February 2009

Should your patient have bariatric surgery?

Get movin' with fun, family games, Part II

Helping patients help themselves

Heart-healthy diet: Tips for parents 

From the desk of a wellness coach

Should your patient have bariatric surgery?

Laure DeMattia, DO, Children's Hospital of Wisconsin

Today, teenagers who weigh in excess of 300 pounds are not difficult to find. As medical providers, we often feel at a loss of what we have to offer these patients. They are having difficulty maintaining an active life due to their weight. They decrease the amount of activity as they increase in size, which makes it more difficult for them to be active. Many of our patients withdraw from school, to pursue homeschooling due to teasing.

What can we do? Sometimes the most viable decision is to suggest bariatric surgery. Currently, there are two procedures available nationally: Gastric Bypass and the Adjustable Gastric Band. At Children's Hospital of Wisconsin, we offer the Adjustable Gastric Band (also known as LAP-BAND) procedure.

If used appropriately, this procedure can be as effective in total weight loss at five years compared to gastric bypass with similar risk of intra-operative and postoperative morbidity and mortality based on research presented by Dillard et al.

Children's Hospital physicians routinely evaluate this criteria for consideration of bariatric procedure:

• The patient's Body Mass Index is greater than 40 with medical comorbidity.

• The patient must have been an active participant in the NEW (Nutrition, Exercise and Weight Management) Kids^TM Program for a least six months.

• The patient must demonstrate compliance to preoperative recommendations by NEW Kids providers.

• The patient must have reached physical maturity (this may be reconsidered dependent on severity of comorbidities).

• Females must agree to avoid pregnancy for a minimum of one year post surgery.

• Patients must commit to life-long nutritional and exercise practices established by the NEW Kids team.

Patients meeting this criteria are presented to the Bariatric Committee. If the committee determines the patient to be an appropriate bariatric candidate, surgery will be scheduled pending insurance approval.

Prior to surgery the patient will undergo:

• A cardiology consult.

• Liver ultrasound.

• Polysomnography.

• Pregnancy testing.

• Psychological screening.

• Screening for bleeding disorders.

• Other tests, as needed.

Please refer patients via the physician referral packet or for more information, contact Michele Polfuss, APNP, bariatric program coordinator, at (414) 266-3187.

References

Initial experience with the adjustable gastric band in morbidly obese US adolescents and recommendations for further investigation. Dillard BE 3rd, Gorodner V, Galvani C, Holterman M, Browne A, Gallo A, Horgan S, Le Holterman AX. Journal of Pediatric Gastroenterology & Nutrition. 45(2):240-6, 2007 Aug.

Bariatric Surgery for Severely Overweight Adolescents: Concerns and Recommendations
Thomas H. Inge, Nancy F. Krebs, Victor F. Garcia, Joseph A. Skelton, Karen S. Guice, Richard S. Strauss, Craig T. Albanese, Mary L. Brandt, Lawrence D. Hammer, Carol M. Harmon, Timothy D. Kane, William J. Klish, Keith T. Oldham, Colin D. Rudolph, Michael A. Helmrath, Edward Donovan, and Stephen R. Daniels, Pediatrics 2004; 114: 217-223. 

Get movin' with fun, family games, part II

Stacy Stolzman, MPT, Children's Hospital of Wisconsin

• Twister Moves. Use your Twister mat and follow the dance moves that DJ Ray and Diamond J call out. For up to two players ages 8 and older.
• Cosmic Catch is the ball that remembers your throws. When the ball calls out the commands, you have to toss it to a friend wearing the correctly colored wristband. For two to six players, ages 7 and older.
• Jump Dancer is a battery-operated skip rope toy that makes it possible for everyone to jump without holding the rope. It offers two speed settings and three time settings to allow kids to make up their own skipping and jumping games. Designed for children ages 6 and older.

Helping patients help themselves

Brian Fidlin, PsyD, director, NEW Kids Program, Children's Hospital of Wisconsin

Admitting you have a problem is the first step to recovery.

There are many parallels that exist between substance abuse and obesity. One of them is the tendency to deny that the problem even exists. Some parents have excused their child's weight by using one of these statements:

• Oh, it's just baby fat.
• He or she will grow out of it.
• A chubby baby is a healthy baby.

Research tells us that 77 percent of obese children will grow up to be obese adults. Interestingly, only 14 percent of children who fall within a normal weight range will grow up to be obese adults.*

Why does this happen? During childhood we are establishing behavioral patterns that will most likely continue into adulthood. When a child becomes bored, does he or she choose to go outside and play or sit and watch TV? When a child gets upset, does he or she talk to someone or eat to soothe his or her feelings?

Now, imagine what happens when these children become adults and are faced with similar decisions. These patterns can become so entrenched that efforts to change them often are met with great resistance even when the need for change is great.

The best time to intervene is before these behavioral patterns have a chance to become habits. That is why I encourage providers to consider addressing behaviors earlier.

For parents of children or toddlers, discuss:

• Why television should be limited.
• Why juice should be limited and only offered in a cup.
• Why fast food should not be a weekly occurrence.

For children ages 2 and older, I suggest using the 3-2-1-0 Blast Off to a Healthier Family! program during all well-child exams. This program helps foster the discussion of a healthy lifestyle.

For patients who already are having weight problems with their weight, evaluate them for a referral to the NEW (Nutrition, Exercise and Weight Management) Kids clinical program at Children's Hospital of Wisconsin. It is far easier to change behaviors in young children (and the parents of young children) that those who have had years to develop unhealthy behavior patterns.

Heart-healthy diet: Tips for parents

Jennifer Allen, RD, Children's Hospital of Wisconsin, and Stacy Brand, dietetic intern, Mount Mary College

Following a heart-healthy diet not only helps the heart, it also helps a patient's ability to maintain a healthy weight. When discussing a heart healthy diet with kids and parents, focus on the following three areas:

• Choosing leaner meats.
• Increasing fruits and vegetables.
• Increasing whole grains.

High-fat meats are among the most significant sources of saturated fat and cholesterol in the diet. Ask your patients what type of meats they eat at home and how they prepare them. Advise patients to limit beef, sausages, hot dogs and fried or battered foods. Encourage patients to choose lean meets such as chicken, turkey and fish. Patients should bake, grill and broil meats instead of frying.

Fruits and vegetables are not only filling and low in calories, but have soluble fiber to help lower cholesterol levels. Five to nine servings per day of fruits and vegetables are recommended, but most people aren't getting close to that. Ask your patients how many servings of each they have in their diet. If their intake is less than recommended, start with a goal of having one more serving of each per day.

Whole grains are another important way to include fiber in the diet. Ask your patients what type of breads and cereals they choose. Instead of white, rye or Italian bread, encourage patients to choose 100 percent whole wheat bread. Instead of sugary cereals, encourage cereals high in fiber and low in sugar.

Here are some specific recommendations:

Breads	Look for three grams or more of dietary fiber per serving. Look for "whole wheat" as the first ingredient. Avoid "wheat" bread that may just be white bread with caramel coloring.
Cereals	Look for three grams or more of dietary fiber per serving. Look for ten grams or less of sugar per serving. Look for "whole grain" as the first ingredient. It may be wheat or corn.

Learn more about heart-healthy diets here.

From the desk of a wellness coach

Erin Ruenger, YMCA of Metropolitan Milwaukee

Families begin the New Year with the best of intentions, as they make resolutions to become healthier and more active. Unfortunately, many times families start strong and burn out in the months ahead. By finding activities and programs that keep everyone motivated and excited, families can stay focused on continuing a healthy lifestyle beyond the first month of the year.

Below are five tips that families can focus on to stay consistent when working towards healthier lifestyles.

• Start with small and achievable steps.

  When starting new health and wellness goals, it's important to begin with small, achievable steps. A steady pace will aid families in staying on track with their goals and remaining consistent throughout the upcoming months.

• Focus on activities for the entire family.

  Whether it's an exercise group, health-based class or family play-time, there are programs and activities for the entire family to enjoy.

• Utilize resources to learn more.

  To learn more about healthy lifestyle options, families can locate a staff person at their local fitness center to make connections with nutrition professionals, personal trainers and health programs.

• Keep routines new and exciting.

  Families may become tired of the same routine. As a result, it's important to remember that variety is the key to staying on track. Even minor changes to a regular routine can keep things interesting and new.

• Have fun!

  Families should enjoy the activities, programs and new lifestyles they are becoming familiar with. If everyone involved has fun participating in new activities, they will be more likely to focus on ways to continue their new lifestyle.

These are just a few tactics that families can focus on to keep their goals in check, and by taking the time to improve the spirit, mind and body, families benefit from a happier, healthier lifestyle.