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