Childhood Mal-Nutrition: Solutions from Family

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Childhood Mal-Nutrition Solutions from Family
Physicians
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2
FOUR PRIMARY RISK FACTORS

• Formula feeding during infancy
• Consumption of sugar-sweetened drinks
• Excessive television/video viewing
• Low physical activity

Whitaker (2003)
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THEMES

• Life on a J-shaped curve
• Applying Newtons Laws of Thermodynamics
• Common Sense vs Evidence

4
Are you comfortable with calculating body mass
index (BMI)?

• Yes
• No

Kg/m2
5
Do you know how to apply BMI to help a child lose
weight?

• Yes
• No

6
Which do you feel is most effective in helping
children lose weight?

• Diet
• Exercise
• Medication
• Motivational counseling
• Multidisciplinary combination of tools

7
Since entering medical school, has your BMI

• Increased
• Decreased
• Stayed the same

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During which period was/has it been it easiest
for you to get enough exercise?

• Medical School
• Residency
• Staff

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What do you think is the worst disease for
children? (Rank 3)

• Obesity
• Cleft Lip
• Cystic Fibrosis
• Muscular Dystrophy
• Cerebral Palsy
• Diabetes
• Asthma

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What is best measure of obesity in children?

• BMI
• Waist Circumference
• Waist to height ratio
• Waist to hip ratio
• No clue

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How may children are overweight or at-risk for
overweight in the US?

• 1 in 6
• 1 in 10
• 1 in 4
• 1 in 3

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OBJECTIVES

• Define terms
• Describe epidemiology
• Discuss risk factors and implications
• Decide what to do about it
• Take home messages
• Central role for Family Physicians

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DEFINITIONS

• Underweight
• BMI lt5 for age
• Normal
• BMI 6-84 for age
• At risk for overweight
• BMI 85-95 for age
• Overweight
• BMI gt95 for age

Overwt Obese (IOM, 2005)
http//www.cdc.gov/growthcharts/
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WHY BMI?

• Can be used from childhood into adolescence and
  adulthood
• Correlates with laboratory measures of fat
• Best we have for now

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DIAGNOSIS

• Based on CDC BMI-for-Age curves
• Children should be screened for obesity (SORT C)

CSBM
VS
DADT?
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So What?

• OVERWEIGHT CHILDREN BECOME OVERWEIGHT ADULTS

Guo, 2002
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So What, Part 2

• OVERWEIGHT ADULTS HAVE MUCH HIGHER RISK

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Background Data

• Overweight has tripled in US kids since 1980
• 31 of 6-19 year-olds are overweight or
  at-risk-to-become overweight
• 10 of 2-5 year-olds are overweight or
  at-risk-to-become overweight

www.cdc.gov
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COLLATERAL DAMAGE
Trifiletti, 2006
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Not Just an American Problem

• Country Boys gt 85ile Girls gt 85ile
• Austria 12 11
• Belgium 13 15
• France 10 13
• Ireland 19 14
• Portugal 14 21
• Sweden 12 12
• USA 28 31

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URBANIZATION AND GLOBALIZATION

• NUTRITION TRANSITION
• Agro-food systems (global corporations)
• Cheap, calorie-dense foods, fats and oils
• Reduction in local subsistence farming
• Congregation in urban areas
• Consumer culture
• Less physical activity
• More oils/fats/calories

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URBANIZATION AND GLOBALIZATION?

• IMAGINE 3 CHILDREN
• 1. Laura Ingalls (19th century pioneer)
• 2. Salvo Barbagallo (early 20th century
  Sicilian)
• 3. Jimmy Smith (21st century American)
• Food sources
• Activity outlets
• Educational opportunities
• Work opportunities

MULTIFACTORIAL!!!
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How many servings of fruits or vegetables are
recommended per day?

• 1
• 2
• 3
• 4
• 5 or more

2006 YRBS data
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How many glasses of milk should adolescents
consume per day?

• 1
• 2
• 3 or more
• No specific intake is currently recommended

2006 YRBS data
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How many HS students watch more than 3 hours of
TV per day?

• 1 in 2
• 1 in 3
• 1 in 4
• 1 in 5
• 1 in 6

2006 YRBS data
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How many HS students meet recommended activity
levels?

• 1 in 2
• 1 in 3
• 1 in 4
• 1 in 5
• 1 in 6

2006 YRBS data
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SO WHAT?
Jot down diseases you think obesity increases
risk for
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Childhood/Adolescent Overweight Increases Risk for

• Hypertension
• Diabetes
• Hyperlipidemia
• Coronary Artery Disease
• Gallbladder disease
• Steatohepatitis

• Obstructive sleep apnea
• Pseutotumor cerebri
• Orthopedic complaints
• PCOS
• Metabolic Syndrome
• Depression
• All-cause mortality

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Psychosocial Effects of Obesity

• Decreased self-esteem
• Bullying
• Stigmatization
• Sadness
• Loneliness
• Isolation
• Increased SI/SA

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STIGMATIZATION

• Children shown pictures of obese kids and kids
  with various disabilities said they would be
  least likely to befriend the obese child

Latner, Obes Res 2003
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STIGMATIZATION

• Overweight adolescent women
• Lower education
• Decreased earning potential
• The worst handicap for young adolescents?

PARENTS OVERLOOK!!
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Causes of Pediatric Obesity

• INTAKE ? OUTPUT
• Energy is neither created nor destroyed
• The disorder of an isolated system can never
  decrease (Entropy)
• A body at rest tends to stay at rest (Inertia)

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CAUSALITY? GENETICS?
Genetics explains 30-50 of tendency to adiposity

• Genetics
• Leptin
• Melanocortin
• Adiponectin
• 1 parent obese (50) 2 parents (80)

At least 430 genes linked with obesity
phenotypes at present (Spieser, 2005)
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CAUSALITY? GENETICS?

• Secondary obesity
• Prader-Willi
• Bardet-Biedl
• Beckwith-Wiedeman

Secondary causes should particularly be
considered when the child is obese AND short OR
dysmorphic
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DIET, EXERCISE and the MODERN ENVIRONMENT
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MAL-NUTRITION
FOOD IS

• Increasingly available
• Calorie-rich
• Nutrient-poor
• CHEAP

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FAT

• 4 decrease in overall fat intake in US since
  1970
• ADDED fat (butter, oil shortening) has doubled
  since 1909 (annual average of 64lb/person)

Recent WHI data!
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CALORIES

• Increased availability (3300 to 3800 kcal/d
  from 70 to 98)
• Increased density

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CARBS

• Added sugars 20 of adolescent Kcal
• Avg of 20 tsp/day
• Glycemic Index has increased.

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CALCIUM

• Inverse relationship between calcium intake and
  adipose levels
• 85 of adolescents do not meet RDI for calcium

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FRUITS AND VEGETABLES

• Overall US intake has increased 24 since 1970
• 80 of children and adolescents do not meet USDA
  recommendations (5-a-day)

Eat a Rainbow
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FAST FOOD

• On any given day, 20-30 of US households
  patronize a restaurant.
• 25-50 of all meals are away-from-home (35 of
  overall energy intake)
• Fast food 10 of school food!

Washington Post, 2007
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FAST FOOD

• Children who consume fast food
• More total energy
• More total fat
• More total carbohydrate
• More added sugars
• Less fiber
• Less calcium
• Fewer fruits and vegetables

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SUGARED BEVERAGES

• Sugar-Sweetened Beverages (SSB)
• Beverage of choice
• Intake has doubled over past 20 years
• Average 19 oz/day for boys 11 oz/day for girls

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HIGH FRUCTOSE CORN SYRUP
Beware the hidden simple sugars!
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PHYSICAL INACTIVITY

• 25 of adolescents do not engage in sufficient
  physical activity 14 do not exercise at all.
• Only 28 of 9th-12th graders have daily PE
• Many in PE arent active!
• Play is the traditional, spontaneous form of
  physical activity
• Organized sports activities

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PHYSICAL INACTIVITY

• Free time is increasing
• 2-3 hours/wk used for physical activity
• 28 hours/wk used for television/videos
• gt40,000 targeted ads for candy, cereal and fast
  food

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TV/VIDEO

• 38 of children watch at least 3 hours of TV on
  most, if not all, school days.
• 98 of households have 1 TV 75 have 2
• Hours of TV viewing correlate directly with BMI

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MOTORIZED TRANSPORTATION

• Walking/cycling decreased 40 from 1977 to 1999
  in ages 5 to 15
• Most families take an average of 4 trips per day
• The average trip is 0.8 miles

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• Enough data!
• I understand that there is a problem!!

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WHAT IS A FAMILY PHYSICIAN TO DO?

• Multifactorial interventions delivered to the
  FAMILY were more effective at reducing BMI than
  interventions delivered to children alone

Clin Ev Handbook, 2007
Do what you do best!!
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Family Physicians The Key to Success!

• Prenatal Care
• Infant Care
• Child Care
• Adolescent Care
• Adult Care
• Geriatric Care

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Life on a J-shaped Curve
Mortality
Clinical Endpoint Birthweight
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BMI AND MORTALITY
Mortality
Clinical Endpoint BMI
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PRENATAL

• SGA at high risk for adult CV mortality!
• Barker Hypothesis The Fetal Jones
• Fetal Programming
• Intrauterine deprivation
• Premature Infants
• LGA infants (fetal over-nutrition)

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WHATS A FAMILY PHYSICIAN TO DO?

• Optimize BMI prior to conception
• Promote tobacco cessation
• Promote and sustain regular physical activity
• Promote and sustain healthy dietary choices
• Identify and treat gestational diabetes

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Family Physicians The Key to Success!

• Prenatal Care
• Infant Care
• Child Care
• Adolescent Care
• Adult Care
• Geriatric Care

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(No Transcript)
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INFANTS

• Breastfeed first 6 (preferably 12) months of life
  (SOR A)
• Restrict sugar sweetened beverage use (SOR C)
• Intake of sugar sweetened fruit drinks (other
  than 100 fruit juice) is associated with excess
  weight gain and obesity (SOR B)

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INFANTS

• If parents choose to introduce fruit juice, do so
  after 6 months (SOR C)
• If parents choose to introduce fruit juice, they
  should provide only 100 fruit juice in a cup.
  Limit intake to 4-6 oz/day (SOR C)
• Do not use fruit juice as a substitute for whole
  fruits. (SOR C)

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Family Physicians The Key to Success!

• Prenatal Care
• Infant Care
• Child Care
• Adolescent Care
• Adult Care
• Geriatric Care

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(No Transcript)
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LIFE ON THE J-SHAPED CURVE
Morbidity
Clinical Endpoint Adiposity Rebound
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CHILD

• AVOID ADIPOSITY REBOUND
• In children with low birth weight, rapid gain in
  BMI after age 2 is associated with highest
  increase in adult mortality from heart disease
  (Cameron, 2002)

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ADIPOSITY REBOUND
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CHILD

• Visceral obesity predicts cardiovascular outcomes
  independent of BMI (Fox, 2007)
• Modern children have higher visceral
  (intra-abominal) fat than prior generations
• Higher BMI in childhood associated with increased
  CHD risk as adult (Baker, 2007)

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CHILD

• Mild caloric restriction
• Grow into weight
• Regular activity (together?!)
• Eat meals together!
• Limit TV/Videos

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Family Physicians The Key to Success!

• Prenatal Care
• Infant Care
• Child Care
• Adolescent Care
• Adult Care
• Geriatric Care

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ADOLESCENCE

• If current rates stay stable, adolescent
  overweight will increase the prevalence of obese
  35-year-olds to 35 in men and 42 in women by
  2020 (Bibbins-Domingo, 2007)

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ADOLESCENT CARE

• Variety of foods
• School cafeteria choices
• School vending machines
• Daily physical activity
• Reduce television/video/computer mindless time

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DIET

• Mild caloric restriction
• Do not severely restrict calories
• No evidence for/against low-carb diets
• Reduce/eliminate pre-sweetened drinks
• Ensure adequate calcium intake
• Ensure adequate fiber intake
• Ensure adequate fruit and vegetable intake

SHOP THE OUTER AISLE
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ACTIVITY

• Imprint activity as a way of life early
• Emphasize health benefits of physical activity
  rather than competition

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BEHAVIOR MODIFICATION

• Involve the family
• Meals
• Activities
• Emphasize the positive
• Important to patient?
• Confident they can change?
• Adjunct professionals

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MEDICATION

• Always a second line
• Metformin (MVI)
• Orlistat
• Sibutramine
• All positive studies are in adolescents only, and
  all incorporate diet, exercise and behavioral
  modification.

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SURGERY

• Only for very carefully selected adolescents at
  very carefully selected centers

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SUMMARY

• J-shaped curve
• Theromodynamics
• Common sense

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LIFE ON THE J-CURVE
Mortality
Clinical Endpoint(s) BP Chol BW etc.
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SUMMARY

• J-shaped curve
• Theromodynamics
• Common sense

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SUMMARY

• J-shaped curve
• Theromodynamics
• Energy
• Entropy
• Inertia
• Common sense

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SUMMARY

• J-shaped curve
• Theromodynamics
• Common sense

Do what you do best!!
CSBM
VS
81

• Unless effective population-level interventions
  to reduce obesity are developed, the steady rise
  in life expectancy observed in the modern era may
  soon come to an end and the youth of today may,
  on average, live less healthy and possibly even
  shorter lives than their parents.
• Olshansky et al. NEJM 3521138-1145, 2005

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VERBS RULE! Counsel the ING
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