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Childhood and Adolescent Obesity

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.

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Childhood and Adolescent Obesity

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

  2. 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

  3. 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

  4. Anthony • 15 yr old • Referred by his new PMC

  5. Anthropometrics • Weight: 121 kg • Height: 175 cm

  6. BMI: 39

  7. How Do We Define Overweight in Children and Adolescents?

  8. 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

  9. 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

  10. Classification of Overweight and Obesity in Adults Using BMI

  11. 43 36 37 35 39 38 University of Miami Blocking Machine

  12. 33 Height: 7-1 Weight: 154 kg Height: 6-6 Weight: 98 kg 25

  13. BMI is Age Specific in Children and Adolescents

  14. 24 21 17

  15. Increasing Incidence of Overweight in Children and Adolescents

  16.  95th%ile for age and gender These #s double when including >85%ile

  17. PERCENT OF OBESE CHILDREN WHO BECOME OBESE ADULTS

  18. Multifactorial Condition Etiology of Obesity • Genetic/heritablility • Molecular • Syndromes • Environmental

  19. 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

  20. In modern industrial environment easy access to calorically dense foods encourages sedentary lifestyle Metabolic consequences of these genes are maladaptive

  21. 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 Familial Risk: 2-3 fold for moderate obesity 5-8 fold for severe obesity Bouchard 01 Buchard 97 Rankinen 02

  22. Spina bifida Prader Willi Down Syndrome Bardet-Biedl More than 50 Obesity Associated Genetic Syndromes

  23. 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

  24. 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

  25. What is Causing this Marked Increase in Overweight??

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

  27. PE sed act calories Causes of Marked Increase in Overweight • Reflects a shift towards positive energy balance energy intake = energy expenditure McDowell 94; Kann 99; Troiano 00,NHANES II to III

  28. 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

  29. 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?

  30. 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

  31. Other Contributors to Sedentary Lifestyles • 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

  32. Medical Consequences of Overweight

  33. 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

  34. 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

  35. Acanthosis Nigricans • Hyperpigmented, velvety plaques in body folds • Caused by hyperinsulinemia which stimulates formation • Associated with obesity

  36. Other Endocrinological Issues • 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

  37. More Complications • Hepatic Steatosis with elevated LFTs • Cholelithiasis • 50% of kids with cholecystitis are overweight • Orthopedic Problems

  38. 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

  39. 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)

  40. Who Needs to be Evaluated?

  41. Evaluating For Overweight in a Primary Care Setting BMI Overweight BMI  95th% At risk for Overweight BMI 85-95th% Not at risk BMI  85th% Return next yr for screen • Family history • Blood pressure • Lipids • Lg  in BMI • Concern re wt  + In depth medical assessment • Note in chart • No therapy • Return next yr

  42. 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

  43. 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

  44. 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

  45. Dietary Information • Picky eater • Consumes NO fruits or vegetables • Mom prepares separate meals for him

  46. 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

  47. 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

  48. 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

  49. 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

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