Understanding Health

1.  A specific symptom of untreated or undiagnosed hypothyroidism in childhood is:

•  Fatigue
• Obesity
• Poor growth in height
• Constipation
• Behavioral Change

Poor linear growth (growth in height) is a red flag for endocrine disease.  Most symptoms of hypothyroidism are nonspecific and experienced by a high percentage of the general population at some time.  Hypothyroidism that is severe and undiagnosed or untreated can result in almost complete cessation of growth in height and can be reversed with treatment.  Longstanding obesity present for many years in the setting of normal or above normal growth for familial expectations (that is, at or above mid-parental height percentile) is almost never due to hypothyroidism. Unexplained obesity with more rapid onset over weeks or months may be worthy of further investigation.

 2.  Which is NOT associated with higher risk of childhood obesity:

•  Large for Gestational Age Birth Weight
• Family history of hyperlipidemia
• Family history of obesity
• Presence of a television in the child’s bedroom
• Lower socioeconomic status

Causes of obesity are multifactorial.  Prenatal history plays a strong role and gestational diabetes and LGA birth weight are considered risk factors for future development of obesity (indeed LGA birth weight might be correctly categorized as congenital obesity).  Genetics plays an extremely strong role particularly if both parents struggle with weight.  Environmental and social factors, like excessive screen time and a screens in a child’s bedroom, as well as lower socioeconomic status are also considered risk factors.  Hyperlipidemia is more common in obesity, typically resulting in elevations in triglycerides and low HDL.  However, family history of hypercholesterolemia, especially isolated elevations in LDL are more likely genetically determined and not necessarily associated with a higher obesity risk.

 3.  An obese child who has a stable BMI over time has which of the following:

•  Higher likelihood of obesity as an adult
• Higher likelihood of an underlying disease
• Higher likelihood of failure in an obesity treatment program
• Lower BMI percentile
• Lower likelihood of Type 1 Diabetes

A stable BMI in growing children or adolescents usually will imply a lower BMI percentile and this in most cases can serve as a useful marker of clinical improvement.  How much a stable BMI affects future adverse health outcomes is unclear.  Any child with higher BMI has a higher likelihood of obesity as an adult.  While a stable BMI in a child of normal weight should be a sign of possible undernutrition or disease, it may be a positive sign in an obese child provided there is an explanation such as a change in lifestyle or rapid pubertal growth in height.  Type 1, or juvenile diabetes, is not generally affected by obesity.  Because both obesity and type 1 diabetes are common in childhood, distinguishing type 1 diabetes from type 2 diabetes in young obese patients can be confusing and should be approached carefully.  While the incidence of Type 2 diabetes in increasing in pediatric populations, it is still relatively uncommon compared to Type 1 diabetes.  Incidence of Type 2 diabetes varies greatly depending on the ethnic makeup of local population.

Understanding Healthy Food

 1.  The single best diet for obesity treatment is:

•  Low calorie
• Low glycemic index
• Low carbohydrate
• Low Fat
• None of the above

There is no known single best prescriptive diet for long term weight loss.  Instead, balancing information from numerous dietary studies may be the best approach.  A healthy diet for all children should include the right amount of calories, carbohydrates, protein, healthy fats, fiber and other vitamins and minerals.  Low glycemic index food choices are very likely to be advantageous for many reasons including slower release of carbohydrate into the circulation and improved satiety.  Some argue that total calories is the only factor that truly matters, and some large studies support this, but our opinion is that strict interpretation of this conclusion ignores differences in how certain nutrients are metabolized and the effect of different macronutrients on the digestive system.  We believe calories are important but that food quality is also important.

 2.  Which of the following is NOT a generally recommended protein source for growing children:

•  Lean Meat
• White Skim Milk
• Protein Bars
• Nuts
• Yogurt

A high incidence of muscle enhancing behaviors in pediatrics has been reported including using protein bars or shakes.  In general these should be avoided in growing children and adolescents in favor of lean meat, milk and dairy products, nuts and other more “natural” choices.  None of this general advice is without exceptions.  Yogurt for example can have significant amounts of added sugar depending on the brand.  Protein bars can contain an excessive amount of calories and usually contain highly processed carbohydrate intended for use in high intensity and prolonged physical activity.

3.  How is a “Portion Plate” (myplate.gov) divided?

•  50% carbohydrate, 25% fruits, 25% protein
• 50% vegetables, 25% fruits, 25% carbohydrate
• 50% protein, 25% carbohydrate, 25% fruit
• 50% fruits and vegetables, 25% protein, 25% carbohydrate
• 50% fruit and carbohydrate, 25% protein, 25% vegetables

The “portion plate” used by the USDA is an easy method of helping families with understanding healthy eating.  Using 25% of a normally sized plate for carbohydrate and 25% for protein, rather than 50% or more as is typical in the American diet, can have a major impact on weight and BMI.  In our practice we give families inexpensive reusable “picnic” style plates with dividers to help with this approach at meals.

 Home Environment

 1. Which of the following is true regarding the home food environment:

•  Parental education programs may be effective ways to improve childhood nutrition.
• Highly processed carbohydrate snacks at home are most effectively dealt with by keeping them away from children.
• Focusing on caloric content of home foods is not an important because children self-regulate caloric intake.
• Parental eating habits are unlikely to affect childhood food choice.

Randomized controlled trials exist showing that specific parental education programs can be effective in modifying child food intake (see reference list).  Keeping sugary snacks at home where children can’t access them is a common practice, but in our view is ineffective.  Children have only a limited ability to modify caloric intake as discussed in greater detail in the module on Portion Sizes.  Parental role modeling certainly has an impact on a child’s food choices and preferences although the magnitude of this effect can be debated.

 2.  Which of the following does NOT reflect a motivational interviewing approach to discussing the home food environment with families:

•  Could you tell me a little bit about the foods you have at home?
• Are there other family members interested in keeping healthy food at home?
• What you need to do is get rid of all junk food in your house, is that ok?
• If you were to go home and make your cupboards more healthy what would you add?  Is there anything you would consider taking out?

Prescriptive advice bears a risk of alienating some families or being unrealistic as much as such advice may seem obvious to providers.  Answers A, B and D are examples of suggested phrases from the next steps guide.

 3.  In childhood obesity treatment, sugary dessert foods should be addressed as followed:

•  By liming to one per day
• By limiting to one per week
• By restricting to a few times per year on holidays
• By assessing if this is an area the family would like to modify

Most children and adults, whether obese or not, would usually benefit from restricting sugary dessert foods to rare occasions.  However, what any individual family is prepared to do will vary.  For some, limiting a high intake of candy and sweets to once pre day may be an appropriate first step.  For others, a less frequent target may be ideal.  As discussed in this module, some families are afraid of depriving their children of special treats.  If this is the case, working with a family on a way to limit, rather than eliminate, them can be an effective way forward.

 Behaviors and Emotions Around Eating

 1. Which statement represents a motivational interviewing approach to asking families about health:

•  You’re child’s weight is normal for someone twice their age, aren’t you worried they’ll be sick?
• Carbohydrates are a trigger for becoming fat, I need you to get all extra sugars out of the house.
• Many families I work with feel their kids eat more than they should because they’re bored or stressed, is this something you’ve ever worried about?
• You just need to feed your child less, it is all about calories in and calories out.

A key concept in motivational interviewing is “ask more than tell”.  Let families lead the way by asking open ended questions.  Provide more specificity if they’re having trouble articulating problems.  Avoid scare tactics and prescriptive advice, as much as we may be tempted to say things included in other responses they’re often of little value and only discourage families from talking to you about difficult issues.

 2. A mother of an obese 10 year old patient tells you their child is constantly hungry.  This is most likely due to:

•  Prader-Willi Syndrome
• A mass lesion in the hypothalamus
• A thyroid problem
• Genetic and hormone factors including leptin resistance
• Diabetes

The sense of satiety is a complicated hypothalamic function that integrates many signals from the periphery.  All other choices are worthy of consideration but are more rare.  PWS usually presents with failure to thrive in the first 2 years of life, neonatal hypotonia, poor linear growth, hypogonadism and developmental delay.  Hypothalamic brain tumors can trigger obesity but are usually accompanied by other clinical signs and poor linear growth, herthyroidism can cause hyperphagia but should be associated with other signs of Graves disease.  Type 1 diabetes can present with hyperphagia but is typically associated with Polyuria and polydipsia (where as early type 2 diabetes in children and teenagers less often has specific symptoms).

 3. True or False: Food Addiction has defined diagnostic criteria in the DSM 5.

 False

Food addiction is a controversial concept although seems to have a strong physiologic basis.  No standard definition exists.  In contrast, binge eating disorder has formal diagnostic criteria in the DSM 5.  Both are common in obesity.

 Portion Sizes

 1. Which of the following is true regarding portion sizes and eating behavior in children.

•  Caloric intake in children has risen independent of portion sizes in prepackaged food.
• Children have the ability to self-regulate caloric intake independent of portion size
• Children offered larger portion sizes have been shown to have increased caloric intake compared to study controls
• The historical increase in portion size does not correlate with rising obesity rates

In the example given in this presentation, authors found that offering larger, more energy dense portions, raised overall caloric intake compared to experimental controls challenging the notion that children can self-regulate energy intake.  The rise in caloric intake and obesity correlates with the historical increase in portion size.

 2. Potential pitfalls with the basic USDA MyPlate image is that:

•  It does not specify type of protein
• It does not specify type of carbohydrate
• It does not specify healthy types of oils
• All of the above

As discussed in this module, the MyPlate concept from the USDA improves upon previous iterations of the “food pyramid”.  Other sources, including the NextSteps guide and the Harvard School for Public Health build more specificity on the MyPlate foundation.

 3. Potential strategies to encourage healthy portion sizes include:

•  Food models
• “Palm of the hand” approach to servings of carbohydrate and protein.
• Using a picnic-type divider plate
• All of the above

 In our clinic we have found success by having multiple means of addressing a particular theme.  Any of the above strategies can be successful.  Smartphone or tablet apps may also be helpful for some families.

 Healthy Drinks

1. When a juice label says that a bottle contains a “serving of fruit” this is defined as:

• 1/2 cup of 100% juice
• 1 cup of 100% juice
• 2 cups of 100% juice
• Has no standard definition and is defined by each beverage manufacturer.

The USDA defines ½ cup of 100% juice as a serving of fruit.    Our view is that this is a misleading definition for consumers.  For example one small whole orange is considered a ½ cup of fruit and contains approximately 45 calories, 11 carbohydrates, 2.5 grams of fiber, 1 gram of protein, and 40 mg of calcium among other vitamins and micronutrients.  In contrast, a ½ cup of orange juice, even freshly squeezed, contains 25% more calories, 2 more grams of carbohydrate, almost no fiber and less than 1/3 the amount of calcium.   Further, very few juices are sold in ½ cup (4 oz) or even 1 cup (8 oz) servings making intake beyond the serving size likely.  This was supported in a recent study suggesting that “healthy” food labels drive up consumption.  100% juice is perhaps a better choice when compared to a sugary soda but drinking water and eating an orange or an apple is preferred.

2. What does the USDA recommend for milk intake for adolescents?

• 200 mg a day
• 3 cups a day
• 4 cups a day
• 400 mg a day
• Not defined by the USDA.

The USDA defines milk intake as follows: Ages 1-3, 2 cups a day, ages 4-8, 3 cups a day and for pre-teens and teenagers 4 cups a day.  One cup of low fat milk has approximately 300 mg of calcium.  Other dairy products such as cheese and yogurt are good alternatives.  Most cheese has very little carbohydrate (lactose) and may be a good choice for those who are lactose intolerant.  Other foods with good sources of calcium include broccoli, salmon, kale, pinto beans, almonds and oranges.  Calcium intake is particularly important in children, adolescents and young adults.  Bone mass accrual continues into the early 20’s and then declines year by year thereafter.

3. How many carbohydrates, calories and serving sizes are in a 20 oz bottle of regular cola?

• 240 calories, 75 g Sodium, 95 g carbohydrates, 1 serving size
• 240 calories, 75 g Sodium, 65 g carbohydrates, 1 serving size
• 500 calories, 75 g Sodium, 65 g carbohydrates, 1 serving size
• 500 calories, 75 g Sodium, 65 g carbohydrates, 2 serving sizes

Regular cola usually contains high quantities of sucrose (composed of monosaccharides glucose and fructose).  Sucrose is rapidly cleaved to its monosaccharide components by the enzyme sucrase, mostly in the duodenum.  Glucose and fructose are rapidly absorbed and result in a brisk insulin response.  Differences in metabolism of fructose compared to glucose may favor adiposity. Serving size can be defined differently by different manufactures but in many cases 20 oz is one serving.

Parenting

1. A parent of an obese 8 year old child buys one case of sugary sports drink each week so that her son “doesn’t get dehydrated during basketball”.  Actions to consider include:

• Nothing, dehydration is a risk in basketball.
• Calling a child protection specialist
• Limiting sports drink to 4 ounces per hour of sports
• Asking if the family is interested in switching to water.

The pervasive advertising for sports drinks has many parents confused about the risk of dehydration and need for electrolytes with physical activity.  Children in sports should have free and ready access to water if they are thirsty but there is almost no role for sports drinks except in rare instances of extreme endurance activities.  Using a motivational interviewing approach to see if the family is willing to think about a change in this behavior is the best choice.

2. A parent of an obese 3 year old with elevated hemoglobin A1C and ALT continues to provide regular cola at every meal and snack throughout the day despite your attempts to help the family modify this practice.  Actions to consider include:

• Nothing, A1C and ALT measurements are inaccurate at this age.
• Call a child protection specialist
• Limiting soda to 4 ounces per day
• Asking if the family is willing to switch to water

While it may seem extreme, this real-life scenario from our practice did prompt engagement of our child protection team who, at our institution, was in the best position in this case to help advocate for the child with multiple supportive services.  In this case, a young child on the road to liver failure and type 2 diabetes warranted dramatic intervention.

3. You are working with an overweight 10 year old whose mother is committed to improving food choices at home.  She is divorced and expressed concerns that “his father is not on board” and that junk food is abundant on weekends when her son is with his father.  Actions to consider include:

• Having the child tell his father not to buy junk food
• Writing a letter to the father explaining that good parents don’t buy junk food for their children.
• Writing a letter to the father explaining that junk food increases the chances of diabetes and heard disease.
• Asking if the father would be willing to bring his son to the next clinic visit.

This scenario is a common one in our clinic.  We believe engagement of the whole family including all of a child’s caregivers is important.  Relaying messages through other family members or with letters may have a role in some cases but more often result in miscommunication in our experience.  Seeing if the patient’s father is willing to be engaged directly is the next best step.

Physical Activity

1. A 200 lb adolescent jogging for 30 minutes burns approximately how many calories?

• 150
• 250
• 350
• 450
• 550

Even vigorous physical activity can have a modest caloric expenditure payoff.  Exercise is beneficial for many reasons beyond simple burning of calories.  Improved insulin and leptin sensitivity, higher HDL, improvements in muscle strength and bone density and positive effects on behavior and school performance are among many documented benefits.

2. You are seeing an obese 7 year old with over 6 hours of screen time per day and almost no physical activity except for minimal school requirements.  Your recommendations might include:

• Structured exercise management with a physical therapist
• High repetition low weight strength training
• Use of an AAP exercise app on a mobile device
• Limiting screen time and encouraging age appropriate active play.

For young children active, age appropriate play should be encouraged.  In this case excessive screen time should also be addressed.  While scheduled activities like a sports team or swim lessons might make meaningful contributions, they rarely happen on a daily basis.  Our opinion is at younger ages there is less of a role for structured exercise coaching or use of the apps demonstrated in this module.

3. Cumulative research on exercise and childhood obesity demonstrates:

• Exercise is of no value when duration of activity is less than 20 minutes.
• A consistent positive effect on BMI and metabolic parameters that is dose dependent.
• High level of non-participation due to musculoskeletal problems.
• High risk of injury.

Although vigorous exercise of long duration (> 60 minutes) makes a more powerful contribution to health, any exercise is better than none.  How much exercise is needed to provide a health benefit is debated. Even high-intensity, short duration exercise programs may have a meaningful health benefit. Muskuloskeletal problems and injuries are important considerations in obese patients but usually improve with gradually increasing physical activity.

Feeling Good About Yourself

1. Quality of life scores in children with obesity are:

• Comparable to children with cancer
• Two times worse than children with cancer
• Not different from normal children
• The same as or better than normal children

Quality of Life measures show that children with obesity have scores similar to those in children with cancer and other severe chronic diseases.

2. Which of the following is true regarding the relationship to BMI and quality of life scores in obese children?

• Lower BMI is associated with lower quality of life score.
• Higher BMI is associated with higher quality of life score
• Higher BMI is associated with lower quality of life score
• There is no correlation between severity of BMI elevation and quality of life.

In the literature presented there seemed to be a correlation between worsening quality of life and higher BMI, particularly in severe obesity (BMI above the 99^th percentile).

3. In the preceding learning module the suggested question: “What don’t you like about your body?” was discussed.  Which of the following was NOT cited as a potential benefit of this question:

• It may reveal an unrealistic goal body weight.
• It may reveal underlying depression.
• It may reveal insights to perceptions of health.
• It may reveal that a patient is comfortable with their appearance.

Asking about body image has many potential benefits if done in a compassionate manner.  Obese children and adolescents are at risk for mental health problems including depression but these are better addressed with other questions or formal screening tools.

Label Reading

1. Food label calorie information is mandated to be:

• Accurate to within 5% of actual calories
• Accurate to within 10% of actual calories
• Accurate to within 20% of actual calories
• Accurate to within 50% of actual calories

FDA regulations do not mandate a high level of accuracy in caloric content as stated on the food label.  In practice, especially in snack foods and in some restaurants, the difference between calories on a food label and those actually contained within a particular product can be significant.  Still, the food label is an essential tool patients and families can utilize to make healthier choices.

2. Which statement correctly defines “sugars” on a food label?

• “Sugars” is the sum of fiber and complex carbohydrate
• “Sugars” refers only to artificially added sugars
• “Sugars” includes only naturally occurring sugars
• “Sugars” includes all simple sugars and excludes complex carbohydrate.

 “Sugars” includes all simple sugars (mono and disaccharide sugars regardless of the source) and excludes complex carbohydrate and fiber.  Sugars can include both naturally present and added sugar.  In general the “Total Carbohydrate” amount on a food label is a more useful number.  Foods that have “zero sugars” may nonetheless provide a high level of rapidly absorbed carbohydrate (for example a typical slice of white bread has 15 grams of carbohydrate and 2 grams of “sugars”).

3. What is the difference between the labels “Whole Grain” and “100% whole grain”

• There is no difference between these two labels.
• “100% whole grain” products contain twice as much fiber as ones labeled “whole grain”.
• “100% whole grain” products contain three times as much fiber as ones labeled “whole grain” .
• “100% whole grain” products contain about six times as much fiber as ones labeled “whole grain” .

In general, foods in their natural state are healthier choices.  One reason for this is that the rate of glucose absorption will be slower when fiber and complex carbohydrate is present.  This reduces insulin secretion and can help improve satiety.  Whole grain foods are usually a better choice because fiber content is higher but portion size is still important.  A significant difference in fiber content exists between foods labeled “whole grain” (8 grams of fiber per serving) compared to “100% whole grain” (47 grams of fiber per serving).

Screen Time and Sleep

1. Which behaviors among toddlers have been shown to have a strong association with childhood obesity?

• Eating together as a family
• More than 10-11 hours of sleep per night
• Limiting screen time to less than 2 hours per day
• All of the above

In the study by Anderson and Whitaker cited in this module a strong case was made for these behaviors being key areas to focus on in obesity prevention and treatment.

2. Physical findings and symptoms that may be clues that obstructive sleep apnea is present include:

• High Arched Palate
• Hypertension
• Morning Headache
• Sleep Enuresis
• All of the above

Obstructive sleep apnea can be associated with a variety of symptoms and signs.  Children who are obese have a higher incidence of sleep apnea which can have metabolic consequences making weight loss more difficult and obesity related comorbidities more likely.  The AAP recently published a clinical practice guideline on this topic that is included in the reference list to this module.

3.   Physicians might decide to advocate for screen time if:

• There is use of an automatic timer so that the TV shuts off after the child is asleep.
• TV time in the bedroom is for video-game use only.
• TV time accompanies use of exercise equipment like a treadmill.
• It is limited to use of a smart phone

In the next steps guide there is mention of screen time as possibly being appropriate for homework or if used during exercise.  In our experience, many adolescent will use exercise equipment at home more readily if they’re allowed to watch TV at the same time.

Meal Patterns and Snacks

1. In the Bogalusa Heart Study citation discussed in this module the following conclusions were   made about children from the 1990’s compared to the 1970’s:

• Intake of school lunches decreased
• Total number of eating episodes per day increased
• Number of times eating dinner away from home increased
• Changes in eating behaviors were not associated with rising BMI.
• All of the above

The study in this module noted interesting trends in eating behaviors but did not find statistically meaningful associations with obesity.  Other studies reach alternative conclusions and for some behaviors, like skipping breakfast, literature lends stronger support to an association with obesity.

2. The AAP HALF (Healthy Active Living for Families) program recommends how many snacks per day for Toddlers?

• 1-2
• 2-3
• 3-5
• 4-5

While no absolute snacking standard exists, the AAP recommends 2-3 snacks per day for toddlers, probably a reasonable goal for older children as well. 

3. In the Next Steps Guide which of the following behaviors are promoted:

• Avoiding multitasking while eating
• Eating slowly
• Limiting Eating out to once a week.
• Eating on a regular schedule
• All of the above

Many behaviors are emphasized in the Next Steps guide.  Working with families on one or two of these at a time is usually a preferred approach compared to multiple changes at once.  Remember to think of using motivational interviewing approaches to determine which area a family would first like to focus on.

Eating Out of the Home

1. Current school lunch standards as defined by the National School Lunch Program call for which of the following:

• 5 servings of whole grain per week
• No more than 1000 mg of sodium per meal
• 5 servings of fruits OR vegetables per week
• 5 servings of fruits AND vegetables per week

5 servings of fruits and vegetables per week are mandated in the updated NSLP guidelines.  Standards for whole grains are 10-12 servings per week and sodium should be limited to less than 650 mg, 700 mg, 850 mg for K-5, 6-8 and 9-12 grades, respectively.

2. In the School Nutrition Dietary Assessment Study cited in this module, what percent of surveyed schools reported meeting guidelines to limit sodium: 

• 0%
• 10%
• 20%
• 30%
• 40%

In the School Nutrition Dietary Assessment Study, reported in 2009, there was variability in meeting guidelines defined by the NSLP.  No schools met standards for limiting sodium and many school lunches had fat content above the set standard.  Meeting fiber content standards was also rare.

3. For low-income families working towards healthy eating habits which of the following goals would be most appropriate?

• Packing a home lunch using prepared foods from the grocery store.
• Making selections off the a la carte menu in the school cafeteria.
• Waiting to have lunch until after school to limit caloric intake
• Working on regular intake of the prepared school lunch

School lunches, even with variable adherence to NSLP standards, may have significant nutritional advantages compared to lunches brought from home.  Home packed lunches have the potential to be outstanding but will depend on parental nutrition knowledge and family resources.  In families where food resources are limited using a school lunch as a step to better health may be most appropriate.

Holidays and Special Occasions

1. The journal article cited in this module concluded that in their study population:

• Adult BMI is stable from November to January
• Adult BMI decreases from November to January
• Adult BMI increases from November to January but then returns to baseline within 6 months.
• Adult BMI increases from November to January and remains elevated thereafter.

Although there was some weight loss after the holidays in this report overall weight for the year increased with a spike during the holiday season.

2. The Next Steps Guide emphasizes which strategies to maintain health during the holidays:

• Keeping a regular Meal Schedule
• Teaching that it is ok to say “No thank you” when offered food.
• Being realistic about having some sugary sweets on special occasions
• Maintaining physical activity
• All of the above

Making sure families know that your expectations are realistic can be helpful.  In our obesity treatment clinic we emphasize that celebrations and enjoying sweet food should still happen but strategize with families on ways to limit overall intake.

3. Which phrase would be LEAST effective in helping families with healthy holiday habits?

• What strategies during the holidays has worked for you before?
• I think you should have only one dessert on the holiday, can you do that?
• What do you think would make it easier to be healthy during the hoidays?
• What has been your experience with eating during the holidays?

In motivational interviewing the practitioner typically asks more than tells and listens more than speaks.  Telling patients what you think is best for them is often a less effective way to promote behavior change.

Healthy Families

1. An obese 11 year old patient you are seeing has 10 year old sister whose “eats whatever she wants” and has a stable BMI the 25^th percentile.  You should:

• Explain that healthy eating is good for all family members
• Limit nutrition advice to your patient alone
• Encourage the sister to continue eating high calorie foods
• Explain to your patient that he will have to eat differently than his sister because of his weight problem.

The core message of Let’s Go (5-2-1-0) was intended for use by all children and families, not as a targeted intervention for obese children alone.  We’ve attempted to make the guidance in Next Steps similarly generalizable.  Singling out a single member of the household to eat in a certain way is less likely to result in a positive health outcome.  Though difficult, sustained change within the family is more likely to be effective.

2. A family you are working with doesn’t understand what you mean when you say “protecting the home food environment”.  You explain that:

• This means locking up sweet treats where children can’t find them
• Only allowing healthy weight family members to have dessert
• Making healthy options available at home most or all of the time.
• Buying only organic fruits and vegetables

This concept was discussed in the “Home Food Environment” module and some families can find it confusing.  Many parents fear that unless certain unhealthy foods are at home their children won’t eat.  If this is their concern then careful goal setting in this area can be helpful rather than a dramatic shift in food availability.

3. An 8 year old obese patient you see stays at his grandmother’s house after school where he has cookies and sugary soda every day.  His mother says “She just doesn’t understand, she thinks it’s ok”.  The LEAST effective strategy to help this family would be to:

• Ask for permission to speak with the patient’s grandmother by phone
• Ask if the patient’s grandmother would like to come to the next clinic visit.
• Write a letter to the patients grandmother explaining that giving cookies and soda to an obese child is considered neglect
• Ask why the patient’s mother thinks this is an area of disagreement.

The vignette in this question is all to common in our obesity clinic.  We believe that working with all adults involved in a child’s food environment is important.  Working with step parents and grandparents is often a very effective way to promote positive change. In the module on parenting we raised issues around parental responsibility and when, in rare circumstances, parental feeding practices might be considered a form of medical neglect.  In a clinical situation such as the one posed here, threatening a family with this type of language is unlikely to be effective.

Community Partners

1. An important concept emphasized in the “Community Partners” theme is that:

• Physicians should be solely responsible for identifying community resources.
• Families are often the best at identifying community resources.
• Obese children should not participate in team sports
• Obese children are unlikely to succeed in team sports

Families can certainly benefit when health care team members are knowledgeable about community resources.  However, in our experience families often are more aware of what’s available near their homes or bring up programs or experiences that are a better fit for them than ones a member of the health care team might suggest.

2. A family tells you they would like to join their local gym and go together 3 days a week.  After congratulating them on this idea you might helping them achieve this goal by asking:

• Do you think this is an achievable goal?
• Are you worried there are things that might get in the way of you achieving this goal?
• Is this something that will fit into your family budget?
• How will this fit into your family schedule?
• All of the above

Helping families anticipate barriers to their goals can be helpful and may also help redefine goals to be more realistic.

3. Key Teaching Concepts contained in the Next Steps Guide for Community Partners include:

• Suggesting that parents try a new activity with their child
• Having patients think of a different activity for each day of the week.
• Encouraging structured or group activities.
• All of the above

Having a few key ideas at your fingertips when working with obese children is what the Next Steps guide is intended to achieve.  Having some helpful suggestions while the motivational interviewing process is taking place can help facilitate defining achievable goals.

Bullying and Teasing

1. Rates of bullying in pediatric obesity are comparable to:

• bullying due to different sexual orientation
• bullying due to of race
• bullying due to low socioeconomic status
• bullying due to short stature

In the studies cited in this section bullying rates in pediatric obesity were comparable to rates of being bullied because of sexual orientation and were worse than being bullied because of race, religion or disability.

2. Common perpetrators for bullying include:

• Peers only
• Peers and teachers
• Peers, teachers and physical education teachers
• Peers, teachers, physical education teachers and parents

Perpetrators of bullying extend beyond other same-aged peers.  Adults in a child’s environment also may be perpetrators of bullying or other forms of weight based victimization.

3. Which of the following is not a potential symptom of bullying:

• Difficulty falling asleep
• Obstructive Sleep Apnea
• Non-specific abdominal pain
• Fear of using the bathroom at schoo

Bullying can present with a myriad of symptoms including non-specific symptoms, problems with sleep, sudden loss of friends, fear of going to the school bathroom or fear of school itself, and the sudden report of “lost” items which may have actually been involuntarily surrendered.  Obstructive sleep apnea is a common comorbidity in pediatric obesity but

Unintentional Disruptions

1. In this module which group was considered most receptive to discussion of disruptions?

• Parents
• Adolescents
• Children
• toddlers

Adolescents face unique challenges to implementing meaningful lifestyle change and many points in this section of the Next Steps guide refers to this age group.

2. Which situation was not discussed as a common way adolescents might encounter disruptions?

• Other family members bringing unhealthy food into the home.
• Other family members with different food priorities.
• Other family members who may intentionally try to disrupt an adolescents efforts.
• Other family members with chronic illness.

Disruptions can come from many different areas in an adolescent’s environment.  While social stressors, like a chronically ill relative, certainly can be a disruption this was not the focus of this module.

3. You begin work with an adolescent whose BMI is 41 (> 99^th percentile).  Over the first 6 months of treatment they lose 20 pounds.  Over the most recent 3 months however weight has been unchanged.  Your patient is upset about this and has reverted to some old unhealthy eating habits.  Which of the following might be the BEST way to approach this situation?

• Tell your patient they should be upset because lack of will power will leave them unsuccessful.
• Tell your patient that they’re almost certain to suffer from metabolic syndrome as a young adult unless they get back on track.
• Tell your patient that their BMI is still severely elevated and they will get diabetes if they don’t start eating less and exercising more.
• Tell your patient that you’re proud of their maintenance of weight loss which comes with a significant health benefit. Then explore if they’re ready to set some new goals.

Even modest weight loss if maintained reduces future risk of obesity related comorbidities.  Maintenance of weight loss will correlate with lower BMI z-score in adolescence and should be seen as a measure of success.  This kind of disruption is preventable if appropriate goals are set with the provider at the start of treatment.