Pediatric Obesity : A Family Affair Samuel N. Grief, MD.

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Pediatric Obesity: A Family Affair Samuel N. Grief, MD

Transcript of Pediatric Obesity : A Family Affair Samuel N. Grief, MD.

Page 1: Pediatric Obesity : A Family Affair Samuel N. Grief, MD.

Pediatric Obesity: A Family Affair

Samuel N. Grief, MD

Page 2: 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

Page 3: Pediatric Obesity : A Family Affair Samuel N. Grief, MD.

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

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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

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NHANES III

Scope of Pediatric Obesity Problem

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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

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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

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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)

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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Assessment of Medical Conditions Related to Obesity

Sleep apnea Gallbladdeer Disease Prader-Willi Syndrome Slipped Capital Femoral Epiphysis Blount’s Disease

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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!

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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

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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.

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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

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Minorities and increased rates of obesity

African-American Hispanic Native Indian Pacific Islander White Asian European Other

Culture and Obesity

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Culture and Obesity

Culture and food Food is a way of life Learn about different cultures: ASK! The taste of Chicago…

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You deserve a…

BREAK!

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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?

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Ready, set…

GO!

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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

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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

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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

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Useful for adolescents with extreme obesity

Last resort option for severely obese adolescents

Choose patients carefully

Surgical Treatment Options for Pediatric Obesity

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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

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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

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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

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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

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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

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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

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BIBLIOGRAPHY

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Thank you very much!