The Pediatric Elephant in the Room

The open mind piece by Nafiu et al1 brings to light a serious medical and public health concern namely the rising rate of pediatric obesity. This rising rate coupled with the high proportion of pediatric anesthesia cases elucidates the opportunity that we as pediatric anesthesiologists have to address this public health concern. As the authors have astutely noted, obesity in the United States affects about 12.7 million children.2–4 Approximately 6 million children undergo anesthesia and surgery annually and about one-third of these children are thought to be obese.5 Obesity is associated with increased perioperative morbidity, underlying cardiovascular disease, renal disease, obstructive sleep apnea, poor self-image, and societal ostracizing.6–12 Thus, as stated in the article by Nafiu et al,1 the perioperative anesthesia visit may present a unique opportunity for the specialty to “get involved” and further address this public health issue. But as pediatric anesthesia providers how does one address a challenging situation in a period of limited time? A discussion of obesity is often times best made with an individual who has an ongoing relationship with the patient. Thus, the chance of the encounter appearing judgmental is less. Day surgery with the anesthesiologist meeting the patient/family for the first time generally does not lend itself to this opportunity. Anesthesiologists have limited time in the preoperative setting and often the patient/parent concerns are focused on the surgery itself. With stress levels of patient and family members being elevated and patient/parental concerns focused on the surgery and surgical outcome, how much information on obesity will the patient/family member process and how amenable are they to hear it at this time? Not uncommonly, obesity runs in families so the intergenerational rate is quite high. Infants and toddlers are not making their own lifestyle choices, and parents and other caregivers are making poor choices for them. Thus, addressing the topic can be a setup for the anesthesiologist to appear to be judgmental. How does one discuss this topic without the patient/family member perceiving this discussion as being judgmental or offensive? Although there is no simple solution to addressing this problem of pediatric obesity in a perioperative setting, there are a few known facts that can help guide the anesthesia-patient encounter. First and foremost is the recognition that the discussion will not solve the issue, but rather the discussion should be an opportunity to direct the family/patient to available resources in the institution and community, as well as discussions that obesity has significant lifetime health issues. Institution and community resources are critical. No single brief encounter with a health care provider will cure a problem that requires a change in lifestyle. Information is generally not the main issue but rather tools and support mechanisms to promote and maintain healthy life style changes is what is needed. Evidence shows that repeated, long-term, time-intensive behavioral intervention is most effective.13 Thus, in a brief perioperative encounter, identification of weight status and appropriate brief interventions may serve as an impetus for introduction into longer-term intervention. Knowledge of weight status is a driver for change, especially for parents concerned about their children’s long-term health. Given the nature of the relationship and the brief contact time, the intervention should be brief and focused. Giving the family a perspective of the child’s weight by using language such as “Compared to other children your child’s age, s/he has a higher body mass index than 99% of her/his peers” becomes less judgmental and more informative. Most patients know what to do, they just have a difficult time doing it. Suggesting and reinforcing a simple concept such as 5-2-1-0 (5 or more servings of fruits and vegetables, 2 hours or less of daily recreational screen time, 1 hour or more of daily physical activity, and more water and 0 sugary drinks) to patients/families can help them in starting the process. Small achievable goals that feel manageable are a good place to start in the setting of a brief patient encounter. For some of these families/patients, past weight management has been futile. Instead, time may be better spent and encouraging them to try again and offering them a referral to established resources before they leave the hospital/outpatient center. If one does have the opportunity to address, the issue of obesity utilizing motivational interviewing (MI) can be very effective.14,15 MI is a person-centered communicative style for addressing the common problem of ambivalence about change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion. The approach upholds 4 principles— expressing empathy and avoiding arguing, developing discrepancy, rolling with sustaining behavior, and supporting self-efficacy. MI involves collaboration not confrontation, evocation not education, autonomy rather than authority, and exploration instead of explanation. MI for anesthesiologists is generally not intuitive, and for those interested, the reader is referred to the Web sites motivationalinterviewing.org and http://www.guilford.com/books/Motivational-Interviewing/Miller-Rollnick/9781609182274. We recognize that talking about people’s weight is uncomfortable for most people, but avoiding the discussion does not make the problem go away. Growing up in society presents numerous challenges for children; however, growing up obese with the potential for a lifetime of health problems that are avoidable is unconscionable. DISCLOSURES Name: Peter J. Davis, MD. Contribution: This author helped write the manuscript. Conflicts of Interest: Octapharma. Name: Dana L. Rofey, PhD. Contribution: This author helped write the manuscript. Conflicts of Interest: None. Name: Sheri L. Goldstrohm, PhD. Contribution: This author helped write the manuscript. Conflicts of Interest: None. This manuscript was handled by: James A. DiNardo, MD, FAAP.