PEDIATRIC OBESITY: A HUGE PROBLEM IN THE USAWilliam J. Cochran, MDDepartment of Pediatric GI & NutritionGeisinger Clinic

WHY WORRY ABOUT PEDIATRIC OBESITY?Pediatric obesity is of epidemic proportion.Pediatric obesity is the most common chronic disease of childhood.

DEFINITION OF PEDIATRIC OBESITYOverweight / At risk of overweightBMI 85-95%Obese / OverweightBMI >95%

OLDER DEFINITIONS OF OBESITYWeight for height >95%Actual weight >120% ideal body weightSuper obese >140% of ideal body weight

Percent of obese children and adolescents

INCIDENCE OF PEDIATRIC OBESITY IN PENNSYLVANIA

RACIAL DIFFERENCES IN PEDIATRIC OBESITYNon-Hispanic white12.3%African American21.5%Hispanic21.8%

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

WHY WORRY ABOUT PEDIATRIC OBESITY?Adult obesity is clearly associated with numerous health problems.Type II DMCADHypertensionCancerJoint diseaseGallbladder diseasePulmonary disease

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

PERCENT OF OBESE CHILDREN BECOMING OBESE ADULTS

WHY WORRY ABOUT PEDIATRIC OBESITY?Economic impactThe estimated cost of obesity in the US in 2002 was $117 billion.The hospital cost of pediatric obesity is also increasing.1979: $35 million1999 $127 million

IMPACT OF CHILDHOOD OBEISTY IN ADULTHOODChildhood obesity has significant adverse effects on health in adulthoodHoffmans 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 ADULTHOODHarvard Growth Study: Two fold increased all cause mortality in obese vs nonobese adolescents as adults2 fold increase in CAD mortalityIncreased risk of colon cancer in malesIncreased risk of arthritis in femalesThe association of adverse effects on adult health may be independent of obesity in adulthood

CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITYPsychosocialMost common complication of pediatric obesityIncreased rates of depression Poor self esteemObese adolescents negative self image may carry over into adulthood

CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITYSocietal discriminationObese females have lower acceptance rate at colleges than non-obese femalesNational 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 OBESITYEndocrineNon-insulin-dependent diabetes mellitusPinhas-Hamiel 1994The incidence of NIDDM has increased 10 fold92% of these had a BMI >90%Geisinger weight management program60% have insulin resistance10% have fasting insulin level > 100 (Nl

CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITYEndocrineIncreased linear growthAdvanced bone ageEarlier onset of pubertyAcanthosis nigricans

CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITYHypertensionPrimary hypertension uncommon in childhood60% of children diagnosed with hypertension are obeseUse pediatric standarsGeisinger weight management program 45% have hypertension

CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITYHyperlipidemiaThe atherosclerotic process begins in childhood.Pediatric obesity is associated with increased cholesterol, LDL-cholesterol, triglyceride levels and lower levels of HDL-cholesterolGeisinger weight management program45% have hypercholesterolemia

CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITYHepatic steatosisHepatic steatosis present in 25-83% of obese children10-15% of obese children have elevated liver enzymes: steatohepatitis or non-alcoholic fatty liver diseaseRashid: 83% of children with steatohepatitis were obese. 75% had fibrosis-cirrhosis

CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITYOrthopedicSlipped capital femoral epiphysis30-50% are obeseBlounts disease (Tibia vara)70% are obeseNeurologicPseudotumor cerebri

CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITYRespiratorySleep disorder in 1/3Sleep apnea: 7% of obese, 1/3 if >150% & breathing difficultiesHypoventilation syndromeGastrointestinalCholelithiasis50% of cases of cholecystitis in adolescents are obese

PEDIATRIC OBESITY IS NOT JUST A COSMETIC PROBLEM!

ETIOLOGY OF PEDIATRIC OBESITY

ETIOLOGY OF PEDIATRIC OBESITYEtiology is multifactorialInteraction of genetics and environmentEnergy imbalanceEnergy In = Energy Used + Energy StoredFor every extra 100 calories consumed per day one will put on 10 pounds per year

ETIOLOGY OF OBESITYCaloric intake has increasedEating unsupervised, lack of family mealsEating at multiple sitesEating out / take out foodBeveragesCalorically dense food

ETIOLOGY OF OBESITYPhysical activity has decreasedSchools with less physical educationAfter school programsSafety concernsConvenience activitiesIncreased sedentary activities: TV, computer, video games

ETIOLOGY OF OBESITYPhysical activityTV / video gamesMore time spent watching TV less time for physical activity: average 2.5 hours / day, 20%>5 hours / dayBMI and obesity associated with higher amount of time spent watching TVHigher cholesterol levels associated with greater amount of time spent watching TV40% of children 1-5 years have TV in their bedroom

TREATMENT OF PEDIATRIC OBESITYWeight management programs are available and can be effectiveHigh rates of recurrencePrevention is the key

PREVENTION: PRECONCEPTIONPrevention starts prior to conceptionObese adolescents have an 80% probability of being obese as an adultToday's adolescents are tomorrows parentsParents act as role models for their childrenThe risk of obesity in a child born to obese parents is significantly increasedNeed to educate and intervene at this time to help prevent obesity is subsequent generation

PREVENTION: POST CONCEPTIONRoutine prenatal careAdvocate normal weight gain during the pregnancyLGA infants and infants of diabetic mothers have higher rates of subsequent obesitySGA infants also at higher riskHediger ML et: Pediatrics104:e33, 1999

PREVENTION: POST CONCEPTIONPromote breastfeedingDewey 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 infantsBMI the same at birthBMI at 3 & 6 months > in formula fed vs. breastfed infantsRate of obesity at 6 years was tripled in formula fed vs. breastfed

PREVENTION OF PEDIATRIC OBESITYMeasure and plot BMI Only done by 20% of primary care providersIdentify those at riskAnticipatory guidanceNutritionPhysical activityHealthy lifestyles

IDENTIFY THOSE AT RISKIncreasing BMI %Family historyRisk of obesity 9% if both parents are leanRisk of obesity 60-80% if both parents are obeseSibling over weightHigh birth weight

IDENTIFY THOSE AT RISKLower socioeconomic statusEthnicity: African-American, Hispanic, Native AmericanEnvironmental / socialBoth parents workLittle cognitive stimulationLack of safe play areasFamily stress

NUTRITION ANTICIPATORY GUIDANCEBeveragesEncourage water intakeLimit sweet beveragesJuice, juice drinks: 120 calories / 8 ozNo nutritional need for any juice

NUTRITION ANTICIPATORY GUIDANCEEat 5 fruits and vegetables a day Structured meal and snack timeDo not use food as a rewardKnow what the child is eating outside the home: school meals, day care etc.

NUTRITION ANTICIPATORY GUIDANCEEncourage childs autonomy in self-regulation of food intake Parents provide, child decides! Do not use the clean the plate rule.Provide choiceEducate parents regarding healthy nutritionHealthy snacksConsider using pediatric food pyramidPortion size: Intake of children >5 years is dependent on how much they are providedDo not skip meals

ACTIVITY ANTICIPATORY GUIDANCEEncourage active play for young childrenPromote physical activityIdeal 30-60 minutes per dayHave several types of potential activitiesBe physically active with othersThink about activity opportunitiesEncourage participation in organized sports

ACTIVITY ANTICIPATORY GUIDANCEDecrease sedentary activityLimit TV, video games and computer to 1-2 hours per day> 2 hours a day associated with higher rates of obesity and hyperlipidemiaDo not have a TV in the childs roomChildren with TVs in bedroom watch more TV

ACTIVITY ANTICIPATORY GUIDANCEDecrease sedentary activityDo not use the remoteExercise on commercialsTV / computer is not a right it is a privilege

BEHAVIORAL ANTICIPATORY GUIDANCEEncourage parents to act as role modelsNutritionActivityPromote parent child interactionHave special family time that is physically active

BEHAVIORAL ANTICIPATORY GUIDANCELimit eating outMore calorically dense foodLarger portion sizesLess intake of fruits and vegetables$0.51 of every nutrition dollar is spent outside the home

BEHAVIORAL ANTICIPATORY GUIDANCEEat as a familyProvides quality timeSlows down the eating processParents act as role modelParents monitor intakeAssociated with lower fat intake and greater intake of fruits and vegetables

BEHAVIORAL ANTICIPATORY GUIDANCEDo not eat in front of the TVAssociated with higher intake of fat and saltLower intake of fruits and vegetablesEncourages over eating60-80% of commercials on during children programs are related to foodEating without awareness

TREATMENT OF PEDIATRIC OBESITY

TREATMENT GOALSBehavioral goalsPromote life long healthy eating and activity behaviorsMedical goalsPrevent complications of obesity in childhood and potentially adulthoodImprove or resolve existing complications of obesity

TREATMENT GOALSWeight goalsFirst step is to achieve weight maintenance2-7 years of ageBMI 85-95%Weight maintenanceBMI >95%No complications: weight maintenanceComplications: weight loss

TREATMENT GOALSWeight goals7-18 years of ageBMI 85-95%No complications: weight maintenanceComplications: weight lossBMI >95%Weight loss

EVALUATION OF THE OBESE CHILDHistory and physical examinationLaboratory evaluationLiver panelFasting lipid panelFasting glucose and insulin levelHgb A1C? Thyroid studies

TREATMENT OF PEDIATRIC OBESITYFirst step is to educate the patient and parents about obesityAssess patient and the familys readiness to make changeTreatment needs to be individualized and family basedMake only a few changes at a time

TREATMENT OF PEDIATRIC OBESITYFor 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 activityStage III: Nutrition education and initial implementation of hypocaloric diet

TREATMENT OF PEDIATRIC OBESITYFormal obesity clinicTeam approachPhysicianTherapistDieticianExercise therapistIntensive program15 sessions: 10 therapist, 3 dietician, 2 exercise therapist

TREATMENT OF PEDIATRIC OBESITYFormal obesity clinicAdvantagesAppropriate timeFrequent visitsUtilize each team members expertiseGood outcomes if completed

Weight Loss PharmacotherapySibutramineFDA approved 1997Induces feeling of satietyIncreases 5HT & Norepi.Caution with use in combination with SSRIsContraindicated with CAD,CVA or uncontrolled blood pressureNeed to monitor BPOnce daily8-10% weight lossOrlistatFDA approved 1999FDA approved 12-18 year oldReduces absorption of ~30% dietary fat1/3 of fat passes undigestedFacilitates weight lossGI side effects3 times daily with meals containing fatVitamin supplementation8-10% weight loss

BARIATRIC SURGERYLittle information on pediatric bariatric surgeryMay be appropriate in individual casesSevere obesity, BMI > 40Significant co-morbiditiesUnresponsive to more conventional weight loss program

BARIATRIC SURGERYPreoperative evaluation in a pediatric weight management programPsych evaluationDepressionAbility to copeSupport systemWillingness to comply

BARIATRIC SURGERYPediatric cases should be done in a pediatric centerProspective multi-institutional study in progressOptions:Gastric bypassLap band

CONCLUSIONSPediatric obesity is of epidemic proportionThe etiology of pediatric obesity is multifactorialPediatric obesity is associated with complications in childhood as well as adulthood

CONCLUSIONSTreatment of obesity is not idealPrevention of obesity may be a more effective means dealing with pediatric obesityIn order to have any significant impact on pediatric obesity a team approach is required: child, family/parents, community, health care providers, insurance companies, government

TREATMENT OF PEDIATRIC OBESITYProtein sparing modified fastLow carbohydrate diet

Restrictive Bariatric Procedures Mun EC, Blackburn GL, Matthews JB. Gastroenterology 2001:120:669-681Adjustable Gastric BandingVertical BandedGastroplastyRoux-en-Y Gastric Bypass

WEB SITEES OF INTERESTwww.panaonline.orgPA Department of Health effort to address obesity and its co-morbiditieshttp://www.trowbridge-associates.comPediatric BMI wheelshttp://www.usda.gov/cnpp/kidspyraPediatric food pyramid

WEB SITEES OF INTERESThttp://www.bam.govSite to answer kids questionshttp://147.208.9.133/A free dietary assessment tool to keep up to a 20-day food loghttp://www.kidnetic.com/An interacitve website for 9-13 year olds and families re healthy eating and activity

WEB SITEES OF INTERESThttp://www.verbnow.comCDC site for 9-13 year olds to promote physical activitywww.aap.org/obesityAmerican Academy of Pediatrics web site regarding obesity

BARRIERS TO THERAPY OF PEDIATRIC OBESITYLack of commitment of primary care physiciansMany physicians do not address obesityPrice 198917% of pediatricians felt physicians did not need to counsel parents of obese children33% did not feel that normal weight is important to child health22% felt competent in treating obesity11% felt treatment of obesity was gratifying

BARRIERS TO THERAPY OF PEDIATRIC OBESITY Time commitmentLack of reimbursementTershakovec 1999Median reimbursement rate 11%Lack of standard treatment protocolSocial / environmental barriers

PREVENTION: SCHOOLPromote physical activityProvide nutritious mealsControl vending machinesHave nutrition education incorporated into regular school curriculum.Encourage children to walk or bike to school safely.

PREVENTION: COMMUNITYHave safe playgroundsProvide safe places for bike riding and walkingPromote physical activity outside of school

PREVENTION: INSURANCE AND GOVERNMENTAcknowledge obesity as a medical condition for which one can be reimbursed.Provide reimbursement for anticipatory guidance for nutrition and physical activity

PREVENTION: PRIMARY CARE PROVIDERBe an advocate

poor self esteem in obese patients also associated with higher rates of sadness, loneliness and nervousness. They are also more likely to engage in high-risk behaviors such as smoking or consumption of alcohol.Weight is typically the goal that most patients and parents focus on the most. This is not necessarily the goal that should be focused on. As you all know young children have the potential for growth so that their BMI will improve with weight maintenance as they continue to grow. Most children who are overweight have an accelerated rate of weight gain. Therefore the first weight goal for everyone should be weight maintenance.Educate the family about the degree of obesity as well as any complications present. Also discuss the potential complications of obesity. There is no magic bullet or pill. There are however things that can be done and if they are done the child will loose weight or maintain weight. These changes however require effort. Show them the growth curve and show them how much the child will weigh at 18 years of age.If the family and or child are not ready to change then any efforts to institute change will fe futile and will frustrate the family and patient and may further diminish the childs self esteem.Assess family readiness1. Does the family perceive the obesity to be a problem2. Does the family think that weight loss is possible3. What problems does the family anticipate4. Is the family willing to work with the child and the obesity team

Based on the initial evaluation I make a decision on how to proceed either with follow up with me and the dietician vs the obesity clinic.Importance of a team approachMake only a few changes a time. If you try and do too much it may feel overwhelming and they will not be able to concentrate on accomplishing a taskBe optimistic and positive. Frequently they have tried to do something before and met with failure. The child and parents need to have hope if they are going to make the effort to change.time, HMO, lack of coverage, they will out grow itless than 20% of pediatric residents were recognized and treated pediatric obesity. Denen et al 1993.