Pediatric Obesity: Prevention & Management

1. Pediatric Obesity: Prevention & Management MaryKathleen Heneghan MD Endocrinology, Diabetes & Metabolism Advocate Medical Group Lutheran General Children’s Hospital

2. I have nothing to disclose

3. Objectives • Define and differentiate between overweight and obese • Briefly discuss co-morbidities of obesity and screening tests available • Discuss recommendations for treatment and prevention of overweight and obesity

4. Available free at www.endo-society.org Available free at www.dietaryguidelines.gov

5. Where have we been and where are we headed?

6. Obesity Trends* Among U.S. AdultsBRFSS, 1985 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

7. Obesity Trends* Among U.S. AdultsBRFSS, 1994 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

8. Obesity Trends* Among U.S. AdultsBRFSS, 2001 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

9. Obesity Trends* Among U.S. AdultsBRFSS, 2008 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

10. Obesity Trends* Among U.S. AdultsBRFSS, 2010 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

11. Prevalence* of Self-Reported Obesity Among U.S. AdultsBRFSS, 2011 *Prevalence reflects BRFSS methodological changes in 2011, and these estimates should not be compared to previous years. 15%–<20% 20%–<25% 25%–<30% 30%–<35% ≥35%

12. Prevalence of Self-Reported Obesity Among U.S. AdultsBRFSS, 2011 Source: Behavioral Risk Factor Surveillance System, CDC. Prevalence reflects BRFSS methodological changes in 2011, and these estimates should not be compared to previous years.

13. Are trends similar for children and adolescents? Are trends similar in the Illinois?

14. Obesity trends

15. Overweight and obesity among 2-19 year olds in the U.S.(Ogden et al, 2006, Ogden et al, 2010) CLOCC press release 2010

16. In Chicago, Children Aged 3 To 7 Have a Much Higher Prevalence of Obesity Than U.S. Children 2-5 Years Old Obese rates in early childhood *U.S. data based on children 2-5 years old       **Chicago data based on children 3-7 years old (Ogden et al, 2010, CLOCC press release, 2010)

17. Chicago Children Aged 10 to 13 Have a Higher Prevalence of Obesity Than U.S. Children 6-11 Years Old Obese rates in middle childhood *U.S. data based on children 6-11 years old   **Chicago data based on children 10-13 years old

18. In Illinois, Pre-teen and Teen (ages 10-17 years) Obesity Rates Exceed U.S. Levels Obese rates in adolescence Illinois children have a higher prevalence of obesity (35%) than US children (31%) of the same age Illinois has the 10th highest percent of obese and overweight children in the U.S.  (Trust for America’s Health, 2009)

19. CLOCC • The Consortium to Lower Obesity in Chicago Children (CLOCC) is a childhood obesity prevention program housed within the Center for Obesity Management and Prevention at Children’s Memorial Hospital.

20. We recognize the problem but need to make the diagnosis

21. How to defineoverweight and obesity • Use of the BMI • Calculated by wt (kg)/ ht (m2) • Increase BMI is related to morbidity and mortality in adults • In females BMI naturally increases with puberty • BMI may be skewed if child goes through puberty outside of normal range

22. How to define overweight and obesity • Overweight - BMI is 85th-95th percentile based on age and sex • Obese - BMI is >95th percentile based on age and sex • In children <4 yr of age – BMI may not be precise and weight for height charts may be used as a warning sign

23. Endocrine causes GH deficiency Hypopituitarism Hypothyroidism Cushing disease Pseudohypoparathyroidism Endocrine causes associated with increased BMI but stature and height velocity is decreased where as Stature and height velocity are usually increased with exogenous obesity

24. Looking for endocrine cause • The Endocrine Society recommends against routine lab evaluation for endocrine causes of obesity in obese children/adolescents unless the child’s height velocity is attenuated • 2 uncommon circumstances • Adrenal tumor – exam should have signs of virilization • Growth without growth hormone (idiopathic isolated GH deficiency)

25. Obesity and hypothyroidism • Hypothyroidism remains an unlikely sole cause of obesity • Recent studies confirm mildly elevated TSH may be seen with obesity • retrospective review of medical records of 191 obese and 125 nonobese children • Six obese patients had Hashimoto disease and TSH values from 0.73 to 12.73 mIU/L • Out of 185 obese subjects, 20 (10.8%) had TSH levels >4 mIU/L, with no control subject measurement exceeding this TSH value. • The highest TSH concentration in an obese study subject was 7.51 mIU/L. Mild elevation of TSH values in the absence of autoimmune thyroid disease is not uncommon in some obese children and adolescents Dekelbab BH, Abou Ouf HA, Jain I. Prevalence of elevated thyroid-stimulating hormone levels in obese children and adolescents. Endocr Pract. 2010 Mar-Apr;16(2):187-90.

26. Genetic Testing Refer to Genetics those children whose obesity is related to a syndrome Early onset obesity & MC4R Gene testing • Melanocortin receptor 4 • Predisposes people to obesity • Children with weight gain since early infancy and are >97th centile for weight by age 3 • Positive in about 2-4% of patients >97th centile • NO TREATMENT AVAILABLE

27. Co-Morbidities • Evaluate those with BMI >85th centile

28. Pre-Diabetes • Impaired fasting plasma glucose • Fasting glucose >100 mg/dl • Impaired glucose tolerance • 2 hour glucose >140 but <200 • New since 2010 – HgbA1c from 5.7 – 6.4%

29. Diabetes Mellitus • Fasting plasma glucose >126 mg/dl • Random plasma glucose >200 mg/dl • 2 hour glucose >200 mg/dl on OGTT • New since 2010 HgbA1c >6.5% ***If asymptomatic must repeat abnormal values***

30. Dyslipidemia Primary treatment is dietary changes – pharmacotherapy is available

31. Hypertension Blood pressure > 90th centile according to sex, age and height percentile Quick estimate: Systolic = 90 + (3 x age in years) Diastolic = 50 + (1.5 x age in years)

32. Nonalcoholic Fatty Liver Disease • Alanine aminotransferase (ALT) > 2 SD above the mean for the laboratory • ALT elevation greater than AST elevation • NAFLD can progress to NASH and cirrhosis

34. Risk factors for developing obesity • Maternal diabetes • SGA • LGA • Parental obesity (maternal >paternal) • Maternal weight gain during pregnancy • Breastfeeding duration • Weight of siblings

35. Medical History • Presence of snoring and apnea • Polyuria, polydipsia or weight loss • Acne, hirsutism, menstrual history • Use of psych meds • **** Dietary History**** • Type and quantity of beverage intake • Frequency of dining out • Frequency and type of snacks • **** Activity History**** • Duration and frequency of exercise during the day • Estimates of screen time • Availability and safety of parks and gyms

36. Physical Exam • Waist circumference • Blood pressure • Acanthosis nigricans and skin tags • Severe acne and hirsutism • Tenderness and range of motion of knee, leg and foot • Peripheral edema

37. Once the diagnosis is made

38. Care Providers Perceived Barriers to Treatment Story M, Neumark-Stzainer D, Sherwood N, et al. Management of Child and Adolescent Obesity: Attitudes, Barriers, Skills, and Training Needs Among Health Care Professionals. Pediatrics [serial online]. July 2, 2002;110(1):210.

39. Care Providers Perceived Barriers to Treatment Story M, Neumark-Stzainer D, Sherwood N, et al. Management of Child and Adolescent Obesity: Attitudes, Barriers, Skills, and Training Needs Among Health Care Professionals. Pediatrics [serial online]. July 2, 2002;110(1):210.

40. Recommendations • Intensive lifestyle modification • Dietary • Physical activity • Behavioral • Age Appropriate

41. Physical Activity • 60 min of daily moderate to vigorous physical activity • Look – Listen - Feel = sweat, breathing hard and heart beating faster • Decreased screen time to 1-2 hours per day • Can balance screen time with activity by allowing X amt of screen time per X minutes of physical activity

42. Exercise • A factor contributing to weigh re-gain may be lack of continued exercise program • The odds for weight regain are 2-fold greater in those patients who are sedentary* • Meta analysis of long term maintenance studies showed a 27.2% weight loss retention in low exercise group and 53.8% weight loss retention in high exercise group◊ * ◊

43. Dietary Guidelines for Americans 2010

44. Dietary Guidelines for Americans 2010

45. Factors for successful weight maintenance • Reduced caloric intake • Reduced fat intake • Reduced fast food consumption

46. Dietary recommendations • Avoid consumption of calorie dense, nutrient poor foods • Sweetened beverages • Sports drinks • Fruit drinks/juices • Most “fast food” • Calorie dense snacks • One must expend or not take in 3500 calories to lose ~1 pound of fat

47. Beverage consumption Beverage consumption in the US population.Storey ML - J Am Diet Assoc - 01-DEC-2006; 106(12): 1992-2000

48. Beverage consumption Beverage consumption in the US population.Storey ML - J Am Diet Assoc - 01-DEC-2006; 106(12): 1992-2000

49. Beverage consumption in the US population.Storey ML - J Am Diet Assoc - 01-DEC-2006; 106(12): 1992-2000

50. Beverage consumption Beverage consumption in the US population.Storey ML - J Am Diet Assoc - 01-DEC-2006; 106(12): 1992-2000