Transcript Obesity in Children and Adoelscents

OBESITY IN CHILDREN AND ADOLESCENTS
A Pediatrician’s Role in Shaping the Future
DISCLOSURES
 We have no financial relations to disclose.
OBJECTIVES
 Discuss current epidemiology
 Review normal growth
 Define obesity in childhood
 Discuss causes
 Discuss complications
 What can we do as physicians?
ACCORDING TO THE CDC IN 2015, THE PERCENTAGE OF
CHILDREN CLASSIFIED AS OVERWEIGHT AND OBESE IN THE
UNITED STATES IS ______.
1. 13%
2. 21%
3. 32%
4. 40%
5. 47%
0%
1
0%
0%
2
3
0%
4
0%
5
WHAT IS THE RECOMMENDED AMOUNT OF
PHYSICAL ACTIVITY FOR CHILDREN BY THE
AMERICAN HEART ASSOCIATION?
1.
2.
3.
4.
5.
60 minutes per day, 7 days per week
60 minutes per day, 5 days per week
45 minutes per day, 7 days per week
45 minutes per day, 5 days per week
30 minutes per day, 5 days per week
0%
1
0%
0%
2
3
0%
4
0%
5
WHAT IS THE PERCENTAGE OF TYPE 2 DIABETES
IN ALL NEW ONSET DIABETES IN CHILDREN?
1. 15%
2. 25%
3. 35%
4. 45%
5. 50%
0%
1
0%
0%
2
3
0%
4
0%
5
KYLE IS A 13 YEAR OLD MALE PRESENTING TO YOUR OFFICE FOR A WELL
CHILD CHECK. HIS HEIGHT IS AT THE 85TH PERCENTILE, HIS WEIGHT IS AT THE
98TH PERCENTILE, AND HIS BMI IS AT THE 96TH PERCENTILE. WHAT SCREENING
LABS SHOULD BE PERFORMED AT THIS VISIT?
1. Fasting glucose and lipid panel
2. Fasting glucose, lipid panel, AST,
and ALT
3. Fasting glucose, lipid panel, AST,
ALT, TSH, and Free T4
4. Fasting glucose, lipid panel, TSH,
and Free T4
0%
1
0%
0%
2
3
0%
4
WORLDWIDE STATISTICS
 Childhood obesity is one of the most important global health problems of the 21st
century.
 Prevalence increasing at an alarming rate.
 In 2010, WHO estimated 43 million children < 5 years of age are overweight.
 It is estimated that by 2020, >60% of global disease burden while be due to
obesity related diseases .
 Primary prevention of pediatric obesity is essential.
UNITED STATES STATISTICS
All
Overweight or Obesity
BMI-for-age >/= 85th
percentile
31.8%
Obesity
BMI-for-age >/=
95th percentile
16.9%
2-5 year olds
22.8%
8.4%
6-11 year olds
34.2%
17.7%
12-19 year olds
34.5%
20.5%
All Females
2-19 years old
31.6%
17.2%
White (non-Hispanic)
29.2%
15.6%
Black (non-Hispanic)
36.1%
20.5%
Hispanic
All Males
2-19 years old
37.0%
20.6%
32.0%
16.7%
White (non-Hispanic)
27.8%
12.6%
Black (non-Hispanic)
34.4%
19.9%
Hispanic
40.7%
24.1%
SOUTH CAROLINA STATISTICS
 17% of adolescents were overweight
 14% of adolescents were obese
 46% of students grades 9-12 ate fruit or drank 100% fruit juice < 1 time daily
 46% of students grades 9-12 consumed vegetables < 1 time daily
 78% of adolescents drank a can, bottle, or glass of regular soda during the 7 days
prior to the survey
 20% of adolescents received < 1 day of 60 minutes of physical activity
 33% of adolescents watched 3 or more hours of TV on an average school day
DEFINING OBESITY
 Excess of body fat
 CDC 2000 growth charts
 Body Mass Index [weight (kg)/ height (m)]
 2-18 years of age
 Obese: BMI at or greater than the 95th percentile of BMI for age
 Overweight: BMI at the 85th but less than the 95th percentile of BMI for age
 Less than 2 years of age
 Overweight: at or greater than the 95th percentile of weight-for-length
NORMAL GROWTH
 Infants typically loss 5-8% of their birth weight in the days following birth
 Back at birth weight by 2 weeks of age
 Double birth weight by 6 months
 Triple birth weight by 12 months
 Quadruple birth weight by 2 years of age
 Average weight gain of 2kg/year between 2year of age and puberty
BODY FAT
 Proportion of body fat increases rapidly from
birth to 12mos
 Slow fall occurs until preadolescence
 Slow rise again until puberty
 After puberty, percentage stabilizes
BMI CHANGES FROM 2-18
 BMI decreases from age 2 years of age to 5-6 years of age and
then increase thereafter.
 V-Shaped Pattern in early childhood has been termed
“adiposity rebound”
THE CAUSE OF OBESITY IS
MULTIFACTORIAL
THE GENETIC ROLE
 Obesity tends to run in families
 Risk is 2-8 times greater with a family history of obesity
 Little is known regarding the specific genes that contribute to obesity
 What is clear: Genetic factors identified thus far account for only a small portion of
obesity risk.
 Specific Genetic Conditions linked to obesity
 Bardet-Biedl and Cohen Syndromes
 Prader Willi
FAST FOOD CONSUMPTION
>1/3 of kids eat fast food
on any given day
SUGARY BEVERAGES
PORTION SIZES
ACTIVITY LEVEL
 Only 22% of American children
meet basic activity level
requirements.
 PE programs in schools are
reduced or eliminated
 Safe places to play outside are
limited in some areas
 Increased screen time
COMPLICATIONS
ENDOCRINE
 Impaired Glucose Tolerance (Pre-Diabetes)
 10-30% of children and adolescents have IGT
 Insulin resistance- increased lipid accumulation and reduced sensitivity of
the Beta-cell
 Majority of this population have normal fasting glucose levels
 Type 2 Diabetes
 45% of all new onset diabetes in adolescents
 Often occurs in the 2nd decade of life
 Positive family history in 1st or 2nd degree relative in >75%
 Biggest risk factor is overweight or obesity
ENDOCRINE
 Hyperandrogenemia
 Polycystic Ovarian Syndrome
 Early puberty in girls
CARDIOVASCULAR
 Hypertension
 37% of hypertensive children are overweight or obese
 Dyslipidemia
 High LDL and Triglycerides, Low HDL
 Early Development of Atherosclerosis
METABOLIC SYNDROME
 Type 2 diabetes, hypertension, dyslipidemia, and a
prothrombotic inflammatory vascular environment
 Incidence of 30% in overweight adolescents
 Increases risk for cardiovascular disease
GASTROINTESTINAL
 NAFLD
 Most common liver disease in the US
 Affects 10% of all children and 38% of obese children
 Obesity alone and obesity related diseases increase risk
 Can progress to fibrosis leading to cirrhosis
 Cholelithiasis
PULMONARY
 Obstructive Sleep Apnea
 Occurs in up to 60% of obese children
 Increases risk of cardiovascular and metabolic syndrome
 Obesity Hypoventilation Syndrome
 Asthma
MUSCULOSKELETAL
 Higher risk for fractures
 Early Arthritis
 Slipped Capital Femoral Epiphysis
 Blount’s Disease
 Pes Planus
OTHER SYSTEMS
 Neuro: Pseudotumor Cerebri
 Integumentary: Chronic irritation and infection of skin folds
PSYCHOSOCIAL
 Stress triggering “emotional” eating
 Neglect or Maltreatment
 Living situation lacking consistency,
limit-setting, and supervision
 Food as a reward
 Food as a part of socializing
WHAT CAN WE DO AS
PHYSICIANS?
EXPERT COMMITTEE RECOMMENDATIONS
 Expert committee is comprised of representatives from 15
different professionals organizations
 First meeting in 1997
 Initial recommendations published in 1998
 Second meeting in 2007 and revision to initial recommendations
published.
 Serves as a guide for physicians in managing childhood obesity
MEDICAL ASSESSMENT
 Identify any underlying syndromes or secondary complications
 History and Physical
HISTORY
 Dietary Assessment
 Physical Activity Assessment
 Family History
Symptom
Anxiety, school avoidance, social isolation
Severe recurrent headaches
Shortness of breath, exercise intolerance
Snoring, apnea, daytime sleepiness
Sleepiness or wakefulness
Abdominal pain
Hip pain, knee pain, walking pain
Foot pain
Irregular menses (<9 cycles per y)
Primary amenorrhea
Polyuria, polydipsia
Unexpected weight loss
Nocturnal enuresis
Tobacco use
Possible Causes
Depression
Pseudotumor cerebri
Asthma, lack of physical conditioning
Obstructive sleep apnea, obesity hypoventilation
syndrome
Depression
Gastroesophageal reflux disease, constipation,
gallbladder disease, NAFLDa
Slipped capital femoral epiphysis, musculoskeletal stress
from weight (may be barrier to physical activity)
Musculoskeletal stress from weight (may be barrier to
physical activity)
Polycystic ovary syndrome; may be normal if recent
menarche
Polycystic ovary syndrome, Prader-Willi syndrome
Type 2 diabetes mellitusa
Type 2 diabetes mellitusa
Obstructive sleep apnea
Increased cardiovascular risk; may be used as form of
weight control
PHYSICAL EXAM
 Vitals: BP, Weight, Height, BMI
 General: Body Habitus
 Neck: Acanthosis Nigricans, Thyromegaly, Buffalo Hump
 HEENT: Moon facies, Tonsillar Hypertrophy
 CV: Murmur
 Abdomen: Hepatomegaly, RUQ tenderness
 GU: Early puberty
 MSK: Bowing of legs, Limited ROM of Hip, Limp
 Skin: Hirsutism, Excessive Acne, Violaceous Striae
SCREENING FOR OBESITY RELATED
CONDITIONS
 Overweight individuals (BMI of 85th-94th percentile) at age 10 or onset of puberty
should have a lipid panel performed and, if risk factors are present, a fasting
glucose, AST, and ALT should be performed.
 Obese individuals (BMI at the 95th percentile or greater at age 10 or onset of
puberty should have a lipid panel, fasting glucose, AST, and ALT performed
regardless of risk factors
 The Endocrine Society recommends obese children have a 25-OH vitamin D
performed
 Repeat every 2 years
INDIVIDUAL BASED TESTING
 Tonsillar hypertrophy + snoring, daytime sleepiness  Sleep
Study  OSA?
 RUQ pain after eating + RUQ tenderness  RUQ Abdominal US
Cholelithiasis?
 Knee pain or limp + limited ROM of hip  AP and Frog Leg
Xrays  SCFE?
TREATMENT OF CHILDHOOD OBESITY
COUNSELING
 Use sensitivity and compassion
 Obesity is an important medical condition that can be treated
 Ask questions in an objective, non-accusatory fashion
 Try to avoid words that may have a negative connotation
MOTIVATIONAL INTERVIEWING
 Patient-centered method for enhancing intrinsic motivation to
change health behavior by exploring and resolving ambivalence.
 Elicit-Provide-Elicit
 Importance and Confidence Scale
 Positive results in health behavior and weight loss
 Reduces physician stress and frustration in obesity counseling
 Increases odds of success!
INEFFECTIVE COMMUNICATION
Doctor: We need to talk about John’s weight and diet. His BMI percentile classifies
him as obese. You state that he eats little to no vegetables or fruit and that his diet
consists of mainly hot dogs, chicken nuggets, fries, and juice. You should increase
the vegetables and fruit that John eats and reduce the high calorie, processed foods
in his diet. John should also only drink 4-6oz of juice per day.
Mother: Well I am a single mother that works a full time job. Fresh fruits and
vegetables are more expensive and take more time to prepare. For our lifestyle, his
current diet is more feasible.
EFFECTIVE COMMUNICATION
Doctor: Would it be okay if we discussed John’s diet and weight today?
Mother: I guess so.
Doctor: The diet of many young kids today consists of a large amount of processed foods
such as hot dogs, chicken nuggets, and fries. These foods are high in calories and low in
nutritional value which can cause children to be overweight and deficient in vitamins and
minerals. They also contain a large amount of salt that isn’t good for the heart. Most
children drink more juice than recommended. We recommend no more than 4-6oz of
juice per day because it contains a large amount of sugar and calories. How do feel about
the information I’ve provided?
Mother: Well after hearing all of that information and when I look closer at John’s diet,
maybe we do need to make some changes.
Doctor: On a scale of 1-10, with 10 being the highest, how important is making a change in
John’s diet to you?
Mother: I guess I’d say an 8.
Doctor: Using this same scale, how confident are you that you can make these changes?
Mother: I think an 8.
Doctor: Great! Well let’s talk about the changes you would like to make and the strategies you
can use to achieve those changes.
4 STAGES OF TREATMENT
 Stage 1: Prevention Plus
 Stage 2: Structured Weight Management
 Stage 3: Comprehensive Multidisciplinary Intervention
 Stage 4: Tertiary Care Intervention
ADDITIONAL TIPS FOR COUNSELING
 Make 1 change at a time.
 Encourage parents not to expect children to make healthy choices on their
own.
 Food should not be used as a reward.
 Encourage positive behavior changes for the entire family.
 Emphasize health not weight.
SUMMARY
 Childhood obesity can be a difficult and frustrating disease to
treat.
 Every child should be screened for obesity and risk factors for
obesity and obesity-related disorders.
 Counsel on preventive measures at every visit.
 Primary prevention is key!
ACCORDING TO THE CDC IN 2015, THE PERCENTAGE OF
CHILDREN CLASSIFIED AS OVERWEIGHT AND OBESE IN THE
UNITED STATES IS ______.
1. 13%
2. 21%
3. 32%
4. 40%
5. 47%
0%
1
0%
0%
2
3
0%
4
0%
5
WHAT IS THE RECOMMENDED AMOUNT OF
PHYSICAL ACTIVITY FOR CHILDREN BY THE
AMERICAN HEART ASSOCIATION?
1.
2.
3.
4.
5.
60 minutes per day, 7 days per week
60 minutes per day, 5 days per week
45 minutes per day, 7 days per week
45 minutes per day, 5 days per week
30 minutes per day, 5 days per week
0%
1
0%
0%
2
3
0%
4
0%
5
WHAT IS THE PERCENTAGE OF TYPE 2 DIABETES
IN ALL NEW ONSET DIABETES IN CHILDREN?
1. 15%
2. 25%
3. 35%
4. 45%
5. 50%
0%
1
0%
0%
2
3
0%
4
0%
5
KYLE IS A 13 YEAR OLD MALE PRESENTING TO YOUR OFFICE FOR A WELL
CHILD CHECK. HIS HEIGHT IS AT THE 85TH PERCENTILE, HIS WEIGHT IS AT THE
98TH PERCENTILE, AND HIS BMI IS AT THE 96TH PERCENTILE. WHAT SCREENING
LABS SHOULD BE PERFORMED AT THIS VISIT?
1. Fasting glucose and lipid panel
2. Fasting glucose, lipid panel, AST,
and ALT
3. Fasting glucose, lipid panel, AST,
ALT, TSH, and Free T4
4. Fasting glucose, lipid panel, TSH,
and Free T4
0%
1
0%
0%
2
3
0%
4
RESOURCES
 Herouvi, Despina, Evangelos Karanasios, Christina Karayianni, and Kyriaki Karavanaki. "Cardiovascular disease in childhood: the role of
obesity." European Journal Pediatrics 172 (2013): 721-32. PubMed. Web. 3 Jan. 2016
 McCrindle, Brian W. "Cardiovascular Complications of Childhood Obesity." Canadian Cardiovascular Society 31.2 (2014): 124-30. PubMed. Web. 3 Jan.
2016
 Indra Narang and Jospeh L. Mathew, “Childhood Obesity and Obstructive Sleep Apnea,” Journal of Nutrition and Metabolism, vol. 2012, Article ID
134202, 8 pages, 2012. doi:10.1155/2012/134202
 Andrew J. Walley, Alexandra I.F. Blakemore, and Philippe Froguel. Genetics of obesity and the prediction of risk for health. Hum. Mol.
Genet. (2006) 15 (suppl 2): R124-R130 doi:10.1093/hmg/ddl21
 Burt Solorzano, Christine M., and Christopher R. McCartney. “Obesity and the Pubertal Transition in Girls and Boys.” Reproduction (Cambridge,
England)140.3 (2010): 399–410. PMC. Web. 6 Jan. 2016.
 Schuman, Andrew J. "Making a Difference: Point of care screening for hyperlipidemia." Contemporary Pediatrics (2013). Web. 9 Jan. 2016
 Kelishadi, Roya, and Fatemeh Azizi-Soleiman. "Controlling Childhood Obesity: A Systematic Review on Strategies and Challenges." Journal of Research
in Medical Sciences (2014): 993-1008. PubMed. Web. 14 Jan. 2016
 Krebs, Nancy F., and John H. Himes. "Assessment of Child and Adolescent Overweight and Obesity." Journal of Research in Medical Sciences (2007): 193219. PubMed. Web. 14 Jan. 2016.
 Vikraman, Sundeep, and Cheryl Fryar. "Caloric Intake From Fast Food Among Children and Adolescents in the United States, 2011-2012." CDC. N.p.,
Sept. 2015. Web. 14 Jan. 2016.
 Golden, Neville H., and Steven A. Abrams. "Optimizing Bone Health in Children and Adolescents." Pediatrics 134.4 (2014). Web. 14 Jan. 2016.
RESOURCES
 Barlow, Sarah E. "Expert Committee Recommendations Regarding Prevention, Assessment, and Treatment of Child and Adolescent Overweight and
Obesity: Summary Report." Pediatrics 120 (2015): 164-92. Web. 14 Jan. 2016
 Barlow, Sarah E., and William H. Dietz. "Obesity Evaluation and Treatment: Expert Committee Recommendations." Pediatrics102 (1998). Web. 14 Jan.
2016.
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THANK YOU!