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A Literature Review of Prevention and Treatment Plans of Overweight and Obese Children and Adults for Medical Professionals

Talha Masood Masters in Public Health Candidate Lake Erie College of Osteopathic Medicine Student, First Year Des Moines University December, 2010

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Introduction Iowans Fit for Life is a state-wide initiative which aims for all Iowans to enjoy balanced nutrition, lead physically active lives, and live in healthy communities. More specifically, Iowans Fit for Life seeks to set priorities for sound policy, programs, resources and messages, and to equip communities and organizations to support an environment that encourages healthy choices about eating and physical activity. The purpose of this literature review is to inform physicians about the latest research on four points related to overweight and obesity prevention. These points include childhood obesity prevention recommendations from the American Academy of Pediatrics; motivational interviewing in the healthcare setting, implementation of behavior change health contracts, and physician attitudes towards obesity prevention.

Defining Obesity Adult obesity has been widespread and growing throughout America and other Westernized countries for quite some time (Flegal, 2007). There have been hundreds of research studies on obesity. But before any real attempt to integrate them into a comprehensive study can be made, definitions must be established. This process of finding a universal definition for obesity has led to many differences in the field of obesity research. A study done by Mei (2002) focused on comparing multiple body-composition screening indexes for the assessment of body fatness in children and adolescents aged 2 to 19. Age-and-sex specific body mass index (BMI) was compared with the Rohrer index (RI) and also with weight-for-height screening in this group of subjects. Using nationally representative data from surveys of over 10,000 standardized

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measurements for people between the ages of 2 to 19, it was found that the BMI was a better predictor of overweight than the RI (Mei, 2002). Mei (2002) showed that the BMI was indeed an appropriate predictor for overweight and obesity. However, this study did not solve the problem of defining obesity within the scope of BMI. Further research still needed to be done in regards to the understanding how and when to use the BMI and how to differentiate between using the BMI and BMI percentiles for children and adults. Krebs (2007) found that there was an absence of established criteria when it came to cutoff points for children based on distributing anthropometric measurements. In this review of research studies, Krebs outlined the differences between childhood obesity and adult obesity in regards to BMI. Children were measured by BMI percentiles, whereas adults were measured by the BMI alone (Krebs, 2007). This has been upheld by the Centers for Disease Control and Prevention. Adult overweight is defined as a BMI between 25 and 29.9 and adult obesity is defined as having a BMI greater than 30. Childhood overweight is defined as a BMI at or above the 85th percentile and lower than the 95th percentile. Childhood obesity is defined as having a BMI of greater than or equal to the 95th percentile for children of the same age and sex. Rather than using a specific BMI to determine obesity among children, their weight status is based on age and sex specific scales. This is because a childs body composition fluctuates with age and sex more than an adults body (Centers for Disease Control and Prevention, 2009).

Childhood Obesity Prevention Recommendations There are three forms of prevention: primary, secondary, and tertiary. Primary prevention is tailored towards reducing the occurrence of the disease before it results. Secondary prevention is geared towards reducing the progress of a disease once it begins. Tertiary

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prevention is related to reducing the limitations of disability from the disease (Friis & Sellers, 2009). It should be noted that overweight and obesity lead to many other symptoms, such as: sleep problems, respiratory problems, gastrointestinal problems, endocrine disorders, menstrual irregularities, orthopedic problems, mental health problems, genitourinary problems, and skin conditions (Krebs, 2007). For this reason, a variety of current research on obesity is dedicated towards primary prevention of obesity. The major goals outlined in The White House Task Force on Childhood Obesity Report to the President (2010) focus on prevention: reducing childhood obesity in early childhood by focusing on prenatal care, breastfeeding, reducing chemical exposures, reducing screen time, and instilling the importance of education; empowering parents and guardians with the ability to make nutrition information more readable and available, and marketing healthy food in a more efficient manner; getting healthier food into schools; having access to healthy, affordable food; and increasing physical activity. The American Academy of Pediatrics (AAP) also recommends the calculation and plotting of BMI once a year in all children and adolescents (Committee on Nutrition, 2003). Furthermore, the AAP also recommends the use of its 5-2-1-0 plan: 5 fruits and vegetables every day, 2 hours or less per day of screen time, 1 hour of physical activity each day, and 0 servings of sugar-sweetened drinks. As physicians, research indicates that education may be the best form of overweight and obesity prevention among children and adults (Krebs, 2007). However, it is important to understand the difficulty of treating obesity. Children of obese parents have double the risk of becoming obese and have many of the same preferences in diet and lifestyles (Zlot, 2007). This not only predisposes children to obesity genetically, but it makes it increasingly difficult as the

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environment they live in is rich with the temptations of an obese lifestyle. There are 170,000 fast food restaurants and three million soft drink vending machines in the United States (Chopra, 2002). Todays children will be tomorrows adults. This objective reality poses a very real threat to our nations health. In a review done by Iowans Fit for Life regarding obesity in Iowa, it was shown that the trends in overweight and obesity in Iowa mirror the trends of the nation. The suggestions at the end of the study were directed at specific populations. To adults that were overweight and obese, the plan was to aim for a slow, steady weight loss by increasing physical activity (to at least 60 minutes of moderate intensity exercise most days of the week) and decreasing caloric intake, while making sure to establish a healthy diet. For children, it was recommended that they should consult a health care provider before beginning a weight-reduction diet. The forms of primary prevention that were recommended were to: create and enhance access to places for physical activity, enhance physical education in schools and child care settings, and support urban design and transportation policies that would result in better neighborhoods for families to exercise (Iowans Fit for Life, 2010). Krebs (2007) concludes, Nevertheless, the access to children and their health information, the authority and respect that physicians and other clinicians earn from families, and the potential to apply their knowledge to the very real medical aspects of obesity and its associated conditions, make an imperative that all clinicians be familiar with at least a rudimentary assessment of overweight or obese child.

Motivational Interviewing

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Motivational interviewing is a newly designed tool which aims to help physicians enhance their relationship with their patients. It is a client-centered, directive method that seeks to instill intrinsic motivation by resolving any semblances of ambivalence (Wagner, 2010). Research on the efficacy of motivational interviewing has shown clinical significance. One study showed that a 51% improvement rate was shown after undergoing motivational interviewing in regards to treating problem behaviors, such as: alcohol, drugs, diet, and exercise (Burke, 2003). The major tenet of motivational interviewing is what Carl Rogers described in 1951 in his studies with psychotherapy as the principle of empathy. Rogers showed that ambivalence from the patient is not something that should be seen as an irregularity or a pathology, but rather as a normal human process (Burke, 2003). Motivational interviewing has adopted this belief and seeks to be client-oriented in its approach to interviewing. In the medical field, the focus is on the patient. Using motivational interviewing, the physician allows the patient to talk. The physician is tasked with steering the conversation into a realistic and positive area so that the patient feels empowered to make changes on his or her own. This can prove to be helpful in targeting childhood and adult obesity. The goal of motivational interviewing in the area of obesity is to get the patient to open up to the physician and to come an agreement with the physician regarding an intervention that seems the most realistic and optimistic to them.

Behavior Change Health Contracts Patient non-compliance has been an area of concern regarding the patient-physician relationship, and has been around for a long time. Some of the determining factors in patient

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compliance are: demographic factors, condition or disease, psychological factors, health belief model, physician-patient relationship, treatment regimen, and setting (Griffith, 1990). An innovative approach to dealing with the problem of non-compliance, especially in the realm of obesity prevention, has been to establish health contracts between the patient and physician. In association with motivational interviewing, health contracts are sought to solidify a behavior change. Using a behavior change theory, such as the Transtheoretical Model (TTM), can help physicians with creating lasting behavior changes. The health contract actually fits into one of the steps of the TTM. This behavior change theory has six steps: 1. Pre-contemplation, 2. Contemplation, 3. Preparation (this is where the health contract canoe used), 4. Action, 5. Maintenance, and 6. Termination (Velicer, 1998).

Physician attitudes towards obesity prevention In a survey of 620 physicians, it was found that most primary care physicians found physical inactivity as the biggest reason for obesity. More than half of the primary care physicians also found their obese patients as awkward, unattractive, ugly, and noncompliant. Fifty-four percent of these physicians said they would spend more of their time on weightmanagement if they were reimbursed for it in an appropriate manner (Foster, 2003). Foster (2003) concluded that most primary care physicians share the same negative stereotypes of obese people as the rest of the nationthat obesity is largely a behavioral problem; and spending time treating obesity is harder than most other chronic conditions. This same view was adopted internationallyin Australia, most general practitioners did not choose the treatment plan which required them to support their patient in achieving and maintaining a

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lifestyle change due to the reason that it was an extremely arduous and unrewarding task (Campbell, 2000).

Conclusion The challenge with treating obesity is its complexity. Overweight and obesity can be a chronic condition with much comorbidity. It is can be difficult for the patient and physician to talk about. It carries with it a negative connotation and stereotype for both the patient and the physician: many physicians feel frustrated by patient non-compliance and lack of reimbursement; and many patients feel frustrated by lack of understanding of their personal, social, and economical scenarios, all while having to tackle the long-term treatment plan to treat their chronic condition of obesity. Most of these complexities between the physician and patient arise from miscommunication or lack of communication, which generally leads to inaccurate assumptions of one another. Research has shown that motivational interviewing, by focusing on empathy and achieving realistic long-term goals, can help both the patient and the physician tackle obesity in adults and children.

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Burke, B. L. (2003). The Efficacy of motivational interviewing: a meta-analysis of controlled clinical trials. Journal of Consulting and Clinical Psychology, 71(5), Retrieved from

Campbell, K. (2000). Obesity management: Australian general practitioners attitudes and practices. Obesity Research, 8(6), Retrieved from %20General%20Practitioners%20Attitudes%20and%20Practices.pdf

Centers for Disease Control and Prevention (2009). Childhood Overweight and Obesity. CDC, Retrieved July 23, 2009, from

Chopra, M. (2002). A global response to a global problem: the epidemic. Bulletin of the World Health Organization, Retrieved July 17, 2009, from

Committee on Nutrition. (2003). Prevention of Pediatric Overweight and Obesity. American Academy of Pediatrics. 112(2).

Flegal, K. (2007). The Epidemiology of Obesity. Gastroenterology, Retrieved July 3, 2009, from

Foster, G. D. (2003). Primary care physicians attitudes about obesity and its treatment. Obesity Research, 11(10), Retrieved from

L i t e r a t u r e R e v i e w | 10 Attitudes%20about%20Obesity%20and%20Its%20Treatment.pdf

Friis, R. H. & Sellers, T. A. (2009). Epidemiology for Public Health Practice. 4th edition. Jones and Bartlett: Sudbury, MA.

Griffith, S. (1990). A Review of the factors associated with patient compliance and the taking of prescribed medicines. British Journal of General Practice, 40. Retrieved from

Iowans Fit for Life. (2010). The Health of Iowa: Impact of overweight and obesity. Nutrition and Physical Activity Summary Burden Report Iowa Department of Public Health, Retrieved from

Krebs, N. F. (2007). Assessment of child and adolescent overweight and obesity. Pediatrics, 120. Retrieved from

Mei, Z. (2002). Validity of body mass index compared with other body-composition screening indexes for the assessment of body fatness in children and adolescents. American Journal of Clinical Nutrition, 75(6), Retrieved from

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Velicer, W. F. (1998). Detailed overview of the transtheoretical model. Cancer Prevention Research Center , Retrieved from

Wagner, C. (2010). Motivation interviewing: resources for clinicians, researchers, and trainers. Retrieved from

White House Task Force on Childhood Obesity. (2010). Solving the problem of childhood obesity within a generation. Let's Move, Retrieved from pdf Zlot, A. (2007). Addressing the Obesity Epidemic: A Genomics Perspective. Preventing Chronic Disease, 4, Retrieved June 18, 2009, from