Pediatric Obesity Problem

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PEDIATRIC OBESITY: A HUGE PROBLEM IN THE USA William J. Cochran, MD Department of Pediatric GI &  Nutrition Geisinger Clinic

 

WHY WORRY ABOUT PEDIATRIC OBESITY? 

Pediatric obesity is of epidemic e pidemic proportion.



Pediatric obesityofischildhood. the most common chronic disease

 

DEFINITION OF PEDIATRIC OBESITY 

Overweight / At risk of overweight 



BMI 85-95%

Obese / Overweight  BMI

>95%

 

OLDER DEFINITIONS OF OBESITY Weight for height >95% Actual weight >120% ideal body weight Super obese >140% of ideal body weight

 

Percent of obese children and adolescents 16 14 12 10 8

6-11 years

6

12-19 years

4 2 0 196 963 3-7 -70 0

1971 19 71-7 -74 4

1976 19 76-8 -80 0

198 19 888-94 94

1999 19 99-0 -02 2

 

INCIDENCE OF PEDIATRIC OBESITY IN PENNSYLVANIA 25

20

15 2000

2001

2002

2003

 

RACIAL DIFFERENCES IN PEDIATRIC OBESITY   Non-Hispanic  

white

African American Hispanic

12.3% 21.5% 21.8%

 

WHY WORRY ABOUT PEDIATRIC OBESITY? 

Is pediatric obesity a real problem or just a cosmetic issue?

 

WHY WORRY ABOUT PEDIATRIC OBESITY? 

Adult obesity is clearly associated with numerous health problems. 

Type II DM



CAD



Hypertension

Cancer  Joint disease 



Gallbladder disease



Pulmonary disease

 

WHY WORRY ABOUT PEDIATRIC OBESITY? 

Significant risk of childhood obesity to  persist into adulthood. adulthood.

 

PERCENT OF OBESE CHILDREN BECOMING OBESE ADULTS 80 70 60 50 40 30 20 10 0 Preschool

School-age

Adolescent

 

WHY WORRY ABOUT PEDIATRIC OBESITY? 

Economic impact 

The cost of obesity in the US in 2002 was estimated $117 billion. 

The hospital cost of pediatric obesity is also increasing.  1979: $35 million  1999

$127 million

 

IMPACT OF CHILDHOOD OBEISTY IN ADULTHOOD Childhood obesity has significant adverse effects on health in adulthood  Hoffmans 1988: Dutch males, increased mortality after 32 years in obese vs. lean adolescent males.  Mossberg

1989:Swedish study, increased mortality after 40 years in obese vs nonobese children

 

IMPACT OF CHILDHOOD OBESITY IN ADULTHOOD 

Harvard Growth Study:  Two fold increased all cause mortality in obese vs nonobese adolescents as adults  2 fold increase in CAD mortality  Increased risk of colon cancer in males  Increased

risk of arthritis in females  The association of adverse effects on adult health may be independent of obesity in adulthood

 

CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITY 

Psychosocial 

Most common complication of pediatric obesity  Increased rates of depression  Poor 

self esteem

Obese adolescents negative self image may carry over into adulthood

 

CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITY 

Societal discrimination 

Obese females have lower acceptance rate at colleges than non-obese females  National

Longitudinal Longitud inal Survey of Youth: obese adolescent females as young adults had less education, less income, higher poverty rate, decreased rate of marriage vs nonose females

 

CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITY 

Endocrine 

 Non-insulin-dependent diabetes mellitus mellitus  Pinhas-Hamiel 1994 • The incidence of NIDDM has increased 10 fold • 92% of these had a BMI >90% 

Geisinger weight management program • 60% have insulin resistance

• 10% have fasting insulin level > 100 (Nl <17) • 1% have type II DM

 

CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITY 

Endocrine 

Increased linear growth  Advanced bone age  Earlier

onset of puberty



Acanthosis nigricans

 

CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITY 

Hypertension 

Primary hypertension uncommon in childhood  60% of children diagnosed with hypertension are obese  Use

pediatric standars

 Geisinger 

weight management program

45% have hypertension

 

CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITY 

Hyperlipidemia 

The atherosclerotic process begins in childhood.  Pediatric

obesity is associated with increased cholesterol, LDL-cholesterol, triglyceride levels and lower levels of HDL-cholesterol  Geisinger weight management program 

45% have hypercholesterolemia

 

CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITY 

Hepatic steatosis 

Hepatic children steatosis present in 25-83% of obese  10-15%

of obese children have elevated liver enzymes: steatohepatitis or non-alcoholic fatty liver disease  Rashid: 83% of children with steatohepatitis were obese. 75% had fibrosis-cirrhosis

 

CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITY 

Orthopedic 

Slipped capital femoral epiphysis 

30-50% are obese

 Blount’s 

disease (Tibia vara) 

70% are obese

  Neurologic  Pseudotumor

cerebri

 

CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITY 

Respiratory 

Sleep disorder in 1/3  Sleep apnea: 7% of obese, 1/3 if >150% &  breathing difficulties  Hypoventilation



syndrome

Gastrointestinal  Cholelithiasis 

50% of cases of cholecystitis in adolescents are obese

 

PEDIATRIC OBESITY

 

IS NOT JUST A

COSMETIC PROBLEM!

 

ETIOLOGY OF PEDIATRIC OBESITY

 

ETIOLOGY OF PEDIATRIC OBESITY 

Etiology is multifactorial 



Interaction of genetics and environment

Energy imbalance  Energy  For

In = Energy Used + Energy Stored

every extra 100 calories consumed per day one will put on 10 pounds per year

 

ETIOLOGY OF OBESITY 

Caloric intake has increased 

Eating unsupervised, lack of family meals  Eating at multiple sites  Eating

out / take out food

 Beverages  Calorically

dense food

 

ETIOLOGY OF OBESITY 

Physical activity has decreased 

Schools with less physical education  After school programs  Safety

concerns

 Convenience activities  Increased sedentary activities:

video games

TV, computer,

 

ETIOLOGY OF OBESITY 

Physical activity 

TV / video games 

More time spent watching TV less time for physical activity: average 2.5 hours / day, 20%>5 hours / day



BMI and obesity associated with higher amount of

time spent watching TV  Higher cholesterol levels associated with greater amount of time spent watching TV 

40% of children 1-5 years have TV in their bedroom

 

TREATMENT OF PEDIATRIC OBESITY 

Weight management programs are available



and can be effective High rates of recurrence



Prevention is the key

 

PREVENTION: PRECONCEPTION 

Prevention starts prior to conception  Obese

adolescents have an 80% probability of  being obese as an adult  Today's adolescents are tomorrows parents  Parents act as role models for their children  The

risk of obesity in a child born to obese  parents is significantly increased increased  Need to educate and intervene at this this time to help prevent obesity is subsequent generation

 

PREVENTION: POST CONCEPTION  

Routine prenatal care Advocate normal weight gain during the  pregnancy  LGA

infants and infants of diabetic mothers

have higher rates of subsequent obesity  SGA infants also at higher risk 

Hediger ML et: Pediatrics104:e33, 1999

 

PREVENTION: POST CONCEPTION 

Promote breastfeeding 

Dewey 2003: 8 out of 11 studies noted a lower rate of obesity in children if breastfed vs. formula fed



Bergmann 2003: Longitudinal study of breastfed vs. formula fed infants 

BMI the same at birth



BMI at 3 & 6 months > in formula fed vs. breastfed infants



Rate of obesity at 6 years was tripled in formula fed vs.  breastfed

 

PREVENTION OF PEDIATRIC OBESITY 

Measure and plot BMI  Only

done by 20% of primary care providers



Identify those at risk



Anticipatory guidance  Nutrition  Physical

activity

 Healthy

lifestyles

 

IDENTIFY THOSE AT RISK 

Increasing BMI %



Family history  Risk

of obesity 9% if both parents are lean

 Risk

of obesity 60-80% if both parents are

obese  Sibling over weight 

High birth weight

 

IDENTIFY THOSE AT RISK 

Lower socioeconomic status



Ethnicity: African-American, Hispanic,  Native American  Environmental / social  Both

parents work  Little cognitive stimulation  Lack of safe play areas  Family stress

 

 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 months of age •• • •



1-6 oz oz 7-18years: years:4-6 8-12 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 -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  Ideal

30-60 minutes per day

 Have

several types of potential activities

 Be

physically active with others  Think about activity opportunities  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

 

ACTIVITY ANTICIPATORY GUIDANCE 

Decrease sedentary activity  Do not use the remote  Exercise on commercials  TV

/ computer is not a right it is a privilege

 

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  Larger portion sizes  Less

food

intake of fruits and vegetables

 $0.51

of every nutrition dollar is spent outside the home

 

BEHAVIORAL ANTICIPATORY GUIDANCE 

Eat as a family  Provides “quality time”   Slows down the eating process  Parents  Parents

act as role model

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  Lower intake of  Encourages

higher intake of fat and salt fruits and vegetables

over eating



60-80% ofare commercials on during children  programs related to to food 

Eating without awareness

 

TREATMENT OF PEDIATRIC OBESITY

 

TREATMENT GOALS 

Behavioral goals  Promote

life long healthy eating and activity  behaviors



Medical goals  Prevent

complications of obesity in childhood and potentially adulthood

 Improve

obesity

or resolve existing complications of

 

TREATMENT GOALS 

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 maintenance • Complications: weight loss

 

TREATMENT GOALS 

Weight goals  7-18 

years of age

BMI 85-95%

•  No complications: weight maintenance maintenance • Complications: weight loss 

BMI >95% • Weight loss

 

EVALUATION OF THE OBESE CHILD 

History and physical examination



Laboratory evaluation  Liver

panel

 Fasting

lipid panel

 Fasting

glucose and insulin level  Hgb A1C ?

Thyroid studies

 

TREATMENT OF PEDIATRIC OBESITY 

First step is to educate the patient and

 parents about obesity  Assess patient and the family’s readiness to make change 

Treatment needs to be individualized and family based



Make only a few changes at a time

 

TREATMENT OF PEDIATRIC OBESITY 

For a child who will not be entering the formal obesity clinic   Stage

I: Limit TV, do not eat in front of the TV and decrease calories from beverages.



Stage II: activity Eatvity as a family, some increase in  physical acti  Stage

III: Nutrition education and initial implementation implement ation of hypocaloric diet

 

TREATMENT OF PEDIATRIC OBESITY 

Formal obesity clinic  Team

approach



Physician



Therapist



Dietician



Exercise therapist

 Intensive 

program

15 sessions: 10 therapist, 3 dietician, 2 exercise therapist

 

TREATMENT OF PEDIATRIC OBESITY 

Formal obesity clinic  Advantages 

Appropriate time



Frequent visits



Utilize each team members expertise



Good outcomes if completed

 

Weight Loss Pharmacotherapy 

Sibutramine



Orlistat



FDA approved 1997



FDA approved 1999



Induces feeling of satiety

 

FDA approved 12-18 year old Reduces absorption of ~30% dietary fat

 

Increases 5HT & Norepi. Caution with use in combination with SSRI’s 

Contraindicated with CAD,CVA or uncontrolled  blood pressure







 Need to monitor monitor BP



Once daily



8-10% weight loss

 

1/3 of fat passes undigested Facilitates weight loss GI side effects

3 times daily with meals containing fat  Vitamin supplementation  8-10% weight loss 

 

BARIATRIC SURGERY 

Little information on pediatric bariatric



surgery May be appropriate in individual cases  Severe

obesity, BMI > 40

 Significant

co-morbidities  Unresponsive to more conventional weight loss  program

 

BARIATRIC SURGERY 

Preoperative evaluation in a pediatric



weight management program Psych evaluation  Depression  Ability

to cope  Support system  Willingness

to comply

 

BARIATRIC SURGERY 

Pediatric cases should be done in a pediatric

center  Prospective multi-institutional study in  progress 

Options:  Gastric  Lap

bypass

band

 

CONCLUSIONS 

Pediatric obesity is of epidemic e pidemic proportion



The etiology of pediatric obesity is multifactorial



Pediatric obesity is associated with complications in childhood as well as adulthood

 

CONCLUSIONS 

Treatment of obesity is not ideal



Prevention of obesity may be obesity a more effective means dealing with pediatric



In order to have any significant impact on  pediatric obesity a team approach is required: child, family/parents, community, health care  providers, insurance companies, companies, government

 

TREATMENT OF PEDIATRIC OBESITY 

Protein sparing modified fast



Low carbohydrate diet

 

Restrictive Bariatric Procedures Gold Standar  d

Vertical Banded Gastroplasty 

Adjustable Gastric Banding 

Roux-en-Y Gastric Bypass

Mun EC, Blackburn GL, Matthews JB. Gastroenterology 2001:120:669-681  

WEB SITEES OF INTEREST 

www.panaonline.org   www.panaonline.org  PA

Department of Health effort to address obesity and its co-morbidities



http://www.trowbridge-associates.com   http://www.trowbridge-associates.com  Pediatric



BMI wheels

http://www.usda.gov/cnpp/kidspyra   http://www.usda.gov/cnpp/kidspyra  Pediatric

food pyramid

 

WEB SITEES OF INTEREST 

http://www.bam.gov   http://www.bam.gov 



Site to answer kids questions

http://147.208.9.133/   http://147.208.9.133/ A

free dietary assessment tool to keep up to a 20-day food log



http://www.kidnetic.com/   http://www.kidnetic.com/  An

interacitve website for 9-13 year olds and families re healthy eating and activity

 

WEB SITEES OF INTEREST 

http://www.verbnow.com   http://www.verbnow.com  CDC

site for 9-13 year olds to promote  physical activity activity



www.aap.org/obesity   www.aap.org/obesity  American

Academy of Pediatrics web site regarding obesity

 

BARRIERS TO THERAPY OF PEDIATRIC OBESITY 

Lack of commitment of primary care  physicians  Many  Price

physicians do not address obesity

1989



17% of pediatricians felt physicians did not need to counsel parents of obese children



33% did not feel that normal weight is important to child health



22% felt competent in treating obesity  11% felt treatment of obesity was gratifying  

BARRIERS TO THERAPY OF PEDIATRIC OBESITY 

Time commitment



Lack of reimbursement  Tershakovec 

 

1999

Median reimbursement rate 11%

Lack of standard treatment protocol Social / environmental barriers

 

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 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 PREVENTION:: PRIMARY CARE PROVIDER 

Be an advocate

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