5/18/13. Disclosures. Outline. Facts & Fiction about Pediatric Obesity Treatment: Nutrition & Metabolic Health Improvement. I have nothing to disclose

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1 Facts & Fiction about Pediatric Obesity Treatment: Nutrition & Metabolic Health Improvement Disclosures I have nothing to disclose Luis A. Rodríguez, RD, CNSC UCSF Benioff Children s Hospital & WATCH Clinic May, 2013 Outline Adult and Pediatric Obesity Trends Health Consequences Associated with Obesity Genetics vs. Environmental Changes Fats, Proteins and Carbohydrates (sugars) Meal Trends, and Locations Screening Obesity and Metabolic Markers Nutritional Recommendations Other Recommendations Summary Obesity Trends* Among U.S. AdultsBRFSS, 1990, 1999, 2009 (*BMI 30, or about 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30% 1

2 Pediatric Obesity Epidemic Pediatric Obesity Epidemic (M. de Onis et al., 2010) Pediatric Obesity Epidemic Pediatric Obesity Epidemic 2

3 Health Consequences Associated with Childhood Obesity and Unhealthy Eating Immediate Health Problems Asthma Sleep Apnea Skin Infections Joint Pain Chronic Health Conditions Hypertension Type 2 Diabetes Hypercholesterolemia Hepatic Steatosis Menstrual Abnormalities Heart Disease PCOS Lower Self-Esteem and Confidence Genetic Syndromes Genetics and Hormonal Defects Prader-Willi Laurence-Moon/Bardet-Biedl Alstrom Turner s Ruvalcaba Genetics and Hormonal Defects Developmental Programming Prenatal Undernutrition (SGA) (Barker, 2004) Dutch Famine Study (Roseboom et al., 2001) Prematurity Overnutrition (LGA, GDM) (Boney et al., 2005) Direct relationship of maternal obesity with child obesity. (Whitaker, 2004) Environmental Changes Food Supply Macronutrient Changes Fats Proteins Carbohydrates Meal Trends, and Locations Food Addictions? Decreased Physical Activity Levels 3

4 Dietary Energy in Food Supply Macronutrient Changes over past 3 Decades Fat Total Kcal % decreased from 40% 30% since 1980 s Kcal/day per person 340 kcal/ day Protein Stable at about 15% Carbohydrate Starch 49 51% Fructose % (Chanmugam et al, 2003) (Putnam, 2002) Fats Fats Dietary Fat Dietary Source Medicinal Value or Danger Omega-3 Fatty Acids Wild fish, flaxseed oil Anti-inflammatory, lowers serum TG, repairs membranes Monounsaturated Fatty Acids Olive and canola oil Stimulates Liver Metabolism, reduces atherogenesis Polyunsaturated Fatty Acids Vegetable oils Anti-inflammatory, excess amount can cause immune dysfunction Saturated Fatty Acids Medium-chain triglycerides Omega-6 fatty acids Grass-fed animal meats, milk and dairy products, egg yolks Palm oil, coconut oil, palm kernel oil Farm-raised animals and fish (corn and soy fed) Atherogenic in Familial Hypercholesterolemia Energy source, some suggestion of stimulation of atherosclerosis Atherosclerosis, insulin resistance, immune dysfuncion, pro-inflammatory Trans fats Synthetic, processed food Atherosclerosis, NASH Women s Health Initiative Randomized controlled, prospective study from ~50,000 post-menopausal women. Goal to decrease Fat Calories and increase F/V and grains. Fat decreased by 8%. No significant risk reduction in CHD, stroke or CVD. (Howard et al, 2006) (Lustig, 2012; Perito et al., 2013) 4

5 Proteins Sugar (Fructose) Branched Chain Amino Acids (L, I, V) Essential Amino Acids High concentration in corn Increased insulin resistance d/t bypassing glycogen storage Patients with metabolic syndrome have higher bloodstream levels (Lustig, 2012; Newgard et al., 2009) Increases nutrient consumption Attenuated Ghrelin response Reduced Insulin response, low Leptin rise. NASH pathogenesis and progression Liver is primary site for metabolism Fructose bypasses rate-limiting step of glycolysis Preferentially metabolized to acetyl coa Provides substrate for FFA Increases Visceral Fat (Teff et al., 2004) (Perito et al., 2013) (Elliot,2002; Lustig, 2012) Increased consumption Fructose 37gm fructose/day ( ) 8% Kcal Intake 55gm fructose/day 10.2% Kcal Intake 78gm fructose/day 12% Kcal Intake (Adolescents) (Vos et al., 2008) Sugar (Fructose) American Heart Association Recommendation for Optimal Cardiovascular Health Women 21gm sugar/day (1,800 Kcal/day) Men 38gm sugar/day (2,200 Kcal/day) (Johnson et al., 2009) 5

6 Fiction Beating obesity will take action by all of us, based on one simple common sense fact: All calories count, no matter where they come from, including Coca-Cola and everything else with calories -The Coca Cola Company, 2013 Fiction Fact A Calorie is A Calorie Calories Calorie output is tightly regulated and dependant on the quantity and quality of ingested calories. A Calorie Burned is a Calorie Burned. Where Do People Eat When They Eat Out? Fast Food 1/3 of U.S adults eat fast food Longitudinal studies show fast food intake predicts weight gain and increased risk for T2D Fast food restaurants overrepresented in poorer neighborhoods; healthy alternatives harder to find Prevalence: 2.5/mile 2 vs. 1.5/mile 2 Source: Factors Influencing Lunchtime Food Choices among Working Americans Low SES associated with increased fast food consumption (Garber, Lustig, 2011) 6

7 Is Fast Food Addictive? Is Fast Food Addictive? Sugar Rodent Models demonstrate binging, withdrawal (teeth chattering, tremors, shakes and anxiety) Seeking and craving Cross-Sensitization Human Studies also suggest sugar is addictive with withdrawal Fructose increases liver and muscle insulin resistance (Sung et al., 2011; Perito et al., 2013) Blocks leptin s ability to extinguish mesolimbic dopamine signaling Photo from cbsnews.com (Garber, Lustig, 2011) Caffeine Flavoring agent Increases salience of high rewarding beverage. Well established psychological & physiological dependence across age spectrum. (Garber, Lustig, 2011) Photo from: Is Fast Food Addictive? Exercise Environmental Cues Required to create addictive patterns Powerful external Stimuli trigger reward in animal and human Vulnerability to environmental cues may explain differences in ability to follow a diet Ads 3-5 per 30 minutes during prime time TV. (Garber, Lustig, 2011) (Brown, 2002) 33% Percentage of youth who are actual couch potatoes, engaging in little or no leisure-time physical activity whatsoever 2/3 Proportion of teens that don t meet the minimum recommended levels of physical activity of one hour a day of moderate to vigorous activity >2-3 Daily number of hours children spend watching TV; more time than on any other single activity except sleeping 7

8 Exercise Screening and Identification of Pediatric Obesity Fiction Facts Exercise alone causes significant weight loss Exercise even in absence of weight loss decreases hepatic steatosis, and other lipotoxicity markers. (Perito et al. 2013) Exercise builds muscle and stimulates new mitochondrial development and improves insulin sensitivity Increases liver s Krebs cycle speed (Lustig, 2012) Children 0-24 months use WHO Growth Standards >97 th %ile for weight for length Children >2 years use CDC BMI curves th %ile: Overweight >95 th %ile: Obese Metabolic Markers Unhealthy Food Patterns Physical Assessment Acanthosis Nigricans (Axilla, neck, flexural areas) Marker of hyperinsulinemia Lab values Fasting insulin, fasting BG, HgA1C ALT Uric Acid Fasting Cholesterol Panel Beverages Soda, Juice (any kind), energy drinks, coffee drinks Foods Fast food, pre-packaged, processed foods Food environment Eating in front of TV, chaotic environment, on the go Stress eating, binge eating, disordered eating 8

9 Clinical Treatment WATCH Clinic (Weight Assessment for Teen and Child Health) DIET AND EXERCISE! WHAT? Nutritional Recommendations Other Recommendations ½ of your plate non-starchy Vegetables and Fruit ¼ of your plate Whole Grains Cereals >5gm fiber/serving Breads >3gm fiber/serving Other packaged >3gm fiber/~100kcal ¼ of your plate Proteins High in Fiber or Healthy Fat Legumes, Nuts, wild fish, free range beef/poultry, eggs and dairy Plain, added-sugar free dairy Wait 20 minutes before offering 2 nd portions Control home environment by limiting treats Everyone at home follows same recommendations Remove TV from Child/Teenage Room Enroll in engaging, entertaining, fun, sustainable, regular physical activity Healthy Fats Olive/Canola Oils 9

10 Summary References Calories are NOT created equal. Unique nutrients contribute to metabolic disease, even in absence of obesity trans fats, fructose. Follow WATCH Clinic Plate Model Avoid processed foods (trans fats, low fiber, high sugar) Avoid all sweetened beverages; only drink water, plain milk or plain milk substitutes, and plain teas Exercise improves cardiometabolic health, even in the absence of weight loss. A. K. Garber, Lustig R. H. (2011) Is Fast Food Addictive? Curr. Drug Abuse Rev. 4, Basu S, Yoffe P, Hills N, Lustig RH (2013) The Relationship of Sugar to Population-Level Diabetes Prevalence: An Econometric Analysis of Repeated Cross-Sectional Data. PLoS ONE 8(2): e Brown JD, Witherspoon EM. The mass media and American adolescents health. J Adoles Health Dec;31 (6 Suppl): B. V. Howard et al., Low-Fat Dietary Pattern and Risk of Cardiovascular Disease: The Women s Health Initiative Randomized Controlled Dietary Modification Trial, JAMA 295 (2006): ; B. V. Howard et al., Low-Fat Dietary Pattern and Weight Change over 7 Years: The Women s Health Initiative Dietary Modification Trial, JAMA 295 (2006) C. B. Newgard et al., A Branched-Chain Amino Acid-Related Metabolic Signature That Differentiates Obese and Lean Humans and Contributes to Insulin Resistance, Cell Metab. 9 (2009): C. M. Boney et al., Metabolic Syndrome in Childhood: Association with Birth Weight, Maternal Obesity, and Gestational Diabetes, Pediatrics 115 (2005): e290-e96. References References D. J. Barker, The Development Origins of Chronic Adult Disease, Acta Paediatr. Supp. 93 (2004): K. C. Sung et al., Interrelationship Between Fatty Liver and Insulin Resistance in the Development of Type 2 Diabetes, J. Clin. Endocrinol. Metab. 96 (2011): M. B. Vos et al., Dietary Fructose Consumption Among US Children and Adults: The Third National Health and Nutrition Examination Survey, Medscape J. Med. 10, (2008): 160. M. de Onis et al., Global Prevalence and Trends of Overweight and Obesity Among Preschool Children, Am. J. Clin. Nutr. 92 (2010): P. Chanmugam et al., Did Fat Intake in the United States Really Decline Between and ? J. Am. Diet Assoc. 103 (2003): Perito ER, Rodriguez LA, Lustig RH. Dietary management of non-alcoholic steatohepatitis. Current Opinion in Gastroenterology, March Invited review, submitted November R.J.F. Loos et al., Genome-wide Association Studies and Human Population Obesity, in Obesity Before Birth, R.H. Lustig ed. (New York: Springer, 2010), pp R.K. Johnson et al., Dietary Sugars Intake and Cardiovascular Health: A Scientific Statement From the American Heart Association. Circulation Sep 15; 120 (11): Robert H. Lustig, Fat Chance: Beating the Odds Against Sugar, Processed Food, Obesity, and Disease. New York: Penguin, P. Chanmugam et al., Did Fat Intake in the United States Really Decline Between and ? J. Am Diet. Assoc. 103 (2003): S. J. Olshansky et al., A Potential Decline in Life Expectancy in the United States in the 21 st Century, New Engl. J. Med. 352 (2005): Teff K, et al. Dietary Fructosse Reduces Circulating Insulin and Leptin, Attenuates Posprandial Suppression of Ghrelin, and increases Triglycerides in Women. J Clin Endocr Metab (2004): 89: T. J. Roseboom et al., Effects of Prenatal Exposure to the Dutch Famine on Adult Disease in Later Life: An Overview, Mol. Cell. Endocrinol. 185 (2001): Whitaker, R. Predicting Preschooler Obesity at Birth: The Role of Maternal Obesity in Early Pregnancy, Pediatrics. (2004): 114; e29. 10