prevention of pediatric obesity

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 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

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