CHILDHOOD OBESITY:HOW WE CAN HELP

1. CHILDHOOD OBESITY:HOW WE CAN HELP Prativa Basnet 04/12/2010

2. DISCLOSURE 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

3. OBJECTIVES: To provide a general overview of the issue of childhood obesity Understand the long term implications of childhood obesity on adult health � To offer practical preventive tips on ways to explore the issues with families

4. INTRODUCTION: Childhood Obesity Most important public health concern. Most common chronic disease of childhood - epidemic proportion. Increasing prevalence : Increases long term co � morbidities Important to identify overweight and obese children early in life

5. DEFINITIONS: OVERWEIGHT: excess body weight OBESITY: excess of fat NOTE: Methods used to directly measure body fat not available in daily practice. Obesity is often assessed by means of indirect estimates of body fat

6. STANDARD MEASURES: Body Mass Index Weight for Height: Useful for <2 years Measurement of regional fat distribution - Waist circumference - Waist to hip ratio Overall obesity (BMI) more accurate than body fat locations or ratios

7. STANDARD MEASURES: Children add weight and increase in length/stature as age progresses which is natural. Some of these children are ahead of the curve for their age. Gain more weight vs. height. Children over 2-20 years are classified into different categories of adiposity based on percentiles for age and gender BMI.

8. BMI:AS PER CDC Provides a guideline for weight in relation to height BMI = body weight divided by the height squared. Metric Formula: weight (kg) / [height (m)]2 English Formula: weight (lb) / [height (in)]2 x 703 Note: Whereas adult BMI interpretation doesn�t take into consideration the age or sex of the person, Pediatric BMI interpretation is relative to age and gender. http://www.cdc.gov/nccdphp/dnpa/bmi/childrens_BMI/childrens_BMI_formula.htm

9. BMI BASED : WEIGHT CATEGORIES: AS PER PERCENTILE FOR AGE AND SEX UNDERWEIGHT: BMI < 5th NORMAL WEIGHT: 5th and 85th OVERWEIGHT: 85th-95th OBESE: > 95th As Per CDC Guidelines:As Per CDC Guidelines:

12. PREVALANCE IN THE US:  Overall Obesity has risen 75% in 10 years. Obesity has risen nearly 100% in 20 years. Rates have doubled in children in 20 years. Rates have tripled in teens in 20 years. Self-reported data indicate that 61% of adults are overweight or obese. Data based on direct measurements indicate that two-thirds of adults are overweight or obese. Maine CDC/DHHS

13. PEDIATRIC OBESITY: RACIAL DIFFERENCES Non-Hispanic white 12.3% African American 21.5% Hispanic 21.8%

14. Prevalence (%) of Overweight Among U.S. Children and Adolescents Source: CDC, National Health and Nutrition Examination Survey (NHANES)

15. Prevalence of obesity in Maine: Obesity rates have risen 100% in only 17 years (from 12% in 1990 to 26% in 2006). Currently, 1 in 5 Mainers is obese. Overweight rates are also rising in Maine. Together, 59% of Maine people are either overweight or obese About 25% of Maine high school students are overweight. 36% of Maine kindergartners have BMI >85th percentile. Maine CDC/DHHS

16. Maine Child Health Survey (MCHS) Conducted in 2003 and 2004 among children in kindergarten, third, and fifth grades Directly measures height and weights, versus self-reported data from YRBS (which is only conducted in middle and high schools) Children entering kindergarten in 2003 Preliminary Data: 18% with BMIs 85-94% (�at risk for overweight�) 15% with BMIs greater than 95% (�overweight�) 33% have high BMIs! Young Risk Behavior SurveyYoung Risk Behavior Survey

17. Maine High School Students: 93% do not attend daily physical education classes 23% watch three or more hours of TV per day on an average school day 22% used a computer for fun or video games for at least three hours per day (Maine YRBS, 2005)

18. ETIOLOGY: Etiology - multi factorial Interaction of nutritional, psychological, familial, and physiological factors Imbalance between energy intake (calories obtained from food) and energy output (calories expended in the basal metabolic rate and physical activity): Energy In = Energy Used + Energy Stored For every extra 100 calories consumed per day one will put on 10 pounds per year

19. ETIOLOGY: Increasing Caloric intake: Eating unsupervised, lack of family meals Eating at multiple sites Eating out / take out food Beverages : soda and juice Calorically dense food

20. ETIOLOGY: Decreased physical activity due to: Schools with less physical education Reduced after school programs Elevated safety concerns Increased convenience activities Increased sedentary activities: TV, computer, video games

21. ETIOLOGY:Impact of Reduced physical activity : TV / video games: More time spent watching TV, less time for physical activity: average 2.5 hours / day, 20%>5 hours / day BMI and obesity associated with higher amount of time spent watching TV Higher cholesterol levels associated with greater amount of time spent watching TV 40% of children 1-5 years have TV in their bedroom

22. ETIOLOGY:Impact of genetics: Plays a role; interacts with environment to produce obesity. 30-50% heritable factors responsible but most genetic polymorphisms not identified yet Pediatrics, 1998 �Despite obesity having strong genetic determinants, the genetic composition of the population does not change rapidly. Therefore, the large increase in obesity must reflect major changes in non-genetic factors�. Childhood Obesity: Future Directions and Research Priorities

23. Why worry about Childhood Obesity? Question: IS PEDIATRIC OBESITY: A real problem Or, just a cosmetic issue?

24. RISK OF OBESE CHILDREN BECOMING OBESE ADULTS

25. IMPACT IN ADULT HOOD: Has significant adverse effects on health in adulthood Hoffman's 1988: Dutch males, increased mortality after 32 years in obese vs. lean adolescent males. Mossberg 1989: Swedish study, increased mortality after 40 years in obese vs. non-obese children

26. IMPACT : IN ADULTHOOD Harvard Growth Study: Two fold increase all - cause mortality in obese vs non-obese adolescents as adults 2 fold increase in CAD mortality Increased risk of colon cancer in males Increased risk of arthritis in females The association of adverse effects on adult health may be independent of obesity in adulthood http://search.nal.usda.gov/bitstream/10113/46/1/FNI92003624.pdfhttp://search.nal.usda.gov/bitstream/10113/46/1/FNI92003624.pdf

27.  IMPACT IN ADULTHOOD: Adult obesity associated with numerous health problems: Type II DM CAD Hypertension Cancer Joint disease Gallbladder disease Pulmonary disease

28. IMPACT ON ECONOMY: Estimated cost of obesity (in US in 2002): $117 billion Increasing hospital cost of pediatric obesity: 1979: $35 million 1999 $127 million

29. IMPACT ON ECONOMY : Over the past 20 years in the U.S., increase in hospitalizations for children ages 6-17 for obesity related diseases: 436% for sleep apnea 228% for gallbladder disease 197% for obesity (Note: Pediatrics, May 2002) Obesity-associated hospital costs for youth ages 6-17: $35 million (1979-81) increased to $127 million (1997-1999).

30. IMPACT ON CHILDHOOD: Can lead to multi-system disorders, such as: Psychosocial Endocrine Cardiovascular Respiratory Gastrointestinal Neurologic Orthopedic

31. PSYCHOSOCIAL: Most common complication of pediatric obesity Increased rates of depression Poor self esteem :obese adolescents, negative self image may carry over into adulthood - Obese females have lower acceptance rate at colleges than non-obese females - National Longitudinal Survey of Youth: obese adolescent females as young adults had less education, less income, higher poverty rate, decreased rate of marriage vs. non-obese females

32. ENDOCRINE: Non-insulin-dependent diabetes mellitus Pinhas-Hamiel 1994 Incidence of NIDDM has increased 10 fold 92% of these had a BMI >90% Increased linear growth Advanced bone age Earlier onset of puberty Acanthosis nigricans

33. CARDIOVASULAR: Hypertension: Primary hypertension uncommon in childhood. 60% of children diagnosed with hypertension are obese Hyperlipidemia: Pediatric obesity is associated with increased cholesterol, LDL-cholesterol, triglyceride levels and lower levels of HDL-cholesterol Hepatic steatosis: Hepatic steatosis present in 25-83% of obese children. 10-15% of obese children have elevated liver enzymes: steato hepatitis or non-alcoholic fatty liver disease

34. OTHERS: Orthopedic: Slipped capital femoral epiphysis: 30-50% are obese Blount�s disease (Tibia vara):70% are obese Neurologic: Pseudotumor cerebri Respiratory: Sleep disorders Sleep apnea: Hypoventilation syndrome Gastrointestinal: Cholelithiasis: 50% of cases of cholecystitis in adolescents are obese

35. PEDIATRIC OBESITY: Inference NOT JUST A COSMETIC PROBLEM!

36. PEDIATRIC OBESITY:TREATMENT Treatment: available & effective. Implementation: Difficult (behavior-based weight loss) Maintenance: Difficult to maintain weight subsequently Medication and surgery � expensive and potentially harmful Childhood - an important opportunity to establish healthy eating and activity behaviors that can protect children against future obesity. Prevention is key and preferable

38. PREVENTION: Obesity is multi factorial: But parents, especially mothers, can create a healthful home environment Prevention starts from preconception stage

39. PREVENTION:PRE & POST CONCEPTION Prevention starts prior to conception Significantly increased risk of obesity in a child born to obese parents Parents - role models for their children 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

40. PREVENTION PRE AND 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 breast fed vs. formula fed infants BMI - same at birth BMI at 3 & 6 months > in formula-fed vs. breast-fed infants Rate of obesity at 6 years was 3 fold greater in formula-fed vs. breast-fed

41. PREVENTION: INFANCY Advocate for continue breast feeding Avoid over-feeding for formula feed Monitor growth curve including weight for length curve in each visit 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 duration of breastfeeding is inversely associated with the risk of overweight Harder T. Am J Epidemiol. 2005;162(5):397-403 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 The duration of breastfeeding is inversely associated with the risk of overweight Harder T. Am J Epidemiol. 2005;162(5):397-403 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

42. PREVENTION: INFANCY Introduction of solids not until 4-6 months of age Introduce vegetables first; infants are born with preference for sweet Continue to provide the food, even if initially rejected Breast-fed babies are more willing to accept other new foods compared to formula-fed infants

43. PREVENTION: INFANCY Promote parental interaction with infant Discuss TV /Screen time: Do not use TV as a �Baby sitter� No TV for the first 2 years of life (AAP reco.) Watching more TV leads to: Higher rates of obesity Associated with increased sedentary time Promotes more social isolation Dennison, BA et al. Pediatrics 109:1028-1035, 2002.

44. PREVENTION: INFANCY Identify those at risk Family history Risk of obesity 60-80% if both parents are obese Sibling over weight (genetics vs. obesogenic environment) Ethnicity: African-American, Hispanic Large for gestational age Lower socio-economic status, family stress Both parents work, or single parent family Little cognitive stimulation Lack of safe play areas

45. PREVENTION: TODDLER Discuss beverages : 20% of obese children: excessive caloric beverages Soda :150 cal/12 oz, Juice: 20 cal/ 8 oz Promote consumption of water when thirsty No�clean the plate rule�,no food as a reward Provide a healthy array of food and appropriate portions Promote physical activity :Free play or play with parents as well as friends

46. PREVENTION: PRE-SCHOOLER TO SCHOOL-AGED CHILDREN Measure, plot and monitor BMI If increasing BMI %, a red flag (even if �normal�) Review BMI curve with parent and child Always discuss age appropriate anticipatory guidance for Physical Activity Life Style Nutrition

47. PHYSICAL ACTIVITY: In the past 100 years, we�ve moved from: Walking to Cars Walking to Elevators Farming to Grocery Shopping/ Fast-Food Restaurants Farming and Maintaining a House to Computer Farming and Maintaining a House to Cubicles and Meetings Day-long Clothes-washing to Washing Machines and Dryers Washing Dishes to Dishwashers Playing to Television and Other Screen Times

48. PHYSICAL ACTIVITY: JAMA Editorial 1999 : Automobile trips that can be safely replaced by walking or bicycling offer the first target for increased physical activities in communities. Recent data indicate that 25% of all trips are less than one mile, and 75% of these are by car.�

49. PHYSICAL ACTIVITY: Promote free play time and 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 Activity needs to be fun so do this with family and or friends Promote life long varieties of activities Encourage to participate in organized sports Participate in after-school activities Limit sedentary time: Discuss screen time: <1-2 hours per day

50. LIFE STYLE: No TV in the bed room: Associated with worse eating, exercise habits and poorer academic performance No eating in front of TV >60% of commercials during children�s programming are related to food -Increase appetite / desire for these foods, eating without awareness Tend to overeat and consume higher fat and salt foods and less fruits and vegetables Limiting screen time in children 4-7 years of age associated with lower BMI and decreased caloric intake TV, computer and video games are a privilege, not a right

51. LIFESTYLE: Emphasize the fact that parents act as role models for nutrition, physical activity and life style Encourage to the family meal: Conversation slows down the eating process Parents determine the food that is to be consumed Can monitor intake of food Family meals associated with higher consumption of fruits, vegetables and milk and lower intake of fat and sweet beverages

52. 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 and 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 on the menu

53. 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 result to tend to over eat at other meals or snack frequently Eat all your colors

54. NUTRITION: Encourage child�s autonomy in self-regulation of food intake Parents provide, child decides! No clean the plate rule. Provide choices Educate parents regarding healthy nutrition Healthy snacks,5 fruits and vegetables a day Consider using pediatric food pyramid Discuss beverages esp. with school-aged kids Structured meal and snack time Know what the child is eating on school meals, day care etc

55. NUTRITION: Portion size : Increased over the years �Super sized� 3 year olds will eat what is appropriate despite how much is on the plate. >5 years children consume more if portion size is larger.

56. Recommended Portion size for children: By Age Group Compared to adults

57. USDA MY PYRAMID:

58. PHYSICIAN AS AN ADVOCATE SCHOOL/PRESCHOOL: Educate administrators, teachers and parents about obesity Be part of School Health Advisory Board Promote nutrition, physical education and lifestyle education Promote appropriate use and items in vending machines Promote nutritious meals

59. PHYSICIAN AS AN ADVOCATE Community: Advocate for :Revising our transportation policies Restructuring our communities Safe and accessible places for children to be physically active Neighborhoods that are environmentally friendly and conducive to physical activity Full service grocery stores with reasonable cost for healthy foods

60. PHYSICIAN AS AN ADVOCATE State: Participate in local chapter of AAP/AAFP 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

61. 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.

62. MAJOR AREAS TO FOCUS: Measure and plot BMI / Weight for length Discuss beverages Limit screen time to less than 2 hours per day Promote breastfeeding Avoid excessive weight gain in infancy Promote physical activity Encourage family meals Educate parents about being role models Pediatricians/Family Practitioners need to be advocates in community

63. 5210: 5 servings of fruits and vegetables/day Less than 2 hours of screen time 1 hour of physical activity 0 sweet beverages

64. Sources: USDA (United States Department of Agriculture): Inside the Pyramid American Academy of Pediatrics: Guide to Your Child's Nutrition American Academy of Pediatrics Policy Statement: Dietary Recommendations for Children and Teens www.mainepublichealth.gov www.CDC.gov