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

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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

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lin

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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