Pediatric Obesity: Prevention

1
Pediatric Obesity Prevention Management

• MaryKathleen Heneghan MD
• Endocrinology, Diabetes Metabolism
• Advocate Medical Group
• Lutheran General Childrens Hospital

2
I have nothing to disclose
3
Objectives

• Define and differentiate between overweight and
  obese
•  
• Briefly discuss co-morbidities of obesity and
  screening tests available
•  
• Discuss recommendations for treatment and
  prevention of overweight and obesity

4
Available free at www.dietaryguidelines.gov
Available free at www.endo-society.org
5

• Where have we been
• and where are we headed?

6
Obesity Trends Among U.S. AdultsBRFSS, 1985
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
7
Obesity Trends Among U.S. AdultsBRFSS, 1994
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
1519
8
Obesity Trends Among U.S. AdultsBRFSS, 2001
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
1519 2024 25
9
Obesity Trends Among U.S. AdultsBRFSS, 2008
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
1519 2024 2529
30
10
Obesity Trends Among U.S. AdultsBRFSS, 2010
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
1519 2024 2529
30
11
Prevalence of Self-Reported Obesity Among U.S.
AdultsBRFSS, 2011
Prevalence reflects BRFSS methodological changes
in 2011, and these estimates should not be
compared to previous years.
15lt20
20lt25 25lt30 30lt35
35
12
Prevalence of Self-Reported Obesity Among U.S.
AdultsBRFSS, 2011
State Prevalence Confidence Interval
Alabama 32.0 (30.5, 33.5)
Alaska 27.4 (25.3, 29.7)
Arizona 24.7 (22.7, 26.9)
Arkansas 30.9 (28.8, 33.1)
California 23.8 (22.9, 24.7)
Colorado 20.7 (19.7, 21.8)
Connecticut 24.5 (23.0, 26.0)
Delaware 28.8 (26.9, 30.7)
District of Columbia 23.7 (21.9, 25.7)
Florida 26.6 (25.4, 27.9)
Georgia 28.0 (26.6, 29.4)
Hawaii 21.8 (20.4, 23.4)
Idaho 27.0 (25.3, 28.9)
Illinois 27.1 (25.4, 28.9)
Indiana 30.8 (29.5, 32.3)
Iowa 29.0 (27.6, 30.3)
Kansas 29.6 (28.7, 30.4)
Kentucky 30.4 (28.9, 31.9)
Louisiana 33.4 (32.0, 34.9)
Maine 27.8 (26.8, 28.9)
Maryland 28.3 (26.9, 29.7)
Massachusetts 22.7 (21.8, 23.7)
Michigan 31.3 (30.0, 32.6)
Minnesota 25.7 (24.6, 26.8)
Mississippi 34.9 (33.5, 36.3)
State Prevalence Confidence Interval
Missouri 30.3 (28.6, 32.0)
Montana 24.6 (23.3, 26.0)
Nebraska 28.4 (27.6, 29.2)
Nevada 24.5 (22.5, 26.6)
New Hampshire 26.2 (24.7, 27.7)
New Jersey 23.7 (22.7, 24.8)
New Mexico 26.3 (25.1, 27.6)
New York 24.5 (23.2, 25.9)
North Carolina 29.1 (27.7, 30.6)
North Dakota 27.8 (26.3, 29.4)
Ohio 29.6 (28.3, 31.0)
Oklahoma 31.1 (29.7, 32.5)
Oregon 26.7 (25.2, 28.3)
Pennsylvania 28.6 (27.3, 29.8)
Rhode Island 25.4 (23.9, 27.0)
South Carolina 30.8 (29.6, 32.1)
South Dakota 28.1 (26.3, 30.1)
Tennessee 29.2 (26.8, 31.7)
Texas 30.4 (29.1, 31.8)
Utah 24.4 (23.4, 25.5)
Vermont 25.4 (24.1, 26.8)
Virginia 29.2 (27.5, 30.9)
Washington 26.5 (25.3, 27.7)
West Virginia 32.4 (30.9, 34.0)
Wisconsin 27.7 (25.8, 29.7)
Wyoming 25.0 (23.5, 26.6)

• Source Behavioral Risk Factor Surveillance
  System, CDC.
• Prevalence reflects BRFSS methodological changes
  in 2011, and these estimates should not be
  compared to previous years.

13

• Are trends similar for
• children and adolescents?
• Are trends similar in the
• Illinois?

14
Obesity trends
15
Overweight and obesity among 2-19 year olds in
the U.S.(Ogden et al, 2006, Ogden et al, 2010)
                                                 
                                                  
                                                  
                                                  
                                                  
                                                  
                                                  
                                                  
      
CLOCC press release 2010
16
In Chicago, Children Aged 3 To 7 Have a Much
Higher Prevalence of Obesity Than U.S. Children
2-5 Years Old
Obese rates in early childhood
U.S. data based on children 2-5 years old      
Chicago data based on children 3-7 years
old (Ogden et al, 2010, CLOCC press release, 2010)
17
Chicago Children Aged 10 to 13 Have a Higher
Prevalence of Obesity Than U.S. Children 6-11
Years Old
Obese rates in middle childhood
U.S. data based on children 6-11 years old  
Chicago data based on children 10-13 years old
18
In Illinois, Pre-teen and Teen (ages 10-17 years)
Obesity Rates Exceed U.S. Levels   
Obese rates in adolescence
Illinois children have a higher prevalence of
obesity (35) than US children (31) of the same
age   Illinois has the 10th highest percent of
obese and overweight children in the
U.S.  (Trust for Americas Health, 2009)
19
CLOCC

• The Consortium to Lower Obesity in Chicago
  Children (CLOCC) is a childhood obesity
  prevention program housed within the Center for
  Obesity Management and Prevention at Childrens
  Memorial Hospital.

20
We recognize the problem but need to make the
diagnosis
21
How to defineoverweight and obesity

• Use of the BMI
• Calculated by wt (kg)/ ht (m2)
• Increase BMI is related to morbidity and
  mortality in adults
• In females BMI naturally increases with puberty
• BMI may be skewed if child goes through puberty
  outside of normal range

22
How to define overweight and obesity

• Overweight - BMI is 85th-95th percentile based on
  age and sex
• Obese - BMI is gt95th percentile based on age and
  sex
• In children lt4 yr of age BMI may not be precise
  and weight for height charts may be used as a
  warning sign

23
Endocrine causes

• GH deficiency
• Hypopituitarism
• Hypothyroidism

• Cushing disease
• Pseudohypoparathyroidism

Endocrine causes associated with increased BMI
but stature and height velocity is
decreased where as Stature and height velocity
are usually increased with exogenous obesity
24
Looking for endocrine cause

• The Endocrine Society recommends against routine
  lab evaluation for endocrine causes of obesity in
  obese children/adolescents unless the childs
  height velocity is attenuated
• 2 uncommon circumstances
• Adrenal tumor exam should have signs of
  virilization
• Growth without growth hormone (idiopathic
  isolated GH deficiency)

25
Obesity and hypothyroidism

• Hypothyroidism remains an unlikely sole cause of
  obesity
• Recent studies confirm mildly elevated TSH may be
  seen with obesity
• retrospective review of medical records of 191
  obese and 125 nonobese children
• Six obese patients had Hashimoto disease and TSH
  values from 0.73 to 12.73 mIU/L
• Out of 185 obese subjects, 20 (10.8) had TSH
  levels gt4 mIU/L, with no control subject
  measurement exceeding this TSH value.
• The highest TSH concentration in an obese study
  subject was 7.51 mIU/L.
• Mild elevation of TSH values in the absence of
• autoimmune thyroid disease is not uncommon in
• some obese children and adolescents

Dekelbab BH, Abou Ouf HA, Jain I. Prevalence of
elevated thyroid-stimulating hormone levels in
obese children and adolescents. Endocr Pract.
2010 Mar-Apr16(2)187-90.
26
Genetic Testing

• Refer to Genetics those children whose obesity is
  related to a syndrome
• Early onset obesity MC4R Gene testing
• Melanocortin receptor 4
• Predisposes people to obesity
• Children with weight gain since early infancy and
  are gt97th centile for weight by age 3
• Positive in about 2-4 of patients gt97th centile
• NO TREATMENT AVAILABLE

27
Co-Morbidities

• Evaluate those with BMI gt85th centile

28
Pre-Diabetes

• Impaired fasting plasma glucose
• Fasting glucose gt100 mg/dl
• Impaired glucose tolerance
• 2 hour glucose gt140 but lt200
• New since 2010 HgbA1c from 5.7 6.4

29
Diabetes Mellitus

• Fasting plasma glucose gt126 mg/dl
• Random plasma glucose gt200 mg/dl
• 2 hour glucose gt200 mg/dl on OGTT
• New since 2010 HgbA1c gt6.5
• If asymptomatic must repeat
• abnormal values

30
Dyslipidemia
Fasting Lipids 75th percentile 90th percentile
Triglycerides (sugar starchy foods and diets high in saturated fat) gt110 mg/dl gt160 mg/dl
LDL (saturated and trans fats) gt 110 mg/dl gt130 mg/dl
Total Cholesterol gt180 mg/dl gt200 mg/dl
HDL (exercise fruits and veggies) (10th percentile) lt35 mg/dl (25th percentile) lt40 mg/dl
Primary treatment is dietary changes
pharmacotherapy is available
31
Hypertension

• Blood pressure gt 90th centile according to sex,
  age and height percentile
• Quick estimate
• Systolic 90 (3 x age in years)
• Diastolic 50 (1.5 x age in years)

32
Nonalcoholic Fatty Liver Disease

• Alanine aminotransferase (ALT) gt 2 SD above the
  mean for the laboratory
• ALT elevation greater than AST elevation
• NAFLD can progress to NASH and cirrhosis

33
(No Transcript)
34
Risk factors for developing obesity

• Maternal diabetes
• SGA
• LGA
• Parental obesity (maternal gtpaternal)
• Maternal weight gain during pregnancy
• Breastfeeding duration
• Weight of siblings

35
Medical History

• Presence of snoring and apnea
• Polyuria, polydipsia or weight loss
• Acne, hirsutism, menstrual history
• Use of psych meds
• Dietary History
• Type and quantity of beverage intake
• Frequency of dining out
• Frequency and type of snacks
• Activity History
• Duration and frequency of exercise during the day
• Estimates of screen time
• Availability and safety of parks and gyms

36
Physical Exam

• Waist circumference
• Blood pressure
• Acanthosis nigricans and skin tags
• Severe acne and hirsutism
• Tenderness and range of motion of knee, leg and
  foot
• Peripheral edema

37
Once the diagnosis is made
38
Care Providers Perceived Barriers to Treatment
Story M, Neumark-Stzainer D, Sherwood N, et al.
Management of Child and Adolescent Obesity
Attitudes, Barriers, Skills, and Training Needs
Among Health Care Professionals. Pediatrics
serial online. July 2, 2002110(1)210.
39
Care Providers Perceived Barriers to Treatment
Story M, Neumark-Stzainer D, Sherwood N, et al.
Management of Child and Adolescent Obesity
Attitudes, Barriers, Skills, and Training Needs
Among Health Care Professionals. Pediatrics
serial online. July 2, 2002110(1)210.
40
Recommendations

• Intensive lifestyle modification
• Dietary
• Physical activity
• Behavioral
• Age Appropriate

41
Physical Activity

• 60 min of daily moderate to vigorous physical
  activity
• Look Listen - Feel sweat, breathing hard and
  heart beating faster
• Decreased screen time to 1-2 hours per day
• Can balance screen time with activity by allowing
  X amt of screen time per X minutes of physical
  activity

42
Exercise

• A factor contributing to weigh re-gain may be
  lack of continued exercise program
• The odds for weight regain are 2-fold greater in
  those patients who are sedentary
• Meta analysis of long term maintenance studies
  showed a 27.2 weight loss retention in low
  exercise group and 53.8 weight loss retention in
  high exercise group?

?
43
Dietary Guidelines for Americans 2010
44
Dietary Guidelines for Americans 2010
45
Factors for successful weight maintenance

• Reduced caloric intake
• Reduced fat intake
• Reduced fast food consumption

46
Dietary recommendations

• Avoid consumption of calorie dense, nutrient poor
  foods
• Sweetened beverages
• Sports drinks
• Fruit drinks/juices
• Most fast food
• Calorie dense snacks
• One must expend or not take in 3500 calories to
  lose 1 pound of fat

47
Beverage consumption
Beverage consumption in the US population.Storey
ML - J Am Diet Assoc - 01-DEC-2006 106(12)
1992-2000
48
Beverage consumption
Beverage consumption in the US population.Storey
ML - J Am Diet Assoc - 01-DEC-2006 106(12)
1992-2000
49
Beverage consumption in the US population.Storey
ML - J Am Diet Assoc - 01-DEC-2006 106(12)
1992-2000
50
Beverage consumption
Beverage consumption in the US population.Storey
ML - J Am Diet Assoc - 01-DEC-2006 106(12)
1992-2000
51
Beverage consumption

• If the average child/adolescent switched to water
  and skim milk (8-12 oz per day) most would lose 1
  pound every 1-2 weeks
• Skim milk (8oz) 91 calories

52
Dietary Recommendations

• Portion control
• Plate method
• Divide plate into quadrants
• ½ with fruit and veggies
• ¼ with starch
• ¼ with protein
• Fist method
• 2 fists veggies
• 1 palm protein
• 1 fist starch
• 1 fist fruits

53
Dietary Recommendations

• Reducing saturated fat for children gt 2 y/o
• Increasing intake of dietary fiber, fruits and
  vegetables
• Eat timely, regular meals (especially breakfast)
  and avoid grazing
• Overweight children and adolescents are more
  likely to skip breakfast and consume few large
  meals per day
• Frequent snacking is associated with higher
  intake of fat, sugar and calories

54
Dietary Guidelines for Americans 2010
55
Dietary Guidelines for Americans 2010
56
Intensive Lifestyle Modifications

• Intensive counseling with at least one person to
  person session per month for the first 3 months
• Intensive plan covering diet, exercise and
  behavior changes
• Monthly follow up
• A maintenance program after the intensive
  treatment
• Is it feasible? Poor reimbursement

57
Parental Guidance Commitment

• Educate parents about the need for
• Modeling of healthy habits
• Avoidance of overly strict diets
• Setting limits of acceptable behavior
• Avoidance of food as a reward or punishment

58
Family Commitment

• Good data is lacking regarding interventions in
  pediatric populations
• Most suggest involving the entire family yields
  better results than targeting individual

59
Success of lifestyle modifications

• Anticipate a success rate of about 25
• Accept this and continue developing techniques to
  help lifestyle modifications be effective in a
  larger percentage of patients

60
Pharmacotherapy

• Reserved for those with co-morbidities who have
  undertaken intensive lifestyle modification with
  no success
• Metformin not FDA approved for treatment of
  obesity. Meta-analysis have failed to show a
  significant change in BMI
• Sibutramine, Orlistat, Octreotide, Topiramate and
  GH are other options reserved for use by those
  who specialize in weight loss therapy.

61
Bariatric Surgery

• Referral to clinic with specific experience in
  bariatric surgery in adolescents
• Reserved for those
• Tanner 4 or 5
• BMI gt50 kg/m2 or gt40 kg/m2 with significant
  severe co-morbidities
• Participation in a formal lifestyle modification
  program
• Psychological evaluation
• Experienced surgeon
• PATIENT DEMONSTRATES THE ABILITY TO FOLLOW
  HEALTHY DIETARY AND ACTIVITY HABITS

62
Prevention
63
Prevention

• Breastfeeding for a minimum of 6 months
• Educate families through anticipatory guidance at
  each visit help them realize there may be a
  problem
• Educate the community

64
Breastfeeding
Percent of births at Baby-Friendly facilities in 2012, by state
                                                                                                                
Data Source CDC National Survey of Maternity Practices in Infant Nutrition and Care (mPINC)
65
Breastfeeding
66
Ban on Happy Meals

• Santa Clara County, California banned restaurants
  from using toys or other goodies to entice kids
  to order unhealthy food. What are the limits?
• 120 calories in a beverage
• 200 calories in a single food item
• 485 calories in a meal
• 480 mg sodium in a single item
• 600 mg sodium in a meal
• 35 percent total calories from fat
• 10 percent of calories from added sweeteners

67
Ban on Happy Meals

• San Francisco followed with similar ban in Nov
  2010
• Passed with an 8-3 vote
• Took effect December 2011
• McDonald's is complying with ordinance by
  charging 0.10 for the addition of a toy -- with
  the proceeds benefitting the Ronald McDonald
  House Charity
• Has made a difference in some aspects
• McDonalds now offering apple slices and fries in
  all meals
• Other fast food companies have eliminated toys in
  California
• New York City is proposing similar legislation

68
Advocacy

• Providers need to advocate for
• Policies to decrease exposure of children and
  adolescents to promotion of unhealthy food
  choices in the community
• School districts to provide healthy food and
  drinks along with physical activity programs
• All communities to have safe recreational areas
  and access to affordable high quality fresh
  fruits and vegetables

69
In Summary

• Obesity is an extremely prevalent disease (even
  in children and adolescents) and needs our
  attention now
• We need to provide guidance for families at every
  visit to help incorporate
• Increased physical activity
• Healthy dietary choices
• Behavior changes for the family
• We need to advocate for change

70
Thank you
71
Available free at www.dietaryguidelines.gov
Available free at www.endo-society.org