CHILDHOOD OBESITY AN EPIDEMIC

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CHILDHOOD OBESITY AN EPIDEMIC
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INCIDENCE OF CHILDHOOD OBESITY IS INCREASING
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DEFINING OBESITY IN CHILDREN- THE PEDIATRIC BMI
CHART
Obese (95TH )
At Risk ?
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CAUSATIVE FACTORS-EXCLUDING SYNDROMES

• PRIMARY
• Poor food choices
• Inactivity
• SECONDARY
• Psychological
• Environmental
• Genetics
• Fetal environment

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CONSEQUENCES

• 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

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EXCESS SUBSTRATE WITHOUT EXCESS
EXPENDITURELIPOGENESIS
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OBESITY A FATAL DISEASE
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TREATMENT OF PEDIATRIC OBESITY

• Nutrition management
• Physical activity
• Behavior modification / Counselling
• Family support

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OUR 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

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CHILDRENS HEART CENTER - NEVADA

• 15,000 OUT-PATIENT VISITS/YR
• 6,000 IN-PATIENT VISITS/YR
• MORE PATIENT VISITS THAN
• -UCLA
• -UCSF
• -STANFORD
• -CHILDRENS HOSPITAL OF LOS ANGELES
• -LOMA LINDA
• -CEDARS SINAI
• FROM PUBLISHED DATA AND PERSONAL CONVERSATIONS

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OUTLINE OF OUR PROGRAM

• PATIENTS REFERRED BY PRIMARY CARE PROVIDERS
• Primary care providers without time or staff to
  treat effectively
• BMI 95ile for age
• Hypertension with BMI 95ile
• Dyslipoproteinemias

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OUTLINE OF OUR PROGRAM

• Initial evaluation
• Laboratory testing
• Intensive initial nutritional evaluation
  recommendations
• If appropriate exercise program enrollment
• If indicated family counselling
• Follow up

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LAB TESTS RESULTS IN 410 PATIENTS BMI 95th 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

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CHILD/ADOLESCENT NORMALS

• Total cholesterol
• HDL 45 mg/dl- Probably 50 desirable
• Triglycerides
• Insulin level

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OUTLINE OF OUR PROGRAM

• 12 WEEK INTEGRATED PROGRAM
• Nutrition counselling
• Simple psychological evaluation
• Exercise RX
• Motivational intervention and family counselling
  referral if indicated

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INTAKE DATA FROM OUR PROGRAM
25 Carbs HFCS
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MOST IMPORTANT NUTRTION-RECOMMENDED INTAKE
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WHO WILL WIN THE BATTLE?
Soft Drink!?
USDA food pyramid

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BRIEF PSYCHOLOGIC EVALUATION

• Perera self esteem test
• 16 true or false questions
• Scored number of true answers
• Initial and repeated at end of 12 week program

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EXERCISE

• INITIAL EVALUATION
• Rockport walk test
• Timed 1 mile walk
• Score based on time and heart rate
• Gender and weight
• Max VO2 estimate
• 50 excellent

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EXERCISE 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)

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EXERCISE RX

• ADDITIONAL PROGRAM ACTIVITIES
• Weights
• Calisthenics
• Stretching

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PROGRAM MATERIALS

• Hand outs
• Homework
• Off site exercise
• Behavior modification
• Positive rewards

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OUR ON SITE EXERCISE FACILITY
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INITIAL BIOMETRIC SELF ESTEEM RESULTS FROM
THE 12 WEEK PROGRAM
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RESULTS FROM 12 WEEK PROGRAM

• N76
• Average age 12.5 (7-18)
• Male 56
• Female 44
• Reported at Society of Pediatric Research in San
  Francisco May 2004

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RESULTS FROM 12 WEEK PROGRAM N76

• RESTING HR
• Pre111 Post98NS
• SYSTOLIC BP
• Pre123 Post113
• 
  P

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RESULTS FROM 12 WEEK PROGRAM N76

• BMI
• Pre33 Post32
• BODY FAT
• Pre40 Post38
• 
  P

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RESULTS FROM 12 WEEK PROGRAM N76

• SELF ESTEEM
• Pre10.6 Post12.4
• WALK TEST SCORE
• Pre10 Post27
• 
  P

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PARENTAL SURVEYED PHYSICAL ACTIVITY AND
NUTRITIONAL CHANGES RESULTS FROM 12 WEEK PROGRAM
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TV watching on weekends
TV watching on school days
Gross Activity
Daily Activity
P-value 34




Breakfast freq.
Fruits consump.
Vegetables consump.
Sodas / Juices
P-value 35
INSULIN RESISTANCE IN OUR PATIENTS
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INSULIN RESISTANCE IN OUR PATIENTS

• Quicki (1/log insulin log glucose)
• Glucose/Insulin ratio
• Increasing IR with age and with BMI in euglycemic
  patients with BMIs 95thile. Presented at the
  AHA LJ Filer San Francisco in March
• J Clin Endocrinol Metab. 2000 Jul85(7)2402-10
  J Clin Endocrinol Metab. 1998832694-2698

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INSULIN RESISTANCE

• N334
• J Clin Endocrinol Metab. 2002 Jan87(1)144-7.

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QUICKI VS AGE
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GLUCOSE/INSULIN VS AGE
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QUICKI VS BMI
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GLUCOSE/INSULIN VS BMI
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CURRENT 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

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CURRENT 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

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CURRENT RESEARCH

• Long term follow up and longitudinal studies
• Possible pharmacologic intervention
• ? Cannabinoid receptor inhibitors
• ? Surgical intervention