PEDIATRIC OBESITY: A HUGE PROBLEM IN THE USA

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PEDIATRIC OBESITY A HUGE PROBLEM IN THE USA

• William J. Cochran, MD
• Department of Pediatric GI Nutrition
• Geisinger Clinic

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WHY WORRY ABOUT PEDIATRIC OBESITY?

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

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DEFINITION OF PEDIATRIC OBESITY

• Overweight / At risk of overweight
• BMI 85-95
• Obese / Overweight
• BMI 95

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OLDER DEFINITIONS OF OBESITY

• Weight for height 95
• Actual weight 120 ideal body weight
• Super obese 140 of ideal body weight

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Percent of obese children and adolescents
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INCIDENCE OF PEDIATRIC OBESITY IN PENNSYLVANIA
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RACIAL DIFFERENCES IN PEDIATRIC OBESITY

• Non-Hispanic white 12.3
• African American 21.5
• Hispanic 21.8

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WHY WORRY ABOUT PEDIATRIC OBESITY?

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

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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

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WHY WORRY ABOUT PEDIATRIC OBESITY?

• Significant risk of childhood obesity to persist
  into adulthood.

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PERCENT OF OBESE CHILDREN BECOMING OBESE ADULTS
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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

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

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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

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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

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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

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CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITY

• Endocrine
• Non-insulin-dependent diabetes 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
• 1 have type II DM

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CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITY

• Endocrine
• Increased linear growth
• Advanced bone age
• Earlier onset of puberty
• Acanthosis nigricans

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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

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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

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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

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CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITY

• Orthopedic
• Slipped capital femoral epiphysis
• 30-50 are obese
• Blounts disease (Tibia vara)
• 70 are obese
• Neurologic
• Pseudotumor cerebri

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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

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• PEDIATRIC OBESITY IS NOT JUST A COSMETIC PROBLEM!

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ETIOLOGY OF PEDIATRIC OBESITY
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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

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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

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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

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ETIOLOGY OF OBESITY

• Physical activity
• TV / video games
• More time spent watching TV less time for
  physical activity average 2.5 hours / day, 205
  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

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TREATMENT OF PEDIATRIC OBESITY

• Weight management programs are available and can
  be effective
• High rates of recurrence
• Prevention is the key

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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

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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 Pediatrics104e33, 1999

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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

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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

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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

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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

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NUTRITION ANTICIPATORY GUIDANCE

• Beverages
• Encourage water intake
• Limit sweet beverages
• Juice, juice drinks 120 calories / 8 oz
• No nutritional need for any juice 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

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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.

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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

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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

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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
• Children with TVs in bedroom watch more TV

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ACTIVITY ANTICIPATORY GUIDANCE

• Decrease sedentary activity
• Do not use the remote
• Exercise on commercials
• TV / computer is not a right it is a privilege

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BEHAVIORAL ANTICIPATORY GUIDANCE

• Encourage parents to act as role models
• Nutrition
• Activity
• Promote parent child interaction
• Have special family time that is physically
  active

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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

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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

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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

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TREATMENT OF PEDIATRIC OBESITY
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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

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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
• Complications weight loss

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TREATMENT GOALS

• Weight goals
• 7-18 years of age
• BMI 85-95
• No complications weight maintenance
• Complications weight loss
• BMI 95
• Weight loss

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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

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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

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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

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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

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TREATMENT OF PEDIATRIC OBESITY

• Formal obesity clinic
• Advantages
• Appropriate time
• Frequent visits
• Utilize each team members expertise
• Good outcomes if completed

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Weight Loss Pharmacotherapy

• Sibutramine
• FDA approved 1997
• Induces feeling of satiety
• Increases 5HT Norepi.
• Caution with use in combination with SSRIs
• Contraindicated with CAD,CVA or uncontrolled
  blood pressure
• Need to monitor BP
• Once daily
• 8-10 weight loss

• Orlistat
• FDA 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
• 3 times daily with meals containing fat
• Vitamin supplementation
• 8-10 weight loss

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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

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BARIATRIC SURGERY

• Preoperative evaluation in a pediatric weight
  management program
• Psych evaluation
• Depression
• Ability to cope
• Support system
• Willingness to comply

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BARIATRIC SURGERY

• Pediatric cases should be done in a pediatric
  center
• Prospective multi-institutional study in progress
• Options
• Gastric bypass
• Lap band

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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

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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

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TREATMENT OF PEDIATRIC OBESITY

• Protein sparing modified fast
• Low carbohydrate diet

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Restrictive Bariatric Procedures
Adjustable Gastric Banding
Vertical Banded Gastroplasty
Roux-en-Y Gastric Bypass
Mun EC, Blackburn GL, Matthews JB.
Gastroenterology 2001120669-681
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WEB SITEES OF INTEREST

• www.panaonline.org
• PA Department of Health effort to address obesity
  and its co-morbidities
• http//www.trowbridge-associates.com
• Pediatric BMI wheels
• http//www.usda.gov/cnpp/kidspyra
• Pediatric food pyramid

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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
• http//www.kidnetic.com/
• An interacitve website for 9-13 year olds and
  families re healthy eating and activity

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WEB SITEES OF INTEREST

• http//www.verbnow.com
• CDC site for 9-13 year olds to promote physical
  activity
• www.aap.org/obesity
• American Academy of Pediatrics web site regarding
  obesity

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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

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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

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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.

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PREVENTION COMMUNITY

• Have safe playgrounds
• Provide safe places for bike riding and walking
• Promote physical activity outside of school

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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

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PREVENTION PRIMARY CARE PROVIDER

• Be an advocate