deposit. The medical or program director introduces the weight management staff and begins the
presentation. The other staff members may participate. The Orientation Handout (Appendix A1.11)
is discussed. The Class Schedule (Appendix A1.13) and Test Preparation Letter (Appendix A1.16)
are distributed and discussed. The clinic coordinator should use the Orientation Checklist (Appendix
A1.12) to ensure that all procedures are performed. The orientation session is discussed in more
detail in Chapter 19 by Carlisle and Gordon.
Baseline Evaluation
The initial evaluation session follows the orientation meeting. Weight management staff members
should arrive at least 30 minutes before meeting time to set up. Refer to the Evaluation Station
Checklist (Appendix A1.18) to direct the staff members to their measurement stations. It is recommended
that each station be set up in a separate clinic room. Each patient is then given his or her
patient file as he or she reports to the weight and height station. The Evaluation Form (Appendix
A1.19) should be located in the patient file. This information will be used to complete the Evaluation
Results Form (Appendix A1.20), which will be given to the parents during the next class. The
patient then carries the file from one station to the next as the measurements are acquired and
recorded. The patients should be directed to stop at the checkout desk before departure, where the
clinic coordinator will fill out the final Evaluation Checklist (Appendix A1.17). The evaluation
forms are then removed from the patient files and given to the coordinator for processing. After
the baseline evaluation, the coordinator will schedule a separate meeting for each patient to
participate in a Fitness Evaluation (Appendix A1.21). This can be done before the baseline evaluation,
after physician clearance. Detailed protocols for the baseline testing procedures are located in
Appendix 2. The staff members should be adequately trained before the baseline evaluation. Staff
members should review the clinic testing protocols (Appendix 2) and extensively practice the
measurement techniques.
Initial Lesson
The initial lesson begins with individual weigh-in and medical monitoring. Approximately 20 to
30 minutes is needed for up to 15 patients. Refer to the Weekly Clinic Checklist (Appendix A1.14)
to ensure that all procedures are completed. Use the Weight Record and Vital Signs Chart (Appendix
A1.15) to record the patient’s weight and vital signs. Following this period, the patients and their
families sit, auditorium style, with all four clinicians in the front of the room. The behavior specialist
leads a discussion of each patient’s accomplishments, including weight loss, for the past week, as
well as since the patient began the program. Accomplishments such as trying new vegetables or a
new exercise activity are also recognized and discussed. Clinicians lead applause after each patient’s
accomplishment. This period lasts approximately 20 to 30 minutes. Positive reinforcement of
healthy eating and exercise behaviors is crucial to the success of the program during this period.
Diet instruction follows for the next 45 to 60 minutes, including questions from the patients
and the parents. If time permits, and if they are available, the results of the baseline evaluations
may be discussed; otherwise, this discussion can be done during lesson 2. The exercise educational
materials are briefly discussed by the exercise physiologist. The behavior specialist briefly discusses
self monitoring.
Intervention Classes
Intervention lessons follow the same general format as lesson 1, which describes a typical setting.
However, in lessons 2 through 9, nutrition, behavior, and exercise sessions are conducted over
approximately 30 minutes each (Tables 2.4 and 2.5). In addition, the clinicians may structure the
group intervention as they feel appropriate. For example, the parents may participate in an activity
with the dietitian while the patients participate in an activity with the behavior specialist. Older
patients and their families may participate in an exercise activity while younger patients and their
families participate in a kitchen activity. Many other combinations may apply. Refer to Chapters 12
by Schumacher et al., 14 by VanVrancken-Tompkins and Sothern et al., 20 by von Almen and
Sothern, and Appendix A3 for sample lesson plans. The final lesson follows the same format as
lessons 2 through 9, except that a small amount of time either at the beginning or at the end of class
is dedicated to preparing the patients for the follow-up evaluations, which should be conducted at
the next class meeting.
Quarterly Evaluation Follow-Up
Interventionists should conduct the quarterly follow-up evaluation in a similar manner as the
baseline evaluation. Remember to use the Evaluation Form (Appendix A1.19) to record the measures,
which will then be inserted into the Quarterly Evaluation Results Form (Appendix A1.22).
Refer to the Protocol descriptions for each of the measures (Appendix 2).
Prior to the last session, Awards, Graduation and New Goals, registration should begin for
incoming participants. Repeat steps 1 through 5. The parent information session for incoming
participants may be scheduled on the same night as the final lesson directly afterward. The
orientation session for incoming participants may be scheduled to run simultaneously with the
follow-up evaluation in a separate meeting room. Likewise, the baseline evaluation for incoming
participants may be conducted in the clinic rooms on the same day continuing participants are
presented with awards in a separate meeting room. Thus, continuing and incoming participants
may begin lesson 1 during the next weekly meeting (Table 2.5).
Awards, Graduation, New Goals
During the class that follows the quarterly evaluations, the parents are again given the results of
their child’s health and fitness evaluations (Appendix A1.22). These are discussed in the group
setting, with particular attention given to the positive changes achieved by the patients over the
term of the program. Before this class, the clinicians calculate the new goal weights and current
BMI percentile; these are listed on the Quarterly Evaluation Results Form (Appendix A1.22). On
the basis of these results, a decision is made whether to “graduate” the patient to the next level.
Patients who graduate can be given a certificate. Awards can also be given for perfect attendance
(prizes may be T-shirts, inexpensive sports equipment, or similar items). An exercise certificate and
award can also be given to the boy and the girl with the highest total number of exercise minutes
recorded on the exercise self-monitoring records. Award certificates can also be given for most new
vegetables sampled.

LEARN TO PEDIATRIC WEIGHT MANAGEMENT PROGRAM: STEP-BY-STEP INSTRUCTIONS

noreply@blogger.com (mesothelioma.abestos.lawyers) — Wed, 29 Aug 2012 04:32:00 +0000

The pediatric weight management program (Table 2.7) emphasizes lifestyle adjustment through
behavioral modification of activity level, eating patterns, and family and personal thoughts and
attitudes. Only one study, by Saelens and colleagues [38], evaluated the posttreatment and shortterm
follow-up efficacy of a 4-month behavioral weight control program for overweight adolescents
in a primary care setting. The results indicated that a physician-based, individual counseling program
including nutrition and physical activity education was superior to a standard care approach in
overweight teenagers. However, over 40 evidence-based studies using a multidisciplinary, familybased
intervention have been published to date [24]. This multidisciplinary approach has produced
some of the most promising results to date in the treatment of pediatric obesity. This section of the
chapter provides the supporting materials you will need to implement a group, family-based,
multidisciplinary pediatric weight management program that effectively serves the needs of overweight
children and adolescents ages 5 to 17 years.
Referral from Pediatrician, Family Physician, or Phone Inquiry
In step 1, the receptionist discusses the program in detail with parents and referring physicians who
have telephoned, inquiring about the program. It is helpful to have a basic information sheet to

assist the receptionist. He or she fills in the Phone Screening and Information Form (Appendix A1.3)
and the Physician Referral Form (Appendix A1.4) completely. These forms are then placed into a
collated patient file. A cover letter, program brochure, and Registration Form (Appendix A1.5) are
mailed to the patient’s address. As a courtesy, program diet and exercise instructions may be mailed
to the referring physician also. The patient’s insurance company or referring physician is contacted
at this time for precertification.
Parent Information Session and Registration
Two to 3 weeks before the orientation meeting the staff may conduct a 1-hour information session
to attract new patients. Media announcements should be mailed at least 2 weeks before the information
session. The session may consist of staff introduction, a formal presentation, and a 15-minute
question-and-answer session. The session is detailed in full in Chapter 19 by Carlisle and Gordon.
Registration forms should be available, and parents may choose to register and pay the appropriate
fees at this time or complete at home and mail to the center.
History and Physical
After receiving the completed registration form and fee deposit from the parent, the receptionist
schedules the patient for an appointment with the staff pediatrician or the referring physician. The
Medical History and Physical Examination Form (Appendix A1.6), located in the patient file, is
completed by the family and the staff pediatrician during this visit. The Clearance Form (Appendix
A1.7) is filled in and put into the file, and the file is given back to the receptionist. The receptionist
mails the Program Information Letter (Appendix A1.8) and telephones the patient to give instructions.
Patient Screening
The staff psychologist meets with the family and completes the Initial Parent Questionnaire (Appendix
A1.9), which should be located in the patient file. This can be done at the same time as the
physical examination or in a separate meeting. However, this must be done before the orientation
meeting. The staff dietitian uses the height and weight variables obtained at the physical examination
to plot the patient on the Centers for Disease Control and Prevention BMI percentiles also to be
housed in the patient file. He or she calculates the BMI and overweight status using the BMI
percentiles (Appendix A1.10).

LEARN TO DESIGNING HEALTH PROMOTION INTERVENTIONS APPLYING HEALTH PROMOTION MODELS AND THEORIES TO PRACTICE

noreply@blogger.com (mesothelioma.abestos.lawyers) — Wed, 29 Aug 2012 04:31:00 +0000

It is vital that pertinent models and theories are used when designing health promotion programs. There are numerous health promotion theories and models that have been applied to the planning and implementation of pediatric intervention programs. In Chapters 5, 14, and 20, Schwimmer, Sothern, and von Almen provide detailed descriptions and thorough literature reviews of studies that have successfully incorporated these models and theories. Once an appropriate model or theory has been selected to meet the established goals and objectives, the design of the intervention can begin. Program planners should consider the results of the needs assessment and the different types of intervention activities [51]. They should also refer to standardized guidelines published by public health, medical, research, and educational institutions to ensure that the intervention will be safe, credible, and ethical [19,24,60,61]. There are hundreds of well-established, well-studied programs available for increasing physical activity and promoting healthy nutrition (see Appendix A3.1.1, A3.1.2, and A3.1.3). Many of these programs target children at risk for developing obesity and those who are already considered overweight. Sometimes it may be more advantageous to consider implementing an existing program or adapting the program components of these interventions to
the specific needs of your population. In all cases, be aware of the existing copyright and trademark
requirements associated with each program.
MARKETING
The current pediatric epidemic is neither the fault nor the responsibility of any one single sector of
society [22]. There are several areas to consider when attempting to change public opinion and
behavior concerning healthy nutrition and physical activity. There are five major target areas that can
be identified (Table 2.2) [22]. The marketing of these various segments is part of a step-by-step process
called audience or market segmentation [27]. This type of marketing approach helps to ensure that
programs are specific to the needs of the target consumer group. Consumers typically want to know
primarily whether weight management interventions are safe [62]. Second, they seek specific information
concerning the type of diet used, a description of the behavior modification component, and
the cost. Surprisingly, in one study, the credentials of the staff were not considered important by
consumers seeking commercial weight loss treatment [62]. This information is valuable when designing
promotions and advertising strategies for weight management programs. There are no specific
TABLE 2.2
Target Areas — Obesity Prevention in Children
Family and Home Environment
Parental education and awareness
Neighborhood safety
Public Educators, Administrators, and School Environment
Cafeteria
Physical education
Academic classroom
After school and recess
Nonfood incentives for academic achievement and positive behavior
Health Care (obstetricians, pediatricians, family physicians, dietitians,
psychologists, exercise and related health care professionals)
Patient education
Monitoring of high-risk populations
Referral system
Prevention and treatment programs
Maintenance and relapse prevention programs.
Public Policy
Insurance and governmental reimbursement for medical evaluation, monitoring prevention, treatment, and maintenance
programs
Food labeling and packaging (portion control)
School nutrition and physical activity policy (cafeteria, vending machines, unstructured physical activity periods [recess],
physical education class, limits on homework, grants and funds to schools that promote a healthy school environment)
Work site policy (flex time, home offices, family and medical leave)
Youth media and marketing
Increased funding for childhood overweight research
Public Awareness
Community programs
Promotions and social marketing campaigns
Source: With permission, Sothern, M. S. Obesity prevention in children: physical activity and nutrition. Nutrition,
20:704–708, 2004.
studies addressing the needs and concerns of parents of overweight children. Thus, careful application
of information gathered from the needs assessment should be included in the marketing process.
Next, it is important to develop informative and persuasive communication flows [27]. Several
questions must first be answered: What are the costs of treatment versus the worth? Will the message
reach a large proportion of the parents of overweight children? If so, how frequently should it be
delivered, and through which channels? Planners should consider the type of product that will meet
the needs of the largest proportion of overweight children. They should first determine who is most
likely going to pay for the program [27]. Typically, third-party payer reimbursement rates for the
treatment of pediatric obesity are very low [8]. Therefore, planners may need to consider a selfpay
program, in which case it will be the parents who are responsible for the costs of the pediatric
weight management program. “Selling” the program to parents may be quite challenging, especially
if they are also overweight. Moreover, adults report that they support school and community
intervention for the prevention and treatment of pediatric obesity, which may indirectly indicate a
lack of support for programs that target the home environment [33].
Program Promotion: Getting the Word Out
The participants who successfully complete the weight management program provide “word-ofmouth”
advertising and promotion; however, if you are just starting up a program in your area,
you will need to let the community know about your services. You should develop two brochures,
one aimed at parents and another at referring physicians. Consider the information obtained in your
needs assessment when drafting the text for the brochure. The brochures should include details of
your program, location, and fees. You may choose to develop and mail a quarterly newsletter to
your patients, along with notices of upcoming special events. As the successes of the program
accumulate, the local newspapers, magazines, and radio and television reporters, along with institutional
public relations departments, may want to offer feature articles on your patients’ progress.
IMPLEMENTING A HEALTH PROMOTION PROGRAM
There are several implementation strategies, including pilot programming, preliminary field testing,
and phasing-in approaches [27]. Experienced planners do not recommend a total implementation
approach. Rather, a pilot or preliminary test is preferred to gain primary data from participants for
the purpose of revising and tailoring the intervention, and to provide marketing information. Borg
and Gall’s Research and Development Cycle provides a sound, systematic plan to health promotion
program implementation that details the use of pilot testing [63].
CONCERNS OF IMPLEMENTATION
Several medical, legal, and ethical issues must be considered before program implementation.
Safety is the primary concern [65,66]. Thorough preliminary testing, along with careful review of
the existing medical literature, will ensure that the components of the program are sound. Regardless,
interventionists must do everything to reduce the risk of liability associated with treatment.
Informed consent must be obtained from the patient and his or her parents [65,66], medical concerns
related to the treatment of obesity must be documented [67,68], and staff must be licensed, degreed,
and certified professionals who are well trained in all aspects of treatment, including testing and
interpersonal skills [69]. These are often standard practices in clinical settings. However, if parts
of the program will be delivered outside of the physician’s office, care must be taken to ensure that
related personnel and sites are well-prepared and safe.
Another concern is sufficient preparation time. Recruiting and training staff, ordering equipment,
and marketing takes weeks and often months in large organizations. A suggested timeline
for successful implementation is presented in Table 2.3.
TABLE 2.3
Pediatric Weight Management Implementation Flow Chart
Time before First
Orientation, days Action
210 Recruit staff and select intervention site
180 Attend Pediatric Weight Management Professional Training (Appendix A3.1.1)
150 Staff meeting to review testing and intervention techniques
Begin media campaign
120 Order supplies and equipment
Mail out physician, school, and community center advertising letters
90 Mail public service announcements introducing program in your area
60 Establish patient/parent communication system
Answer phone and mail inquiries
Mail out information brochures as necessary
Enroll and register new patients
Begin screening of new patients
45 Mail public service announcement for community/parent information session
Continue screening and enrollment of new patients
21 Community/parent information session
Continue screening and enrollment of new patients
14 Continue screening and enrollment of new patients
Staff meeting to finalize intervention schedule
7 Review intervention materials
Finalize class roster
Begin media campaign for next session
IDENTIFICATION AND ALLOCATION OF RESOURCES
Personnel
Organization of the Pediatric Weight Management Program Staff
At the center of the pediatric weight management program is the family (Figure 2.1). A family
physician or pediatrician leads the team as the medical director. He or she provides medical
supervision and guidance for the clinic, performs medical history and physical examinations, and
conducts educational sessions on the medical aspects of the program. The remaining staff members
include a registered dietician, a behavior specialist, an exercise specialist, and the clinic coordinator.
The registered dietitian provides nutritional supervision and guidance for the clinic, conducts weekly
educational sessions on nutrition topics, and instructs patients in the proper administration of the
clinic diet. A dietician with experience in the pediatric setting is desirable. The exercise specialist
provides exercise supervision and guidance and conducts weekly educational sessions on the
physical fitness aspects of pediatric obesity. The exercise specialist should be a degreed professional
with experience in adapting exercise to children of all ages. The behavior specialist provides
instruction in behavior-modification skills and techniques and conducts weekly educational sessions
on the psychosocial aspects of obesity in children. The behavior specialist should be a degreed and
licensed counselor or psychologist with experience in family therapy. The clinic coordinator supervises
patient scheduling and billing for the program and is responsible for day-to-day office and
program functions. It is recommended that the coordinator be experienced in health care management.
He or she supervises the secretary-receptionist, who provides clerical support for the clinic
and is responsible for communicating with parents and patients. The coordinator also oversees the
distribution of information about the clinic to prospective clients, as well as news of upcoming
events (see Table 2.3). A sample job description for pediatric weight management clinical coordinator
may be found in the Appendix A1.1.
Space
The minimal space requirements to conduct a multidisciplinary intervention in a clinical setting
for 10 to 15 families are as follows: meeting room (500 sq. ft.), exercise room (800 sq. ft.), patient
examination rooms (2 @ 200 sq. ft.), kitchen or nutrition demonstration area (500 sq. ft.), and
clinic waiting area (500 sq. ft.)
Suggested sites for pediatric clinical management programs include hospitals, medical centers,
and wellness/fitness centers. The following sites may be used for the delivery of the educational
intervention in conjunction with a family physician or pediatrician office: community centers,
church activity centers, school auditoriums/cafeterias, recreation centers, and reception halls.
Scheduling
If there is a large amount of meeting space in the facility, staff expenses can be reduced by scheduling
several different groups of families during the same clinic interval. This strategy makes the most
efficient use of the clinicians’ time, which is especially desirable when part-time clinicians are paid
on an hourly basis. However, if full-time staff are employed, but meeting space is limited, several
groups can be scheduled into separate clinic intervals, whereby the program is offered several times
per day on several days per week. This strategy most fully employs existing full-time staff, with the
additional advantage of smaller intervention groups. In all cases, if different groups of families are
conducted during one clinic interval, there should be at least a 10- to 20-minute interval of time
when all of the members of the intervention team are conducting the session together. This is the
time during which the “team” approach is greatly reinforced. Researchers attribute much of the
success of multidisciplinary pediatric weight management programs to the peer support and counseling
the kids receive during these integrated, interactive, multidisciplinary sessions [49,50,70]. A
sample pediatric weight management class schedule may be found in Table 2.4. If there are more
than two groups of families attending clinic at the same time, the intervention clinicians can alternate
between groups during the session (Table 2.5). A blank schedule may be found in Appendix A1.2.
Intervention Materials, Equipment, and Supplies
The intervention materials, equipment, and supplies required to deliver a pediatric weight management
program can be classified in four different categories: clinical administration, educational,
incentive, and marketing. Clinical administration materials include patient charts, record forms,
growth charts, etc. and equipment and supplies that are necessary to conduct a medical examination
and obesity evaluation (Appendix A1). Refer to the testing protocol in Appendix 2 for descriptions
of suitable equipment. Educational materials include books, self-monitoring forms, handouts, pamphlets,
and so on. Appendix A3 provides a list of resources for pediatric weight management
educational materials and sample handouts and self-monitoring forms. Educational equipment and
supplies may include audiovisual items, flip charts, and props for modeling sessions, exercise aids,
and games (see Appendix A3). Incentives for participants should be healthy, nonfood items. For
example, sports equipment and active play games promote increased physical activity and are
typically well-received by program participants. Marketing materials should be developed for your
individual program. This is discussed in more detail earlier in this chapter. However, there are
dozens of national resource centers that provide, often free of charge, items to assist you with
promoting your program (see Appendix A3.1.2).
Financial Resources
Funding remains the greatest barrier to successful implementation of pediatric weight management
programs. Even though there is a consistent message of concern regarding pediatric obesity in the
media, clinical weight management programs receive minimal federal funding [7], are often not
reimbursed by insurance companies or other third parties [8], and lack understanding by the general
public [33]. Unless you are able to engage the support of decision makers to provide funding for
treatment, you will need to survey the financial resources that are available. The first step in this
process is the development of a budget.
Preparing a Budget
Sponsors ultimately want to know the “bottom line” of pediatric weight management. Will the
costs to deliver such a service outweigh the proposed funding? A carefully planned budget will
consider the various sources of income, including participant fees, grants, insurance reimbursement,
and contributions [27]. Expenses will include personnel, space, medical testing, intervention materials,
supplies, marketing, and travel. Table 2.6 describes a typical 1-year budget for a pediatric
weight management program enrolling approximately 10 families per session. Carefully consider
any additional income sources or expenses specific to your institution before finalizing your budget.

DEFINITION ASSESSING THE NEEDS OF YOUR TARGET POPULATION

noreply@blogger.com (mesothelioma.abestos.lawyers) — Wed, 29 Aug 2012 04:29:00 +0000

Needs Assessment
The needs assessment determines the health problems of a specific population [51] and what action
will resolve the problem. Data can be collected from secondary sources, such as scientific literature
searches and government statistics, or from primary sources, such as surveys, focus groups, or
observations. Secondary data on the prevalence and progression of pediatric obesity are abundant.
Nationally published statistics and reference material may be used to establish program need (see
Appendix A3.1.2). For example, the prevalence of obesity in children and adolescents is higher than
20 years ago in all ethnic, age, and gender groups [52–54]. Over 11% of these children are considered
overweight or obese, defined as greater than the 95th percentile for age and height (U.S. Centers
for Disease Control Body Mass Index Percentiles) [55], and children are becoming obese at younger
ages [56]. The prevalence of obesity in teenagers has tripled in the past 40 years. Additional
prevalence data and advocacy information can be found in Chapter 1 of this volume by Styne.
The research literature clearly establishes a link between pediatric obesity and a multitude of
health problems. This information may be used to further establish the need for the creation of a
pediatric weight management program. For example, the escalating rates of adolescent obesity will
affect the future health of Americans [57,58]. According to the U.S. Surgeon General, risk factors
for heart disease, such as high cholesterol and high blood pressure, occur with increased frequency
in overweight children and adolescents compared with children with a healthy weight. At present,
80% of children diagnosed with Blount disease and 50 to 70% of those with slipped capital femoral
epiphyses are significantly overweight [1]. There is an 80% correlation between obesity and a very
serious neurological disorder called Pseudotumor cerebri. Type 2 diabetes, previously considered
an adult disease, has increased dramatically in children and adolescents. Overweight and obesity
are closely linked to type 2 diabetes, which has increased 10-fold between 1982 and 1994. Refer
to Chapter 3 by Jacobson for more information on the medical complications of childhood obesity.
An example of primary data collection can be found in a recent study by Roux and colleagues
[59]. They applied a method called the Discrete Choice Experiment to evaluate a monetary measure
of benefit, willingness to pay, to overweight individuals seeking treatment. The willingness to pay
factors considered most valuable to consumers were accessibility, individualized or tailored approach
specific to their needs, and comprehensive program (including diet, self management, and exercise).
Although an adult study, results could be considered in the planning of pediatric weight management
programs because it is the parents of overweight children who typically make financial decisions
with regard to medical treatment. Service needs and demands must both be considered. Thus, when
acquiring needs assessment data, primary source information from the target population is equally
as critical as that provided by the planner’s survey of secondary sources.
Site Analysis
As was stated earlier, in adults, one of the most desirable factors in seeking weight management
treatment is convenience [59]. Selecting a site for treatment that is within easy reach of families
may be important. Care must be taken to ensure that the site has sufficient space and equipment
to facilitate the delivery of quality care. Specific space requirements for conducting a pediatric
weight management program are detailed in the “Identification and Allocation of Resources” section
later in this chapter.
Learner Analysis
Participants who should be considered eligible for pediatric weight management programs are
children ranging in age from 5 to 17 years. Their parents will typically range in age from 25 to
55 years. Participants will be referred to the program by physicians or other health care professionals
or may be self-referred after learning of the program through the media. The overweight level of
the patients will range from greater than the 85th to greater than the 99th percentile BMI (body
mass index; Appendix A1.10). If the program is a private endeavor requiring a self payment, the
participants will most likely be from middle- to upper-socioeconomic status households. Government-
assisted programs will likely enroll youth from lower-socioeconomic status households. The
participants may be from a variety of ethnic backgrounds. For the purposes of designing the program
materials for readability, it is usually safe to assume an average eighth-grade level of education for
the parents. Because the children range in age from 7 to 17 years, the materials targeting the children
should be developed specifically for each age group — elementary, middle, and high school.
The participants’ knowledge base of medicine, nutrition, physical fitness, and psychology may
be low and obtained primarily from television, radio, and print media and from elementary school
courses. For most participants, this may be the first time they have had experience in a formal,
medically supervised multidisciplinary setting. The participants will likely arrive at the pediatric
weight management program with many misconceptions about health, nutrition, exercise, and
appropriate child development.
Establishing Goals and Objectives
The goals of a pediatric weight management program are to establish an outpatient clinical service
to manage pediatric obesity; to provide a quality medical, nutritional, psychosocial, and physical
activity/exercise educational intervention to the overweight child or adolescent along with the entire
family; to coordinate the clinical intervention with ongoing medical care and research; and to periodically
evaluate the intervention and testing methods to improve program quality and effectiveness.
Specific objectives for patients are as follows: (1) children and adolescents completing the
pediatric weight management program will become motivated to adopt specific behaviors associated
with long-term emotional, physical, and psychological health; (2) from a medical perspective,
children will learn to identify safe and effective methods for achieving and maintaining weight
loss; (3) concerning nutrition, children will acquire knowledge of the basic principles of sound
nutrition and healthy eating patterns; (4) in the realm of behavior modification, children will become
aware of their eating behaviors and activity patterns and will learn alternate behaviors to promote
long-term health; and (5) in terms of physical activity and exercise, children will gain the physiologic
and kinesthetic awareness necessary to adopt activity patterns that promote long-term health.
The main objective of treatment is to improve eating patterns and increase daily energy
expenditure to maintain an existing healthy weight; to stabilize the existing weight while growing,
TABLE 2.1
Suggested Objectives of Pediatric Weight Management Program
Nutrition Education
Children will classify foods into the basic food groups.
Children will understand their healthy body weight for age and height.
Children will accurately measure foods and calculate caloric and fat content.
Children will identify foods high in calories, sugar, and saturated fat.
Children will analyze food labels and menus.
Behavior Modification
Children will improve their self-esteem, self-efficacy, and self-control.
Children will reduce anxiety and depression associated with obesity.
Children will recognize techniques to alter eating behaviors to promote and maintain weight loss and health.
Children will identify positive behaviors associated with long-term health.
Exercise and Fitness
Children will identify the basic components of fitness.
Children will identify the types of exercise appropriate to achieving a healthy body weight.
Children will become aware of body parts and movements that facilitate the acquisition of a balanced, well-trained,
and healthy physique.
Children will increase daily activity levels and, therefore, increase daily energy expenditure.
Children will maintain or increase lean muscle tissue.
Children will improve muscular strength and endurance.
Children will improve cardiorespiratory endurance.
Children will improve muscular flexibility.
Children will gain vigor and an overall feeling of well-being.
until a healthy weight is achieved; or to reduce body weight to a healthy level. Specific medical
objectives include maintaining or achieving a body weight that corresponds with ≤ 85th percentile
BMI, and a reduction in total cholesterol, triglycerides, and percentage body fat while maintaining
normal biochemical parameters, thus significantly reducing the present and future risk of chronic
disease. Specific nutrition education, behavior modification, and physical activity/exercise objectives
are outlined in Table 2.1.

LEARN TO MODELS FOR HEALTH EDUCATION, HEALTH PROMOTION AND PROGRAM DEVELOPMENT

noreply@blogger.com (mesothelioma.abestos.lawyers) — Wed, 29 Aug 2012 04:28:00 +0000

Systematic planning models should be consulted before beginning the process of organizing a
weight management program. Popular health promotion models include the Predisposing, Reinforcing,
and Enabling constructs in Educational/Ecological Diagnosis and Evaluation (PRECEDE)–Policy,
Regulatory, and Organizational Constructs in Educational and Environmental Development
(PROCEED) model, the Multilevel Approach to Community Health (MATCH) model, the Social
Marketing Assesment and Response Tool (SMART), and others [27]. Green and Kreuter [28] detail
the PRECEDE-PROCEED model, which was developed over two decades. There are nine phases
of this model, which begin with a detailed assessment of social, epidemiological, behavioral, and
environmental factors related to the target population. Educational, ecological, and administrative
and policy factors are also reviewed. It is only after careful consideration and study of these factors
that planners then select the methods and strategies required for implementation of the health
promotion program [28]. The MATCH model was developed for use in community settings [29].
It is a multilevel approach that begins with goals selection and intervention planning and places
less emphasis on the assessment of target audience needs [30]. Consumer-based planning requires
a different approach and uses health communication skills to influence perceptions, social norms,
and awareness. SMART is a social marketing planning framework composed of seven phases
including consumer analysis, market analysis, and channel analysis [31,32]. SMART is a useful
model to refer to when analyzing the needs of the target audience and during the planning of the
marketing phase of weight management interventions.
THE PLANNING PROCESS
Perhaps the most significant step in the planning process is enlisting the support of the organization’s
administration and decision makers [27]. This requires precise and accurate information concerning
the specific health problem, a careful analysis of the needs of the target population, and the
identification of common values and benefits. In the case of pediatric obesity treatment, studies
indicate that the public, in general, recognizes that pediatric obesity is a significant health problem
and is very supportive of interventions to reduce weight in youth [33]. Of particular interest to the
public are school-, community-, and media-based approaches that increase healthy nutrition and
physical activity. Although the family environment was not considered, 91% of study respondents
felt that parents were most responsible for reducing overweight conditions in childhood [33]. This
indicates, at least in part, support for family-based educational interventions.
The argument of a reduction in heath care costs is often used to promote pediatric weight
management programs to decision makers and high-level administration. As stated earlier, obesityrelated
chronic diseases significantly affect health care costs not only during childhood [2,4] but
also later, during adulthood [3,34,35]. However, a link must be established between the pediatric
obesity risk factors that the intervention will modify and the medical expenditures associated with
those risks specifically [36]. Wang and colleagues [2] conducted an economic analysis of a schoolbased
program, Planet Health, to assess the cost effectiveness and cost benefit of preventing obesity
in youth. They estimated intervention costs to be approximately $14.00 per child and illustrated
that if only 2% of children were prevented from developing obesity, the total savings to society
would be $7300 per child. These types of analysis are suggested for use in influencing federal and
state level health care decision makers [37]. However, many organizations favor programs that
promote health care reductions in the short term. Often it is difficult to “sell” downstream benefits
to decision makers, and ultimately, the cost to modify behaviors that lower health risks must clearly
be below the cost of later treatment [36].
Another approach to gaining the support of decision makers is the presentation of successful
program outcomes, both locally and nationally [27]. There are a few studies that demonstrate
successful weight loss outcome in individual primary care settings [38–40]. However, the shortterm
benefits of multidisciplinary treatment programs including dietary, exercise, and behavioral
counseling intervention for overweight youth are well established [41–50] (see Appendix A3.1.1).
In Chapter 13 of this volume, Martin and Myers detail the results of successful pediatric weight
management programs over the last two decades.