Childhood and Adolescent Obesity Kathryn Camp, MS, RD, CSP.

Childhood and Adolescent Obesity

Kathryn Camp, MS, RD, CSP

WHY WORRY ABOUT PEDIATRIC OBESITY?

• Pediatric obesity is of epidemic proportion.

• Pediatric obesity is the most common chronic disease of childhood.

• The epidemic is worldwide

Some Scary Stats

• 300,000 Americans died from obesity-related causes in 2000 (Surgeon General Report)– $117 billion in obesity-related

economic costs

• Cost of caring for obese patients is 35% greater than normal weight

• Anthony• 15 yr old• Referred by

his new PMC

• Anthropometrics– Weight: 121 kg– Height: 175 cm

BMI: 39

How Do We Define Overweight in Children and

Adolescents?

Definition of Overweight in Children and Adolescents

• Overweight = BMI 95th %ile

• At risk for overweight = BMI between 85th-95th %ile

Expert Committee Recommendations from the Maternal and Child Health Bureau, 1997

Calculate Your BMI

• kg m2

• Height in inches x 2.54 100 = meters

• Meters x meters = m2

• Weight in pounds 2.2 = kg• Divide your weight in kg by m2 =

BMI

Classification of Overweight and Obesity in Adults Using BMI

Obesity Class BMI

Underweight <18.5

Normal 18.5-24.9

Overweight 25-29.9

Obesity I 30-34.9

II 35-39.9

III Extreme 40

3536 37

39 38

43

University of Miami Blocking Machine

Height: 6-6

Weight: 98 kg

25

Height: 7-1

Weight: 154 kg33

BMI is Age Specific in Children and Adolescents

17

21

24

Increasing Incidence of Overweight in Children and

Adolescents

95th%ile for age and gender

These #s double when

including >85%ile

PERCENT OF OBESE CHILDREN WHO BECOME OBESE ADULTS

0

10

20

30

40

50

60

70

80

Preschool School-age Adolescent

Etiology of Obesity

• Genetic/heritablility

• Molecular• Syndromes• Environmental

Multifactorial Condition

Heritability

• Survival advantage to conserve energy as fat through human evolution

• Humans enriched for genes that promote energy intake and storage and minimize expenditure.

• Enhance female fertility and ability to breastfeed offspring

• In modern industrial environment – easy access to calorically dense foods– encourages sedentary lifestyle

• Metabolic consequences of these genes are maladaptive

Genetic Factors account for 20-40% of heritability of BMI • 173 human obesity cases due to single gene

mutations in 10 different genes were reported by 2004 (Perusse, 2005)

• > 600 genes, markers, and chromosomal regions have been linked with human obesity phenotypes

Buchard 97 Rankinen 02

Familial Risk:

2-3 fold for moderate obesity

5-8 fold for severe obesity

Bouchard 01

More than 50 Obesity Associated Genetic Syndromes

Bardet-BiedlPrader Willi

Spina bifida

Down Syndrome

Hormones, Neurotransmitters, Enzyme defects???

• Obesity is not well understood at the molecular level.

• Discovery of leptin was hoped to revolutionize the field but its role has remained obscure

• Role of other hormones, neurotransmitters, etc remains unknown

• But doctor, my child must have a low metabolism….– Little evidence that metabolic rate is

different (Baker, 05)– Obese adolescents have a higher

total daily energy expenditure and REE (Bandini, 90)

– There may be small differences in metabolic efficiency but these are hard to measure

What is Causing this Marked Increase in Overweight??

Obesity is not a genetic shift, rather it is an environmental

shift

Causes of Marked Increase in Overweight

• Reflects a shift towards positive energy balance

energy intake = energy expenditure

calories

McDowell 94; Kann 99; Troiano 00,NHANES II to III

PE

sed act

Increased Energy Intake

• Kids are – Eating more away from home– Eating more fast food and snack

foods – Drinking more sodas

• 100 kcal/day above needs = 10 pound weight gain per year

Physical Activity

• Daily participation in PE declined from 42% to 29% between 1991 and 1999 (www.cdc.gov/HealthyYouth)

• Walking and bicycling dropped 40% in kids aged 5-15 between 1977 and 1995

• What constitutes “active” these days?

Increase in Sedentary Activity• Excessive TV watching–

– The average child spent 6 hr/day watching TV or playing on computers.

– Encourages overeating while viewing • Influences food choices

– 80% of commercials on children’s programs are for food

• Lower resting metabolic rate compared to at rest (Klesges 1993)

• Reduces time available for more active pursuits

• Video and computer games• Parental work schedules• Unsafe neighborhoods

– discourage parents from allowing children to play outdoors

– force parents to drive children to school

• Lack of recreational facilities in low-income neighborhoods

Other Contributors to Sedentary Lifestyles

Medical Consequences of Overweight

• 60% of OW children have 1 or more CVD risk factors

• Hyperlipidemia-- LDL and TG, HDL– 90% of children with elevated TGs are

overweight• Hypertension

– Low frequency in children• 60% with BP were >120% of IBW

• Obtain fasting lipid profile and blood pressure on all overweight children.

Cardiovascular

Type 2 Diabetes• 95% of teens with Type 2 diabetes

have a BMI >85%ile • Tremendous public health

implications– Longer duration of disease, > risks of

complications

• Obtain fasting glucose and insulin on all overweight children, especially those with..

Dabelea 99; Vinicor 00; Richards 85

• Acanthosis Nigricans

• Hyperpigmented, velvety plaques in body folds

• Caused by hyperinsulinemia which stimulates formation

• Associated with obesity

• Growth– Taller, advanced bone age, mature

earlier– Early maturation is associated with

• increased fatness and truncal fat distribution in adulthood

– Short, obese children should be evaluated for hypothyroidism, Cushing syndrome or Turner syndrome

Other Endocrinological Issues

More Complications

• Hepatic Steatosis with elevated LFTs

• Cholelithiasis– 50% of kids with cholecystitis are

overweight• Orthopedic Problems

Acute Complications that Require Immediate Medical Attention

• Sleep Apnea – Occurs in 17% of obese children and

teens (Marcus 1996)– Deficits in learning, memory, and

vocabulary (Rhodes 1995)

• Obesity hypoventilation syndrome– rare, potentially fatal disorder

Psychological and Economic Consequences of Pediatric and Adolescent Obesity

• Discrimination, rejection and low self-esteem (Gortmaker 93), particularly for females

• Less participation in PE and sports activities

• Lower college acceptance rates (Canning 1966)

Who Needs to be Evaluated?

Evaluating For Overweight in a Primary Care Setting

BMI

OverweightBMI 95th%

Not at riskBMI 85th%

At risk forOverweight

BMI 85-95th%

•Family history•Blood pressure•Lipids•Lg in BMI•Concern re wt •Note in chart

•No therapy•Return next yr

Return next yr for screen

In depth medical assessment

+

Medical Assessment

• r/o genetic syndromes, esp if associated with mental retardation

• Blood pressure• Labs to include

– Fasting lipid panel– Fasting glucose and insulin

• OGTT

– LFTs– Thyroid fx tests

Back to Anthony—Medical

• PMHx – chronic otitis media and allergies– overweight since 7 yrs of age

• Currently c/o headache• On no chronic meds• Blood Pressure

– 136/73– >95th%ile

Social hx

• Only child• High school sophomore, gets good

grades• No exercise or organized sports

activities• Spends 6 hrs/day watching TV and

playing video games

Dietary Information

• Picky eater• Consumes NO fruits or vegetables• Mom prepares separate meals for

him

24-Hour Recall

• Breakfast--none• Mid morning--16 oz ginger ale• Lunch--none

– generally has lunch at school of chocolate milk, pizza, and french fries

• Dinner--10 beef tacos, 2 cans of soda

What to Do with Anthony?

• Weight goals– First step is to achieve weight maintenance– 2-7 years of age

• BMI 85-95%– Weight maintenance

• BMI >95%– No complications: weight maintenance– Complications: weight loss

– 7 and above• BMI 85-95th%

– No complications--weight maintenance– Complications—weight loss

• BMI >95th weight loss

General 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

Refer?

• Formal obesity clinic--Team approach– Physician, therapist, dietitian,

exercise therapist– Intensive multi-session programs

• Parent and child/teen participate

– Advantages• Multidisciplinary approach, frequent visits

– Disadvantages• Expensive, time consuming, require

parent participation

If Going It Alone…Where Do You Start?

• Assess child’s and family’s willingness to change

• Negotiate with child/family on specific, targeted changes

• Develop realistic, achievable goals• Involve the entire family in making

changes• Establish a monitoring/assessment

tool

Goals for Anthony

• Eat 3 meals per day (establish regular meals)

• Have 1 piece of fruit each day (introduce new food groups)

• NO calorie containing beverages except skim milk (eliminate empty calories)

• Daily exercise (increase energy expenditure)

• Keep a notebook of food intake and exercise (self-monitoring)

Follow-up

• Weekly visits or as frequent as possible

• lipid profile, HgbA1c, fasting insulin and glucose, blood pressure

• Identify and reinforce positive changes

• Set new goals based on goals achieved

Anthony’s Lab Data

• Lipid panel– Total cholesterol 156 (<200)– Triglycerides 129 (35-250)– HDL 34 (35-82)– LDL 96 (<100)

• HgbA1C 5.8 (4.3-5.3)• Fasting glucose 77• Insulin 30.3 (0-30)

• Weight– 97 kg– Down 53#

• Height– 179 cm– Up 4 cm

• BMI– 30– Down from

40

Childhood ObesityChildhood ObesityCan be prevented

Shaping HabitsShaping HabitsThat Shape That Shape America’s America’s ChildrenChildren

PREVENTION: PRECONCEPTION• Prevention starts prior to conception

– Obese adolescents have an 80% probability of being obese as adults

– Today's adolescents are tomorrows parents– Parents are role models for their children– Obesity risk in a child born to obese parents

is significantly increased– Educate and intervene at this time to help

prevent obesity in subsequent generations

PREVENTION: POST CONCEPTION

• Routine prenatal care• Achieve normal weight gain during

pregnancy– LGA infants and infants of diabetic

mothers have higher rates of subsequent obesity

– SGA infants also at higher risk• Hediger ML et: Pediatrics 104:e33, 1999

• Promote breast feeding

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

• Have safe playgrounds• Provide safe places for bike riding

and walking• Promote physical activity outside

of school

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

• Be an advocate• Provide anticipatory guidance to

families

NUTRITION ANTICIPATORY GUIDANCE

• Beverages– Encourage water intake– Limit sweet beverages

•Juice, juice drinks: 120 calories / 8 oz– No nutritional need for any juice <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


• 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.


• 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 >5 years is

dependent on how much they are provided

• Do not skip meals

ACTIVITY ANTICIPATORY GUIDANCE

• Encourage active play for young children

• Promote physical activity for school age children and teens

• Encourage participation in organized sports

ACTIVITY ANTICIPATORY GUIDANCE

• Decrease sedentary activity– Limit TV, video games and computer

to 1-2 hours per day• > 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

BEHAVIORAL ANTICIPATORY GUIDANCE

• Encourage parents to act as role models– Nutrition– Activity

• Promote parent child interaction• Have special “family time” that is

physically active


• Limit eating out– More calorically dense food– Larger portion sizes– Less intake of fruits and vegetables


• 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


• 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

Summary

• Pediatric obesity is epidemic• Overweight kids become

overweight adults• Treatment is difficult• Prevention is the key

Childhood and Adolescent Obesity Kathryn Camp, MS, RD, CSP.

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