Pediatric Obesity : A Family Affair Samuel N. Grief, MD.
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Transcript of Pediatric Obesity : A Family Affair Samuel N. Grief, MD.
Pediatric Obesity: A Family Affair
Samuel N. Grief, MD
Outline Introduction Definition of childhood overweight/obesity Scope of Problem Etiology: Multifactorial Genetics and obesity Environment and obesity Culture and obesity Taking a pediatric nutrition history Nutrition recommendations for treating
obesity Practical pointers for all Family Physicians in
dealing with the obese child Conclusion
Pediatric obesity is rapidly becoming a serious health epidemic in the united states. Health officials estimate the percentage of overweight/obese children has risen to 30% and is climbing.
This symposium will bring the topic of pediatric obesity into the limelight elucidating:
The severity of this health epidemic, The multiple causes of pediatric obesity, The genetic connection, The latest nutrition recommendations, A practical approach for family doctors to assess a
child’s nutrition habits in the context of the family unit and provide sensitive and sound medical advice to help children and their family members conquer obesity.
Pediatric Obesity: A Family Affair
Definition of Childhood Overweight/obesity
Adults: BMI – mild, moderate, severe or extreme
For children, not clearly established BMI >85% defined as overweight BMI >=95% for age and gender BMI not used for infants Definition of overweight BMI varies with
age
NHANES III
Scope of Pediatric Obesity Problem
Boys
Age/Month NHANES I NHANES II HHANES NHANES III
2-5 322
6-11 152 47 595
12-23 285 368 101 648
24-35 166 361 116 610
36-47 300 403 113 497
48-59 304 403 126 546
60-71 273 393 116 495
NHANES III
Number of Survey Participants in Sex and Age Groups by Survey
Girls
Age/Month NHANES I NHANES II HHANES NHANES III
2-5 334
6-11 143 53 576
12-23 267 350 118 635
24-35 129 315 112 591
36-47 286 340 85 545
48-59 281 386 93 532
60-71 314 369 112 554
NHANES III
Number of Survey Participants in Sex and Age Groups by Survey
Boys 2-3 Girls 2-3 Boys 4-5 Girls 4-50
2
4
6
8
10
12
14
Non Hispanic White
Non Hispanic Black
Mexican American
Non Hispanic White 1.1 2.8 2.7 9
Non Hispanic Black 2.8 5.6 8.5 11.2
Mexican American 6.2 10.5 12 13.2
Prevalence of overweight Based on Percentage of 2-5 year-old children above the 95% of the weight-for-stature growth reference (NHANES III)
NHANES I, II, III
6-11 Months Boys Girls
White
NHANES I
NHANES II 2.7 6.5
NHANES III 7.3 11.1
Black
NHANES I
NHANES II 9.0
NHANES III 9.5 10.7
Mexican American
HHANES 4.5 7.3
NHANES III 12.2 16.3
NHANES I, II, III
6-11 Months Boys Girls
ALL RACES
NHANES I
NHANES II 4.0 6.2
NHANES III 7.5 10.8
NHANES I, II, III
12-23 Months Boys Girls
White
NHANES I 8.3 5.7
NHANES II 6.6 7.5
NHANES III 7.6 7.9
Black
NHANES I 3.8 8.9
NHANES II 11.8 6.8
NHANES III 6.4 15.2
Mexican American
HHANES 7.9 11.3
NHANES III 13.6 14.0
NHANES I, II, III
12-23 Months Boys Girls
ALL RACES
NHANES I 7.5 6.1
NHANES II 7.2 7.2
NHANES III 7.5 9.5
NHANES I, II, III
2 – 3 Years Boys Girls
White
NHANES I 1.9 1.6
NHANES II 1.5 2.9
NHANES III 2.0 4.5
Black
NHANES I 3.4 2.2
NHANES II 2.2 1.0
NHANES III 3.0 6.2
Mexican American
HHANES 5.6 4.2
NHANES III 3.0 6.2
NHANES I, II, III
2 - 3 Years Boys Girls
ALL RACES
NHANES I 3.1 2.0
NHANES II 2.0 2.5
NHANES III 2.1 4.8
NHANES I, II, III
4 - 5 Years Boys Girls
White
NHANES I 4.0 6.0
NHANES II 4.6 7.4
NHANES III 4.3 11.2
Black
NHANES I 7.0 5.0
NHANES II 3.0 6.5
NHANES III 8.7 12.6
Mexican American
HHANES 4.9 10.6
NHANES III 12.0 13.2
NHANES I, II, III
4 - 5 Years Boys Girls
ALL RACES
NHANES I 4.4 5.8
NHANES II 4.4 7.6
NHANES III 5.0 10.8
NHANES III
Under 1 Ages 1 & 2
Boys 9.6 7.5
NHW 9.1 6.4
NHB 10.2 8.9
MA 12.8 13.0
Girls 11.0 11.5
NHW 10.2 8.4
NHB 15.0 14.0
MA 15.5 16.8
Both Sexes 10.3 9.4
Percentage of children younger than 3 years above the 95% of the weight-for-length growth reference, NHANES III
Assessment of Medical Conditions Related to Obesity
Findings Potential ConditionsHistory
Developmental Delay Genetic Disorders
Poor linear growth Hypothyroidism, Cushing’s syndromePrader-Willi syndrome
Headaches Pseudotumor Cerebri
Nighttime breathing difficulty
Sleep apnea, obesity hypoventilation syndrome
Daytime somnolence As above
Abdominal pain Gallbladder disease
Hip or knee pain Slipped capital femoral epiphysis
Oligomenorrhea or amenorrhea
Polycystic ovarian syndrome
Assessment of Medical Conditions Related to Obesity
Family History Obesity NIDDM Cardiovascular disease Hypertension Dyslipidemia Gallbladder disease
Social/psychologic history Tobacco use Depression Eating Disorder
Physical exam Height, weight, BMI Triceps skinfold thickness Truncal obesity Blood pressure Dysmorphic features Acanthosis nigricans Hirsutism Violaceous striae Optic disks
Assessment of Medical Conditions Related to Obesity
Assessment of Medical Conditions Related to Obesity
Tonsils Abdominal tenderness Undescended testicle Limited hip range of motion Lower leg bowing Risk of cardiovascular
disease; Cushing’s syndrome Genetic disorders (PW) NIDDM, insulin resistance Polycystic ovarian syndrome; Cushing’s
syn Pseudotumor cerebri
Assessment of Medical Conditions Related to Obesity
Sleep apnea Gallbladdeer Disease Prader-Willi Syndrome Slipped Capital Femoral Epiphysis Blount’s Disease
Etiology of Pediatric Obesity: Multifactorial
Environmental: Neighborhood, school, community Genetic: Inborn diseases, chromosomal
mutations, familial, ethnic predisposition Cultural: Increased risk with minorities Societal: Affluent vs. Underserved Physical: Height and body frame; sick vs. healthy Attitude: Family influence on nutrition habits and
physical activity Medical advice: Doctors not taking an active role The American way of life!
Genetics and Obesity
Twin studies Familial syndromes: Cohen’s,
Alstrom’s, and Bardet-Biedl (look these up!!!)
Ob gene and leptin POMC
Pro-opiomelanocortin MC4R – a melanocortin receptor
Genetics and obesityWhat next? Additional leptin to those who are
deficient. Ongoing research for
pharmacological manipulation. Continued research in rodents is
directly relevant to humans.
Socioeconomic status and rates of obesity
Single parent families and risk of obesity
Social support and relevance to pediatric obesity
School and extracurricular activities Inner city vs. suburban setting Western vs. third world setting
Environment and Obesity
Minorities and increased rates of obesity
African-American Hispanic Native Indian Pacific Islander White Asian European Other
Culture and Obesity
Culture and Obesity
Culture and food Food is a way of life Learn about different cultures: ASK! The taste of Chicago…
You deserve a…
BREAK!
Nutrition Exercise1. Split into groups of three2. Designate one member as the physician3. Designate one member as the parent of
an obese child4. Designate one member as the observer5. The physician has ten minutes to obtain a
complete nutrition history from the parent6. Observer to take notes re:
1. Style – effective or not and why? 2. Open or closed ended questions 3. Anything missing? 4. Anything else?
Ready, set…
GO!
Taking a pediatric nutrition history
Back to basics! Methods of assessing dietary intake:
1) 24-Hour recall2) Usual Intake/Diet history3) Food frequency questionnaire4) Family history5) Past medical history6) Any diets that have been tried? Successful?7) Social habits: cigs, caffeine, illicit drugs, ETOH8) MEDS, vitamins, herbals9) Food allergies? Lactose intolerance?
10) ROS: Constitutional, GI, GU
Refer to a trusted Registered Dietitian! Recommendations based on the USDA
Food Guide Pyramid Most children will need to maintain their
current weight until they reach a lower level BMI
There is no magic wand to wave The three Es:
Emphasize proper nutrition, Encourage an overall family approach to
modifying nutrition habits, and Empathize with all those concerned.
Pediatric Nutrition
Few are currently viable OTCs: Diet pills, ephedra, metabolife, caffeine,
chitosan, hydroxycitric acid, pyruvate, etc. Methylphenidate, dextroamphetamine, etc. Diuretics Thyroid hormone Growth hormone Testosterone Leptin Metformin Xenical Sibutramine
Medicinal Treatment Options for Pediatric Obesity
Useful for adolescents with extreme obesity
Last resort option for severely obese adolescents
Choose patients carefully
Surgical Treatment Options for Pediatric Obesity
Do obese children suffer from greater rates of depression? Study of 868 third grade students KEDS Results: there is a relationship between depressive
symptoms and BMI in preadolescent girls; not in boys. Girls express more overweight concerns.
Take home message: when girls present to Family Docs, assessing overweight concerns with the 5-question scale may help identify overweight girls at highest risk of developing depression, and perhaps subsequent eating disorders.
Obesity and Psychological Disorders in Children
At any given time, 44% of adolescent girls and 15% of adolescent boys are “dieting”
Prevalence of eating disorders (anorexia and bulimia) is estimated to be 1-4% of adolescent and young adult women
Predisposing factors may include: genetic, biological vulnerability, individual psychopathology, familial and cultural influences
Survey of women on the most common weight loss practices: weighing oneself regularly, walking, fasting, meal skipping, diet pills, cigs
Weight cycling: not related to increased psychopathology!
Obesity and Eating Disorders
Non-dieting approaches for obese children
Identify and combat cultural notions that “thinner is better” and that body weight can be controlled by willpower
Help participants “stop dieting” by abandoning efforts to restrict energy intake and avoid certain foods
Help participants identify and eat in response to the body’s “natural” hunger and satiety signals
Increase self-esteem and positive body image through self-acceptance rather than weight reduction
Increase awareness about dieting behaviors and their purported ill effects
Early onset of adiposity rebound (AR)
Early onset of puberty related to obesity in girls
Increased rates of Type 2 diabetes diagnosed among obese children
Adult food fears impact children
Obesity and Children Miscellaneous
Intervention should begin early The family must be ready for change Clinicians should educate families about
medical complications of obesity Clinicians should involve the family and all
caregivers in the treatment program Treatment programs should institute
permanent changes, not short-term diets or exercise programs aimed at rapid weight loss
General Approach to Treating Pediatric Obesity
As part of the treatment program, a family should learn to monitor eating and activity
The treatment program should help the family make small, gradual changes
Clinicians should encourage and emphasize and not criticize
A variety of experienced professionals can accomplish many aspects of a weight management program
General Approach to Treating Pediatric Obesity
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BIBLIOGRAPHY
BIBLIOGRAPHY
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Thank you very much!