The Causes of Pediatric Obesity
Janet Carter, MS, RD, LD
Sodexo Dietitian/CNM1
Heart Health Program Manager
Childhood obesity is “…a coming
tidal wave…The current
unprecedented epidemic of obesity
may result in the first generation of
children who will not live as long as
their parents.”
Dr. W. Dietz, CDC
Is this child overweight?
Is this child overweight?
Is this child overweight?
Is this child overweight?
BMI 95th %ile
Is this child overweight?
BMI >>95th %ile
Is this child overweight?
BMI 90-95th %ile
Objectives
Upon completion of this presentation, you will be able
to:
 List the prevalence and effects of pediatric obesity on
the national and state level
 List the main causes of pediatric obesity that
currently have supportive data
 List a sampling of the treatment strategies for
pediatric obesity
Prevalence of Pediatric Obesity
Nation
 Between the 1988-1994 survey and the 2003-2004
statistics:
 overweight increased from 7.2 to 13.9% among 2-5 year
olds
 from 11 to 19% among 6-11 year olds
 from 11 to 17% among adolescents aged 12-19
 Overall estimates state 16.9% of children and
adolescents aged 2-19 are obese (Ogden, CDC;
http://www.cdc.gov/nchs/data/hestat/obesity_child_07_08/obesity_child_07_08.htm )
Prevalence of Pediatric Obesity
Nation
Prevalence of Pediatric Obesity
State
 South Carolina ranks 10th in the US for the
highest number of overweight and obese
people
 SC Practice Partner Research Network
 14.0% 2-5 year olds (13.9% nationally)
 21.7% 6-11 year olds (19% nationally)
 Self-reported state data suggest that 25.3% of high
school students are overweight or obese
Effects of Pediatric Obesity
 Obesity is the leading preventable cause of death
 Each year 2.5 million deaths are weight related
 In the US, South Carolina ranks:
 #1 in stroke
 #3 in heart disease
 #10 in diabetes
Effects of Pediatric Obesity
Specific for overweight children, are increased risk of:
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Type 2 diabetes
Hypertension
Dyslipidemia
Metabolic Syndrome
Hyperinsulinemia
Obstructive sleep apnea
Early puberty
Polycystic ovary syndrome
Asthma
Psychosocial effects
Orthopedic issues
Effects of Pediatric Obesity
 40% of overweight kids have fatty liver
 10% of obese kids and 40-50% of severely obese kids
have elevated FTEs
 Overweight & obese kids have ventricular
hypertrophy
(Lars, NEJM; 2007)
 65% of obese 5-10 year olds have at least one risk
factor for cardiovascular disease
 25% of obese 5-10 year olds have two or more risk
factors for cardiovascular disease
Causes
Genetic
 Genotyping has shown evidence of obesity-related genes
 Various studies have shown 20 gene variants associated
with BMI, body weight, or both
 Examples:
 FTO gene variants in children show hyperphagia and
preference for energy-dense foods (Scuteri, PLoS Genet; 2007)
 MC4R gene mutations in children manifest in early-onset
severe obesity, persistent food-seeking behavior, increased
fat & lean masses, hyperinsulinemia and hyperphagia
(Farooqi, N Engl J Med; 2003 and Martinelli, J Clin Endrocrinol
Metab; 2011)
Causes
Genetic
 Associations between gene variants and physical activity
have been shown
 Higher risk of obesity observed in children who carried highrisk alleles and engaged in sedentary behavior ≥2 hours per
day (Xi, BMC Med Genet; 2010)
 Low physical activity accentuated the effect of FTO variant
(Cauchi, J Mol Med (Berl); 2009)
 Evidence is showing the environment can alter gene
expression and influence the individual’s phenotype
(Lillycrop, Int J Obes (Lond); 2011)
Causes
Genetic
However…
“Despite obesity having strong genetic
determinants, the gentic composition of the
population does not change rapidly. Therefore,
the large increase in…[obesity] must reflect
major changes in non-genetic factors.”
Hill, James O., and Townbridge, Frederick L, Childhood obesity: future directions and
research priorities. Pediatrics. 1998; Supplements: 571.
Causes
Socio-Economic
 In 2007—2008, Hispanic boys, aged 2 to 19 years were
significantly more likely to be obese than nonHispanic white boys, and non-Hispanic black girls
were significantly more likely to be obese than nonHispanic white girls (CDC)
 1 of 7 low-income, preschool-aged children is obese
Causes
Socio-Economic
 23.5+ million Americans live in food deserts
 Low-income families generally have less access to healthy
food choices and opportunities for physical activity
 Low-income moms are less likely to breastfeed
 Material conditions and non-material resources
--housing
--parent time
--neighborhoods
--stress
--schools
Causes
Prenatal and Neonatal
 Stress causes the fetus to adapt (any kind of stress)
 Feeding modality early in life can increase risk for obesity
later
 Example (Lucas and Singhal, 2003, 2004):
 Preterm infants randomized at birth to standard formula,
donor breast milk, enriched pre-term formula
 Examined at age 13-16
 Those on enriched pre-term formula had increased obesity in
addition to blood pressure, cholesterol, and insulin resistance
Causes
Prenatal and Neonatal
 Breast feeding compared to formula feeding has been
shown to decrease propensity for:
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Obesity
Dyslipidemia
High blood pressure
Insulin resistance
 Faster early postnatal growth leads to:
 Insulin resistance
 Higher blood pressure
 Endothelial dysfunction (early stage in atherosclerosis)
(Singhal, Lancet; 2004)
Causes
Prenatal and Neonatal
 Example (Stettler, et al, 2005):
 Non-premies formula fed
 Examined at age 20-32
 Rapid weight gain (100grams) in week 1 raised risk of
obesity 28%
 Breastfed infants tend to have a slight weight loss in
the first 2 weeks while bottle fed babies gain weight
Causes
Environmental
 Children in the US watch 20-30 hours TV per week
 American kids view 40,000 ads per year
 Ad exposure is related to childhood obesity, poor
nutrition, and cigarette and alcohol abuse
(Pediatrics, 2006 & Caroli, et al; 2004)
Causes
Environmental
 Overweight and obesity can result from a very small positive
energy balance over a long period of time
 Top 5 sources of calories among Americans 2 years and older:
1.
2.
3.
4.
5.
Grain-based desserts (cakes, cookies, pie, cobbler, etc.)
Yeast breads (white bread & rolls, mixed-grain bread, whole
wheat bread, tortillas, etc.)
Chicken and chicken mixed dishes (fried & baked chicken parts,
chicken strips/patties, stir fries, casseroles, etc.)
Soda/energy/sports drinks
Pizza
(National Cancer Institute. http://riskfactor.cancer.gov/diet/foodsources/energy/. Updated December 21,
2010)
Treatment Strategies
Position Statement of the Academy of Nutrition and
Dietetics:
“The AND, recognizing that overweight is a significant
problem for children and adolescents in the United States,
takes the position that pediatric overweight intervention
requires a combination of family-based and school-based
multi-component programs that include the promotion of
physical activity, parent training/modeling, behavioral
counseling, and nutrition education.”
Treatment Strategies
 AND reviewed 29 randomized controlled trials and 15
studies of other design examining multi-component,
group, family-based interventions to develop the Position
Statement
 In 28 of the studies, children significantly reduced weight
status/adiposity
 Studies in children <13 years of age consistently showed
significant reductions in weight status/adiposity over 6month to 2-year time periods when parents were included
in behavioral counseling
J Amer Diet Assoc 2006; 106: 925-945
Treatment Strategies
Family-based
 Heart Health
 Children and adolescents ages 2 to 21
 Focus: patients with abnormal weight gain and associated
cardiovascular risk factors (dyslipidemia, hypertension, pre-diabetes)
 Family-centered and lifestyle-oriented
 Comprehensive physical assessments
 One-on-one health coaching
 Psychological counseling
 Group sessions
 Fitness sessions
 Monthly newsletter
Heart Health
Success
 Heart Health currently has over 150 active families
 For those who are improving, average decrease in
BMI is 1.5
 For those active in Fitness Sessions, anthropometrics
have improved dramatically:
 Waist circumference: loss of 3.9cm (1.5”)
 Hip circumference: loss of 1.3cm (0.5”)
 % body fat: loss of 11%
 Knowledge & attitude about health and nutrition is
not easily measured
Heart Health
Heart Health
Treatment Strategies
School-based
 The Lean Team
 Individual services for students and teachers
 School Wellness Councils
 Policy & environment change
 Focus on healthy eating & physical activity
 Web-based resources
 Education in schools & community
 Coalition formation
Treatment Strategies
Hospital-based
 68% of Children’s hospitals provide services through
an obesity clinic or weight management program
 Stability and sustainability hindered by lack of
reimbursement and reliance on grant funding
 Many childhood obesity programs are active in
educating and training pediatric providers in the
community
Treatment Strategies
Hospital-based
 Brenner FIT @ Wake Forest Baptist Health, NC
 Multi-disciplinary team
 Program is one year long
 Pts see MD 4x/yr and other staff 12x/year
 Includes education and some on-site exercise (mostly takehome recommendations)
 USC Healthy Lifestyles
 Partnerships with Peds Endo and exercise physiology
program
 Pts mainly see MD, but program includes a 4-hour group
session (MD does majority of education)
Treatment Strategies
Other
 Solmaz Institute for Obesity @ Lenoir-Rhyne, Hickory, NC (1319) and Healthy House (12 and under)
 Includes nutrition & fitness assessments
 Pts seen every week for the first three months, then every
other week for the next three months
 Wellspring Camps
 3-weeks ($6,400) or longer
 Includes physical activity, group sessions, culinary classes,
grocery store tours, dining out together to discuss healthy
options
 Family members not included
Questions?