May 2008

Overweight and overtired

Make healthier food choices away from home

Ways to make walking as a family fun

NEW Kids enhances clinical treatment process

Overweight and overtired

By Megan L. Grekowicz, MSW, APRN, FNP-BC, Children's Hospital of Wisconsin Sleep Center

Snoring, snorting and gasping
It is no secret that the waistlines of American children are expanding as the percentage of overweight children in our country reaches record levels. Unfortunately, the extra pounds put children at an increased risk for sleep apnea.¹ Obstructive sleep apnea is a common sleep disorder in children that is characterized by episodes of repetitive, prolonged upper airway obstruction during sleep. The most common presenting complaint is loud snoring and gasping during sleep. One to 3 percent of children have OSA. The usual cause is adenotonsillar hypertrophy, although it is believed that the incidence of OSA in the overweight population may be higher. Excess adipose tissue deposited in the pharyngeal fat pads and chest wall creates increased upper airway resistance and increased work of breathing.

The American Academy of Pediatrics released clinical practice guidelines in 2002 stating that all children should be screened for snoring.² If OSA is suspected, high-risk children should be referred to a specialist for further evaluation.²

Common symptoms of pediatric OSA
Nighttime symptoms include:

• Loud, nightly snoring.

• Labored breathing.

• Snorting and gasping.

• Restless sleep.

• Sleep in unusual positions.

• Sweating.

• Cyanosis.

Daytime symptoms include:

• Mouth breathing.

• Daytime sleepiness.

• Change in behavior.

• Morning headache.

Late to bed, early to rise
Recently, it has been identified that shorter sleep duration in children is associated with weight issues and obesity. In 2007, Pediatrics published data from the National Institute of Child Health and Human Development Study of Early Child Care and Youth Development reporting that children who did not get enough sleep in third grade were more likely to be overweight in sixth grade.³ Although the study showed a relationship between less sleep and obesity, the cause and effect relationship still is unclear. It is hypothesized that the short sleep duration may increase appetite by altering the release of the appetite-regulating hormone leptin.⁴ Another theory is that longer sleep duration is associated with greater amount of exercise, therefore decreasing the risk for obesity. ⁵

How much sleep is enough?

Even though we need more research to better understand the link between weight and sleep, good sleep still can be encouraged. According to a 2004 poll by the National Sleep Foundation, most children are getting less than the recommended amount of sleep per night.⁶ Despite our sleep-deprived nation, greater than half of parents reported their doctors did not ask about their child's sleep.⁶ Health care providers can help children and their families get the sleep they need.

Creating savvy sleepers

• Develop a consistent and quiet bedtime routine.

• Turn off televisions, computers and radios before bedtime.

• Create a sleep environment that is dark, quiet and cool.

• Maintain a regular bedtime and wake-up time.

• Avoid oversleeping on weekends.

• Avoid caffeine at least four hours before bedtime.

• Get daily exercise.

The Sleep Center at Children's Hospital of Wisconsin is the only sleep disorders center in the state dedicated exclusively to children. The Sleep Center is accredited by the American Academy of Sleep Medicine. For more information contact us at (414) 266-2790.

1. Redline S, Tishler PV, Schluchter M, Aylor J, Clark K, Graham G. Risk factors for sleep-disordered breathing in children: associations with obesity, race, and respiratory problems. Am J Respir Crti Care Med. 1999; 159: 1527-1532

2. American Academy of Pediatrics. Pediatrics. 2002; 109: 704

3. Lumeng J, Somashekar D, Appugliese D, Kacitoti N, Corwyn R, Bradley R. Shorter sleep duration is associated with increased risk for being overweight at ages 9 and 12 years. Pediatrics. 2007; 120: 1020-1029

4. Spiegel K, Leproult R, VanCauter E. Impact of sleep length on the 24-hour leptin profile. Sleep. 2001; 24: A74.

5. Youngstedt SD. Effects of exercise on sleep. Clin Sports Med. 2005; 24: 355-365.

6. National Sleep Foundation. Sleep in America Poll; 2004. Available at http://www.sleepfoundation.org. Accessed May 8, 2008

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Make healthier food choices away from home

By Michelle Smith-Beckley, RD, CD, and Jennifer Eakins, dietetic intern

Every day 1 out of 4 Americans eats at least one meal away from their homes. To help lessen the obesity problem our nation faces, the public needs to be educated on ways to make healthier choices while dining out. Making these choices may be difficult for many people simply because they are unaware of the nutritional content of their favorite meals. While dining out, it is easy to overeat and consume more than double the amount of recommended calories for one meal. However, there is hope. The following tips can help anyone eat healthily while enjoying a meal away from their home.

1. Look before you eat. The key to eating healthily is to know exactly what you are eating. Many restaurants and fast food chains have developed Web sites that contain their menu's nutritional information.

2. Pay attention to how your food is cooked. Avoid ordering foods that are fried, breaded, batter-dipped or tempura because they are high in fat. Instead, order menus items that are grilled, broiled, flame-cooked, steamed, poached, roasted or baked.

3. Go easy on the "add-ons." Avoid adding on the high-calorie sauces, dressings, cheese, sour cream and mayonnaise. Ask to have these items removed to shave some calories off of your meal.

4. Avoid buffets. All-you-can-eat buffets are just asking for people to overeat. Avoid this temptation by choosing another place to dine.

5. Share your meals. Portion sizes at restaurants and fast food chains are often too large for one person. Buy one entree and split it with another person to eat less and save money.

6. Make one meal into two. As soon as you get your entree, cut it in half and take it home as leftovers for a second meal.

7. Go for the smaller portion option. Order an appetizer as a main course, or go for the smaller portion if two sizes are offered.

8. Choose a healthier side and type of bread. In place of fries, order a baked potato, side salad, fresh fruit or vegetables. Order whole-wheat bread instead of white bread.

9. Pass on the soda. Choose water, or fat-free or low-fat milk instead of high-fat shakes and sugary soda.

10. Last but not least – the dessert. Treat yourself to a low-fat frozen yogurt, fruit popsicles, sorbet, or sherbet rather than ice cream, cookies or cake. Sprinkles are a healthier option than caramel or chocolate sauces.

Dining out has become part of many Americans' lifestyles. By following these tips, one can start making better-quality choices when dining out, giving way to a healthier lifestyle.

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Ways to make walking as a family fun

Stacy Stolzman, MPT, and Margaret Morrissy, Exercise Science student intern

Walking is a great, cost effective way to get active. Families can implement walking into their daily lives to become healthier and spend more quality time together. Encourage families to establish a regular walking schedule. It can be a time for catching up on what is going on in each others' lives.

Before families get started, encourage them to wear good walking shoes that are tightly secured. This will help prevent joint pain and increase the ability to walk faster. Bringing a water bottle also will help ensure proper hydration.

Playing games along the way provides fun, family interaction. Games such as "20 questions" or "I Spy" can be engaging and help time on the walk pass by faster. It can be fun to play "Follow the Leader" by marching, galloping or skipping for a little while instead of walking. Scavenger hunts while walking also will keep children engaged. Make a list of things for children to see, touch, hear and smell throughout the course of the walk that they can check off during the scavenger hunt.

Taking different routes can help make walking more exciting. Many parks have nature walks mapped out and trails marked; this also can be a fun alternative to walking around your neighborhood.

Pedometers are one way of monitoring how much you are walking in a day. Track your steps for several days, determine your average steps, and gradually increase your steps by 250 to 500 steps each day. In addition, check out http://www.mapmyrun.com and plot out your walking route to determine the distance you are walking and new routes around your community. When traveling to different cities, use the Web site to track your steps around tourist sites. Keep track of each family member's distances over time and see who is walking the most.

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NEW Kids enhances clinical treatment process

By Brian Fidlin PsyD, NEW Kids Program Director

Within Children's Hospital of Wisconsin's NEW (Nutrition, Exercise and Weight Management) Kids^TM Program, we have seen an increase in average body mass index for every age group over the past four years. This pattern has led us to examine how to better serve this population.

After careful examination, we have decided to make some changes to our program to better meet the needs of patients, families and referring physicians.

Referral process
We are not making any changes to the referral process. A patient is still required to have a BMI at or above the 95th percentile and a weight-related medical comorbidity. Our referral form is available at www.chw.org/newkids (go to the link for the Physician Referral Packet).

Orientation
Families who meet requirements are invited to a 45-minute, no-cost orientation at Children's Hospital. The orientation is designed to educate patients and their families about the program, what they can expect from the program and what the program expects from them.

Initial assessment
A patient and his or her family will be seen by a multidisciplinary team specialized in the evaluation and treatment of pediatric obesity. The initial assessment takes approximately two hours. Families are provided with education regarding their child's health status as well as an initial care plan detailing our recommendations to begin improving their health status.

Phase 1: Beginning changes
We will follow up with families approximately every two weeks for the first three months to evaluate compliance with treatment recommendations, improve motivational status, explore barriers to change and advance our treatment recommendations. A medical reassessment and blood work will be done at the end of phase 1 to re-evaluate health status. The treatment team, in collaboration with the patient and his or her family, will discuss the most appropriate level of continued care based upon their health status and willingness to engage in further change.

With mutual agreement, some patients and families may be discharged from the clinical program at the completion of Phase 1.

Phase 2: Advanced changes
Some families may want or need to make further changes. Those who are ready for Phase 2 will be seen by the treatment team until they have achieved their goals or it has become apparent that they are no longer willing to make further changes.

The NEW Kids treatment team recognizes that patients and their families arrive on our doorstep in many different ways. Our job is much easier with those who are ready, willing and able to make the necessary changes to improve their health and lose weight the first time they are referred. However, not everyone is at this point and may need to go through the program several times before they are able to fully commit to necessary lifestyle changes.

This change in our approach does ask families to make an initial three-month commitment to the program by coming to Children's Hospital approximately every two weeks. Increasing our frequency of visits focuses a family's effort, which should result in better compliance with recommendations, maintain motivation and improve outcomes.

If you have any questions, contact the NEW Kids program at newkids@chw.org.

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