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PEDIATRIC OBESITY: A HUGE PROBLEM IN THE USA

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  1. PEDIATRIC OBESITY: A HUGE PROBLEM IN THE USA William J. Cochran, MD Department of Pediatric GI & Nutrition Geisinger Clinic

  2. WHY WORRY ABOUT PEDIATRIC OBESITY? • Pediatric obesity is of epidemic proportion. • Pediatric obesity is the most common chronic disease of childhood.

  3. DEFINITION OF PEDIATRIC OBESITY • Overweight / At risk of overweight • BMI 85-95% • Obese / Overweight • BMI >95%

  4. OLDER DEFINITIONS OF OBESITY Weight for height >95% Actual weight >120% ideal body weight Super obese >140% of ideal body weight

  5. Percent of obese children and adolescents

  6. INCIDENCE OF PEDIATRIC OBESITY IN PENNSYLVANIA

  7. RACIAL DIFFERENCES IN PEDIATRIC OBESITY • Non-Hispanic white 12.3% • African American 21.5% • Hispanic 21.8%

  8. WHY WORRY ABOUT PEDIATRIC OBESITY? • Is pediatric obesity a real problem or just a cosmetic issue?

  9. WHY WORRY ABOUT PEDIATRIC OBESITY? • Adult obesity is clearly associated with numerous health problems. • Type II DM • CAD • Hypertension • Cancer • Joint disease • Gallbladder disease • Pulmonary disease

  10. Significant risk of childhood obesity to persist into adulthood. WHY WORRY ABOUT PEDIATRIC OBESITY?

  11. PERCENT OF OBESE CHILDREN BECOMING OBESE ADULTS

  12. WHY WORRY ABOUT PEDIATRIC OBESITY? • Economic impact • The estimated cost of obesity in the US in 2002 was $117 billion. • The hospital cost of pediatric obesity is also increasing. • 1979: $35 million • 1999 $127 million

  13. IMPACT OF CHILDHOOD OBEISTY IN ADULTHOOD Childhood obesity has significant adverse effects on health in adulthood • Hoffmans 1988: Dutch males, increased mortality after 32 years in obese vs. lean adolescent males. • Mossberg 1989:Swedish study, increased mortality after 40 years in obese vs nonobese children

  14. IMPACT OF CHILDHOOD OBESITY IN ADULTHOOD • Harvard Growth Study: • Two fold increased all cause mortality in obese vs nonobese adolescents as adults • 2 fold increase in CAD mortality • Increased risk of colon cancer in males • Increased risk of arthritis in females • The association of adverse effects on adult health may be independent of obesity in adulthood

  15. CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITY • Psychosocial • Most common complication of pediatric obesity • Increased rates of depression • Poor self esteem • Obese adolescents negative self image may carry over into adulthood

  16. CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITY • Societal discrimination • Obese females have lower acceptance rate at colleges than non-obese females • National Longitudinal Survey of Youth: obese adolescent females as young adults had less education, less income, higher poverty rate, decreased rate of marriage vs nonose females

  17. CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITY • Endocrine • Non-insulin-dependent diabetes mellitus • Pinhas-Hamiel 1994 • The incidence of NIDDM has increased 10 fold • 92% of these had a BMI >90% • Geisinger weight management program • 60% have insulin resistance • 10% have fasting insulin level > 100 (Nl <17) • 1% have type II DM

  18. CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITY • Endocrine • Increased linear growth • Advanced bone age • Earlier onset of puberty • Acanthosis nigricans

  19. CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITY • Hypertension • Primary hypertension uncommon in childhood • 60% of children diagnosed with hypertension are obese • Use pediatric standars • Geisinger weight management program • 45% have hypertension

  20. CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITY • Hyperlipidemia • The atherosclerotic process begins in childhood. • Pediatric obesity is associated with increased cholesterol, LDL-cholesterol, triglyceride levels and lower levels of HDL-cholesterol • Geisinger weight management program • 45% have hypercholesterolemia

  21. CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITY • Hepatic steatosis • Hepatic steatosis present in 25-83% of obese children • 10-15% of obese children have elevated liver enzymes: steatohepatitis or non-alcoholic fatty liver disease • Rashid: 83% of children with steatohepatitis were obese. 75% had fibrosis-cirrhosis

  22. CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITY • Orthopedic • Slipped capital femoral epiphysis • 30-50% are obese • Blount’s disease (Tibia vara) • 70% are obese • Neurologic • Pseudotumor cerebri

  23. CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITY • Respiratory • Sleep disorder in 1/3 • Sleep apnea: 7% of obese, 1/3 if >150% & breathing difficulties • Hypoventilation syndrome • Gastrointestinal • Cholelithiasis • 50% of cases of cholecystitis in adolescents are obese

  24. PEDIATRIC OBESITY IS NOT JUST A COSMETIC PROBLEM!

  25. ETIOLOGY OF PEDIATRIC OBESITY

  26. ETIOLOGY OF PEDIATRIC OBESITY • Etiology is multifactorial • Interaction of genetics and environment • Energy imbalance • Energy In = Energy Used + Energy Stored • For every extra 100 calories consumed per day one will put on 10 pounds per year

  27. ETIOLOGY OF OBESITY • Caloric intake has increased • Eating unsupervised, lack of family meals • Eating at multiple sites • Eating out / take out food • Beverages • Calorically dense food

  28. ETIOLOGY OF OBESITY • Physical activity has decreased • Schools with less physical education • After school programs • Safety concerns • Convenience activities • Increased sedentary activities: TV, computer, video games

  29. ETIOLOGY OF OBESITY • Physical activity • TV / video games • More time spent watching TV less time for physical activity: average 2.5 hours / day, 20%>5 hours / day • BMI and obesity associated with higher amount of time spent watching TV • Higher cholesterol levels associated with greater amount of time spent watching TV • 40% of children 1-5 years have TV in their bedroom

  30. TREATMENT OF PEDIATRIC OBESITY • Weight management programs are available and can be effective • High rates of recurrence • Prevention is the key

  31. PREVENTION: PRECONCEPTION • Prevention starts prior to conception • Obese adolescents have an 80% probability of being obese as an adult • Today's adolescents are tomorrows parents • Parents act as role models for their children • The risk of obesity in a child born to obese parents is significantly increased • Need to educate and intervene at this time to help prevent obesity is subsequent generation

  32. PREVENTION: POST CONCEPTION • Routine prenatal care • Advocate normal weight gain during the pregnancy • LGA infants and infants of diabetic mothers have higher rates of subsequent obesity • SGA infants also at higher risk • Hediger ML et: Pediatrics104:e33, 1999

  33. PREVENTION: POST CONCEPTION • Promote breastfeeding • Dewey 2003: 8 out of 11 studies noted a lower rate of obesity in children if breastfed vs. formula fed • Bergmann 2003: Longitudinal study of breastfed vs. formula fed infants • BMI the same at birth • BMI at 3 & 6 months > in formula fed vs. breastfed infants • Rate of obesity at 6 years was tripled in formula fed vs. breastfed

  34. PREVENTION OF PEDIATRIC OBESITY • Measure and plot BMI • Only done by 20% of primary care providers • Identify those at risk • Anticipatory guidance • Nutrition • Physical activity • Healthy lifestyles

  35. IDENTIFY THOSE AT RISK • Increasing BMI % • Family history • Risk of obesity 9% if both parents are lean • Risk of obesity 60-80% if both parents are obese • Sibling over weight • High birth weight

  36. IDENTIFY THOSE AT RISK • Lower socioeconomic status • Ethnicity: African-American, Hispanic, Native American • Environmental / social • Both parents work • Little cognitive stimulation • Lack of safe play areas • Family stress

  37. 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

  38. NUTRITION ANTICIPATORY GUIDANCE • 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.

  39. NUTRITION ANTICIPATORY GUIDANCE • 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

  40. ACTIVITY ANTICIPATORY GUIDANCE • Encourage active play for young children • Promote physical activity • Ideal 30-60 minutes per day • Have several types of potential activities • Be physically active with others • Think about activity opportunities • Encourage participation in organized sports

  41. 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

  42. ACTIVITY ANTICIPATORY GUIDANCE • Decrease sedentary activity • Do not use the remote • Exercise on commercials • TV / computer is not a right it is a privilege

  43. BEHAVIORAL ANTICIPATORY GUIDANCE • Encourage parents to act as role models • Nutrition • Activity • Promote parent child interaction • Have special “family time” that is physically active

  44. BEHAVIORAL ANTICIPATORY GUIDANCE • Limit eating out • More calorically dense food • Larger portion sizes • Less intake of fruits and vegetables • $0.51 of every nutrition dollar is spent outside the home

  45. BEHAVIORAL ANTICIPATORY GUIDANCE • 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

  46. BEHAVIORAL ANTICIPATORY GUIDANCE • 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