PREVENTION OF PEDIATRIC OBESITY William J. Cochran, MD, FAAP Department of Pediatric Nutrition Geisinger Clinic, Danville PA
Faculty Disclosure Information In the past 12 months, I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this CME activity. I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.
IMPACT OF CHILDHOOD OBESITY ON ADULT HEALTH • Adverse effects of childhood obesity on adult health • Increased rates of all cause mortality in adulthood • Increased rates of mortality from CAD in adult males • Increased morbidity from CAD in adult males and females
IMPACT OF CHILDHOOD OBESITY ON ADULT HEALTH • Adverse effects of childhood obesity on adult health • Increased rates of colon cancer in males • Increased rates of arthritis in females • Childhood obesity may be a greater predictor of complications in adulthood than obesity in adulthood
TREATMENT OF PEDIATRIC OBESITY IS AVAILABLE AND CAN BE EFFECTIVE • PREVENTION IS PREFERABLE
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 • The risk of obesity in a child born to obese parents is significantly increased • Parents act as role models for their children • Need to educate and intervene in childhood to help prevent obesity in subsequent generations
PREVENTION: POST CONCEPTION • Routine prenatal care • Advocate appropriate 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
PREVENTION: POST CONCEPTION • Promote breastfeeding prior to delivery • 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 3 fold greater in formula fed vs. breastfed
PREVENTION: INFANCY • Advocate for continued breast feeding • The duration of breastfeeding is inversely associated with the risk of overweight • Harder T. Am J Epidemiol. 2005;162(5):397-403 • Avoid over feeding formula feed infants • Monitor growth curve including weight for length curve • Excessive weight gain associated obesity • Taveras EM et al. Weight status in the first 6 months of life and obesity at 3 years of age. Pediatrics 2009;123:1177-1183
PREVENTION: INFANCY • Educate parents about beverages • No nutritional need for juice for at least the first 6 months of age • 1-6 year olds limit juice to 4-6 oz per day • Provision of sweet beverages promotes desire to consume sweet beverages • The use and misuse of fruit juice in pediatrics. Pediatrics 107:1210-1213, 2001.
PREVENTION: INFANCY • Introduction of solids • Do not introduce solids until 4-6 months of age • Introduce vegetables first • Infants born with preference for sweet • Continue to provided the food even if initially rejected • Breast fed babies are more willing to accept other new foods compared to formula fed infants
PREVENTION: INFANCY • Promote parental interaction with infant • Discuss TV • Do not use TV as a “Baby sitter” • AAP recommends no TV for the first 2 years of life • AAP recommends no TV in bedroom • Children, adolescents and television. Pediatrics 107:423-426, 2001
PREVENTION: INFANCY • TV in bedroom • 40% of 1-5 year olds have TV in bedroom • Children with TV in bedroom • Watch more TV • Have higher rates of obesity • Associated with increased sedentary time • Promotes more social isolation • Dennison, BA et al. Pediatrics 109:1028-1035, 2002.
PREVENTION: INFANCY • Identify those at risk • Family history • Risk of obesity 9% if both parents are lean • Risk of obesity 60-80% if both parents are obese • Sibling over weight (genetics vs. obesigenic environment) • Ethnicity: African-American, Hispanic • Large for gestational age • Small for gestational age
PREVENTION: INFANCY • Identify those at risk • Lower socioeconomic status • Rural setting • Both parents work • Single parent family • Little cognitive stimulation • Lack of safe play areas • Family stress • Strauss, RS et al. Pediatrics 1999;103 (6) e-pages
PREVENTION: TODDLER • Discuss beverages • 20% of obese children are obese due to excessive caloric consumption from beverages • Soda has 150 calories per 12 oz • Juice on average has 120 calories per 8 oz • For every 100 calories consumed per day in excess will result in 10 pound weight gain per year • Promote consumption of water when thirsty
PREVENTION: TODDLER • Do not use the “clean the plate rule” • “Parents provide, children decide what to eat” • Parents should provide a healthy array of food and appropriate portions • Child’s intake varies from day to day • Do not use food as a reward
PREVENTION: TODDLER • No TV for children less than 2 • Promote physical activity • Free play • Play with parents as well as friends
PREVENTION: PRESCHOOLER • Measure and plot BMI • Monitor BMI • If increasing BMI % even if “normal” this is a red flag • Review BMI curve with parent and child • Provide positive reinforcement for being normal • Being over weight at one time between ages of 24 and 54 months was associated with a 5 fold increased risk of obesity at 12 years • Nader, PR et al. Pediatrics 118: e594-601, 2006
PREVENTION: PRESCHOOLER • Anticipatory guidance • Nutrition • Discuss beverages • Do not use “clean the plate rule” • Do not use food as reward • Offer balanced diet: fruits, vegetables, high fiber
PREVENTION: PRESCHOOLER • Anticipatory guidance • Physical activity • Promote free play time • Encourage special family time that is physically active • Think about physical activity opportunities • Walk up steps instead of taking the elevator • Park at a distance from store • 50% of car trips are less than 5 miles
PREVENTION: PRESCHOOLER • Anticipatory guidance • Physical activity • Limit sedentary time • Discuss screen time: <1-2 hours per day • Higher rates of obesity, hypertension and hypercholesterolemia in those who watch >2 hours per day • Prevention of pediatric overweight and obesity. Pediatrics 112; 424-430, 2003 • Pardee et al., American J of Preventive Medicine, December 2007 • Martinez-Gomez D et al. Arch Pediatr Adolesc Med 2009;163:724-730
PREVENTION: PRESCHOOLER • Anticipatory guidance • Life style • Do not eat in front of TV • >60% of commercials during children’s programming are related to food • Increase appetite / desire for these foods • Tend to over eat: do not pay attention to if they are full, eat until food is gone • Children who eat in front of TV consume higher fat and salt foods and less fruits and vegetable than those who do not
PREVENTION: PRESCHOOLER • Anticipatory guidance • Life style • Limiting screen time in children 4-7 years of age associated with lower BMI • Associated with decreased caloric intake • Epstein,LH et al. Arch Pediatr Adolesc Me 162(3): 239-245, 2008
PREVENTION: PRESCHOOLER • Anticipatory guidance • Life style • Stress the fact that parents act as role models for nutrition, physical activity and life style • Promote the family meal • Conversation slows down the eating process • Parents determine the food that is to be consumed • Parents can monitor intake of food • Family meals associated with higher consumption of fruits, vegetables and milk • Family meals associated with lower intake of fat and sweet beverages
PREVENTION: PRESCHOOLER • Day care / preschool • What and how much are the children being fed? • Beverages • Snacks • What type and how much physical activity? • Russell, RP et al. Pediatrics 114:1258-1263, 2004 • What type and how much sedentary activity is there?
PREVENTION: SCHOOL AGED CHILD • Measure and plot BMI • Monitor BMI • If increasing BMI % even if “normal” this is a red flag • Review BMI curve with parents and child • Provide positive reinforcement if normal
PREVENTION: SCHOOL AGED CHILD • Anticipatory guidance • Nutrition • Discuss beverages • Soda consumption has increased 300% in last 20 years • 20% of adolescent males consume >4 sodas per day • Promote consumption of low fat dairy products and water • Soft drinks in schools. Pediatrics 113:152-154, 2004
PREVENTION: SCHOOL AGED CHILD • Anticipatory guidance • Nutrition • Portion size • 3 year olds will eat what is appropriate despite how much is on the plate. Older children consume more if portion size is larger. • Portion size has increased over the years especially at fast food restaurants: “Biggie sized” • Read labels on food regarding portion size (adult portion size) • www.mypyramid.gov
PREVENTION: SCHOOL AGED CHILD • Anticipatory guidance • Nutrition • Eat regular meals • Skipping breakfast is a risk factor for obesity • Children who eat breakfast do better in school vs. those who do not • Skipping meals does not result in decrease caloric consumption, tend to over eat at other meals or snack frequently
PREVENTION: SCHOOL AGED CHILD • Anticipatory guidance • Physical activity • Ask the child how much physical activity they do • What type of activities are they involved in • What are the barriers to doing physical activity • CDC recommends 60 minutes of moderate physical activity per day
PREVENTION: SCHOOL AGED CHILD • Anticipatory guidance • Physical activity • Activity needs to be fun • Do this with family and or friends • Promote life long activities • Have a variety of activities
PREVENTION: SCHOOL AGED CHILD • Anticipatory guidance • Lifestyle • Promote <1-2 hours of screen time • 25% watch more than 4 hours per day • For overweight children decreasing sedentary activity was more effective at inducing weight loss than promotion of physical activity • Prevention of pediatric overweight and obesity. Pediatrics 112; 424-430, 2003.
PREVENTION: SCHOOL AGED CHILD • Anticipatory guidance • Lifestyle • No TV in bedroom • TV in bedroom associated with: • More TV time • Worse eating and exercise habits • Poorer academic performance • Barr-Anderson et al. Pediatrics April 2008 • TV, computer and video games are a privilege, not a right
PREVENTION: SCHOOL AGED CHILD • Anticipatory guidance • Lifestyle • Eat as a family • Special family time being physically active • Parents act as a role model • Promote healthy life long habits of physical activity and nutritious eating
PREVENTION: SCHOOL AGED CHILD • Anticipatory guidance • Lifestyle • Eating out / take out food • Approximately $0.50 of every nutrition dollar is spent on food out side the home • The portion size tends to be larger • The food tends to be higher in fat and salt • When eating out try to make healthier choices • Baked potato or salad instead of french fries • Water or low fat milk instead of soda • Nutrition information for fast food available on line and in some restaurants
PREVENTION SCHOOL AGED CHILD • Anticipatory guidance • Physical environment • Proximity of fast-food restaurants to school • Fast food restaurant within ½ mile of school • Consumed fewer fruits and vegetables • Consumed more soda • Were more likely to be overweight • Davis, B et al. Proximity of fast-food restaurants to schools and adolescent obesity. Am J Public Health 99:505-510, 2009
PREVENTION: SCHOOL AGED CHILD • Anticipatory guidance • Lifestyle • Encourage to participate in organized sports • Weintraub DL et al. Arch Pediatr Adolesc Med 162(3):232-237, 2008 • Participate in after school activities • Volunteer
PHYSICIAN AS COMMUNITY ADVOCATE • School / preschool • Educate administrators, teachers and parents about obesity • Be part of School Health Advisory Board • Promote nutrition, physical education and lifestyle education
PHYSICIAN AS COMMUNITY ADVOCATE • Promote appropriate use and items in vending machines • 73% of elementary schools, 97% of middle schools and 100% of high schools have 1 or more sources of competitive food • Improving child nutrition policy: Insights from national USDA study of school food environments. RWJF Policy Brief 2/09 • Students in schools where competitive foods are restricted consumed less sweet beverages • Briefel R et al. J Am Dietetic Assoc 109:S9a-S107, 2009 • Soft drinks in schools. Pediatrics 113:152-154, 2004.
PHYSICIAN AS COMMUNITY ADVOCATE • School / preschool • Promote nutritious meals • 42% of schools do not offer fresh fruit or raw vegetables every day for lunch • Less than 5% offer whole grain bread products • Commercially prepared food products ie pizza, chicken nuggets, beef patties etc account for 40% of lunch entrees • Fewer than 1/3 of schools met recommendations for total and saturated fats • Crepinsek MK et al. J Am Dietetic Assoc 109:S31-S43, 2009 • Condon E et al. J Am Dietetic Assoc 109:S67-S78, 2009
PHYSICIAN AS COMMUNITY ADVOCATE • Community • Advocate for safe and accessible places for children to be physically active • Need to develop neighborhoods that are environmentally friendly and conducive to physical activity • Franzini L et al. Influences of physical and social neighborhood environments on children’s physical activity and obesity. Am J Public Health 99:271-278, 2007 • Need access to full service grocery stores with reasonable cost for healthy foods • Obesity Prevalence Among Low-Income, Preschool-Aged Children --- United States, 1998—2008, MMWR July 24, 2009 58(28): 769-773