pediatric obesity and cardiovascular health: what we learned from the cardiovascular health...
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Pediatric Obesity and Cardiovascular Health: What We Learned From the
Cardiovascular Health Intervention Program (CHIP)
Paul S. Visich PhD, MPH, University of New EnglandBill Saltarelli, PhD, Central Michigan University
1. Understand the prevalence and implications of pediatric obesity
2. Understanding of the CVD risk factors observed in overweight andobese children along with structural and functional changes in one’sblood vessels.
3. How CVD risk factors are quantified (MetS)
4. Lessons learned from the CHIP
5. How do we alter the course of obesity in children? Is anything working?
Objectives
1999
Obesity Trends* Among U.S. AdultsBRFSS, 1990, 1999, 2009
(*BMI 30, or about 30 lbs. overweight for 5’4” person)
2009
1990
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
BRFSS; Behavioral Risk Factor Surveillance Survey, www.cdc.gov/brfss
What About children and adolescents?
Trends in Obesity
1976 - 20082-5y, 5.0 to 10.4%
6-11y, 6.5 to 19.6% 12-19y, 5.0 to 18.1%
http://www.cdc.gov/obesity/childhood/index.html
Prevalence of Obesity among U.S. Adolescents aged 12-19y of age
Ogden, C. and M. Carroll, Division of Health and Nutrition Examination Surveys, June, 2010
Note: Native Americans/American Indians and Alaskan natives were found to have the highest rate of obesity
*
*
Percentage of High School students who were Obese*
* Obesity; BMI> to th 95th% for age and sex. Youth Risk Behavior Survey, 2003 and 2011
2003
2011
Geographic Similarities Between Adults and High School Students
Adults High School Students
State of Maine/2010
http://www.cdc.gov/brfsshttp://www.cdc.gov/HealthyYouth/yrbs/index.htmhttp://www.cdc.gov/pednss/pednss_tables/tables_health_indicators.htm
Adults62.9% overweight (BMI> 25)26.8% obese (BMI > 30) Vs 35.7% for US 2009-2010
Adolescents15.1% overweight (85th to < 95th%)12.5% obese (> 95th%)
Children (2-<5y of age)17.1% overweight (85th to < 95th%)14.3% obese (> 95th%) Vs 12.1% for US in 2010
Bottom Line or Waist Line for Children and Adolescents
17% of the US population 2-19y of age are obese
Since 1980 prevalence of obesity has almost tripled
There are significant racial and ethnic disparities inobesity prevalence among US children and adolescents
There was no change in the prevalence of obesity amongadults or children from 2007-2008 to 2009-2010
http://www.cdc.gov/obesity/childhood/index.html
S.J. Olshansky, etal. A Potential Decline in Life Expectancy in the United States in the 21st Century. N Engl J Med 352(11):1138-1144, 2005
Life
Exp
ecta
ncy
Year Born
How Much of an Impact is Obesity having on our children’s Health?
Contributing Factors to Obesity
Strong4Life, Atlanta Georgia (40% of the children are obese)
Meals Away From Home
From 1970 to the late 1990’s meals eaten away from home have nearly doubled
Ebbeling, CB, etal Lancet, 2002; 360(9331):473-482
Typically higher saturated and trans fat, higher glycaemic index, high energy density and larger portion sizes
Portion Sizes7-Eleven (1976)Gulps (20 ounces)Big Gulps (30 ounces)Super Big Gulps (40 ounces)Double Gulps (64 ounces), 1988 but reduced to 50 ounces this spring, why?
Caloric content of Double Gulp with Coca-Cola:600 calories (25% the recommended caloricIntake for a 30y old, 160 lb. man)
Interesting note:Mayor Bloomberg proposed a ban on the sale
of large size of sugary drinks in NYC
Price of Foods
Fruits and vegetables have increased inprice 118% from 1985 to 2000 whereas
prices for foods high in fats and oils has only increased by 35%
Major problem with those with a limited budget!
Influence of Technology on Obesity
- 26% of US children watched 4h+/day of TV per day- 67% watched at least 2h/day - Non-Hispanic black children had the highest rate of watching TV 4h+/day (42%)- The children that watched 4+h/day had significantly > %fat and BMI Vs those that watched < 2h/day
Andersen, R.E., JAMA, March 25, 1998, Vol 279, No. 12
Physical Activity and ObesityGeneral consensus (though not consistent) is that moderate/vigorous activity has a positive benefit in reducing adiposity in overweight/obese youths.
Physical activity recommendation: 60 minutes of combined moderate and vigorous activity daily. Problem: only 18.4% of our youth are achieving this recommendation (YRBS, 2009)
Daily PE in schools has dropped 33% from 1991 to 2009 (YRBS, 2009)
Davis, MM, etal, Pediatrics, 2007
Obesity and Socioeconomic Status in Children
Boys 2-19y
Girls 2-19y
0 5 10 15 20 25
PIR < 130%130%< PIR <350%PIR >350%
Percentage Obese
PIR: Poverty Income Ratio (130%= salary of $29,000 for a familyof four and 350%= salary of $77,000 for a family of four).Ogden, C.L., NCHS Brief, No. 51, December, 2010
Gender Differences with Obesity
< 12y of age, very little gender difference
12 to 17y, males more likely to become overweight
Possible reason: increased concern in respect to body self-image in females
Obesity and Type 2 Diabetes“Adult Onset”
Unheard of in children in the mid-1990s
With the obesity epidemic we have seen a rise in Type 2 Diabetes in children (10 fold increase in the last two decades)Hannon, TS, etal. Pediatrics. 2005;116(2):473-480
80% of Type 2 diabetics are overweight or obese
1 in 3 young people born in 2000 will develop Type 2 Diabetes (CDC)
http://www.kaiserhealthnews.org/Storeis/2011/March/22/Obesity-Type2-Diabetes-Children.aspx
What’s the Big Deal?Large percentage of children and adolescents (10-15y old) that are obese turn into obese adults (80%).
Prevalence of CHD is estimated to Increase 5-16% by 2035, with more than 100,000 cases of CHD attributed to the predicted increase in obesity. Bibbins-Domingo, K. etal, N Engl J Med.2007;57(23):2371-2379
The risk of increasing one’s CVD risk factors is significantlyhigher with obesity (not only in adults but also children)-
- hypertension- high cholesterol- low HDL-cholesterol- Type 2 diabetes- insulin resistance- Oxidative stress
Additional Health Risks- asthma, sleep apnea, fatty liver disease, formation of gall stones,orthopedic problems
Psychosocial Risks- social discrimination; lowself-esteem, hinder academic performance, social functioning, etc.
Pathophysiology and evidence of blood vessel changes
• The CVD process has been shown to begin in children as young as 2 years of age (Berenson et al, 1998).
• Multiple risk factors in children have been shown to persist into adulthood (i.e. tracking) (Boa et al, 1994).
Fatty streaks Plaque
Bogolossa
Direct evidence of blood vessel changes in children
Autopsy (Bogulosa Heart Study)
Vascular ultrasound evidence
Vascular Ultra-sound evidence1. Carotid artery-Intima-media thickness (IMT)
BMISystolic BP
Influence of Diet and Exercise on Individual Cardiovascular Risk Factors in Obese Children
(1 Year Program)
Variable Baseline 1 y Later
BMI (kg/m2) 24.6 22.4***
HDL-C (mg/dl) 46 50*
Trig.s(mg/dl) 111 92*
SBP(mmHg) 116 108**
DBP(mmHg) 62 55*
Glucose (mg/dl) 87 85
Insulin (mU/L) 16 8*
Insulin Resist. 3.5 1.9*
IMT (mm) .62 .55***
Subjects: 56 obese children, median age- 9y old
P<.05*, p<.01**, p<.001***
Wunsch, R. etal, Pediatrics118(6): 2334-2340, 2006
TreatmentNutrition and EatingBehavior Course
ExerciseTherapy
Psychological Family Counseling
2. Arterial ComplianceBrachial artery reactivity-Flow Mediated
Dilation
Physiological Process
Definition of Metabolic Syndrome“Clustering of CVD risk factors”
Children with multiple CVD risk factors (three or more) are more likely to have corresponding blood vessel changes (Strong et al, 1999).
METs link between: Insulin resistance
(Impaired glucose metabolism)Hypertension DyslipidemiaObesity
And the atherosclerotic process
Pediatr Clin N Am 58(2011) 1241-1255
Definitions of metabolic syndrome in children
IDF definition of metabolic syndrome in children Obesity (waist) plus 2 other factors
About 63 cm
Age 12-17 Total: 4.0% (0.6) Boys: 6.6% (1.3) Girls: 2.1% (0.6)
NHANES data 04Linear rise with age
Cardiovascular Health Intervention Program
Central Michigan UniversityCOLLEGE OF HEALTH PROFESSIONS
SCHOOL OF HEALTH SCIENCES
Bill Saltarelli, PhD and Paul Visich, PhD, MPH
Overall Purpose for Developing the CHIP
Awareness:To begin to make children and parents aware and personally responsible of their health by physically participating in a screening program to learn about their individual cardiovascular disease risk factors.
Personal Information:If a child and parent(s) knows what their health risks are, they are more likely to consider making changes to improve their health”
School Bus To CMU Finch Fieldhouse
Station # 1 Blood Lipids and
Glucose
Total Cholesterol HDL Cholesterol LDL Cholesterol Triglycerides Non-HDL
Cholesterol TC/HDL ratio Blood Glucose
Station # 2Assessment of Body Composition:
Height, Weight, Skinfold thickness, waist and hip circumference
Station # 3Heart Rate Monitor
(Resting Heart Rate)
Station # 4Resting Blood
Pressure
Station # 5Aerobic Capacity
Seven Minutes of Stepping to musicRecovery HR
A Healthy Lunch and Interactive Presentation on Physical Activity and Health Food choices
CMU Campus Tour
Tour Guide
CC
CMU Class HSC 586 (2011)
Screening CVD risk
Factors in children
1. Individual Child Reports Are Sent Home
120/80
RISK FACTOR Percent of Boys at
risk
Percent of Girls at
risk
Percent of children at
risk
BMI (Boys >20, Girls >21) 43.3 41.2 42.2Blood Pressure>90 percentile>119/7 Boys >118/76 Girls
28.8 28.1 28.6
Glucose (>100mg/dl) 28.2 21.5 28.6Cholesterol(TCL >170 or HDL <39)
63.1 61.2 62.1
Family History (parents or grandparents)
27.7 27.0 27.3
Physical Inactivity <5 days/wk/ 60min-all types PA
66.6 76.1 71.5
Cardiovascular Disease Risk Factors 2005-2008
Total N= 3022 Girls N=1550 Boys N=1472Mid-Michigan Children: Age= 11.7y (6th graders)
Percent of Children with Multiple CVD Risk Factors
Number of
CVDRF
Percent at Risk
CVDRFTotal
Percent of girls at each #
of CVDRF
Percent of boys at each #
of CVDRF
0 3.8 3.6 4.0
1+ 96.2 96.4 95.9
2+ 79.4 79.8 78.9
3+ 50.2 49.4 50.9
4+ 23.3 22.4 24.2
5+ 6.7 6.3 7.0
Girls N=1426
* 50% of the children express 3 or more CVDRF
Boys N=1441
Mid-Michigan Children: Age= 11.7y (6th graders)
Risk factor Risk Criteria % at risk
HDL-C <40mg/dl 20%
Triglycerides > 110mg/dl 26%
Waist Circumference
>90th percentile >81.4 cm boys 14%>79.7 cm girls 11%
Blood glucose > 110mg/dL .3%
Blood pressure 90th percentile>119/78 mmHg Boys, 8%>118/76mmHg) Girls 9%
Metabolic Syndrome“clustering of CVD risk factors”
Criteria for Metabolic syndromeWaist risk plus 2 more
CHIP=5.5%
NHANES=4.0%
Screen lipids of high risk kids (after 2 but before 10 yrs) if:1. Positive family history of CVD or dyslipidemia (<55 father<65 mother)2. History is not known3. BMI > 85th percentile (overweight or obese)4. Hypertension >95th percentile5. Smoker or diabetes
To screen or not to screen lipidsTo treat or not to treat dyslipidemia
Pediatrics 2008;122:198-208
Treatment 1. Population approach = for all children, healthy diet and increased PA2. Individual approach =
Overweight or obese with high triglyceride ( >150mg/dl) or low HDL (<40mg/dl) = diet and phisical activity counseling
3. > 8 years with LDL>160 with family history or > 2 CVD risk factors or LDL >130 with diabetes
= Pharmological intervention
Is the school the answer to correctObesity?
Reviewed 51 studies 4 wk-8yr15 in- school PE 17 health education models19 combination PE/health
Conclusion:No consistency of positive resultsin reducing obesity have been observed!!!!
Prevention/Treatment of Childhood Obesity Through the Developmental Stages
Perinatal: good prenatal nutrition, avoid excessive maternal wt. increase, control diabetes, help mothers lose wt. postpartum (nutrition education)
Infancy: breast feeding > 6 months of age, delay solid food until 6 months of age, provide balanced diet and avoid high-calorie snacks, follow wt. increase slowly
Preschool: develop healthy food preferences, appropriate parental feeding practices, monitor rate of wt. increase, provide child and parent nutritioneducation
Childhood: monitor wt. increase for ht., avoid prepubertal adiposity, nutrition education and encourage daily physical activity
Adolescence: prevent excess wt. increase after growth spurt, maintain healthy nutrition as next generation of parents, continue daily physical activity
Deckelbaum R., etal, Obesity Research,2001;9:239S-243S
Patient-Level Interventions for all children
1. Limit consumption of sugar-sweetened beverages2. Encourage consumption of recommend fruits and vegetables3. Limiting screen time4. Eating breakfast5. Limit restaurant eating6. Encouraging family meals7. Limiting portion size8. Limiting consumption of energy dense foods9. Eating diet rich in calcium and fiber10. Encourage breastfeeding11. Encourage physical activity 60 min each day of moderate and vigorous
Practice and Community level interventions
1. Advocate public policy changes to increase school physical activity 2. Advocate to preserve and enhance community physical activity facilities3. Make available resources for families to engage in physical activity
Addressing Obesity in Clinical Practice
EMR
15-Minute Obesity Prevention Protocol
Step 1 Access and discuss with parent and childBMI Diet
Fruits and vegetables, sweetened beverages, fast food, portion size etc.
Fast foodFamily mealsPortion size
Physical activity
Step 2. Set agendaSuggest one or 2 behaviors to be changed
Step 3. Assess motivation and confidence to begin change
Step 4 Help begin steps to change by suggesting resources
Step 5 Schedule a follow-up to evaluate and adjust plan
Motivational InterviewingAutonomy-supportive Counseling
American College of Sports Medicine
Exercise prescription every patient every time
Let’s Go!, a program of The Kids CO-OP at The Barbara Bush Children’s Hospital at Maine Medical Center, is implemented in partnership with MaineHealth. In addition, Let’s Go! and Maine CDC/DHHS have engaged in a public private partnership to improve the health of Youth and families through the work of the Healthy Maine Partnerships.
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