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 proportion. Pediatric obesity is the most common chronic disease of childhood.

DEFINITION OF PEDIATRIC OBESITY

Overweight / At risk of overweight

BMI

85-95% >95%

Obese / Overweight
BMI

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 4 2 0 1963-70 1971-74 1976-80 1988-94 1999-02 6-11 years 12-19 years

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 CAD Hypertension Cancer Joint

II DM

disease Gallbladder disease Pulmonary disease

WHY WORRY ABOUT PEDIATRIC OBESITY?

Significant risk of childhood obesity to persist into 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

estimated cost of obesity in the US in 2002 was $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 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
Pinhas-Hamiel

diabetes mellitus

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

steatosis present in 25-83% of obese

children 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

are obese

30-50%

Blounts
70%

disease (Tibia vara)

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

In = Energy Used + Energy Stored For 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: TV, computer, video games

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 Need to educate and intervene at 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
Juice,

water intake Limit sweet beverages

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 childs 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

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 childs room

with TVs in bedroom watch more TV

Children

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 food Larger portion sizes Less 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 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

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 or resolve existing complications of obesity

TREATMENT GOALS

Weight goals
First

step is to achieve weight maintenance 2-7 years of age

BMI

85-95% >95%

Weight maintenance
BMI

No complications: weight maintenance Complications: weight loss

TREATMENT GOALS

Weight goals
7-18

years of age
85-95%

BMI

No complications: weight 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 familys 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: Eat as a family, some increase in physical activity Stage III: Nutrition education and initial implementation of hypocaloric diet

TREATMENT OF PEDIATRIC OBESITY

Formal obesity clinic

Team

approach

Physician

Therapist
Dietician Exercise

therapist

Intensive
15

program

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
FDA

Orlistat
FDA

approved 1997 Induces feeling of satiety

Increases 5HT & Norepi. Caution with use in combination with SSRIs
Contraindicated

approved 1999 FDA approved 12-18 year old Reduces absorption of ~30% dietary fat
1/3 of fat passes undigested Facilitates weight loss GI side effects

with CAD,CVA or uncontrolled blood pressure

Need to monitor BP

Once

daily 8-10% weight loss

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

bypass Lap band

CONCLUSIONS
Pediatric obesity is of epidemic 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 a more effective means dealing with pediatric obesity In order to have any significant impact on pediatric obesity a team approach is required: child, family/parents, community, health care providers, insurance 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
PA

Department of Health effort to address obesity and its co-morbidities BMI wheels food pyramid

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

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

WEB SITEES OF INTEREST

http://www.bam.gov
Site

to answer kids questions

http://147.208.9.133/
A

free dietary assessment tool to keep up to a 20-day food log interacitve website for 9-13 year olds and families re healthy eating and activity

http://www.kidnetic.com/
An

WEB SITEES OF INTEREST

http://www.verbnow.com
CDC

site for 9-13 year olds to promote physical activity Academy of Pediatrics web site regarding obesity

www.aap.org/obesity
American

BARRIERS TO THERAPY OF PEDIATRIC OBESITY

Lack of commitment of primary care physicians

Many

physicians do not address obesity Price 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
Median

1999

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: 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