Pediatric Obesity: Prevention & Management

MaryKathleen Heneghan MDEndocrinology, Diabetes & Metabolism

Advocate Medical Group

Lutheran General Children’s Hospital

I have nothing to disclose

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

Available free at www.dietaryguidelines.govAvailable free at www.endo-society.org

Where have we been

and where are we headed?

Obesity Trends* Among U.S. AdultsBRFSS, 1985

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%

Obesity Trends* Among U.S. AdultsBRFSS, 1994

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19%

Obesity Trends* Among U.S. AdultsBRFSS, 2001

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

Obesity Trends* Among U.S. AdultsBRFSS, 2008

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Obesity Trends* Among U.S. AdultsBRFSS, 2010

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

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.

15%–<20% 20%–<25% 25%–<30% 30%–<35% ≥35%

Prevalence of Self-Reported Obesity Among U.S. Adults

BRFSS, 2011

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

State Prevalence Confidence IntervalAlabama 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 IntervalMissouri 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)

Are trends similar for

children and adolescents?

Are trends similar in the

Illinois?

Obesity trends

Overweight and obesity among 2-19 year olds in the U.S.

(Ogden et al, 2006, Ogden et al, 2010)

                                                                                                                                                                                                                                                                                                                                                                                        

                              

CLOCC press release 2010

*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)

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

Chicago Children Aged 10 to 13 Have a Higher Prevalence of Obesity Than U.S. Children 6-11 Years Old

*U.S. data based on children 6-11 years old   **Chicago data based on children 10-13 years old

Obese rates in middle childhood

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 America’s Health, 2009)

In Illinois, Pre-teen and Teen (ages 10-17 years) Obesity Rates Exceed U.S. Levels 

 Obese rates in adolescence

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 Children’s Memorial Hospital.

We recognize the problem but need to make the

diagnosis

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

How to define overweight and obesity

• Overweight - BMI is 85th-95th percentile based on age and sex

• Obese - BMI is >95th percentile based on age and sex

• In children <4 yr of age – BMI may not be precise and weight for height charts may be used as a warning sign

Endocrine causes

•GH deficiency•Hypopituitarism•Hypothyroidism

•Cushing disease•Pseudohypoparathyroidism

Endocrine causes associated with increased BMI but stature and height velocity is decreased

where asStature and height velocity are usually

increased with exogenous obesity

Looking for endocrine cause

• The Endocrine Society recommends against routine lab evaluation for endocrine causes of obesity in obese children/adolescents unless the child’s height velocity is attenuated

• 2 uncommon circumstances• Adrenal tumor – exam should have signs of

virilization• Growth without growth hormone (idiopathic

isolated GH deficiency)

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 >4 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-Apr;16(2):187-90.

Genetic TestingRefer 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 >97th centile for weight by age 3

• Positive in about 2-4% of patients >97th centile

• NO TREATMENT AVAILABLE

Co-Morbidities

• Evaluate those with BMI >85th centile

Pre-Diabetes

• Impaired fasting plasma glucose• Fasting glucose >100 mg/dl

• Impaired glucose tolerance• 2 hour glucose >140 but <200

• New since 2010 – HgbA1c from 5.7 – 6.4%

Diabetes Mellitus

• Fasting plasma glucose >126 mg/dl

• Random plasma glucose >200 mg/dl

• 2 hour glucose >200 mg/dl on OGTT

• New since 2010 HgbA1c >6.5%

***If asymptomatic must repeat abnormal values***

Dyslipidemia

Fasting Lipids 75th percentile 90th percentile

Triglycerides(sugar & starchy foods

and diets high in saturated fat)

>110 mg/dl >160 mg/dl

LDL(saturated and trans

fats)

> 110 mg/dl >130 mg/dl

Total Cholesterol >180 mg/dl >200 mg/dl

HDL(exercise & fruits and

veggies)

(10th percentile)

<35 mg/dl

(25th percentile)

<40 mg/dl

Primary treatment is dietary changes – pharmacotherapy is available

Hypertension•Blood pressure > 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)

Nonalcoholic Fatty Liver Disease

• Alanine aminotransferase (ALT) > 2 SD above the mean for the laboratory

• ALT elevation greater than AST elevation

• NAFLD can progress to NASH and cirrhosis

Risk factors for developing obesity

• Maternal diabetes

• SGA

• LGA

• Parental obesity (maternal >paternal)

• Maternal weight gain during pregnancy

• Breastfeeding duration

• Weight of siblings

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

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

Once the diagnosis is made

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, 2002;110(1):210.

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, 2002;110(1):210.

Recommendations

• Intensive lifestyle modification• Dietary• Physical activity• Behavioral

• Age Appropriate

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

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◊

* ◊

Dietary Guidelines for Americans 2010

Dietary Guidelines for Americans 2010

Factors for successful weight maintenance

• Reduced caloric intake

• Reduced fat intake

• Reduced fast food consumption

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

Beverage consumption

Beverage consumption in the US population.Storey ML - J Am Diet Assoc - 01-DEC-2006; 106(12): 1992-2000

Beverage consumption

Beverage consumption in the US population.Storey ML - J Am Diet Assoc - 01-DEC-2006; 106(12): 1992-2000

Beverage consumption in the US population.Storey ML - J Am Diet Assoc - 01-DEC-2006; 106(12): 1992-2000

Beverage consumption in the US population.Storey ML - J Am Diet Assoc - 01-DEC-2006; 106(12): 1992-2000

Beverage consumption

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

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

Dietary Recommendations• Reducing saturated fat for children > 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

Dietary Guidelines for Americans 2010

Dietary Guidelines for Americans 2010

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

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

Family Commitment

• Good data is lacking regarding interventions in pediatric populations

• Most suggest involving the entire family yields better results than targeting individual

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

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.

Bariatric Surgery

• Referral to clinic with specific experience in bariatric surgery in adolescents

• Reserved for those:• Tanner 4 or 5• BMI >50 kg/m2 or >40 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

Prevention

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

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)

Breastfeeding

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

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

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

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

Thank you

Available free at www.dietaryguidelines.govAvailable free at www.endo-society.org