Pediatric Obesity : A Family Affair

1. Pediatric Obesity:A Family Affair Samuel N. Grief, MD

2. Outline • Introduction • Definition of childhood overweight/obesity • Scope of Problem • Etiology: Multifactorial • Genetics and obesity • Environment and obesity • Culture and obesity • Taking a pediatric nutrition history • Nutrition recommendations for treating obesity • Practical pointers for all Family Physicians in dealing with the obese child • Conclusion

3. Pediatric Obesity: A Family Affair • Pediatric obesity is rapidly becoming a serious health epidemic in the united states. Health officials estimate the percentage of overweight/obese children has risen to 30% and is climbing. • This symposium will bring the topic of pediatric obesity into the limelight elucidating: • The severity of this health epidemic, • The multiple causes of pediatric obesity, • The genetic connection, • The latest nutrition recommendations, • A practical approach for family doctors to assess a child’s nutrition habits in the context of the family unit and provide sensitive and sound medical advice to help children and their family members conquer obesity.

4. Definition of Childhood Overweight/obesity • Adults: BMI – mild, moderate, severe or extreme • For children, not clearly established • BMI >85% defined as overweight • BMI >=95% for age and gender • BMI not used for infants • Definition of overweight BMI varies with age

5. Scope of Pediatric Obesity Problem NHANES III

6. NHANES III Boys Number of Survey Participants in Sex and Age Groups by Survey

7. NHANES III Girls Number of Survey Participants in Sex and Age Groups by Survey

8. Prevalence of overweight Based on Percentage of 2-5 year-old children above the 95% of the weight-for-stature growth reference (NHANES III)

9. NHANES I, II, III

10. NHANES I, II, III

11. NHANES I, II, III

12. NHANES I, II, III

13. NHANES I, II, III

14. NHANES I, II, III

15. NHANES I, II, III

16. NHANES I, II, III

17. Percentage of children younger than 3 years above the 95% of the weight-for-length growth reference, NHANES III NHANES III

18. Assessment of Medical Conditions Related to Obesity

19. Assessment of Medical Conditions Related to Obesity • Family History • Obesity • NIDDM • Cardiovascular disease • Hypertension • Dyslipidemia • Gallbladder disease • Social/psychologic history • Tobacco use • Depression • Eating Disorder

20. Assessment of Medical Conditions Related to Obesity • Physical exam • Height, weight, BMI • Triceps skinfold thickness • Truncal obesity • Blood pressure • Dysmorphic features • Acanthosis nigricans • Hirsutism • Violaceous striae • Optic disks

21. Assessment of Medical Conditions Related to Obesity • Tonsils • Abdominal tenderness • Undescended testicle • Limited hip range of motion • Lower leg bowing Risk of cardiovascular disease; Cushing’s syndrome • Genetic disorders (PW) • NIDDM, insulin resistance • Polycystic ovarian syndrome; Cushing’s syn • Pseudotumor cerebri

22. Assessment of Medical Conditions Related to Obesity • Sleep apnea • Gallbladdeer Disease • Prader-Willi Syndrome • Slipped Capital Femoral Epiphysis • Blount’s Disease

23. Etiology of Pediatric Obesity: Multifactorial • Environmental: Neighborhood, school, community • Genetic: Inborn diseases, chromosomal mutations, familial, ethnic predisposition • Cultural: Increased risk with minorities • Societal: Affluent vs. Underserved • Physical: Height and body frame; sick vs. healthy • Attitude: Family influence on nutrition habits and physical activity • Medical advice: Doctors not taking an active role • The American way of life!

24. Genetics and Obesity • Twin studies • Familial syndromes: Cohen’s, Alstrom’s, and Bardet-Biedl (look these up!!!) • Ob gene and leptin • POMC • Pro-opiomelanocortin • MC4R – a melanocortin receptor

25. Genetics and obesity What next? • Additional leptin to those who are deficient. • Ongoing research for pharmacological manipulation. • Continued research in rodents is directly relevant to humans.

26. Environment and Obesity • Socioeconomic status and rates of obesity • Single parent families and risk of obesity • Social support and relevance to pediatric obesity • School and extracurricular activities • Inner city vs. suburban setting • Western vs. third world setting

27. Culture and Obesity • Minorities and increased rates of obesity • African-American • Hispanic • Native Indian • Pacific Islander • White • Asian • European • Other

28. Culture and Obesity • Culture and food • Food is a way of life • Learn about different cultures: ASK! • The taste of Chicago…

29. You deserve a… BREAK!

30. Nutrition Exercise • Split into groups of three • Designate one member as the physician • Designate one member as the parent of an obese child • Designate one member as the observer • The physician has ten minutes to obtain a complete nutrition history from the parent • Observer to take notes re: • Style – effective or not and why? • Open or closed ended questions • Anything missing? • Anything else?

31. Ready, set… GO!

32. Taking a pediatric nutrition history • Back to basics! • Methods of assessing dietary intake: 1) 24-Hour recall 2) Usual Intake/Diet history 3) Food frequency questionnaire 4) Family history 5) Past medical history 6) Any diets that have been tried? Successful? 7) Social habits: cigs, caffeine, illicit drugs, ETOH 8) MEDS, vitamins, herbals 9) Food allergies? Lactose intolerance? 10) ROS: Constitutional, GI, GU

33. Pediatric Nutrition • Refer to a trusted Registered Dietitian! • Recommendations based on the USDA Food Guide Pyramid • Most children will need to maintain their current weight until they reach a lower level BMI • There is no magic wand to wave • The three Es: • Emphasize proper nutrition, • Encourage an overall family approach to modifying nutrition habits, and • Empathize with all those concerned.

34. Medicinal Treatment Options for Pediatric Obesity • Few are currently viable • OTCs: Diet pills, ephedra, metabolife, caffeine, chitosan, hydroxycitric acid, pyruvate, etc. • Methylphenidate, dextroamphetamine, etc. • Diuretics • Thyroid hormone • Growth hormone • Testosterone • Leptin • Metformin • Xenical • Sibutramine

35. Surgical Treatment Options for Pediatric Obesity • Useful for adolescents with extreme obesity • Last resort option for severely obese adolescents • Choose patients carefully

36. Obesity and Psychological Disorders in Children • Do obese children suffer from greater rates of depression? • Study of 868 third grade students • KEDS • Results: there is a relationship between depressive symptoms and BMI in preadolescent girls; not in boys. Girls express more overweight concerns. • Take home message: when girls present to Family Docs, assessing overweight concerns with the 5-question scale may help identify overweight girls at highest risk of developing depression, and perhaps subsequent eating disorders.

37. Obesity and Eating Disorders • At any given time, 44% of adolescent girls and 15% of adolescent boys are “dieting” • Prevalence of eating disorders (anorexia and bulimia) is estimated to be 1-4% of adolescent and young adult women • Predisposing factors may include: genetic, biological vulnerability, individual psychopathology, familial and cultural influences • Survey of women on the most common weight loss practices: weighing oneself regularly, walking, fasting, meal skipping, diet pills, cigs • Weight cycling: not related to increased psychopathology!

38. Non-dieting approaches for obese children • Identify and combat cultural notions that “thinner is better” and that body weight can be controlled by willpower • Help participants “stop dieting” by abandoning efforts to restrict energy intake and avoid certain foods • Help participants identify and eat in response to the body’s “natural” hunger and satiety signals • Increase self-esteem and positive body image through self-acceptance rather than weight reduction • Increase awareness about dieting behaviors and their purported ill effects

39. Obesity and ChildrenMiscellaneous • Early onset of adiposity rebound (AR) • Early onset of puberty related to obesity in girls • Increased rates of Type 2 diabetes diagnosed among obese children • Adult food fears impact children

40. General Approach to Treating Pediatric Obesity • Intervention should begin early • The family must be ready for change • Clinicians should educate families about medical complications of obesity • Clinicians should involve the family and all caregivers in the treatment program • Treatment programs should institute permanent changes, not short-term diets or exercise programs aimed at rapid weight loss

41. General Approach to Treating Pediatric Obesity • As part of the treatment program, a family should learn to monitor eating and activity • The treatment program should help the family make small, gradual changes • Clinicians should encourage and emphasize and not criticize • A variety of experienced professionals can accomplish many aspects of a weight management program

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45. Thank you very much!