A Healthy Weight Intervention for Children in the Dental Office

Yvonne Lee, DMD Donna Henley-Jackson, DDS, MS

Introduction
According to the most recent prevalence data, childhood overweight has more than tripled since 1970 and currently affects 32% of all children and adolescents. One of the most common obesity-associated diseases of childhood is type-2 diabetes. Svetlana et al reported a 61% increase in the prevalence of obesity-related type-2 diabetes. Additionally, gallstones previously seen predominantly in adults, have begun to increase in school-age children. Other co-morbidities include obstructive sleep apnea, fatty liver disease, hypercholestolemia, dislipidemia, hypertension, and other cardiovascular risk factors.

Introduction, cont.
Psychological aspects have been documented as well. Negative stigma, anxiety, depression, and body dissatisfaction are only some of the problems found more in overweight children than in their normal weight peers. 63% of children who are overweight may develop into overweight/ obese adults. This has substantial economic consequences both now and in the future as obesity-related health care costs have more than tripled over the past two decades.

Happy Meal toys no longer free in San Francisco

http://www.cnn.com/2011/11/30/health/california-mcdonalds-happy-meals/index.html

How did we get ourselves into this situation?

Children today lead more sedentary lifestyles, watching over fours hours of television per day, effectively decreasing their total energy expenditure. Recent studies have also shown that children, while watching television, consume energy-dense snacks, tipping the scale toward increased energy consumption. To put it simply, there is an imbalance between energy expenditure and energy intake.
Todays youth are eating larger sized portions of food, eating less fruits and vegetables, and consuming excessive amounts of both juice and soda.

Johnson R. Proc Nutr Soc 2000; 59:295-301 Coon KA, Goldberg J, Rogers BL, Tucker KL. Pediatrics 2001;107:E7. Matthiessen J, Fagt S, Biltoft-Jensen A, Beck AM, Ovesen L. Public Health Nutr 2003; 6:65-72.

Who is at risk?
All Americans Low socio-economic status is associated with an overweight condition in children. Minority youth are more likely to experience extreme BMI levels than non-Hispanic Caucasian children and adolescents.

Pastor PN, Makuc DM, Reuben C, Xia H. National Center for Health Statistics; 2002. Troianao RP, Flegal KM. Pediatrics 1998; 101; 497-504. Kopycka-Kedzierawski DT, Auinger P, Billings RJ, Weitzman M. Community Dent Oral Epidemiol. 2008 Apr;36(2):157-67.

Why should pediatric dentists care?

Overweight/ obesity carries dental implications for children caries and obesity share similar risk factors

accelerated dental growth and development

may need earlier orthodontic referral and treatment Challenge for sedation, including respiratory complications, cardiovascular complications, and increased likelihood for aspiration
Hilgers KK, Kinane DF, Scheetz, JP. Pediatr Dent. 2006 Jan-Feb;28(1):23-8.

Why should pediatric dentists care?

Dentists may see children by age 1, providing an opportunity for longitudinal counseling and monitoring of weight at an early age Dentists have higher likelihood than pediatricians of seeing older children on regular basis for recall visits

Hilgers KK, Akridge M, Sheetz JP, et al. Pediatr Dent. 2006 Jan-Feb;28(1):18-22.

What can pediatric dentists do?

Record a childs height and weight and calculate BMIat least annually for patients 2 years and older
CDC defines overweight as 85th BMI percentile and obesity as 95th BMI percentile. Underweight is defined as less than 5th percentile.

Multi-disciplined approach between medicine and dentistry. Pediatric dentists can refer selected patients to their pediatrician for more comprehensive counseling with a dietitian.
Kushner RF. Prev Med 1995; 24: 546-52 AAPD. Reference Manual 2006-07. Pediatr Dent 2007;29:125-30. Tseng R, Vann WF, Jr., Perrin EM. Pediatric Dentistry 32: 417-423, 2010.

Research Aim
To analyze the efficacy of addressing childhood obesity in the dental office as determined by parental compliance with referrals to other health care providers (pediatricians or family health care physicians) made during the oral health maintenance visit. To examine our population by gender, socioeconomic status, weight status and if there are any statistical significance between groups.

Methods
Examined a healthy population (ASA I) ages 2-14 who presented for oral health maintenance visits from May 2012 July 2012 at both the UCLA Childrens Dental Center and the Fort Bend Family Health Care Center in Stafford, Texas. During the dental appointment, children had their height and weight recorded. Next, the BMI and BMI percentile was calculated using a Smartphone application.

Methods, cont.
For patients who were within normal BMI, we encouraged them to eat right and thanked them for their time. For patients who had an abnormal weight (at or above the 85th percentile or below the 5th percentile), a referral letter was given to the parent to take to either their pediatrician or dietician. A brief explanation of the data and any need for referral was provided.

Referral Letter

Methods, cont.
If a referral was made, the parent was called one month later to determine whether an appointment was secured with the appropriate health care professional. The compliance outcome was recorded as yes or no. The compliance outcomes were recorded as compliant and noncompliant and reported as percentages.

Results/ Discussion Demographic

Average Age Cal iforni a (31 pati ents) Texas (20 pati ents) Total (51 pati ents) 6.4 years ol d Range: (3y5m 13y0m) 6.1 years ol d Range: (2y-12y) 6.3 years ol d Range: (2y-13y) Mal es 15 48% 11 55% 26 50.9% Females 16 51% 9 45% 25 49.1% Engl i sh-speaki ng 20 64% 11 55% 31 62% Spanis h-speaking 11 35% 9 45% 20 39%

Results/ Discussion Weight

Average Wei ght (l bs ) Average Hei ght (i nches)
Average BMI (kg/m2) Average BMI percentile Referral? % of patients w ho are overw eight and/or obese

Cal iforni a (31 pati ents) Texas (20 pati ents) Total (51 pati ents)

59.3 l bs

47.2 inches

17.43 Range: (13-33.6) 18.21 Range: (12.5 - 37.8) 17.7 Range: (12.5-37.8)

62.1 percentile Range: 1-99 % 60.6 percentile Range: 16-99 % 61.5 percentile Range: (1-99%)

21 (No) 10 (Yes) = 32% 15 (No) 5 (Yes) = 25% 36 (No) 15 (Yes) = 29%

22%

Range: (33-202 l bs) Range: (38.5-63 i n) 73.2 l bs 48.9 inches

25%

Range: (32-234 l bs) Range: (39-66 i n) 63.8 l bs 47.8 inches

23%

Range: (32-234 l bs) Range: (38.5-66 i nches)

Results/ Discussion Time

Average Time

California (31 patients) Texas (20 patients) Total (51 patients)

267.7 seconds = 4.4 minutes 296.8 seconds = 4.9 minutes 278.7 seconds = 4.6 minutes

Unadjusted Estimate (95% CI) Referral 95.8 s (-13.3, 204.9) Sex 27.2 (-63.1, 117.6)

Adjusted for child's age and language p-value Estimate (95% CI) 0.08 130.9 (17.2, 244.7) 0.55 32.2 (-53.0, 117.6)

p-value 0.03 0.36

Results/ Discussion Efficacy of Referrals

Overall Mal e Female Spanish Engl i sh Cal iforni a Texas Underweight Overweight or obese Cash Private i ns uran ce Medi-Cal Number of observations 14 8 6 3 11 9 5 3 11 2 3 9 Percent compl i a nt 71.4 62.5 83.3 66.7 72.7 55.6 100.0 33.3 81.8 50.0 33.3 88.9 95% CI (44.4, 98.5) (19.2, 100) (40.5, 100) (0, 100) (41.3, 100) (15.0, 96.1) ---(0, 100) (54.6, 100) (0, 100) (0, 100) (63.3, 100)

Limitations of Study
Small sample size Statistical significance

Areas for Future Research

How much impact do dentists have addressing
weight in reducing childs weight?

Different strategies for addressing weight in the

dental clinic.

Conclusions
It is efficacious to calculate BMI in the dental clinic
and refer to pediatricians.

71.4% of patients scheduled an appointment with the

appropriate health care professional to address abnormal weight.

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Thank you!
All of our mentors: Dr. Henley-Jackson, Dr. Law, Dr. Silva, Dr. Robbins, Dr. Ramos, Dr. Liu, and Dr. Crall
Our amazing research assistants: Alex, Hayley, Ryann, and Annie Our thorough webIRB owner: Dr. Augustine Fernandes

My colleague and friend: Katie