pediatric obesity : a family affair samuel n. grief, md

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Slide 2 Pediatric Obesity : A Family Affair Samuel N. Grief, MD Slide 3 Outline Introduction Definition of childhood overweight/obesity Scope of Problem Etiology: Multifactorial Genetics and obesity Environment and obesity Culture and obesity Taking a pediatric nutrition history Nutrition recommendations for treating obesity Practical pointers for all Family Physicians in dealing with the obese child Conclusion Slide 4 Pediatric obesity is rapidly becoming a serious health epidemic in the united states. Health officials estimate the percentage of overweight/obese children has risen to 30% and is climbing. This symposium will bring the topic of pediatric obesity into the limelight elucidating: The severity of this health epidemic, The multiple causes of pediatric obesity, The genetic connection, The latest nutrition recommendations, A practical approach for family doctors to assess a childs nutrition habits in the context of the family unit and provide sensitive and sound medical advice to help children and their family members conquer obesity. Pediatric Obesity: A Family Affair Slide 5 Definition of Childhood Overweight/obesity Adults: BMI mild, moderate, severe or extreme For children, not clearly established BMI >85% defined as overweight BMI >=95% for age and gender BMI not used for infants Definition of overweight BMI varies with age Slide 6 NHANES III Scope of Pediatric Obesity Problem Slide 7 Boys Age/MonthNHANES INHANES IIHHANESNHANES III 2-5322 6-1115247595 12-23285368101648 24-35166361116610 36-47300403113497 48-59304403126546 60-71273393116495 NHANES III Number of Survey Participants in Sex and Age Groups by Survey Slide 8 Girls Age/MonthNHANES INHANES IIHHANESNHANES III 2-5334 6-1114353576 12-23267350118635 24-35129315112591 36-4728634085545 48-5928138693532 60-71314369112554 NHANES III Number of Survey Participants in Sex and Age Groups by Survey Slide 9 Prevalence of overweight Based on Percentage of 2-5 year-old children above the 95% of the weight-for-stature growth reference (NHANES III) Slide 10 NHANES I, II, III 6-11 MonthsBoysGirls White NHANES I NHANES II2.76.5 NHANES III7.311.1 Black NHANES I NHANES II9.0 NHANES III9.510.7 Mexican American HHANES4.57.3 NHANES III12.216.3 Slide 11 NHANES I, II, III 6-11 MonthsBoysGirls ALL RACES NHANES I NHANES II4.06.2 NHANES III7.510.8 Slide 12 NHANES I, II, III 12-23 MonthsBoysGirls White NHANES I8.35.7 NHANES II6.67.5 NHANES III7.67.9 Black NHANES I3.88.9 NHANES II11.86.8 NHANES III6.415.2 Mexican American HHANES7.911.3 NHANES III13.614.0 Slide 13 NHANES I, II, III 12-23 MonthsBoysGirls ALL RACES NHANES I7.56.1 NHANES II7.2 NHANES III7.59.5 Slide 14 NHANES I, II, III 2 3 YearsBoysGirls White NHANES I1.91.6 NHANES II1.52.9 NHANES III2.04.5 Black NHANES I3.42.2 NHANES II2.21.0 NHANES III3.06.2 Mexican American HHANES5.64.2 NHANES III3.06.2 Slide 15 NHANES I, II, III 2 - 3 YearsBoysGirls ALL RACES NHANES I3.12.0 NHANES II2.02.5 NHANES III2.14.8 Slide 16 NHANES I, II, III 4 - 5 YearsBoysGirls White NHANES I4.06.0 NHANES II4.67.4 NHANES III4.311.2 Black NHANES I7.05.0 NHANES II3.06.5 NHANES III8.712.6 Mexican American HHANES4.910.6 NHANES III12.013.2 Slide 17 NHANES I, II, III 4 - 5 YearsBoysGirls ALL RACES NHANES I4.45.8 NHANES II4.47.6 NHANES III5.010.8 Slide 18 NHANES III Under 1Ages 1 & 2 Boys9.67.5 NHW9.16.4 NHB10.28.9 MA12.813.0 Girls11.011.5 NHW10.28.4 NHB15.014.0 MA15.516.8 Both Sexes10.39.4 Percentage of children younger than 3 years above the 95% of the weight-for-length growth reference, NHANES III Slide 19 Assessment of Medical Conditions Related to Obesity FindingsPotential Conditions History Developmental DelayGenetic Disorders Poor linear growthHypothyroidism, Cushings syndromePrader-Willi syndrome HeadachesPseudotumor Cerebri Nighttime breathing difficultySleep apnea, obesity hypoventilation syndrome Daytime somnolenceAs above Abdominal painGallbladder disease Hip or knee painSlipped capital femoral epiphysis Oligomenorrhea or amenorrhea Polycystic ovarian syndrome Slide 20 Assessment of Medical Conditions Related to Obesity Family History Obesity NIDDM Cardiovascular disease Hypertension Dyslipidemia Gallbladder disease Social/psychologic history Tobacco use Depression Eating Disorder Slide 21 Physical exam Height, weight, BMI Triceps skinfold thickness Truncal obesity Blood pressure Dysmorphic features Acanthosis nigricans Hirsutism Violaceous striae Optic disks Assessment of Medical Conditions Related to Obesity Slide 22 Tonsils Abdominal tenderness Undescended testicle Limited hip range of motion Lower leg bowing Risk of cardiovascular disease; Cushings syndrome Genetic disorders (PW) NIDDM, insulin resistance Polycystic ovarian syndrome; Cushings syn Pseudotumor cerebri Slide 23 Assessment of Medical Conditions Related to Obesity Sleep apnea Gallbladdeer Disease Prader-Willi Syndrome Slipped Capital Femoral Epiphysis Blounts Disease Slide 24 Etiology of Pediatric Obesity: Multifactorial Environmental: Neighborhood, school, community Genetic: Inborn diseases, chromosomal mutations, familial, ethnic predisposition Cultural: Increased risk with minorities Societal: Affluent vs. Underserved Physical: Height and body frame; sick vs. healthy Attitude: Family influence on nutrition habits and physical activity Medical advice: Doctors not taking an active role The American way of life! Slide 25 Genetics and Obesity Twin studies Familial syndromes: Cohens, Alstroms, and Bardet-Biedl (look these up!!!) Ob gene and leptin POMC Pro-opiomelanocortin MC4R a melanocortin receptor Slide 26 Genetics and obesity What next? Additional leptin to those who are deficient. Ongoing research for pharmacological manipulation. Continued research in rodents is directly relevant to humans. Slide 27 Socioeconomic status and rates of obesity Single parent families and risk of obesity Social support and relevance to pediatric obesity School and extracurricular activities Inner city vs. suburban setting Western vs. third world setting Environment and Obesity Slide 28 Minorities and increased rates of obesity African-American Hispanic Native Indian Pacific Islander White Asian European Other Culture and Obesity Slide 29 Culture and food Food is a way of life Learn about different cultures: ASK! The taste of Chicago Slide 30 You deserve a BREAK! Slide 31 Nutrition Exercise 1. Split into groups of three 2. Designate one member as the physician 3. Designate one member as the parent of an obese child 4. Designate one member as the observer 5. The physician has ten minutes to obtain a complete nutrition history from the parent 6. Observer to take notes re: 1. Style effective or not and why? 2. Open or closed ended questions 3. Anything missing? 4. Anything else? Slide 32 Ready, set GO! Slide 33 Taking a pediatric nutrition history Back to basics! Methods of assessing dietary intake: 1) 24-Hour recall 2) Usual Intake/Diet history 3) Food frequency questionnaire 4) Family history 5) Past medical history 6) Any diets that have been tried? Successful? 7) Social habits: cigs, caffeine, illicit drugs, ETOH 8) MEDS, vitamins, herbals 9) Food allergies? Lactose intolerance? 10) ROS: Constitutional, GI, GU Slide 34 Refer to a trusted Registered Dietitian! Recommendations based on the USDA Food Guide Pyramid Most children will need to maintain their current weight until they reach a lower level BMI There is no magic wand to wave The three Es: Emphasize proper nutrition, Encourage an overall family approach to modifying nutrition habits, and Empathize with all those concerned. Pediatric Nutrition Slide 35 Few are currently viable OTCs: Diet pills, ephedra, metabolife, caffeine, chitosan, hydroxycitric acid, pyruvate, etc. Methylphenidate, dextroamphetamine, etc. Diuretics Thyroid hormone Growth hormone Testosterone Leptin Metformin Xenical Sibutramine Medicinal Treatment Options for Pediatric Obesity Slide 36 Useful for adolescents with extreme obesity Last resort option for severely obese adolescents Choose patients carefully Surgical Treatment Options for Pediatric Obesity Slide 37 Do obese children suffer from greater rates of depression? Study of 868 third grade students KEDS Results: there is a relationship between depressive symptoms and BMI in preadolescent girls; not in boys. Girls express more overweight concerns. Take home message: when girls present to Family Docs, assessing overweight concerns with the 5- question scale may help identify overweight girls at highest risk of developing depression, and perhaps subsequent eating disorders. Obesity and Psychological Disorders in Children Slide 38 At any given time, 44% of adolescent girls and 15% of adolescent boys are dieting Prevalence of eating disorders (anorexia and bulimia) is estimated to be 1-4% of adolescent and young adult women Predisposing factors may include: genetic, biological vulnerability, individual psychopathology, familial and cultural influences Survey of women on the most common weight loss practices: weighing oneself regularly, walking, fasting, meal skipping, diet pills, cigs Weight cycling: not related to increased psychopathology! Obesity and Eating Disorders Slide 39 Non-dieting approaches for obese children Identify and combat cultural notions that thinner is better and that body weight can be controlled by willpower Help participants stop dieting by abandoning efforts to restrict energy intake and avoid certain foods Help participants identify and eat in response to the bodys natural hunger and satiety signals Increase self-esteem and positive body image through self-acceptance rather than weight reduction Increase awareness about dieting behaviors and their purported ill effects Slide 40 Early onset of adiposity rebound (AR) Early onset of puberty related to obesity in girls Increased rates of Type 2 diabetes diagnosed among obese children Adult food fears impact children Obesity and Children Miscellaneous Slide 41