GR2012-06 Periatric Obesity and Our Future - Dr Savio

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Pediatric Obesity and our future:

Pediatric Obesity and our future Bob Savio MD Chief of Pediatrics, Highland Hospital June 9th, 2012

Outline:

Outline Three current clinic patients The obesity epidemic Our community: obesity and health care disparities Addressing the obese child in clinic Pilot project “Bite To Balance” Hope

Definitions:

Definitions Adult overweight = BMI 25-29.9 Adult obesity = BMI>=30 Childhood Overweight = BMI% > 85% for age/sex Childhood Obesity = BMI% > 95% for age/sex

Clinic Case #1: Patient S.V. 5 year old female:

Clinic Case #1: Patient S.V. 5 year old female Morbid obesity by 1 1/2 years Elevated LFTs, (ALT = 112) BMI = 31.5 by 2 1/2 years!! Referred to GI, Healthy Hearts, and Endocrine. W/U negative, including normal brain MRI to r/o pituitary tumor Patient S.V.

PowerPoint Presentation:

Updated WHO growth curves (with more breastfeeding) Patient S.V. New 2010 WHO growth chart Old WHO growth chart Patient S.V.

PowerPoint Presentation:

Patient S.V.: Growth Curve 2-6 years old Patient S.V. Patient S.V.

Patient S.V.:

Patient S.V. “For breakfast, S.V. typically eats two plates of rice and vegetables, spiced fruits, milk, juice and water. For lunch..spiced fruits, cookies, chips, and full-fat yogurt. For dinner...will eat a combination of beans, egg, soup with pasta, meat, chicken or sausages....frequently snacks and is looking for food between meals. Her favorite food is bread, but she often seeks out sweets, chips, and cookies....”

Clinic Case #2: Patient K.R. 10 year old female:

Clinic Case #2: Patient K.R. 10 year old female New obese clinic patient at 3 years old Recurrent UTI’s (10) since then. Incontinence, constipation, poor hygiene Referred to nephrology, nutrition, GI and endocrinology Patient K.R.

Patient K.R.:

Patient K.R. 10/2009: “Her incontinence is becoming a serious issue that is affecting her at school...She also has problematic interactions with her peers as they tell her that she “smells”. 8/2011: Endocrine and GI consultation as increased LFT’s, HgA1C and abnormal liver ultrasound

Patient K.R.:

Patient K.R. Patient K.R. Patient K.R.

Clinic Case #3: Patient A.L. 15 year old male:

Clinic Case #3: Patient A.L. 15 year old male New well child for shots and school physical 4/16/2012 FMHx: No hypertension, although father with high BP’s during recent anal fistula surgery at Highland. 4 men on maternal side died of cardiac disease in past two years. Patient A.L.

Patient A.L.:

Patient A.L. Weight 215.5, Height 71 inches. BMI = 30.1 (>95%) Blood pressure = 147/87, 138/84 No complaints. P.E.: acanthosis nigricans Mom and patient think weight is down from about 240

Obesity as an epidemic:

Obesity as an epidemic In epidemiology , an epidemic ( ε π ί (epi)- meaning "upon or above" and δήμος (demos)- meaning "people"), occurs when new cases of a certain disease , in a given human population, and during a given period, substantially exceed what is expected based on recent experience.

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US Adult Obesity Trends:

US Adult Obesity Trends

US Pediatric Obesity Trends:

US Pediatric Obesity Trends

Epidemiology of Obesity:

Epidemiology of Obesity 2/3 of adults in US are overweight/obese 1970’s: 5% of kids obese/overweight Today: 30+% are obese/overweight ( 19+% are obese)

Pediatric Obesity Pathway:

Pediatric Obesity Pathway Childhood Obesity Adult Obesity Heart disease (hypertension) Cardiovascular disease (stroke) Diabetes 77% of obese kids in Bogalusa Heart Study became obese adults......

Bogalusa, Louisiana:

Bogalusa, Louisiana Dr. Gerald Berenson ...longest running biracial health study in the world

Bogalusa Heart Study:

Bogalusa Heart Study Followed 16,000 kids into adulthood since early 1970’s 77% of obese kids became obese adults Only 7% of normal weight kids became obese adults First evidence that cardiac pathology starts in children 20% of autopsied kids had plaque = those known to have hypertension and high cholesterol

Basic Science:

Basic Science Inflammatory markers point to connection of obesity and its co-morbidities (CVD, DM2, HTN) 35% higher monocyte concentration Cytokines interact with monocytes to contribute to the inflamed state: TNF-alpha (tumor necrosis factor alpha). Involved in pathophysiology of athrosclerosis and insulin resistance. 34% higher in obese group MCP-1 (Monocyte chemoattractant protein 1) Stimulated by TNF-alpha, recruits monocytes to inflamed adipose and vascular tissue. 22% higher Breslin et al, Pediatrics 2012 129;e1180

Epidemiology of Obesity:

Epidemiology of Obesity NATURE & NURTURE GENES ENVIRONMENT are not our destiny! behavior modifies Likely hundreds of genes 60-70% of obesity risk is inheritable Diet Exercise Built environment Advertising

US Socioeconomic Disparities in Obesity:

US Socioeconomic Disparities in Obesity

Disparities in Obesity Rates:

Disparities in Obesity Rates Of the 10 states with the highest obesity rates , 9 are among the nation’s poorest 1/3 of children born in 2000 will get diabetes; 1/2 if you are African American or Latino WHY???

Alameda County Statistics:

Alameda County Statistics In Alameda County... 30.5% were obese. African Americans had the highest prevalence of obesity (42.4%)—over five times the rate among Asian/Pacific Islanders and 2.4 times the rate among Whites. Prevalence of overweight increased with income; the reverse pattern was observed for obesity. Alameda County Public Health Department. The Health of Alameda County Cities and Places: A Report for the Hospital Council of Northern and Central California, 2010. Oakland, California. July 2010.

WHY?:

WHY? Processed, calorically dense foods are cheap and fast and readily available Advertising Food deserts Dangerous neighborhoods Education disparities Lower breast feeding rates

Disparities in Obesity Rates:

Disparities in Obesity Rates Obese kids are hospitalized at 2-3x typical rate Obesity increase pediatric asthma risk by 50% Obese kids have much higher mental health issues

The clinic setting:

The clinic setting Universal assessment (BMI for all over 2 years annually) Medical evaluation Motivational interviewing Target behaviors (5-4-3-2-1), set agenda

Medical evaluation:

Medical evaluation Family history Evaluation of weight related problems (sleep issues, respiratory, GI, orthopedic complications, bullying...) Physical exam. BMI, blood pressure Labs (Lipid panel, fasting insulin and glucose, ALT, AST)

Universal Lipid screening:

Universal Lipid screening Universal non-fasting cholesterol and HDL screening for all children at 9-11 years and 17-21 years

AAP approach:

AAP approach

PowerPoint Presentation:

ACOPP: Alameda County Obesity Prevention Program

Education - Physical activity:

Education - Physical activity Regular exercise Limit screen time “TV free week ” Oakland marathon!

Education - diet:

Education - diet Breastfeeding! “Soda Free Summer” campaign

Food Choice:

Food Choice

Bite To Balance: A pilot study:

Bite To Balance: A pilot study 15 families, 20 kids Weekly CSA bag x 6 months Monthly educational session Tracked BMI, labs, food attitudes (pre- and post-)

Pilot Study- Demographics:

Pilot Study- Demographics Average family income for family of 4.1 = $18,000 35% of family budget spent on food Average distance to grocery store = 7+ blocks Average distance to “corner”/liquor store = 2.6 blocks Most families ate together most nights of the week; all felt there was value in family meal time

Pilot study: outcomes:

Pilot study: outcomes Even in hand-picked, “motivated families”, significant participant drop-out 79% (11/14) had reduction of triglycerides and HgA1C. 64% (9/14) with decrease in fasting insulin and cholesterol 71% (10/14) showed a rise in HDL 66.7% maintained or decreased BMI Increased knowledge and enjoyment of fresh produce

Back to our three patients...:

Back to our three patients... S.V. - 5 year old female with early morbid obesity..... K.R . - 10 year old female with recurrent UTI’s rising HgA1c and LFT’s, with fatty liver on ultrasound A.L - 15 year old overweight male with high blood pressure on intake physical 4/2012..... storybook endings?

Three patients revisited...:

Three patients revisited... S.V. - 5 year old female with early morbid obesity..... Premature puberty; low self esteem, in therapy Lee et al: “Weight status of young girls and the onset of puberty” Pediatrics, 2006 page 2188 . Our finding that increased body fatness is associated with earlier pubertal development lends support for the hypothesis that increased rates of obesity among children in the United States may be contributing to a possible secular trend of early maturation in US girls. Earlier onset of puberty in girls has been associated with a number of adverse outcomes, including psychiatric disorders and deficits in psychosocial functioning; earlier initiation of alcohol use, sexual intercourse and teenage pregnancy; and increased rates of adult obesity and reproductive cancers

Three patients revisited...:

Three patients revisited... K.R . - 10 year old female with recurrent UTI’s rising HgA1c and LFT’s, with fatty liver on ultrasound 4/3/2012: Admitted to Children’s with labial abscess (growing E.Coli and Proteus). ED urinalysis: 3+ glucose, no ketones. Serum glucose = 499, HgA1C = 9.8 New onset Insulin dependent diabetes , home on metformin and Levemir

Three patients revisited...:

Three patients revisited... A.L - 15 year old overweight male with high blood pressure on intake physical 4/2012..... Labs OK (CBC, renal function, LFT’s; HgA1C = 5.9, mildly high fasting insulin, chol . Follow-up exams in May - BP’s 133/94, 141/92. UA dip negative, - renal ultrasound negative. Cardiac ECHO negative; Children’s referral Probable new diagnosis primary hypertension

But there is hope...:

But there is hope... Recent plateau nationally of obesity rates in preschoolers Children in preschool age groups are a bellwether for trends in older children and adults The reason for the stabilization is not known and likely complex. MMWR July 24, 2009 58(28); 769-773

But there is hope...:

But there is hope... WIC programs targeting behaviors related to obesity? Public awareness, acceptance, and support of breastfeeding? Increased% of low-fat or fat-free milk vouchers issued for children aged >2 years? Reduced television viewing?

Current events....:

Current events.... Walt Disney Co. confirmed this morning that it is going to apply new standards to food ads aimed at children and their families during programming for kids. The entertainment giant says it will try "to inspire kids to lead healthier lifestyles." The changes, which go into effect by 2015, apply to "all food and beverage products advertised, sponsored, or promoted on Disney Channel, Disney XD, Disney Junior, Radio Disney, and Disney-owned online destinations," .... "the restrictions on ads extend to Saturday-morning cartoons on ABC stations owned by Disney."

PowerPoint Presentation:

Let’s move! Role of government in an epidemic?

PowerPoint Presentation:

"The physical and emotional health of an entire generation and the economic health and security of our nation is at stake." - First Lady Michelle Obama at the Let’s Move! launch on February 9, 2010

PowerPoint Presentation:

HBO : The Weight of the Nation the weightofthenation . hbo .com/

THANK YOU!:

THANK YOU!

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