It is an epidemic unlike any other. In the past 30 years, the rates of childhood obesity in this country have tripled. Twenty percent of 6- to 11-year-olds are medically obese.1 Childhood obesity is defined as having a body mass index in the 95th percentile when adjusted for age and sex.2 Children who are obese face numerous health challenges that are often thought of as "adult" problems. They are at increased risk for high blood pressure or high cholesterol, and are more likely to develop pre-diabetes. There is a correlation between childhood obesity and adult obesity, with obese children more likely to grow up into obese adults. Obesity in adults can increase the risk of stroke, heart disease and certain types of cancer.1
Fortunately, there is hope. Nemours/Alfred I. duPont Hospital for Children in Wilmington, DE, takes a comprehensive approach to treating childhood obesity. With 40 percent of Delaware's children either overweight or obese, the program is definitely filling a niche.3 Specialists in the hospital's weight management program work with both children and their parents to get them back on a healthy living track.
One boy who is trying to get back on track is Jai'Bri Benson, an 11-year-old from New Castle, DE. He's passionate about football and is a defensive lineman for the Wilmington Soldiers youth football team. In August 2011, he broke his ankle and had to sit out the 2011 season. He had been in good shape from playing football, but the lack of physical activity caused Benson to put on weight. His pediatrician referred him to the weight management program at Nemours in January 2012.
Like Jai'Bri, all children in the program start with an initial visit to one of four team physicians. The Health Care Affordability Care Act of 2010 mandates that private insurers cover obesity screening and counseling for children.4 The average participant's age is between 11 and 13; however, some children who have genetic disorders that could predispose them to obesity come in as early as infancy. In those cases, the focus is on educating the parents.
The physician determines the overall care plan for the patient. At a follow-up visit, the child sees any combination of clinicians in the program-two nutritionists, two nurses, a psychologist and an exercise physiologist; not every patient needs to see every specialist. The weight management program prides itself on individualization, with clinicians coming together to figure out the best plan of care for each patient. At first, the weight management specialists see each child once a month. Then the time between visits can increase and children can come in as often as they need until they turn 21.
When children first meet with Lauren Falini, the exercise physiologist, she takes their physical activity history, much like a physician takes a medical history. The goal is to find out what activities they like and dislike. What, if any, physical activity do they get in an average day? Falini conducts fitness tests in the office, including a 6-minute walk test, a strength test using a hand grip dynamometer, plus agility, hand-eye coordination and balance tests. Research has shown obesity can have a negative effect on balance.
PT's Role
Although there isn't a physical therapist in the weight management program, some of the children will be referred to Nemours/Alfred I. duPont Hospital for Children's outpatient physical therapy program. "We see them for secondary diagnoses," said Michelle DeMaio, PTA. Length of physical therapy is different for each child, with an average of eight weeks of treatment. DeMaio is currently treating Jai'Bri for his broken ankle. "He works hard," she observed. During his sessions, Jai'Bri uses the elliptical machine, plays basketball with DeMaio and works out on the power tower.
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Michelle DeMaio, PTA, talks with Jai'Bri Benson at his physical therapy session.
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Some of the other kids come to physical therapy for back pain and/or lower-extremity joint pain, as excess weight causes increased pressure on the joints. Others receive physical therapy for Blount's disease, a common co-morbidity of childhood obesity. With Blount's disease, excess weight on the growth plate of the tibia causes the lower leg to turn inward. The inner part of the tibia doesn't develop properly. Unlike bow legs, which can straighten as a child grows, Blount's disease can worsen over time.5
"From a physical therapy standpoint, if they have strength deficits, we create a strength program," noted DeMaio. Aquatic therapy is a popular choice for children in the weight management program, as it is easy on their joints. DeMaio and her fellow PTs and PTAs work with children and their parents to set goals.
Some pediatric physical therapy patients take fitness classes, such as dance, karate or aquatics, offered by the hospital's Center for Sports Medicine. The classes are all taught by either physical or occupational therapists. DeMaio teaches a weekly aquatics class. The instructors adapt the classes for different activity levels, letting kids with cerebral palsy, muscular dystrophy and other genetic disorders participate. It's especially important for patients with Duchenne's muscular dystrophy to exercise, as their difficulty moving can contribute to obesity.
Falini has three goals for kids in the weight management program: increase their cardiovascular exercise, increase their daily physical activity, and limit their sedentary time, especially time spent in front of a computer or television. According to the National Institutes of Health, most children spend between five to seven hours a day in front of a computer, television or video game system. They are also exposed to commercials for high fat, high sugar and salty foods, encouraging them to make poor food choices.6 Experts recommend limiting screen time to two hours or less per day.7
Accomplishing these goals is a team effort, with parents' buy-in to the program's mission crucial for their children's success. "We need to get parents thinking early on that it's important to plan for physical activity," said Falini. For kids with hypertension or pre-diabetes, Falini will explain how exercise can lower blood pressure and decrease the risk of developing diabetes. Parents observe the sessions to see what works and to learn how they can adapt the exercises for the home. The exercise physiologist creates a fitness plan for the whole family.
What participants do outside of their office visits is even more important than what occurs inside the hospital. The weight management program is about giving kids the tools they need for healthy living. The major question when setting up a home exercise program is: What is realistic for the children and their families? Clinicians in the weight management program have them create their own plans. "If they set their own goals, they are more likely to stick to them," Falini observed. "We look at what kids are already doing and what they have available," she said. For some children, getting involved in sports is a great way to boost physical activity.
Not every child is like Jai'Bri though, with aptitude and desire to play organized team sports. For some children, clinicians may need to think outside the box to recommend activities. Does the family belong to a gym where children can exercise? Do they have access to a pool for the child to swim? Do they like to play outside and is it safe to do so where they live? For some patients, using exercise DVDs may be the best option. "We need to give them a home program they will be consistent with," said Falini.
Falini asks, "What will the child have the most fun doing?" It's important to offer choices and switch it up to stave off boredom. Parents can use different motivators to keep kids on track. Some kids respond well to reminders to exercise, others need parents to limit their screen time and others respond well to rewards.
Nemours/Alfred I. duPont Hospital for Children's commitment to fighting childhood obesity extends beyond their weight management program. Nemours Health and Prevention Services focuses on helping children grow up healthy through community-based activities to fight obesity. The goal is to encourage children to make better food and lifestyle choices and to become physically active.
Most of the program revolves around the 5-2-1-Almost None slogan: Five servings of fruits and vegetables a day; two hours or less of screen time a day; one hour of physical activity a day; and almost no sugary drinks.
Nemours Health and Prevention Services take a four-pronged approach to educating children, parents, teachers and health care professionals. In schools, NHPS works to encourage healthier eating and more physical activity. In child care centers, they train providers to promote healthy behaviors. NHPS organizes meetings of pediatricians to discuss weight management intervention tools. And they partner with community organizations serving children, such as YMCAs and the Boys and Girls Club, to train ambassadors who will spread the healthy living message.8
"It's important that the education is there because this may be something they battle for a long time," DeMaio observed.
For more on physical therapy at Nemours/Alfred I. DuPont Hospital for Children, watch our video "Weighty Issues." Also check out our interactive guide to making weight loss fun.
References
1. Childhood Obesity Facts. www.cdc.gov/healthyyouth/obesity/facts.htm
2. Basics about Childhood Obesity. www.cdc.gov/obesity/childhood/basics.html
3. Childhood Obesity in Delaware. www.nemours.org/content/nemours/www/service/preventive/nhps/campaign/obesity.html
4. Preventive Services Covered Under the Affordable Care Act. www.healthcare.gov/news/factsheets/2010/07/preventive-services-list.html
5. Blount's Disease.www.nlm.nih.gov/medlineplus/ency/article/001584.htm
6. Screen Time and Children. www.nlm.nih.gov/medlineplus/ency/patientinstructions/000355.htm
7. Help Your Child Stay At a Healthy Weight. http://healthfinder.gov/prevention/ViewTopicFull.aspx?topicID=62
8. About Neumors Health and Prevention Services. www.nemours.org/service/preventive/nhps/about.html
Danielle Bullen is an associate editor at ADVANCE and can be reached at dbullen@advanceweb.com