Title: Pharmacists’ Interventions to Decrease Child Obesity at a Community Hospital
Abstract:
Purpose: To decrease the complications that can occur from childhood obesity, such as asthma, type 2 diabetes, and cardiovascular diseases.
Methods: It was estimated in 2003-2004 that 17.1% of patients, ranging from 2 years old to 18 years old, have a BMI in the 95th percentile and are considered obese. This is up from 13.9% in 1999-2000. It is also estimated that 33.6% of patients are at risk of being obese. At risk patients are deemed to have a BMI in the 85th percentile. Since the prevalence of obesity is on the rise, an intervention is needed. Establishing an outpatient obesity clinic associated with a community hospital will allow an opportunity for pharmacist intervention. Pubmed was searched with the terms obesity, overweight, clinic, and program. Inclusion criteria were English, human trials published after 1989, children, randomized control trial, programs that could be extrapolated to the United States and access to full text. Exclusion criteria were non-peer reviewed journals, supplements, abstracts, specific ethnicity or gender. A total of 4 articles met this criteria and were chosen to be reviewed.
Background:
It was estimated in 2003-2004 that 17.1% of patients, ranging from 2 years old to 18 years old, have a BMI in the 95th percentile and are considered obese. This is up from 13.9% in 1999-2000. It is also estimated that 33.6% of patients are at risk of being obese. At risk patients are deemed to have a BMI in the 85th percentile. (1)
An imbalance in energy intake and expenditure causes obesity which can lead to many complications. Some of these complications include asthma, metabolic syndrome, type 2 diabetes, and cardiovascular diseases. (2) Also, if a child is overweight this leads to a higher probability of becoming an overweight adult. (3)
Since the prevalence of obesity is on the rise and there are many risks associated with obesity, an intervention is needed. The purpose of this review is to help establish a way to decrease the complications that can occur from childhood obesity. Establishing an outpatient obesity clinic associated with a community hospital will allow an opportunity for pharmacist interventions to help reduce childhood obesity.
Methods:
Data sources and searches
Pubmed was searched with the terms obesity, overweight, clinic, and program. Inclusion criteria were English, human trials published after 1989, children, randomized control trial, programs that could be extrapolated to the United States and access to full text. Exclusion criteria were non-peer reviewed journals, supplements, abstracts, and specific ethnicity or gender. A total of 4 articles met this criteria and were chosen to be reviewed.
Data extraction and analysis
For each trial, a reviewer recorded details about the type of study, number of patients, where the study was conducted, and the methods and results from each study. From this information, information was grouped, and an assessment about the present programs that are available for overweight children was made.
Results:
Two of the trials, the HIKCUPS and SWITCH trial, are on-going multi-site studies that discuss the need and design of starting a childhood overweight and obese modification program. The HIKCUPS trial is being conducted in Australia and involves 205 children that are otherwise healthy overweight or obese children aged 5-9 years old. Both the parents and the child are involved in the trial , similar to the SWITCH trial. The HIKCUPS intervention strategy is to conduct 2-hour face-to-face weekly sessions for a total of ten weeks. These weekly sessions, to be conducted by trained physical education teachers and accredited practicing dieticians, will discuss dietary modification and physical activity skill development. The primary outcomes are a change in BMI z score and waist circumference with significant differences of p < 0.05. (4)
The SWITCH trial taking place in the United States has enrolled 1359 children in the age groups 8-10 years old from 10 schools. This trial will be conducted for 9 months. Not only does this method involve the parents and children but also the child’s teacher, although the teachers were not mandated to participate. Their intervention strategy involved modifying behaviors such as physical activity, television time, and nutrition. The primary objectives are to increase the amount of habitual physical activity, reduce the amount of time spent watching television, and increase the consumption of vegetables and fruits. (5)
The last two articles reviewed are randomized control trials that discuss their findings on the development of an overweight or obese clinic/program in children. The first article, a parallel-group, randomized controlled trial was conducted between October 1999 and July 2004. Two hundred and four children between the ages 7-12 years old that were 20-100% overweight and had at least one involved parent with a BMI >25 were enrolled into the clinic. The groups were randomly assigned into three groups. The first group focused on behavioral skills maintenance (BSM) intervention, the second group was a social facilitation maintenance (SFM) intervention, and the third group was a control group. The behavioral group emphasized on self regulation behaviors and relapse prevention strategies. The social group emphasized on healthy eating habits and physical activity. The control group were also given tips on healthy eating habits, physical activity, and self regulation behaviors but were not continually followed and given advice after the initial weight loss program. Primary outcomes were BMI z score and percentage overweight. The results of this trial showed that children receiving either BSM or SFM maintained relative weight significantly better than children from the control group (BMI z score -0.04, -0.04, and 0.05 and percentage overweight p = 0.008, 0.05, and 0.86 respectively). This trial showed that in order for weight loss programs to work, future clinics need to include long-term maintenance programs. (6)
The final article that was reviewed was a 12 month parallel-group, randomized trial that enrolled 174 families with children ranging from 8-16 years old with a BMI >95%. Primary endpoints were changes in BMI, body composition, insulin sensitivity, blood pressure, and lipid profiles. Children were randomized in a 2:1 fashion to a managed group or the control group. Children randomized to the weight management group were seen twice a week for six months that included fitness performances, nutritional support, and behavioral modification. They were then seen every other week for an additional six months. The control group was seen once every 6 months and received diet and exercise counseling with brief psychological counseling. The results of this trial showed that the dropout rates between the two groups were similar and there was no statistical significance between the two. Statistical significance was seen at 6 and 12 months between the two groups in favor of the weight management group in regards to BMI, weight, body fat, fasting insulin, and insulin resistance (p <0.001). This article also shows that in order for weight management programs to work continued support needs to be conducted and simple education is insufficient.(3)
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Jones RA, Okely AD, Collins CE, et al. |
Eisenmann JC, Gentile DA, Welk GJ, et al. |
Savoye M, Shaw M, Dziura, et al. |
Wilfley DE, Stein RI, Saelens BE, et al. |
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Place of Study
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Australia |
United States |
United States |
United States |
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Length of Study
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6 months |
9 months |
12 months |
6 years |
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Enrollment Number
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205 families |
1359 families
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174 participants |
204 children |
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Inclusion Criteria |
overweight and obese, pre-pubertal, generally healthy |
Not reported |
BMI >95% |
Children 20-100% overweight with at least 1 parent with BMI > 25
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Exclusion Criteria |
extreme obesity (BMI Z-score >4), known syndromal cause of obesity, long term steroid use, meds associated with weight gain, chronic illness, significant dietary restrictions |
Not reported |
Diabetes, psychiatric, or serious medical condition, medications that cause weight gain/weight loss
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child or parent were involved in psychological or weight loss treatment, appetite or weight loss medications, or had a psychiatric condition |
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Age group of children |
5 to 9 years old |
8 to 10 years old |
8 to 16 years old |
7 to 12 years old |
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Involvement of others |
Trained physical education teacher and accredited practicing dieticians |
Not reported |
Registered dietician, social worker, exercise physiologist
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Exercise physiologist, registered dietician |
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Intervention |
1. parent centered dietary modification 2. child centered physical activity skill development program 3. combination of the two |
1. community component 2. school component 3. family component |
1. weight management |
1. Weight loss treatment 2. family based intervention 3. weight maintenance intervention (behavioral skills or social facilitation)
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Primary outcomes |
BMI Z-score and waist circumference |
increase amount of habitual physical activity, reduce amount of total screen time, increase fruits and vegetable intake |
changes in BMI (between baseline and 6 months), body composition, insulin sensitivity, BP, lipid profiles
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BMI z score and percentage overweight |
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Secondary outcomes |
BP, fasting levels of total CHO, HDL, LDL, TG, glucose, insulin and C-reactive protein, dietary intake, movement skill proficiency and perceived competence, objective physical activity, time spent on sedentary activities, proficiency in performing an activity of daily living, and health related QOL
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reduce the occurrence of overweight/excessive weight gain and Increase community awareness
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nutritional components |
None reported |
Conclusions:
The results demonstrate a lack of consistency on how to set up a child obesity clinic. These studies focused on a more community based clinic and had some deficiencies, including a lack of long term follow up and a multidisciplinary healthcare team. The studies discussed involved parents, teachers, dieticians, an exercise physiologist, and social workers, but not physicians or pharmacists. Therefore, it may be beneficial to create a clinic that is based out of a hospital so all disciplines participate in the care of the patient.
Discussion:
A proposed way to set-up a clinic may be by having a three component obesity clinic. This would include an assessment survey, a counseling session, and a visit to the clinic. If a child is admitted into the hospital and considered to be obese, parents of the child will be given a survey. Included in the survey will be questions about their child’s lifestyle habits, the amount of time they exercise, and an estimate of how many calories they consume each day. Based on the survey a counseling session with the parent and child will be conducted by a dietician, pharmacist or physician. The caregiver will then have the option to enroll the child into the obesity clinic. Children may also be referred to the clinic by a physician. At the clinic visit, the patient will be provided with an active session involving a certified fitness trainer, a dietary consultant, and a one-on-one session with a registered pharmacist. The fitness trainer will have the child actively involved in weekly activities and set fitness goals. The dietitian will monitor the caloric intake and type of calories the patient intakes weekly. The pharmacist will discuss medical options and review the patients’ medications. Obese children may have already developed complications due to obesity and they may be on various medications depending on their condition. Another benefit to having a pharmacist would be the ability to monitor the child’s medications. It has been shown that pharmacist’s can have an important impact on monitoring patient medications. This includes preventing adverse drug reactions and cost saving interventions. Each patient will be assessed weekly for the first 5 weeks with the goal of seeing a continual decline in BMI, an improvement in eating habits and an increase in exercise. After 5 weeks the patient will continue to be seen at the clinic every month or less as determined by the health care providers. (7)
References:
1. Ogden CL, Carroll MD, Curtin LR, et al. Prevalence of overweight and obesity in the United States, 1999-2004. JAMA. 2006;295(13):1549-55.
2. Daniels SR, Arnett DK, Eckel RH, et al. Overweight in children and adolescents: pathophysiology, consequences, prevention, and treatment. Circulation. 2005;111:1999-2012.
3. Savoye M, Shaw M, Dziura, et al. Effects of weight managements program on body composition and metabolic parameters in overweight children: a randomized control trial. JAMA. 2007;291(24):2697-2704.
4. Jones RA, Okely AD, Collins CE, et al. The HIKUPS trial: a multi-site randomized controlled trial of combined physical activity skill-development and dietary modification program in overweight and obese children. BMC Public Health. 2007 Jan 31;7:15.
5. Eisenmann JC, Gentile DA, Welk GJ, et al. SWITCH: rationale, design, and implantation of a community, school, and family-based intervention to modify behaviors related to childhood obesity. BMC Public Health 2008 Jun 29;8:223.
6. Wilfley DE, Stein RI, Saelens BE, et al. Efficacy of maintenance treatment approaches for childhood overweight: a randomized controlled trial. JAMA 2007;298(14):1661-73.
7. Rijdt TD, Willems L, Simoens S. Economic effects of clinical pharmacy interventions: a literature review. Am J Health-Syst Pharm. 2008 Jun 15:65:1162-72.