March 2008

Welcome

Overview of the NEW Kids Program

3210 Blast off to a healthier Family

Nutrition

Difference between mild, moderate and vigorous activity

Liver disease

YMCA Camps offer great opportunity

How to refer/contact information 

NEW Kids news is e-mailed monthly to subscribers. To be added to the subscription list, e-mail NEWKids@chw.org.

Welcome

Message from Brian Fidlin, PsyD, program director, NEW Kids Program

Pediatric obesity has reached epidemic proportions. In the United States, the rates of overweight and obese children and adolescents have tripled since 1980 with the highest rates of increase occurring among ethnic minorities and the economically disadvantaged.

The NEW Kids^TM Program was created with the mission to not only provide the specialized treatment that these children and adolescents require but also to help prevent others from becoming overweight and obese.

Our efforts have led to the creation of this - a monthly electronic newsletter. It is designed to provide those on the front line with the most current information related to treating and preventing pediatric overweight and obesity.

Each month will focus on the main areas of the program: nutrition, exercise and weight management as well as a feature from the YMCA.

We hope you find this newsletter helpful, and we welcome your feedback.

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Overview of NEW Kids Program

The NEW Kids program has been in existence for almost five years. We have undergone significant changes and improved the care we provide your patients. We have also expanded our offerings beyond our clinical program. The NEW Kids program has several components. Here is what your patients can expect:

The NEW Kids clinic at Children's Hospital of Wisconsin

• Serves children 2-18 years old with BMIs > the 95^th percentile and a weight-related medical complication.
• Families are invited to a free program orientation.
• Families are required to complete a series of questionnaires before starting their clinical care.
• Each child takes part in a one hour initial evaluation where a physician or nurse practitioner, a clinical psychologist, a registered dietitian and a physical therapist meet the family and complete a variety of assessments.
• Care is provided one-on-one to families; not a group setting.
• Together, the team and the family develop measurable and attainable goals. The long-term goal is to reduce medical complications and improve weight status.
• Follow-up visits are scheduled monthly to track progress, identify any barriers and enhance motivation.

Each family's readiness and willingness to change is key to success. The program staff utilizes motivational interviewing techniques to encourage and facilitate change.

NEW Kids at the YMCA

• The group program is offered at four branches in the Metro Milwaukee area.
• Serves children 2-18 years old with BMIs > the 85^th percentile but do not presently have a weight-related medical complication. (For details see our physician referral packet)
• The group program meets once a week for 12 weeks and focuses on weight management techniques including improved nutrition and physical activity with YMCA fitness coaches.

3 ... 2 ... 1 ... 0 ... Blast Off to a Healthier Family

• A primary care office-based program designed to screen for health habits at all well-child visits (for children 2-18 years old) to prevent and treat pediatric weight problems. For detailed information regarding the program: www.chw.org/3210family.
• Innovative on-line material supports the program goals between office visits. Check it out at www.bluekids.org.

We look forward to continuing to provide these services to you and your patients.

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Blast off to a Healthier Family program launches online component for kids

The 3... 2... 1... 0... Blast off to a Healthier Family primary care program now has an online component for parents and kids.

The parent section contains information and tools to help families make healthy lifestyle changes. The kids and teens section contains fun games where they defeat evil creatures while learning about the importance of eating three meals a day, limiting sedentary activity, increasing physical activity, eliminating sweetened beverages and eating meals as a family.

To check it out go to www.bluekids.org select either parents and caregivers or teens and kids and choose the 3 2 1 0 Blast Off option.

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Nutrition

by Michelle Trumpy, MPH, RD, CD, registered dietitian, Children's Hospital of Wisconsin

March is National Nutrition Month^¨ and this year's theme is "It's a matter of fact." This is a timely theme, as there are certainly many nutrition myths that need to be dispelled, especially around managing overweight children and obesity. When helping families decide what is fact, you can direct them to www.mypyramid.gov. This is a science-based Web site that gives reliable nutrition and physical activity information based on age, gender and current level of physical activity. The registered dietitians on the NEW Kids team also are available if you have specific questions.

Remind families to critically evaluate nutrition information and recommendations. If it seems too good to be true, it probably is. If a diet relies on a single food or omission of an entire food group, the diet is not considered balanced and not good to follow.

The best general diet advice you can give to patients and families is to eat a variety of foods including: whole grains, low-fat dairy, lean meats, healthy fats, fruits and vegetables. The MyPyramid Web page can help guide families to the amounts of each type of food they need every day.

Here are some common myths dispelled:

Fresh fruits and vegetables are healthier than canned or frozen.
The nutritional content is basically the same. Make sure to choose fruit packed in its own juice or water versus heavy syrup.

100% fruit juice is healthy and a way to get extra fruit in the diet.
Fruit juice of any kind is not recommended for weight control. Eating whole fruit is better because it does not have added sugar and maintains the fiber content.

VitaminWater and Gatorade^¨ are good for kids to drink.
VitaminWater and Gatorade only sound good. They are actually full of added sugar and do not enhance performance. It is best for kids to drink plain water.

Healthy eating is boring and not tasty.
There are a lot of healthy and tasty combinations for kids to eat. Suggest families try: cutting up fresh vegetables with salsa for dipping, refried beans rolled in a whole wheat tortilla or celery topped with peanut butter.

Kids need lots of snacks.
Kids only need to eat in 3-4 hour intervals. If there is a longer time between meals, then a snack should be scheduled. Kids who graze tend to eat more calories than if they eat with a structured schedule. Make sure to offer water to drink between meals and snacks.

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Exercise: Differences between mild, moderate and vigorous activity

by Stacy Stolzman, MPT, physical therapist, Children's Hospital of Wisconsin

Physical activity can range from leisurely walking to intense running or biking. Educating families on the differences between physical activity levels and their effects on the body is very important.

Mild activity: consists of activities such as: reading, studying, short leisure walks and watching TV.

Moderate activity: elevates the heart rate and requires more exertion than mild activities. Moderate activities include: household cleaning, non competitive sports and dancing.

Vigorous activity: challenges children and adults to exert themselves and is characterized by a highly elevated heart rate, elevated breathing rate and increased sweating. Vigorous activities include heavy yard work and running.

Screen time is defined as sedentary time spent watching TV, playing video games, listening to music, talking on the phone or using the computer.

Children should perform 60 minutes of moderate or vigorous physical activity daily to achieve the benefits associated with regular exercise. Moderate and vigorous physical activities promote flexibility, strong muscles/bones, weight loss and increased energy levels. On a typical day, physical activity is best performed after school before the child begins screen time. Physical activity after school can also help children focus on school work and projects afterward.

Family schedules vary and often are extremely busy. Suggest families designate time for physical activity on a regular basis. Exercising with family members and friends can help increase motivation and adds variety to routines. Parents should model physical activity and encourage fun activities to promote a healthy lifestyle throughout the family for many years to come.

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Liver Disease

The prevalence of obesity has reached an all-time high. Data from two NHANES surveys demonstrate that the prevalence of obesity is increasing among children and teens. For instance, in children aged 2–5 years, the prevalence of obesity has increased from 5 percent to 13.9 percent; while for those aged 6–11 years, the prevalence has increased from 6.5 percent to 18.8 percent; and for those aged 12–19 years, prevalence increased from 5 percent to 17.4 percent. Paralleling this increasing prevalence of obesity, there has been a corresponding increase in the rates of childhood hypertension, dyslipidemia (for example, high total cholesterol or high levels of triglycerides), and type 2 diabetes. Associated with these entities there also has been an increasing incidence of nonalcoholic fatty liver disease and especially its more severe histological form nonalcoholic steato-hepatitis. Based on current trends, together these entities are expected to become the most common causes of end-stage liver disease in both children and young adults .

NASH is a clinico-pathological entity characterized by the development of histological changes of inflammation and fibrosis in the liver that are nearly identical to those induced by excessive alcohol intake, but in the absence of alcohol abuse . Multivariate analysis suggests that although increased BMI is the sole independent variable predictive of NASH on liver biopsy in children, older age, obesity, diabetes and an increased AST/ALT ratio have been documented to be predictors of fibrosis on liver biopsy in adults. Furthermore, although chronic hyperinsulinemia coupled with hepatocellular insulin resistance may be important for the development of NASH, genetic differences related to carbohydrate and lipid metabolism may account for the heterogeneity of clinical findings as well as provide insight as to why some individuals with nonalcoholic fatty liver disease rapidly progress to steatohepatis, or even, cirrhosis (Rashid JPGN 2000). Although no genomewide association studies have been conducted in association with NASH to date, individual candidate gene investigations have identified several genes associated with increase susceptibility to NASH in adults and have lead to the current "double hit" hypothesis of disease pathogenesis.

The first "hit" is represented by fatty infiltration of the liver, an alteration common to several liver diseases such as those caused by alcohol, certain drugs and insulin resistance, as well as being present in almost all patients with the "metabolic syndrome." However, this increased fat deposition is insufficient in explaining the progression to inflammation or fibrosis associated with NASH. As a result, the progression to NASH or second "hit" occurs when additional damaging factors act on the predisposed liver, resulting in hepatocellular damage and eventually fibrosis. Oxidative stress, due to excessive production of reactive oxygen species (ROS) within the cells, has been indicated as a possible factor responsible for the second "hit" leading to steatohepatitis, in analogy with the proposed mechanisms of severe damage in alcoholic liver disease.

Currently, there are limited pharmacologic options that may be used for direct therapy of children with NASH/NAFLD. Insulin sensitizers, antioxidants, hepatoprotective agents, and hypolipidemic drugs have all been studied for the treatment of NAFLD with some success, and therefore, require further evaluation in the pediatric population (Ramesh & Sanyal, 2005). Until then, a safe approach would be to ensure adequate intake of vitamins and minerals and limit the use of insulin sensitizing agents to more severe cases where risk of disease complications outweighs risk of the medication.

Bariatric surgery also has been considered as a viable treatment approach. In fact, a recent study from Brazil in 2006 followed 18 patients with biopsy-proven NAFLD who underwent Roux-en-Y gastric bypass surgery. Results of the study demonstrated that repeat biopsy two years after surgery showed resolution of steatosis in 84 percent of patients and resolution of fibrosis in 75 percent of the patients (Furuya, 2006). The role of bariatric surgery in pediatrics remains controversial and has not been studied in NAFLD (Roberts & Yap, 2006) but may be promising in severe cases.

Accordingly, lifestyle modification continues to be the mainstay of treatment for NAFLD. Simple lifestyle modification consisting of diet and physical exercise leading to improvement of insulin sensitivity and improved lipid levels has been demonstrated to improve liver enzyme elevation associated with NAFLD (Nobili, Marcellini, Devito, Ciampalini, Piemonte, Comparcola, Sartorelli, Angulo, 2006). Even mild weight loss in obese children has been clinically proven to improve insulin sensitivity and liver enzyme elevation (Nobili et al, 2006). As a result, weight reduction through a healthy diet and regular exercise remains the mainstay for the current treatment of NALFD and its more severe histological form NASH (Roberts, 2003, Roberts & Yap, 2006).

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YMCA camps offer great opportunity for kids

The YMCA of Metropolitan Milwaukee, celebrating its 150^th anniversary this year, has tons of fun activities for kids. All of these activities provide a welcoming, nurturing, safe and educational environment.

YDay Camps are offered at four locations within the city of Milwaukee and at eight other locations in the greater Milwaukee area. YDay Camps encourage kids to try new things, fine-tune their skills and have fun in a variety of entertaining activities. YDay Campers can enjoy swimming, learning new games, field trips, sports, specialty skills and activities, and more. Children are cared for in a friendly and safe environment by experienced camp counselors and staff. YDay Camps are both licensed by the state of Wisconsin and accredited by the American Camping Association. Before and after camp care sessions also are offered at no additional cost to accommodate working families.

A complete listing of all YDay Camps can be found at www.ymcamke.org/Ydaycamps.

In addition to day camp, Camp Matawa (www.matawa.org), located in Campbellsport, Wis., and Camp Minikani (www.minikani.org), located in Hubertus, Wis., also offer on-site programming, including resident camps. Both of these camps are among only 25 percent of camps in the United States accredited by the American Camping Association.

Camp Matawa is a fun, educational and exciting adventure. With more than 130 acres of pines and open fields, and 30,000 acres of adjacent state forest, Camp Matawa offers a wide variety of activities that challenge and inspire campers of all ages. In this beautiful setting, campers wade in a spring-fed stream, observe abundant wildlife, gaze at the splendor of a star-filled sky and experience the wonders of nature. While they're learning more about the natural world, they're also learning more about themselves.

Camp Minikani sits on the shores of beautiful Amy Belle Lake, just 30 minutes from downtown Milwaukee. Camp Minikani offers a wide variety of activities that challenge and inspire campers of all ages through personal goal setting and hands-on learning experiences. Camp Minikani offers progressive skill development in swimming, boating, canoeing, sailing, crafts, archery, riflery, snorkeling, horseback riding, wall climbing, disc golf, a high ropes course and much more. Both Camp Matawa and Camp Minikani instill positive values such as caring, respect, honesty and responsibility – values that help young people make positive choices for a healthy life.

In addition to amazing day and resident camps, the YMCA of Metropolitan Milwaukee offers great programming at Y branches for kids and families, including aquatics, preschool enrichment, youth sports, birthday parties, YTribes and Healthy Kids Day. Find out more by calling (414) 224-9622 or www.ymcamke.org.

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Referral information

NEW Kids Clinic

The NEW (Nutrition, Exercise and Weight Management) Kids Program at Children's Hospital of Wisconsin is geared toward a holistic treatment of pediatric overweight for children ages 2-18. It involves a coordinated effort of nurse practitioners, psychologists, dietitians, physical therapists and physicians. The NEW Kids Clinic at Children's Hospital of Wisconsin offers a multidisciplinary team to care for and design individual treatment plans for children with medical problems caused by being overweight. The NEW Kids Clinic only sees patients with medical co-morbidities and by physician referral.

To refer a patient:
Phone: (414) 266-6864
Fax: (414) 266-4709

NEW Kids at the Y

NEW Kids at the Y is a community-based program that takes place at four branches of the YMCA of Metropolitan Milwaukee. This program provides families with basic nutrition, behavior change and exercise education in a comfortable, family-friendly atmosphere. NEW Kids at the Y is open to children with overweight without a medical co-morbidity, but does require physician clearance for participation.

Southwest YMCA
Lydia Witkiewicz
Phone: (414) 329-3874
Fax: (414) 546-9630

Schroeder YMCA
Kristi Gorsline
Phone: (414) 354-9622
Fax: (414) 354-0309

Northside YMCA
Porsche Carmon
Phone: (414) 324-4140
Fax: (414) 374-3459

West Suburban YMCA
Christine McBride
Phone: (414) 454-4669
Fax: (414) 778-4955

Download a referral packet for either program. If you have questions, e-mail NEWKids@chw.org or call (414) 266-7555.