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Pediatric Obesity

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Pediatric Obesity

  1. 1. Childhood and Adolescent Obesity Kathryn Camp, MS, RD, CSP
  2. 2. WHY WORRY ABOUT PEDIATRIC OBESITY? <ul><li>Pediatric obesity is of epidemic proportion. </li></ul><ul><li>Pediatric obesity is the most common chronic disease of childhood. </li></ul><ul><li>The epidemic is worldwide </li></ul>
  3. 3. Some Scary Stats <ul><li>300,000 Americans died from obesity-related causes in 2000 (Surgeon General Report) </li></ul><ul><ul><li>$117 billion in obesity-related economic costs </li></ul></ul><ul><li>Cost of caring for obese patients is 35% greater than normal weight </li></ul>
  4. 4. <ul><li>Anthony </li></ul><ul><li>15 yr old </li></ul><ul><li>Referred by his new PMC </li></ul>
  5. 5. <ul><li>Anthropometrics </li></ul><ul><ul><li>Weight: 121 kg </li></ul></ul><ul><ul><li>Height: 175 cm </li></ul></ul>
  6. 6. BMI: 39
  7. 7. How Do We Define Overweight in Children and Adolescents?
  8. 8. Definition of Overweight in Children and Adolescents <ul><li>Overweight = </li></ul><ul><li>BMI  95th %ile </li></ul><ul><li>At risk for overweight = </li></ul><ul><li>BMI between 85th-95th %ile </li></ul><ul><li>Expert Committee Recommendations from the Maternal and Child Health Bureau, 1997 </li></ul>
  9. 9. Calculate Your BMI <ul><li>kg  m 2 </li></ul><ul><li>Height in inches x 2.54  100 = meters </li></ul><ul><li>Meters x meters = m 2 </li></ul><ul><li>Weight in pounds  2.2 = kg </li></ul><ul><li>Divide your weight in kg by m 2 = BMI </li></ul>
  10. 10. Classification of Overweight and Obesity in Adults Using BMI
  11. 11. University of Miami Blocking Machine 35 36 37 39 38 43
  12. 12. Height: 6-6 Weight: 98 kg 25 Height: 7-1 Weight: 154 kg 33
  13. 13. BMI is Age Specific in Children and Adolescents
  14. 14. 17 21 24
  15. 15. Increasing Incidence of Overweight in Children and Adolescents
  16. 16.  95 th %ile for age and gender These #s double when including >85%ile
  18. 18. Etiology of Obesity <ul><li>Genetic/heritablility </li></ul><ul><li>Molecular </li></ul><ul><li>Syndromes </li></ul><ul><li>Environmental </li></ul>Multifactorial Condition
  19. 19. Heritability <ul><li>Survival advantage to conserve energy as fat through human evolution </li></ul><ul><li>Humans enriched for genes that promote energy intake and storage and minimize expenditure. </li></ul><ul><li>Enhance female fertility and ability to breastfeed offspring </li></ul>
  20. 20. <ul><li>In modern industrial environment </li></ul><ul><ul><li>easy access to calorically dense foods </li></ul></ul><ul><ul><li>encourages sedentary lifestyle </li></ul></ul><ul><li>Metabolic consequences of these genes are maladaptive </li></ul>
  21. 21. <ul><li>173 human obesity cases due to single gene mutations in 10 different genes were reported by 2004 (Perusse, 2005) </li></ul><ul><li>> 600 genes, markers, and chromosomal regions have been linked with human obesity phenotypes </li></ul>Genetic Factors account for 20-40% of heritability of BMI Buchard 97 Rankinen 02 Familial Risk: 2-3 fold for moderate obesity 5-8 fold for severe obesity Bouchard 01
  22. 22. More than 50 Obesity Associated Genetic Syndromes Bardet-Biedl Prader Willi Spina bifida Down Syndrome
  23. 23. Hormones, Neurotransmitters, Enzyme defects??? <ul><li>Obesity is not well understood at the molecular level. </li></ul><ul><li>Discovery of leptin was hoped to revolutionize the field but its role has remained obscure </li></ul><ul><li>Role of other hormones, neurotransmitters, etc remains unknown </li></ul>
  24. 24. <ul><li>But doctor, my child must have a low metabolism…. </li></ul><ul><ul><li>Little evidence that metabolic rate is different (Baker, 05) </li></ul></ul><ul><ul><li>Obese adolescents have a higher total daily energy expenditure and REE (Bandini, 90) </li></ul></ul><ul><ul><li>There may be small differences in metabolic efficiency but these are hard to measure </li></ul></ul>
  25. 25. What is Causing this Marked Increase in Overweight??
  26. 26. <ul><li>Obesity is not a genetic shift, rather it is an environmental shift </li></ul>
  27. 27. Causes of Marked Increase in Overweight <ul><li>Reflects a shift towards positive energy balance </li></ul><ul><li>energy intake = energy expenditure </li></ul>McDowell 94; Kann 99; Troiano 00, NHANES II to III calories PE sed act
  28. 28. Increased Energy Intake <ul><li>Kids are </li></ul><ul><ul><li>Eating more away from home </li></ul></ul><ul><ul><li>Eating more fast food and snack foods </li></ul></ul><ul><ul><li>Drinking more sodas </li></ul></ul><ul><li>100 kcal/day above needs = 10 pound weight gain per year </li></ul>
  29. 30. Physical Activity <ul><li>Daily participation in PE declined from 42% to 29% between 1991 and 1999 ( www.cdc.gov/HealthyYouth ) </li></ul><ul><li>Walking and bicycling dropped 40% in kids aged 5-15 between 1977 and 1995 </li></ul><ul><li>What constitutes “active” these days? </li></ul>
  30. 31. Increase in Sedentary Activity <ul><li>Excessive TV watching– </li></ul><ul><ul><li>The average child spent 6 hr/day watching TV or playing on computers. </li></ul></ul><ul><ul><li>Encourages overeating while viewing </li></ul></ul><ul><ul><ul><li>Influences food choices </li></ul></ul></ul><ul><ul><ul><ul><li>80% of commercials on children’s programs are for food </li></ul></ul></ul></ul><ul><ul><ul><li>Lower resting metabolic rate compared to at rest (Klesges 1993) </li></ul></ul></ul><ul><ul><ul><li>Reduces time available for more active pursuits </li></ul></ul></ul>
  31. 32. <ul><li>Video and computer games </li></ul><ul><li>Parental work schedules </li></ul><ul><li>Unsafe neighborhoods </li></ul><ul><ul><li>discourage parents from allowing children to play outdoors </li></ul></ul><ul><ul><li>force parents to drive children to school </li></ul></ul><ul><li>Lack of recreational facilities in low-income neighborhoods </li></ul>Other Contributors to Sedentary Lifestyles
  32. 33. Medical Consequences of Overweight
  33. 34. <ul><li>60% of OW children have 1 or more CVD risk factors </li></ul><ul><li>Hyperlipidemia--  LDL and TG,  HDL </li></ul><ul><ul><li>90% of children with elevated TGs are overweight </li></ul></ul><ul><li>Hypertension </li></ul><ul><ul><li>Low frequency in children </li></ul></ul><ul><ul><ul><li>60% with  BP were >120% of IBW </li></ul></ul></ul><ul><li>Obtain fasting lipid profile and blood pressure on all overweight children. </li></ul>Cardiovascular
  34. 35. Type 2 Diabetes <ul><li>95% of teens with Type 2 diabetes have a BMI >85%ile </li></ul><ul><li>Tremendous public health implications </li></ul><ul><ul><li>Longer duration of disease, > risks of complications </li></ul></ul><ul><li>Obtain fasting glucose and insulin on all overweight children, especially those with.. </li></ul>Dabelea 99; Vinicor 00; Richards 85
  35. 36. <ul><li>Acanthosis Nigricans </li></ul><ul><li>Hyperpigmented, velvety plaques in body folds </li></ul><ul><li>Caused by hyperinsulinemia which stimulates formation </li></ul><ul><li>Associated with obesity </li></ul>
  36. 37. <ul><li>Growth </li></ul><ul><ul><li>Taller, advanced bone age, mature earlier </li></ul></ul><ul><ul><li>Early maturation is associated with </li></ul></ul><ul><ul><ul><li>increased fatness and truncal fat distribution in adulthood </li></ul></ul></ul><ul><ul><li>Short, obese children should be evaluated for hypothyroidism, Cushing syndrome or Turner syndrome </li></ul></ul>Other Endocrinological Issues
  37. 38. More Complications <ul><li>Hepatic Steatosis with elevated LFTs </li></ul><ul><li>Cholelithiasis </li></ul><ul><ul><li>50% of kids with cholecystitis are overweight </li></ul></ul><ul><li>Orthopedic Problems </li></ul>
  38. 39. Acute Complications that Require Immediate Medical Attention <ul><li>Sleep Apnea </li></ul><ul><ul><li>Occurs in 17% of obese children and teens (Marcus 1996) </li></ul></ul><ul><ul><li>Deficits in learning, memory, and vocabulary (Rhodes 1995) </li></ul></ul><ul><li>Obesity hypoventilation syndrome </li></ul><ul><ul><li>rare, potentially fatal disorder </li></ul></ul>
  39. 40. Psychological and Economic Consequences of Pediatric and Adolescent Obesity <ul><li>Discrimination, rejection and low self-esteem (Gortmaker 93), particularly for females </li></ul><ul><li>Less participation in PE and sports activities </li></ul><ul><li>Lower college acceptance rates (Canning 1966) </li></ul>
  40. 41. Who Needs to be Evaluated?
  41. 42. Evaluating For Overweight in a Primary Care Setting BMI Overweight BMI  95 th % Not at risk BMI  85 th % At risk for Overweight BMI 85-95 th % <ul><li>Family history </li></ul><ul><li>Blood pressure </li></ul><ul><li>Lipids </li></ul><ul><li>Lg  in BMI </li></ul><ul><li>Concern re wt </li></ul><ul><li>Note in chart </li></ul><ul><li>No therapy </li></ul><ul><li>Return next yr </li></ul>Return next yr for screen In depth medical assessment + 
  42. 43. Medical Assessment <ul><li>r/o genetic syndromes, esp if associated with mental retardation </li></ul><ul><li>Blood pressure </li></ul><ul><li>Labs to include </li></ul><ul><ul><li>Fasting lipid panel </li></ul></ul><ul><ul><li>Fasting glucose and insulin </li></ul></ul><ul><ul><ul><li>OGTT </li></ul></ul></ul><ul><ul><li>LFTs </li></ul></ul><ul><ul><li>Thyroid fx tests </li></ul></ul>
  43. 44. Back to Anthony—Medical <ul><li>PMHx </li></ul><ul><ul><li>chronic otitis media and allergies </li></ul></ul><ul><ul><li>overweight since 7 yrs of age </li></ul></ul><ul><li>Currently c/o headache </li></ul><ul><li>On no chronic meds </li></ul><ul><li>Blood Pressure </li></ul><ul><ul><li>136/73 </li></ul></ul><ul><ul><li>>95 th %ile </li></ul></ul>
  44. 45. Social hx <ul><li>Only child </li></ul><ul><li>High school sophomore, gets good grades </li></ul><ul><li>No exercise or organized sports activities </li></ul><ul><li>Spends 6 hrs/day watching TV and playing video games </li></ul>
  45. 46. Dietary Information <ul><li>Picky eater </li></ul><ul><li>Consumes NO fruits or vegetables </li></ul><ul><li>Mom prepares separate meals for him </li></ul>
  46. 47. 24-Hour Recall <ul><li>Breakfast--none </li></ul><ul><li>Mid morning--16 oz ginger ale </li></ul><ul><li>Lunch--none </li></ul><ul><ul><li>generally has lunch at school of chocolate milk, pizza, and french fries </li></ul></ul><ul><li>Dinner--10 beef tacos, 2 cans of soda </li></ul>
  47. 48. What to Do with Anthony? <ul><li>Weight goals </li></ul><ul><ul><li>First step is to achieve weight maintenance </li></ul></ul><ul><ul><li>2-7 years of age </li></ul></ul><ul><ul><ul><li>BMI 85-95% </li></ul></ul></ul><ul><ul><ul><ul><li>Weight maintenance </li></ul></ul></ul></ul><ul><ul><ul><li>BMI >95% </li></ul></ul></ul><ul><ul><ul><ul><li>No complications: weight maintenance </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Complications: weight loss </li></ul></ul></ul></ul><ul><ul><li>7 and above </li></ul></ul><ul><ul><ul><li>BMI 85-95 th % </li></ul></ul></ul><ul><ul><ul><ul><li>No complications--weight maintenance </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Complications—weight loss </li></ul></ul></ul></ul><ul><ul><ul><li>BMI >95 th weight loss </li></ul></ul></ul>
  48. 49. What to Do with Anthony? <ul><li>Weight goals </li></ul><ul><ul><li>First step is to achieve weight maintenance </li></ul></ul><ul><ul><li>2-7 years of age </li></ul></ul><ul><ul><ul><li>BMI 85-95% </li></ul></ul></ul><ul><ul><ul><ul><li>Weight maintenance </li></ul></ul></ul></ul><ul><ul><ul><li>BMI >95% </li></ul></ul></ul><ul><ul><ul><ul><li>No complications: weight maintenance </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Complications: weight loss </li></ul></ul></ul></ul><ul><ul><li>7 and above </li></ul></ul><ul><ul><ul><li>BMI 85-95 th % </li></ul></ul></ul><ul><ul><ul><ul><li>No complications--weight maintenance </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Complications—weight loss </li></ul></ul></ul></ul><ul><ul><ul><li>BMI >95 th weight loss </li></ul></ul></ul>
  49. 50. General Treatment Goals <ul><li>Behavioral goals </li></ul><ul><ul><li>Promote life long healthy eating and activity behaviors </li></ul></ul><ul><li>Medical goals </li></ul><ul><ul><li>Prevent complications of obesity in childhood and potentially adulthood </li></ul></ul><ul><ul><li>Improve or resolve existing complications of obesity </li></ul></ul>
  50. 51. Refer? <ul><li>Formal obesity clinic--Team approach </li></ul><ul><ul><li>Physician, therapist, dietitian, exercise therapist </li></ul></ul><ul><ul><li>Intensive multi-session programs </li></ul></ul><ul><ul><ul><li>Parent and child/teen participate </li></ul></ul></ul><ul><ul><li>Advantages </li></ul></ul><ul><ul><ul><li>Multidisciplinary approach, frequent visits </li></ul></ul></ul><ul><ul><li>Disadvantages </li></ul></ul><ul><ul><ul><li>Expensive, time consuming, require parent participation </li></ul></ul></ul>
  51. 52. If Going It Alone… Where Do You Start? <ul><li>Assess child’s and family’s willingness to change </li></ul><ul><li>Negotiate with child/family on specific, targeted changes </li></ul><ul><li>Develop realistic, achievable goals </li></ul><ul><li>Involve the entire family in making changes </li></ul><ul><li>Establish a monitoring/assessment tool </li></ul>
  52. 53. Goals for Anthony <ul><li>Eat 3 meals per day (establish regular meals) </li></ul><ul><li>Have 1 piece of fruit each day (introduce new food groups) </li></ul><ul><li>NO calorie containing beverages except skim milk (eliminate empty calories) </li></ul><ul><li>Daily exercise (increase energy expenditure) </li></ul><ul><li>Keep a notebook of food intake and exercise (self-monitoring) </li></ul>
  53. 54. Follow-up <ul><li>Weekly visits or as frequent as possible </li></ul><ul><li>lipid profile, HgbA1c, fasting insulin and glucose, blood pressure </li></ul><ul><li>Identify and reinforce positive changes </li></ul><ul><li>Set new goals based on goals achieved </li></ul>
  54. 55. Anthony’s Lab Data <ul><li>Lipid panel </li></ul><ul><ul><li>Total cholesterol 156 (<200) </li></ul></ul><ul><ul><li>Triglycerides 129 (35-250) </li></ul></ul><ul><ul><li>HDL 34 (35-82) </li></ul></ul><ul><ul><li>LDL 96 (<100) </li></ul></ul><ul><li>HgbA1C 5.8 (4.3-5.3) </li></ul><ul><li>Fasting glucose 77 </li></ul><ul><li>Insulin 30.3 (0-30) </li></ul>
  55. 56. <ul><li>Weight </li></ul><ul><ul><li>97 kg </li></ul></ul><ul><ul><li>Down 53# </li></ul></ul><ul><li>Height </li></ul><ul><ul><li>179 cm </li></ul></ul><ul><ul><li>Up 4 cm </li></ul></ul>
  56. 57. <ul><li>BMI </li></ul><ul><ul><li>30 </li></ul></ul><ul><ul><li>Down from 40 </li></ul></ul>
  57. 58. Brian <ul><li>13 yrs, 10 mo </li></ul><ul><li>Referred for elevated cholesterol </li></ul><ul><li>Weight: 74 kg </li></ul><ul><li>Height: 166 cm </li></ul><ul><li>BMI: ? </li></ul><ul><li>What do you want to know? </li></ul>
  58. 59. Brian cont: <ul><li>Medical history </li></ul><ul><ul><li>uncomplicated </li></ul></ul><ul><li>Results of lipid panel </li></ul><ul><ul><li>Total chol, 208, LDL 150, HDL 41 </li></ul></ul><ul><li>Blood pressure </li></ul><ul><ul><li>105/61 </li></ul></ul><ul><li>Family history </li></ul><ul><ul><li>Father died at age 48 from heart attack, maternal aunt died at 45 from CHD, paternal grandfather had type II diabetes </li></ul></ul><ul><li>Diet </li></ul><ul><ul><li>Low in fruits and vegetables and dairy products </li></ul></ul><ul><li>Exercise </li></ul><ul><ul><li>Plays basketball with friends after school, no organized sports </li></ul></ul><ul><li>Physical exam </li></ul><ul><ul><li>Acanthosis nigricans </li></ul></ul>
  59. 60. Childhood Obesity Can be prevented Shaping Habits That Shape America’s Children
  60. 61. PREVENTION: PRECONCEPTION <ul><li>Prevention starts prior to conception </li></ul><ul><ul><li>Obese adolescents have an 80% probability of being obese as adults </li></ul></ul><ul><ul><li>Today's adolescents are tomorrows parents </li></ul></ul><ul><ul><li>Parents are role models for their children </li></ul></ul><ul><ul><li>Obesity risk in a child born to obese parents is significantly increased </li></ul></ul><ul><ul><li>Educate and intervene at this time to help prevent obesity in subsequent generations </li></ul></ul>
  61. 62. PREVENTION: POST CONCEPTION <ul><li>Routine prenatal care </li></ul><ul><li>Achieve normal weight gain during pregnancy </li></ul><ul><ul><li>LGA infants and infants of diabetic mothers have higher rates of subsequent obesity </li></ul></ul><ul><ul><li>SGA infants also at higher risk </li></ul></ul><ul><ul><ul><li>Hediger ML et: Pediatrics 104:e33, 1999 </li></ul></ul></ul><ul><li>Promote breast feeding </li></ul>
  62. 64. PREVENTION: SCHOOL <ul><li>Promote physical activity </li></ul><ul><li>Provide nutritious meals </li></ul><ul><li>Control vending machines </li></ul><ul><li>Have nutrition education incorporated into regular school curriculum. </li></ul><ul><li>Encourage children to walk or bike to school safely. </li></ul>
  63. 65. PREVENTION: COMMUNITY <ul><li>Have safe playgrounds </li></ul><ul><li>Provide safe places for bike riding and walking </li></ul><ul><li>Promote physical activity outside of school </li></ul>
  64. 66. PREVENTION: INSURANCE AND GOVERNMENT <ul><li>Acknowledge obesity as a medical condition for which one can be reimbursed. </li></ul><ul><li>Provide reimbursement for anticipatory guidance for nutrition and physical activity </li></ul>
  65. 67. PREVENTION: PRIMARY CARE PROVIDER <ul><li>Be an advocate </li></ul><ul><li>Provide anticipatory guidance to families </li></ul>
  66. 68. NUTRITION ANTICIPATORY GUIDANCE <ul><li>Beverages </li></ul><ul><ul><li>Encourage water intake </li></ul></ul><ul><ul><li>Limit sweet beverages </li></ul></ul><ul><ul><ul><li>Juice, juice drinks: 120 calories / 8 oz </li></ul></ul></ul><ul><ul><ul><ul><li>No nutritional need for any juice <6 months of age </li></ul></ul></ul></ul><ul><ul><ul><ul><li>1-6 years: 4-6 oz </li></ul></ul></ul></ul><ul><ul><ul><ul><li>7-18 years: 8-12 oz </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Discourage free use of box drinks </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Discourage continuous access to sippy cups </li></ul></ul></ul></ul><ul><ul><ul><li>Soda: 150 calories / 12 oz </li></ul></ul></ul>
  67. 69. NUTRITION ANTICIPATORY GUIDANCE <ul><li>Eat 5 fruits and vegetables a day </li></ul><ul><li>Structured meal and snack time </li></ul><ul><li>Do not use food as a reward </li></ul><ul><li>Know what the child is eating outside the home: school meals, day care etc. </li></ul>
  68. 70. NUTRITION ANTICIPATORY GUIDANCE <ul><li>Encourage child’s autonomy in self-regulation of food intake </li></ul><ul><ul><li>Parents provide, child decides! </li></ul></ul><ul><ul><li>Do not use the clean the plate rule. </li></ul></ul><ul><li>Provide choice </li></ul><ul><li>Educate parents regarding healthy nutrition </li></ul><ul><ul><li>Healthy snacks </li></ul></ul><ul><ul><li>Consider using pediatric food pyramid </li></ul></ul><ul><ul><li>Portion size: Intake of children >5 years is dependent on how much they are provided </li></ul></ul><ul><li>Do not skip meals </li></ul>
  69. 71. ACTIVITY ANTICIPATORY GUIDANCE <ul><li>Encourage active play for young children </li></ul><ul><li>Promote physical activity for school age children and teens </li></ul><ul><li>Encourage participation in organized sports </li></ul>
  70. 72. ACTIVITY ANTICIPATORY GUIDANCE <ul><li>Decrease sedentary activity </li></ul><ul><ul><li>Limit TV, video games and computer to 1-2 hours per day </li></ul></ul><ul><ul><ul><li>> 2 hours a day associated with higher rates of obesity and hyperlipidemia </li></ul></ul></ul><ul><ul><li>Do not have a TV in the child’s room </li></ul></ul><ul><ul><ul><li>Children with TVs in bedroom watch more TV </li></ul></ul></ul>
  71. 73. BEHAVIORAL ANTICIPATORY GUIDANCE <ul><li>Encourage parents to act as role models </li></ul><ul><ul><li>Nutrition </li></ul></ul><ul><ul><li>Activity </li></ul></ul><ul><li>Promote parent child interaction </li></ul><ul><li>Have special “family time” that is physically active </li></ul>
  72. 74. BEHAVIORAL ANTICIPATORY GUIDANCE <ul><li>Limit eating out </li></ul><ul><ul><li>More calorically dense food </li></ul></ul><ul><ul><li>Larger portion sizes </li></ul></ul><ul><ul><li>Less intake of fruits and vegetables </li></ul></ul>
  73. 75. BEHAVIORAL ANTICIPATORY GUIDANCE <ul><li>Eat as a family </li></ul><ul><ul><li>Provides “quality time” </li></ul></ul><ul><ul><li>Slows down the eating process </li></ul></ul><ul><ul><li>Parents act as role model </li></ul></ul><ul><ul><li>Parents monitor intake </li></ul></ul><ul><ul><li>Associated with lower fat intake and greater intake of fruits and vegetables </li></ul></ul>
  74. 76. BEHAVIORAL ANTICIPATORY GUIDANCE <ul><li>Do not eat in front of the TV </li></ul><ul><ul><li>Associated with higher intake of fat and salt </li></ul></ul><ul><ul><li>Lower intake of fruits and vegetables </li></ul></ul><ul><ul><li>Encourages over eating </li></ul></ul><ul><ul><ul><li>60-80% of commercials on during children programs are related to food </li></ul></ul></ul><ul><ul><ul><li>Eating without awareness </li></ul></ul></ul>
  75. 77. Summary <ul><li>Pediatric obesity is epidemic </li></ul><ul><li>Overweight kids become overweight adults </li></ul><ul><li>Treatment is difficult </li></ul><ul><li>Prevention is the key </li></ul>