childhood obesity an epidemic incidence of childhood obesity
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CHILDHOOD OBESITY CHILDHOOD OBESITY AN EPIDEMICAN EPIDEMIC
INCIDENCE OF CHILDHOOD INCIDENCE OF CHILDHOOD OBESITY IS INCREASINGOBESITY IS INCREASING
DEFINING OBESITY IN CHILDREN- DEFINING OBESITY IN CHILDREN- THE PEDIATRIC BMI CHARTTHE PEDIATRIC BMI CHART
Obese (>95TH %)
At Risk ?
CAUSATIVE FACTORS-CAUSATIVE FACTORS-EXCLUDING SYNDROMESEXCLUDING SYNDROMES
PRIMARY Poor food choices Inactivity
SECONDARY Psychological Environmental Genetics Fetal environment
CONSEQUENCESCONSEQUENCES
The epidemic of obesity is affecting children as young as 2
More overweight children are developing, insulin resistance or metabolic syndrome and type 2 diabetes
Sleep apnea, asthma, hypertension, orthopedic problems and others
If we do not reverse the trend health costs will be astronomical
EXCESS SUBSTRATE WITHOUT EXCESS EXCESS SUBSTRATE WITHOUT EXCESS
EXPENDITURE=LIPOGENESISEXPENDITURE=LIPOGENESIS
OBESITY A FATAL DISEASEOBESITY A FATAL DISEASE
TREATMENT OF PEDIATRIC TREATMENT OF PEDIATRIC OBESITYOBESITY
Nutrition management
Physical activity
Behavior modification / Counselling
Family support
OUR PRACTICEOUR PRACTICE
Faculty of the UNSOM
Full service cardiology program: Echo Cath Surgery Intervention EP
Full-time M.D., MPH research director, extensive data base system
Pediatric Risk Factor Reduction Program
CHILDREN’S HEART CENTER - CHILDREN’S HEART CENTER - NEVADANEVADA
15,000 OUT-PATIENT VISITS/YR
6,000 IN-PATIENT VISITS/YR
MORE PATIENT VISITS THAN*
-UCLA -UCSF -STANFORD -CHILDREN’S HOSPITAL OF LOS ANGELES -LOMA LINDA -CEDARS SINAI*FROM PUBLISHED DATA AND PERSONAL CONVERSATIONS
OUTLINE OF OUR PROGRAMOUTLINE OF OUR PROGRAM
PATIENTS REFERRED BY PRIMARY CARE PROVIDERS
Primary care providers without time or staff to treat effectively
BMI > 95%ile for age
Hypertension with BMI >95%ile
Dyslipoproteinemias
OUTLINE OF OUR PROGRAMOUTLINE OF OUR PROGRAM
Initial evaluation
Laboratory testing
Intensive initial nutritional evaluation & recommendations
If appropriate exercise program enrollment
If indicated family counselling
Follow up
LAB TESTS RESULTS IN 410 LAB TESTS RESULTS IN 410 PATIENTS BMI >95PATIENTS BMI >95thth %tile %tile
Average age 11.4 years 44% Females 56% males
Average BMI 32.5
Total cholesterol 179 ± 45
HDL 42 ± 10
Triglycerides 149 ± 97
Insulin 22 ± 25
CHILD/ADOLESCENT NORMALSCHILD/ADOLESCENT NORMALS
Total cholesterol < 170 mg/dl
HDL > 45 mg/dl- Probably >50 desirable
Triglycerides <125- Probably <100 desirable
Insulin level <10 (Dr. Sears <5)
OUTLINE OF OUR PROGRAMOUTLINE OF OUR PROGRAM
12 WEEK INTEGRATED PROGRAM
Nutrition counselling
Simple psychological evaluation
Exercise RX
Motivational intervention and family counselling referral if indicated
INTAKE DATA FROM OUR INTAKE DATA FROM OUR PROGRAMPROGRAM
Protein
Fat
Carbs25% Carbs HFCS
MOST IMPORTANT NUTRTION-MOST IMPORTANT NUTRTION-RECOMMENDED INTAKERECOMMENDED INTAKE
Protein
Fat
Carbs
WHO WILL WIN THE BATTLE?WHO WILL WIN THE BATTLE?
Soft Drink!?USDA food pyramid
BRIEF PSYCHOLOGIC BRIEF PSYCHOLOGIC EVALUATIONEVALUATION
Perera self esteem test
16 true or false questions
Scored number of “true answers”
Initial and repeated at end of 12 week program
EXERCISEEXERCISE
INITIAL EVALUATION Rockport walk test
• Timed 1 mile walk
• Score based on time and heart rate
• Gender and weight
• Max VO2 estimate
• <25 Poor, 25-30 Fair, 30-40 Average, 40-50 good, >50 excellent
EXERCISE RXEXERCISE RX
AEROBIC
Treadmill, bike or walking
At home we recommend 30-45 min 3-5x/week
Supervised in program 2x per week
Our exercise staff tries to achieve 40-70% of VO2 max(estimated)
EXERCISE RXEXERCISE RX
ADDITIONAL PROGRAM ACTIVITIES
Weights
Calisthenics
Stretching
PROGRAM MATERIALSPROGRAM MATERIALS
Hand outs
Homework
Off site exercise
Behavior modification
Positive rewards
OUR ON SITE EXERCISE OUR ON SITE EXERCISE FACILITYFACILITY
INITIAL BIOMETRIC & SELF INITIAL BIOMETRIC & SELF ESTEEM RESULTS FROM ESTEEM RESULTS FROM THE 12 WEEK PROGRAMTHE 12 WEEK PROGRAM
RESULTS FROM 12 WEEK RESULTS FROM 12 WEEK PROGRAMPROGRAM
N=76
Average age 12.5 (7-18)
Male 56%
Female 44%
Reported at Society of Pediatric Research in San Francisco May 2004
RESULTS FROM 12 WEEK RESULTS FROM 12 WEEK PROGRAM N=76PROGRAM N=76
RESTING HR
Pre=111 Post=98NS
SYSTOLIC BP
Pre=123 Post=113* * P <.05
RESULTS FROM 12 WEEK RESULTS FROM 12 WEEK PROGRAM N=76PROGRAM N=76
BMI
Pre=33 Post=32*
% BODY FAT
Pre=40 Post=38* * P <.05
RESULTS FROM 12 WEEK RESULTS FROM 12 WEEK PROGRAM N=76PROGRAM N=76
SELF ESTEEM
Pre=10.6 Post=12.4*
WALK TEST SCORE
Pre=10 Post=27* * P <.05
PARENTAL SURVEYED PARENTAL SURVEYED PHYSICAL ACTIVITY AND PHYSICAL ACTIVITY AND NUTRITIONAL CHANGES NUTRITIONAL CHANGES RESULTS FROM 12 WEEK RESULTS FROM 12 WEEK
PROGRAMPROGRAM
Changes in physical activity
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
≥ 4 Hours (PRE)
≥ 4 Hours (POST)
≥ 4 Hours (PRE)
≥ 4 Hours (POST)
≥ Average (PRE)
≥ Average (POST)
≥4 days (PRE)
≥4 days (POST)
Pe
rce
nta
ge
*
*
*
*
* P-value < 0.05
TV watching on weekends
TV watching on school days
Gross Activity Daily Activity
Changes in nutrition behaviors
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
≥ 4 days(PRE)
≥ 4 days (POST)
≥ 2servings
(PRE)
≥ 2servings (POST)
≥ 2servings
(PRE)
≥ 2servings(POST)
≥ 12ounces(PRE)
≥ 12ounces(POST)
Pe
rce
nta
ge
Breakfast freq. Fruits consump. Vegetables consump. Sodas / Juices
* *
*
*
* P-value < 0.05
INSULIN RESISTANCE IN INSULIN RESISTANCE IN OUR PATIENTSOUR PATIENTS
INSULIN RESISTANCE IN OUR INSULIN RESISTANCE IN OUR PATIENTSPATIENTS
Quicki (1/log insulin +log glucose)*
Glucose/Insulin ratio**
Increasing IR with age and with BMI in euglycemic patients with BMIs >95th%ile. Presented at the AHA LJ Filer San Francisco in March
*J Clin Endocrinol Metab. 2000 Jul;85(7):2402-10 ** J Clin Endocrinol Metab. 1998;83:2694-2698
Glucose/Insulin ratio Quicki
< 6 ≥ 6 < 0.357* ≥ 0.357
Mean Insulin (µU/ml) 28.88 9.66 24.49 6.65
S.E. 2.31 0.37 1.87 0.49
Range 12.3 - 173.6 2 - 16.1 7.7 - 173.6 2 - 8.2
INSULIN RESISTANCEINSULIN RESISTANCE
N=334
*J Clin Endocrinol Metab. 2002 Jan;87(1):144-7.
Linear regression plot
0.200
0.250
0.300
0.350
0.400
0.450
0.500
3 6 9 12 15 18
Age
Qu
ick
i
Quicki
Linear (Quicki)
QUICKI VS AGEQUICKI VS AGE
Linear regression plot
0
5
10
15
20
25
30
35
40
3 6 9 12 15 18
Age
Glu
c/In
suli
n
Gluc/Insulin
Linear (Gluc/Insulin)
GLUCOSE/INSULIN VS AGEGLUCOSE/INSULIN VS AGE
Linear regression plot
0.200
0.250
0.300
0.350
0.400
0.450
0.500
18 28 38 48 58 68 78 88
BMI
Qu
icki
Quicki
Linear (Quicki)
QUICKI VS BMIQUICKI VS BMI
Linear regression plot
0
5
10
15
20
25
30
18 28 38 48 58 68 78 88
BMI
Glu
co
se
/In
su
lin
ra
tio
Gluc/Insulin
Linear (Gluc/Insulin)
GLUCOSE/INSULIN VS BMIGLUCOSE/INSULIN VS BMI
CURRENT RESEARCHCURRENT RESEARCH
Analysis of metabolic abnormalities in our population
Biometric, psychological and metabolic abnormalities pre and post treatment intervention
Effects of Omega 3 fish oil supplementation effect on eicosanoids and inflammation
Vascular reactivity
Urinary / salivary inflammatory markers
CURRENT RESEARCHCURRENT RESEARCH
Maternal factors on fetal environment
Infants born SGA/LGA and relationship to obesity in our population
Cardiac function/ LV Hypertrophy/ BNP
Measured VO2 studies
Possible animal studies
CURRENT RESEARCHCURRENT RESEARCH
Long term follow up and longitudinal studies
Possible pharmacologic intervention
? Cannabinoid receptor inhibitors
? Surgical intervention
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