PEDIATRIC OBESITY: A HUGE PROBLEM IN THE USA: PEDIATRIC OBESITY: A HUGE PROBLEM IN THE USA William J. Cochran, MD Department of Pediatric GI andamp; Nutrition Geisinger Clinic


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WHY WORRY ABOUT PEDIATRIC OBESITY?: 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: DEFINITION OF PEDIATRIC OBESITY Overweight / At risk of overweight BMI 85-95% Obese / Overweight BMI andgt;95%


OLDER DEFINITIONS OF OBESITY: OLDER DEFINITIONS OF OBESITY Weight for height andgt;95% Actual weight andgt;120% ideal body weight Super obese andgt;140% of ideal body weight


Percent of obese children and adolescents: Percent of obese children and adolescents


INCIDENCE OF PEDIATRIC OBESITY IN PENNSYLVANIA: INCIDENCE OF PEDIATRIC OBESITY IN PENNSYLVANIA


RACIAL DIFFERENCES IN PEDIATRIC OBESITY: RACIAL DIFFERENCES IN PEDIATRIC OBESITY Non-Hispanic white 12.3% African American 21.5% Hispanic 21.8%


WHY WORRY ABOUT PEDIATRIC OBESITY?: WHY WORRY ABOUT PEDIATRIC OBESITY? Is pediatric obesity a real problem or just a cosmetic issue?


WHY WORRY ABOUT PEDIATRIC OBESITY?: 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


WHY WORRY ABOUT PEDIATRIC OBESITY?: WHY WORRY ABOUT PEDIATRIC OBESITY? Significant risk of childhood obesity to persist into adulthood.


PERCENT OF OBESE CHILDREN BECOMING OBESE ADULTS: PERCENT OF OBESE CHILDREN BECOMING OBESE ADULTS


WHY WORRY ABOUT PEDIATRIC OBESITY?: 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: 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: 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: 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: 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: 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 andgt;90% Geisinger weight management program 60% have insulin resistance 10% have fasting insulin level andgt; 100 (Nl andlt;17) 1% have type II DM


CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITY: 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: 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: 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: 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: CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITY Orthopedic Slipped capital femoral epiphysis 30-50% are obese Blount’s disease (Tibia vara) 70% are obese Neurologic Pseudotumor cerebri


CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITY: CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITY Respiratory Sleep disorder in 1/3 Sleep apnea: 7% of obese, 1/3 if andgt;150% andamp; breathing difficulties Hypoventilation syndrome Gastrointestinal Cholelithiasis 50% of cases of cholecystitis in adolescents are obese


Slide28: PEDIATRIC OBESITY IS NOT JUST A COSMETIC PROBLEM!


ETIOLOGY OF PEDIATRIC OBESITY: ETIOLOGY OF PEDIATRIC OBESITY


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: 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: 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: ETIOLOGY OF OBESITY Physical activity TV / video games More time spent watching TV less time for physical activity: average 2.5 hours / day, 20%andgt;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: TREATMENT OF PEDIATRIC OBESITY Weight management programs are available and can be effective High rates of recurrence Prevention is the key


PREVENTION: PRECONCEPTION: 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: 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: 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 andamp; 6 months andgt; in formula fed vs. breastfed infants Rate of obesity at 6 years was tripled in formula fed vs. breastfed


PREVENTION OF PEDIATRIC OBESITY: 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: 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: 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: NUTRITION ANTICIPATORY GUIDANCE Beverages Encourage water intake Limit sweet beverages Juice, juice drinks: 120 calories / 8 oz No nutritional need for any juice andlt;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: 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: NUTRITION ANTICIPATORY GUIDANCE Encourage child’s 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 andgt;5 years is dependent on how much they are provided Do not skip meals


ACTIVITY ANTICIPATORY GUIDANCE: 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: ACTIVITY ANTICIPATORY GUIDANCE Decrease sedentary activity Limit TV, video games and computer to 1-2 hours per day andgt; 2 hours a day associated with higher rates of obesity and hyperlipidemia Do not have a TV in the child’s room Children with TVs in bedroom watch more TV


ACTIVITY ANTICIPATORY GUIDANCE: 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: 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: 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: 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: 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 OF PEDIATRIC OBESITY


TREATMENT GOALS: 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: TREATMENT GOALS Weight goals First step is to achieve weight maintenance 2-7 years of age BMI 85-95% Weight maintenance BMI andgt;95% No complications: weight maintenance Complications: weight loss


TREATMENT GOALS: TREATMENT GOALS Weight goals 7-18 years of age BMI 85-95% No complications: weight maintenance Complications: weight loss BMI andgt;95% Weight loss


EVALUATION OF THE OBESE CHILD: 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: TREATMENT OF PEDIATRIC OBESITY First step is to educate the patient and parents about obesity Assess patient and the family’s readiness to make change Treatment needs to be individualized and family based Make only a few changes at a time


TREATMENT OF PEDIATRIC OBESITY: 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: 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


TREATMENT OF PEDIATRIC OBESITY: TREATMENT OF PEDIATRIC OBESITY Formal obesity clinic Advantages Appropriate time Frequent visits Utilize each team members expertise Good outcomes if completed


Weight Loss Pharmacotherapy: Weight Loss Pharmacotherapy Sibutramine FDA approved 1997 Induces feeling of satiety Increases 5HT andamp; Norepi. Caution with use in combination with SSRI’s 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


BARIATRIC SURGERY: BARIATRIC SURGERY Little information on pediatric bariatric surgery May be appropriate in individual cases Severe obesity, BMI andgt; 40 Significant co-morbidities Unresponsive to more conventional weight loss program


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


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


CONCLUSIONS: 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: 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: TREATMENT OF PEDIATRIC OBESITY Protein sparing modified fast Low carbohydrate diet


Restrictive Bariatric Procedures: Restrictive Bariatric Procedures Mun EC, Blackburn GL, Matthews JB. Gastroenterology 2001:120:669-681 Adjustable Gastric Banding Vertical Banded Gastroplasty Roux-en-Y Gastric Bypass


WEB SITEES OF INTEREST: 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


WEB SITEES OF INTEREST: 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


WEB SITEES OF INTEREST: 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


BARRIERS TO THERAPY OF PEDIATRIC OBESITY: 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 : 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


PREVENTION: SCHOOL: 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: PREVENTION: COMMUNITY Have safe playgrounds Provide safe places for bike riding and walking Promote physical activity outside of school


PREVENTION: INSURANCE AND GOVERNMENT: 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: PREVENTION: PRIMARY CARE PROVIDER Be an advocate