Childhood Obesity

1. Childhood Obesity Sarah Hallberg, D.O., M.S.

2. Objectives • Review epidemiology and risk factors for childhood obesity • Review the 2007 Expert Committee Recommendations • Discuss the evaluation of an obese child and family • Discuss treatment stages and medications • Discuss the impact of soda on children

3. Childhood Obesity – a growing problem • The proportion of children who are obese is 5 x higher than in 1970’s • 1/3 of children are now overweight or obese Youth Risk Behav Surg - US, 2011

4. Genetics and persistence • If one parent is obese, there is a 50% chance that the child will be obese • When both parents are obese, the children have an 80% change of being obese. • If a child is obese at age 4 there is a 20% chance they will be obese as an adult and by adolescence 80% chance Guo SS. Am J Cln Nutr. 1999 Am Ac of Ch and Adol Psych 2012

5. Finances of it all • Childhood Obesity is costing $14 billion/yr • Costs related to the current prevalence of adolescent overweight and obesity is estimated to be at $254 billion • If current trends continue total healthcare costs attributable to obesity could reach $861 – 957 billion by 2030 • This would be 16 – 18% of US health expenditures Finkelstein EA 2009 GO, AS et al Circ 2013

6. Many of these children are food insecure Obesity is hiding hunger for many kids

7. Income Level • 1 of 3 low income children are obese or overweight before their 5th birthday Ped NSS data 2009

8. What are we subsidizing? • High calorie and nutrient poor foods • This is what is in our food banks • Cheap, calorie dense foods

9. What should we be subsidizing? • Fruits and non-corn veggies • www.fruitsandveggiesmatter.gov/health

10. 2007 Expert Committee Recommendations • Identification, assessment, prevention and early intervention

12. Identification • %BMI instead of BMI • Plot on graph

13. Defining Overweight and Obesity • Less than 5% • 5% - 85% • 85% to <95% • 95% to <99% • >99% • Underweight • Healthy Weight • Overweight • Obese • Severely obese Percentile Range (% BMI) Weight Status Category

14. Measuring Adolescents • Either BMI% >95% OR • BMI > 30 Whichever is LOWER

15. Assessment • Medical Risk • Behavioral Risk • Attitudes

16. Medical Risk Assessment • Parental Obesity • Family Medical history • Evaluation of weight related problems • Sleep apnea, Diabetes, PCOS, Htn, high cholesterol, Blouts disease, slipped capital femoral epiphysis, acanthosis nigricans • NAFLD – 1/3 of obese children • Depression **Bullying (60% are bullied) Mallory GB J Pediatr. 1989 Eisenberg ME. Arch Pediatr Adolesc Med 2003

17. Kindergarteners would rather sit next to a child with a physical handicap over one with obesity Neumark-Aztainer D. J Nutr Educ. 1999

18. Lab Testing • BMI 85 – 94% - Lipid always • If risk factors than fasting glucose, ast, alt • Measure q 2 years for >10 years of age • BMI > 95% - lipid, fasting glucose, alt, ast

19. Behavior and Attitude Assessment • ID child dietary and physical activity behaviors that promote weight gain and are modifiable • Assess the capacity of patient and patients family to make changes

20. Behavior and Attitude Assessment • Eating out (esp fast food) • Sugar sweetened beverages (more to come on this) • Portions • Juice • Breakfast • #fruits and veggies • Snacks • Activity • Screen time • Eating together as a family

21. Who Should Lose Weight? <2 years – Prevention counseling 2 – 5 years • 85 – 94% weight maintenance or slow gain • >95% maintenance or loss up to 1# per month 6 – 11 years • 85 -94% maintenance • 95 – 99% gradual loss 1#/month • >99% average 2#/wk

22. Who Should Lose Weight? • 12 – 18 years • 85 – 94% maintenance or gradual loss • 95 – 99% weight loss, average 2#/wk • >99% weight loss average 2#/wk

23. Medications • Mood stabilizers • Antipsychotics (Geodon the best) • ?Add topamax if on antipsychotics • ?Add metformin if on antipsychotics

24. Metformin • Shown to improve body composition, fasting insulin, fatty liver in obese kids and adolescents • 500mg qd to start up to 1000mg XR best

25. http://pediatrics.aappublications.org/cgi/content/full/120/supplement4/s164http://pediatrics.aappublications.org/cgi/content/full/120/supplement4/s164

26. Prevention • ID problem behaviors • Praise if no problems identified • Patient and family counseling about behavior

27. Treatment • Stage I - Prevention Plus • Stage II -Structured weight management • Stage III -comprehensive multidisciplinary intervention • Stage IV -Tertiary Care

28. Stage I • PCP office • Visit for this alone • Establish goals • If no progress in 3 – 6 months than stage II

29. Stage II • Planned diet and snacks • Planned activity • Dietician • Counselor • Monthly visits

30. Stage III • Structured and monitored • Negative energy balance • Parent home training • Weight management program • Meds • Meal replacements

31. Stage IV • Tertiary care • VLCD • Surgery • Appetite suppressants

32. Carb restriction • Carbs <50gr per day generally produce ketosis referred to as “ketogenic diet” • Carbs 50 – 150 considered – low carb with no ketosis • Ketogenic diet has been used safely for years for children with refractory seizures

33. Coding Help http://www.aap.org/obesity/pdf/obesitycodingfactsheet0208.pdf

36. So what about soda?

37. Soda is BAD for kids

38. Don’t Feed it Soda!!

39. Why is Soda bad? • Non Alcohol Fatty Liver Disease • 1/3 of overweight kids have this • How many normal weight kids do? Mallort GB. J Pediatr. 1989

40. NAFLD • Pathologically the same as alcohol liver disease

41. Fructose • Before 1900, Americans consumed approx 15 gr/day of fructose (4% of cal) • Current estimates put fructose consumption by adolescents at 73/gr/day (12% of cal) Lustig R. J Am Diet Assoc 2010

42. Soda vs beer • 1 soda = 1 beer hitting the liver • Only the liver can metabolize fructose so 100% of the fructose in a sucrose load hits the liver • De novo lipogenesis • Hepatic insulin resistance

43. Fructose: Metabolic, Hedonic, and Societal parallels with Ethanol Robert H. Lustig, MD Journal of the American Dietetic Association – Vol 110, Issue 9 Sept 2010

44. Summary • Look for it • Be comfortable with discussions • Allied Health Professionals • Broader scope- policy changes • No soda

45. Families Exercise!