childhood and adolescent obesity kathryn camp, ms, rd, csp
TRANSCRIPT
Childhood and Adolescent Obesity
Kathryn Camp, MS, RD, CSP
WHY WORRY ABOUT PEDIATRIC OBESITY?
• Pediatric obesity is of epidemic proportion.
• Pediatric obesity is the most common chronic disease of childhood.
• The epidemic is worldwide
Some Scary Stats
• 300,000 Americans died from obesity-related causes in 2000 (Surgeon General Report)– $117 billion in obesity-related
economic costs
• Cost of caring for obese patients is 35% greater than normal weight
• Anthony• 15 yr old• Referred by
his new PMC
• Anthropometrics– Weight: 121 kg– Height: 175 cm
BMI: 39
How Do We Define Overweight in Children and
Adolescents?
Definition of Overweight in Children and Adolescents
• Overweight = BMI 95th %ile
• At risk for overweight = BMI between 85th-95th %ile
Expert Committee Recommendations from the Maternal and Child Health Bureau, 1997
Calculate Your BMI
• kg m2
• Height in inches x 2.54 100 = meters
• Meters x meters = m2
• Weight in pounds 2.2 = kg• Divide your weight in kg by m2 =
BMI
Classification of Overweight and Obesity in Adults Using BMI
Obesity Class BMI
Underweight <18.5
Normal 18.5-24.9
Overweight 25-29.9
Obesity I 30-34.9
II 35-39.9
III Extreme 40
3536 37
39 38
43
University of Miami Blocking Machine
Height: 6-6
Weight: 98 kg
25
Height: 7-1
Weight: 154 kg33
BMI is Age Specific in Children and Adolescents
17
21
24
Increasing Incidence of Overweight in Children and
Adolescents
95th%ile for age and gender
These #s double when
including >85%ile
PERCENT OF OBESE CHILDREN WHO BECOME OBESE ADULTS
0
10
20
30
40
50
60
70
80
Preschool School-age Adolescent
Etiology of Obesity
• Genetic/heritablility
• Molecular• Syndromes• Environmental
Multifactorial Condition
Heritability
• Survival advantage to conserve energy as fat through human evolution
• Humans enriched for genes that promote energy intake and storage and minimize expenditure.
• Enhance female fertility and ability to breastfeed offspring
• In modern industrial environment – easy access to calorically dense foods– encourages sedentary lifestyle
• Metabolic consequences of these genes are maladaptive
Genetic Factors account for 20-40% of heritability of BMI • 173 human obesity cases due to single gene
mutations in 10 different genes were reported by 2004 (Perusse, 2005)
• > 600 genes, markers, and chromosomal regions have been linked with human obesity phenotypes
Buchard 97 Rankinen 02
Familial Risk:
2-3 fold for moderate obesity
5-8 fold for severe obesity
Bouchard 01
More than 50 Obesity Associated Genetic Syndromes
Bardet-BiedlPrader Willi
Spina bifida
Down Syndrome
Hormones, Neurotransmitters, Enzyme defects???
• Obesity is not well understood at the molecular level.
• Discovery of leptin was hoped to revolutionize the field but its role has remained obscure
• Role of other hormones, neurotransmitters, etc remains unknown
• But doctor, my child must have a low metabolism….– Little evidence that metabolic rate is
different (Baker, 05)– Obese adolescents have a higher
total daily energy expenditure and REE (Bandini, 90)
– There may be small differences in metabolic efficiency but these are hard to measure
What is Causing this Marked Increase in Overweight??
Obesity is not a genetic shift, rather it is an environmental
shift
Causes of Marked Increase in Overweight
• Reflects a shift towards positive energy balance
energy intake = energy expenditure
calories
McDowell 94; Kann 99; Troiano 00,NHANES II to III
PE
sed act
Increased Energy Intake
• Kids are – Eating more away from home– Eating more fast food and snack
foods – Drinking more sodas
• 100 kcal/day above needs = 10 pound weight gain per year
Physical Activity
• Daily participation in PE declined from 42% to 29% between 1991 and 1999 (www.cdc.gov/HealthyYouth)
• Walking and bicycling dropped 40% in kids aged 5-15 between 1977 and 1995
• What constitutes “active” these days?
Increase in Sedentary Activity• Excessive TV watching–
– The average child spent 6 hr/day watching TV or playing on computers.
– Encourages overeating while viewing • Influences food choices
– 80% of commercials on children’s programs are for food
• Lower resting metabolic rate compared to at rest (Klesges 1993)
• Reduces time available for more active pursuits
• Video and computer games• Parental work schedules• Unsafe neighborhoods
– discourage parents from allowing children to play outdoors
– force parents to drive children to school
• Lack of recreational facilities in low-income neighborhoods
Other Contributors to Sedentary Lifestyles
Medical Consequences of Overweight
• 60% of OW children have 1 or more CVD risk factors
• Hyperlipidemia-- LDL and TG, HDL– 90% of children with elevated TGs are
overweight• Hypertension
– Low frequency in children• 60% with BP were >120% of IBW
• Obtain fasting lipid profile and blood pressure on all overweight children.
Cardiovascular
Type 2 Diabetes• 95% of teens with Type 2 diabetes
have a BMI >85%ile • Tremendous public health
implications– Longer duration of disease, > risks of
complications
• Obtain fasting glucose and insulin on all overweight children, especially those with..
Dabelea 99; Vinicor 00; Richards 85
• Acanthosis Nigricans
• Hyperpigmented, velvety plaques in body folds
• Caused by hyperinsulinemia which stimulates formation
• Associated with obesity
• Growth– Taller, advanced bone age, mature
earlier– Early maturation is associated with
• increased fatness and truncal fat distribution in adulthood
– Short, obese children should be evaluated for hypothyroidism, Cushing syndrome or Turner syndrome
Other Endocrinological Issues
More Complications
• Hepatic Steatosis with elevated LFTs
• Cholelithiasis– 50% of kids with cholecystitis are
overweight• Orthopedic Problems
Acute Complications that Require Immediate Medical Attention
• Sleep Apnea – Occurs in 17% of obese children and
teens (Marcus 1996)– Deficits in learning, memory, and
vocabulary (Rhodes 1995)
• Obesity hypoventilation syndrome– rare, potentially fatal disorder
Psychological and Economic Consequences of Pediatric and Adolescent Obesity
• Discrimination, rejection and low self-esteem (Gortmaker 93), particularly for females
• Less participation in PE and sports activities
• Lower college acceptance rates (Canning 1966)
Who Needs to be Evaluated?
Evaluating For Overweight in a Primary Care Setting
BMI
OverweightBMI 95th%
Not at riskBMI 85th%
At risk forOverweight
BMI 85-95th%
•Family history•Blood pressure•Lipids•Lg in BMI•Concern re wt •Note in chart
•No therapy•Return next yr
Return next yr for screen
In depth medical assessment
+
Medical Assessment
• r/o genetic syndromes, esp if associated with mental retardation
• Blood pressure• Labs to include
– Fasting lipid panel– Fasting glucose and insulin
• OGTT
– LFTs– Thyroid fx tests
Back to Anthony—Medical
• PMHx – chronic otitis media and allergies– overweight since 7 yrs of age
• Currently c/o headache• On no chronic meds• Blood Pressure
– 136/73– >95th%ile
Social hx
• Only child• High school sophomore, gets good
grades• No exercise or organized sports
activities• Spends 6 hrs/day watching TV and
playing video games
Dietary Information
• Picky eater• Consumes NO fruits or vegetables• Mom prepares separate meals for
him
24-Hour Recall
• Breakfast--none• Mid morning--16 oz ginger ale• Lunch--none
– generally has lunch at school of chocolate milk, pizza, and french fries
• Dinner--10 beef tacos, 2 cans of soda
What to Do with Anthony?
• Weight goals– First step is to achieve weight maintenance– 2-7 years of age
• BMI 85-95%– Weight maintenance
• BMI >95%– No complications: weight maintenance– Complications: weight loss
– 7 and above• BMI 85-95th%
– No complications--weight maintenance– Complications—weight loss
• BMI >95th weight loss
What to Do with Anthony?
• Weight goals– First step is to achieve weight maintenance– 2-7 years of age
• BMI 85-95%– Weight maintenance
• BMI >95%– No complications: weight maintenance– Complications: weight loss
– 7 and above• BMI 85-95th%
– No complications--weight maintenance– Complications—weight loss
• BMI >95th weight loss
General Treatment Goals
• Behavioral goals– Promote life long healthy eating and
activity behaviors
• Medical goals– Prevent complications of obesity in
childhood and potentially adulthood– Improve or resolve existing
complications of obesity
Refer?
• Formal obesity clinic--Team approach– Physician, therapist, dietitian,
exercise therapist– Intensive multi-session programs
• Parent and child/teen participate
– Advantages• Multidisciplinary approach, frequent visits
– Disadvantages• Expensive, time consuming, require
parent participation
If Going It Alone…Where Do You Start?
• Assess child’s and family’s willingness to change
• Negotiate with child/family on specific, targeted changes
• Develop realistic, achievable goals• Involve the entire family in making
changes• Establish a monitoring/assessment
tool
Goals for Anthony
• Eat 3 meals per day (establish regular meals)
• Have 1 piece of fruit each day (introduce new food groups)
• NO calorie containing beverages except skim milk (eliminate empty calories)
• Daily exercise (increase energy expenditure)
• Keep a notebook of food intake and exercise (self-monitoring)
Follow-up
• Weekly visits or as frequent as possible
• lipid profile, HgbA1c, fasting insulin and glucose, blood pressure
• Identify and reinforce positive changes
• Set new goals based on goals achieved
Anthony’s Lab Data
• Lipid panel– Total cholesterol 156 (<200)– Triglycerides 129 (35-250)– HDL 34 (35-82)– LDL 96 (<100)
• HgbA1C 5.8 (4.3-5.3)• Fasting glucose 77• Insulin 30.3 (0-30)
• Weight– 97 kg– Down 53#
• Height– 179 cm– Up 4 cm
• BMI– 30– Down from
40
Childhood ObesityChildhood ObesityCan be prevented
Shaping HabitsShaping HabitsThat Shape That Shape America’s America’s ChildrenChildren
PREVENTION: PRECONCEPTION• Prevention starts prior to conception
– Obese adolescents have an 80% probability of being obese as adults
– Today's adolescents are tomorrows parents– Parents are role models for their children– Obesity risk in a child born to obese parents
is significantly increased– Educate and intervene at this time to help
prevent obesity in subsequent generations
PREVENTION: POST CONCEPTION
• Routine prenatal care• Achieve normal weight gain during
pregnancy– LGA infants and infants of diabetic
mothers have higher rates of subsequent obesity
– SGA infants also at higher risk• Hediger ML et: Pediatrics 104:e33, 1999
• Promote breast feeding
PREVENTION: SCHOOL
• Promote physical activity• Provide nutritious meals• Control vending machines• Have nutrition education
incorporated into regular school curriculum.
• Encourage children to walk or bike to school safely.
PREVENTION: COMMUNITY
• Have safe playgrounds• Provide safe places for bike riding
and walking• Promote physical activity outside
of school
PREVENTION: INSURANCE AND GOVERNMENT
• Acknowledge obesity as a medical condition for which one can be reimbursed.
• Provide reimbursement for anticipatory guidance for nutrition and physical activity
PREVENTION: PRIMARY CARE PROVIDER
• Be an advocate• Provide anticipatory guidance to
families
NUTRITION ANTICIPATORY GUIDANCE
• Beverages– Encourage water intake– Limit sweet beverages
•Juice, juice drinks: 120 calories / 8 oz– No nutritional need for any juice <6
months of age– 1-6 years: 4-6 oz– 7-18 years: 8-12 oz– Discourage free use of box drinks– Discourage continuous access to sippy
cups
•Soda: 150 calories / 12 oz
NUTRITION ANTICIPATORY GUIDANCE
• Eat 5 fruits and vegetables a day • Structured meal and snack time• Do not use food as a reward• Know what the child is eating
outside the home: school meals, day care etc.
NUTRITION ANTICIPATORY GUIDANCE
• Encourage child’s autonomy in self-regulation of food intake – Parents provide, child decides! – Do not use the clean the plate rule.
• Provide choice• Educate parents regarding healthy nutrition
– Healthy snacks– Consider using pediatric food pyramid– Portion size: Intake of children >5 years is
dependent on how much they are provided
• Do not skip meals
ACTIVITY ANTICIPATORY GUIDANCE
• Encourage active play for young children
• Promote physical activity for school age children and teens
• Encourage participation in organized sports
ACTIVITY ANTICIPATORY GUIDANCE
• Decrease sedentary activity– Limit TV, video games and computer
to 1-2 hours per day• > 2 hours a day associated with higher
rates of obesity and hyperlipidemia
– Do not have a TV in the child’s room• Children with TVs in bedroom watch more
TV
BEHAVIORAL ANTICIPATORY GUIDANCE
• Encourage parents to act as role models– Nutrition– Activity
• Promote parent child interaction• Have special “family time” that is
physically active
BEHAVIORAL ANTICIPATORY GUIDANCE
• Limit eating out– More calorically dense food– Larger portion sizes– Less intake of fruits and vegetables
BEHAVIORAL ANTICIPATORY GUIDANCE
• Eat as a family– Provides “quality time”– Slows down the eating process– Parents act as role model– Parents monitor intake– Associated with lower fat intake and
greater intake of fruits and vegetables
BEHAVIORAL ANTICIPATORY GUIDANCE
• Do not eat in front of the TV– Associated with higher intake of fat
and salt– Lower intake of fruits and vegetables– Encourages over eating
• 60-80% of commercials on during children programs are related to food
• Eating without awareness
Summary
• Pediatric obesity is epidemic• Overweight kids become
overweight adults• Treatment is difficult• Prevention is the key