Evaluation and Treatment of Childhood Obesity

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1 Evaluation and Treatment of Childhood Obesity Stephen R. Daniels, MD, PhD Department of Pediatrics University of Colorado School of Medicine and Children s Hospital Colorado

2 In 1953, Morris et al compared London bus drivers who were inactive to bus conductors who had to move around the bus to collect fares.

5 Three years later in a subsequent analysis, the authors pointed out that the waist size of the drivers uniforms was substantially larger than that of the conductors.

7 The relationship of obesity to mortality has been recognized for some time. For more than 75 years, height and weight tables developed by the Metropolitan Life Insurance Company have been used. This recognizes that adult overweight is associated with a shorter life span.

9 Obesity is associated with a variety of adverse health outcomes Cardiovascular Metabolic (diabetes) Orthopedic Hepatic (NASH)

10 Adverse outcomes continued: Pulmonary (OSA) Psychologic Neurologic (pseudotumor cerebri) Renal (proteinuria ESRD) Mortality

11 Obesity Trends* Among U.S. Adults BRFSS, 1990, 2000, 2010 (*BMI 30, or about 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30%

12 Prevalence of Self-Reported Obesity Among U.S. Adults by State and Territory BRFSS, 2016 Source: CDC Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System *Sample size <50 or the relative standard error (dividing the standard error by the prevalence) 30%. Prevalence estimates reflect BRFSS methodological changes started in These estimates should not be compared to prevalence estimates before 2011.

13 The prevalence of overweight appears to be increasing in children and adolescents.

10 8 6 4 2 0 17.5 17.0 11.3 10.5 6.1 6.5 4.0 5.

14 Prevalence of Overweight Among U.S. Children and Adolescents Ages 6-19 Years Percent of Population Age in Years (NHANES, , , and ). Source: Health, United States, NCHS.

15 Background With the increase in prevalence and severity of obesity there has also been an increase in the prevalence of type 2 diabetes in adolescents.

16 CCHMC Type 2 Diabetes Number of Patients Total number of Type 2 patients : 311 Dolan L (personal communication)

17 7-year incidence rate of MI Type 2 Diabetes and CHD 7-Year Incidence of Fatal/Nonfatal MI (East West Study) % P <0.001 P < % 20.2% 3.5% Non-Diabetic No DM. No MI No DM. MI DM. No MI DM. MI Nondiabetic Diabetic (CHD=coronary heart disease; MI=myocardial infarction; DM=diabetes mellitus) Haffner SM et al. N Engl J Med 1998;339:

18 Diabetes and Cardiovascular Disease The time from diagnosis of diabetes to CVD event is approximately years in adults. There is often a pre-diagnosis period of hyperglycemia (5-10 years).

19 Diabetes and Cardiovascular Disease If the time course of CVD related to diabetes is the same for adolescents as adults, it is anticipated that adolescents with diabetes will begin having substantial CVD morbidity and mortality in their 30 s or 40 s.

20 Obesity and Cardiovascular Disease Juonala et al combined data from the Bogalusa Heart Study, Muscatine Study, Cardiovascular Disease in the Young Finns Study and the Childhood Determinants of Adult Health Study (Australia) to evaluate longitudinal data between childhood (BMI, CVD risk factors) and adulthood (BMI, CVD Risk Factors, carotid IMT). NEJM 2011; 365:1876

21 Childhood Adult Group I Normal BMI Non-obese Group II Obese Non-obese Group III Obese Obese Group IV Normal BMI Obese NEJM 2011;365:1876

22 Conclusions 1) Children who were overweight or obese and remained obese in adulthood (Group III) had increased risk of T2DM, hypertension, dyslipidemia and increased carotid IMT 2) Overweight or obese children who became non-obese by adulthood (Group II) were similar in CVD risk and carotid IMT to those who were never obese (Group I) NEJM 2011;365:1876

23 Conclusions This means that while prevention of obesity in childhood is optimal, treatment of those children who have become obese is also very important. NEJM 2011;365:1876

24 Obesity - Assessment Most childhood obesity is a result of energy imbalance caloric intake caloric expenditure 100 kcal excess per day x 365 days = 10 lb weight gain

25 Pre-Agriculture Energy poor environmental Evolution Diet Agriculture 1900 Energy sufficient Food Industry 1990 Energy Dense Obesogenic Pre-Industrialization Intense energy expenditure for survival Physical Activity Industrialization 1900 Increased leisure time Not published Computer 1990 Increased sedentary time

26 Calories Do They Matter?

27 Fast food meal Total Calories = 1390

- 99% Boys: 11-14 yr 15-18 yr 1800-2000 2200-2400 70% - 77% 58% - 63% Girls: 11-18 yr

28 Percent of Energy Needs Fast Food Meal = 1390 calories Category Energy Needs sedentary* Percent of Energy Needs Children: 4-6 yr % - 116% Children: 7-10 yr % - 99% Boys: yr yr % - 77% 58% - 63% Girls: yr % - 77% *Sedentary = less than 30 minutes a day of moderate physical activity Photo: Telegraph.co.uk

29 Apple medium size Calories = 100 Amount of physical activity WT Moderate Vigorous 110 lb 30 min 15 min 220 lb 15 min 8 min 330 lb 10 min 5 min

30 Fruit Snacks 1 serving = 12 pieces = 90 calories 1 snack bag = 2.5 servings = 225 calories Amount of physical activity WT Moderate Vigorous 110 lb 1.1 hr 34 min 220 lb 34 min 17 min 330 lb 20 min 10 min

31 Portions

32 WHOPPER Sandwich TRIPLE WHOPPER Sandwich photos: bk.com; 2013 calorie counts: calorielab.com 670 CALORIES 1,130 CALORIES

33 2013 calorie counts: calorielab.com 2013 McDonald s 5.4 oz 500 calories

34 Is there such a thing as too much chocolate?

35 Coca-Cola In 1907 In fl oz = 79 calories 20 oz = 240 calories 55 oz Double Gulp = 744 calories

36 1950 s Movie Popcorn cups 21 cups (buttered) 174 calories 1,700 calories

37 Clinical Evaluation Assessment of Overweight: The most useful clinical measure is body mass index. BMI = Weight (kg)/height (m) 2 This should be calculated for children as they grow and compared to population standards.

39 Clinical Evaluation A child whose BMI exceeds the 95 th percentile should be considered obese and undergo evaluation A child between the 85 th and 95 th percentiles is considered overweight The older the child, presence of obesity in parents, the higher the BMI the more likely the child will become an obese adult

40 Assessment Medical History Growth A history of adequate growth makes genetic (syndromic) and metabolic (thyroid) causes of obesity very unlikely.

41 Assessment Diet History Patterns of diet may identify sources of excess calorie intake: Snacks High calorie drinks (soda, juice) Eating out School breakfast, lunch

42 Assessment Physical Activity History Active Organized sports Activities of daily living Play Inactive Television Computer Video games Telephone Homework Barriers to Activity Unsafe neighborhood After school care

43 Overweight/Obesity Therapy Options Behavioral Pharmacologic Surgical

44 Goals of Therapy Behavioral change Healthy eating More activity Less inactivity Feeling good about making changes Focus is not on weight

45 Principles of Behavior Change 1) Stimulus control/environment 2) Goal setting (must be realistic) 3) Self monitoring (key to success) 4) Reward good behavior/ignore bad behavior 5) Family support

46 blogs.denverpost.com

47 Evidence-based Practice 10-year Follow-up 4 randomized studies (N = 154) Intervention Family-based, behavioral management Stop-Light diet Physical activity Epstein et al. Health Psychol 1994; 13:373

48 Pediatric Behavioral Treatment Long-term Outcomes Percentage Overweight Change Parent Child Months Epstein et al. 1995

49 Overweight Management The treatment program should involve small, gradual changes. No quick fix Clinicians should empathize and encourage, not criticize.

50 Overweight Management A variety of health professionals are needed for weight management. Physicians Nutritionists Exercise physiologists Psychologists Social workers Nurses

51 Healthy Eating Identification of: Problem foods Problem settings Substitution of healthy for less healthy foods

52 Healthy Eating Be aware that the child is an individual who makes decisions. This is particularly true as the child grows older and more independent. Change the home environment.

53 Healthy Activity Decrease sedentary time. Remove barriers/emphasize fun. Experiment with new and different activities. Develop healthful patterns of activity. Reward success.

54 A Paradigm for Prevention of Obesity Can we develop a method of identifying children at higher risk of obesity before they become obese?

55 A Paradigm for Prevention of Obesity If we can identify those at risk, can we intervene to prevent obesity?

Childhood Obesity Epidemic- African American Community

Childhood Obesity Epidemic- African American Community Link D Juanna Satcher MD MPH Assistant Professor of Pediatrics Baylor College of Medicine Gulf Coast Apollo Chapter Objectives Summarize obesity rates