410 likes | 687 Views
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..
E N D
1. PREVENTION OF PEDIATRIC OBESITY William J. Cochran, MD, FAAP
Department of Pediatric Nutrition
Geisinger Clinic, Danville PA
4. WHY WORRY ABOUT PEDIDATRIC OBESITY?
5. Prevalence of obese children and adolescents 11% of children are above 97%, 36% are above the 85%. Ogden CL et al JAMA 2006;295:1549-1555
The frequency of severe obesity is also increasing; BMI>99% 0.8% 1976-1980 to 3.8% between 1999-2004
11% of children are above 97%, 36% are above the 85%. Ogden CL et al JAMA 2006;295:1549-1555
The frequency of severe obesity is also increasing; BMI>99% 0.8% 1976-1980 to 3.8% between 1999-2004
6. RISK OF OBESE CHILDREN BECOMING OBESE ADULTS
7. 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
8. 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
Harvard Growth study: Must et all NEJM 1992Harvard Growth study: Must et all NEJM 1992
9. CHILDHOOD OBESITY IS ALSO ASSOCIATED WITH PROBLEMS IN CHILDHOOD
10. PEDIATRIC OBESITY IS NOT JUST A COSMETIC PROBLEM! This is a serious health problem and obesity is now the most common chronic disease of childhoodThis is a serious health problem and obesity is now the most common chronic disease of childhood
11. TREATMENT OF PEDIATRIC OBESITY IS AVAILABLE AND CAN BE EFFECTIVE
PREVENTION IS PREFERABLE
12. What is the etiology of pediatric obesity?
13. 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 Need to educate people and intervene in childhood now to promote healthy lifestyles to help prevent obesity in subsequent generations.Need to educate people and intervene in childhood now to promote healthy lifestyles to help prevent obesity in subsequent generations.
14. 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
15. 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
The reason for breastfeeding preventing obesity is unknown but there are two major theories. 1. Breastfed infants consume fewer calories and have lower rates of weight gain than do formula fed infants. 2. In animal experiments, the kind of neonatal nutrition was shown to influence the development of neuroendocrine circuits in the mediobasal hypothalamus that regulates appetite control and body weight. ( see Harder et al)The reason for breastfeeding preventing obesity is unknown but there are two major theories. 1. Breastfed infants consume fewer calories and have lower rates of weight gain than do formula fed infants. 2. In animal experiments, the kind of neonatal nutrition was shown to influence the development of neuroendocrine circuits in the mediobasal hypothalamus that regulates appetite control and body weight. ( see Harder et al)
16. 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
17. 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.
WIC no longer providing juice WIC no longer providing juice
18. 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
19. 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
20. 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.
Need to talk with parents prior to a year of age to help prevent the TV from getting into the bedroom as it is harder to take it away than to never put it there at all.Need to talk with parents prior to a year of age to help prevent the TV from getting into the bedroom as it is harder to take it away than to never put it there at all.
21. 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
22. 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
23. 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
24. 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
25. PREVENTION: TODDLER No TV for children less than 2
Promote physical activity
Free play
Play with parents as well as friends
26. 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
27. 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
28. 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
29. 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 Sedentary behavior especially TV viewing was associated with HTN in children and was independent of BMISedentary behavior especially TV viewing was associated with HTN in children and was independent of BMI
30. 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
31. 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
32. 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
Gillman MW et all. Family dinner and diet quality among older children and adolescents. Arch Fam Med 2000;9:235-240
Videon TM et al. Influences on adolescent eating patterns: the importance of family meals. J Adolesc Health 2003;32:365-373.Gillman MW et all. Family dinner and diet quality among older children and adolescents. Arch Fam Med 2000;9:235-240
Videon TM et al. Influences on adolescent eating patterns: the importance of family meals. J Adolesc Health 2003;32:365-373.
33. 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?
34. 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
35. 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 2 liters of soda is over 800 calories2 liters of soda is over 800 calories
36. 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
A Wendys triple with everything, large fries and large soda is about 2000 caloriesA Wendys triple with everything, large fries and large soda is about 2000 calories
37. 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
www.adaevidencelibrary.com/topic.cfm?cat=1046www.adaevidencelibrary.com/topic.cfm?cat=1046
38. 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
39. 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
40. “NO CHILD LEFT ON THEIR BEHIND!”
41. 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.
42. 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
43. 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
44. 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
45. PREVENTION SCHOOL AGED CHILD Anticipatory guidance
Physical environment
Proximity of fast-food restaurants to school
Fast food restaurant within ˝ 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
46. 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
Study by Paula Dunkin, peds in Vermont, who noted that the rate of adolescent obesity was inversley proportional to the amount of time spent as a volunteer.Study by Paula Dunkin, peds in Vermont, who noted that the rate of adolescent obesity was inversley proportional to the amount of time spent as a volunteer.
47. 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
48. 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.
49. 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
50. 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
51. PHYSICIAN AS COMMUNITY ADVOCATE State
Participate in local chapter of AAP
Encourage policy / law makers to support healthful lifestyle for all children
Encourage insurance coverage for obesity prevention
Advocate for social marketing intended to promote healthful food choices and increased physical activity
52. CONCLUSION Pediatric obesity is increasing at an alarming rate
Pediatric obesity is associated with significant adverse effects in childhood and adulthood
Treatment of pediatric obesity is available
Prevention should be our goal
53. CONCLUSION Major areas to focus on
Measure and plot BMI / Weight for length
Discuss beverages
Limit screen time to less than 2 hours per day
54. CONCLUSION Major areas to focus on
Promote breastfeeding
Avoid excessive weight gain in infancy
Promote physical activity
Encourage family meals
Educate parents about being role models
Pediatricians need to be advocates in community
55. CONCLUSION 5210
5 servings of fruits and vegetables per day
Less than 2 hours of screen time
1 hour of physical activity
0 sweet beverages
56. CONCLUSION If we are to seriously have an impact on pediatric obesity, there has to be a comprehensive and multifaceted approach involving the child, family, communities, health care providers, insurance companies, government and corporate America.
58. REFERENCES William J. Cochran: Weight Management Childhood and Adolescence: Frequently Asked Questions. B C Decker, 2007
59. REFERENCES Preventing Childhood Obesity. Institute of Medicine. The National Academies Press, Washington, DC 2005
Pediatric Obesity: Prevention, Intervention and Treatment Strategies. Sandra Hassink, American Academy of Pediatrics, 2006
A parents guide to childhood obesity. Sandra Hassink, American Academy of Pediatrics, 2005
60. REFERENCES Davis MM et al. Recommendations for prevention of childhood obesity. Pediatr 2007;120;S229-S253
We Can Prevent Obesity
www.nhlbi.nih.gov/health/public/heart/obesity/wecan/get-involved
1-800-359-3226
Weight-control Information Network
1-877-946-4627
www.activelivingbydesign.org
www.aap.org/obesity