Childhood and
Adolescent Obesity
Kathryn Camp, MS, RD, CSP
WHY WORRY ABOUT PEDIATRIC
OBESITY?
• Pediatric obesity is of epidemic
proportion.
• Pediatric obesity is the most
common chronic disease of
childhood.
• The epidemic is worldwide
Some Scary Stats
• 300,000 Americans died from obesityrelated causes in 2000 (Surgeon
General Report)
– $117 billion in obesity-related economic
costs
• Cost of caring for obese patients is 35%
greater than normal weight
• Anthony
• 15 yr old
• Referred by his
new PMC
• Anthropometrics
– Weight: 121 kg
– Height: 175 cm
BMI: 39
How Do We Define Overweight
in Children and Adolescents?
Definition of Overweight in Children
and Adolescents
• Overweight =
BMI  95th %ile
• At risk for overweight =
BMI between 85th-95th %ile
Expert Committee Recommendations from the Maternal and Child
Health Bureau, 1997
Calculate Your BMI
•
•
•
•
•
kg  m2
Height in inches x 2.54  100 = meters
Meters x meters = m2
Weight in pounds  2.2 = kg
Divide your weight in kg by m2 = BMI
Classification of Overweight and Obesity in
Adults Using BMI
Obesity Class
BMI
Underweight
<18.5
Normal
18.5-24.9
Overweight
25-29.9
Obesity
I
30-34.9
II
35-39.9
III Extreme
 40
35
4
3
36 37
University of Miami
Blocking Machine
39
38
Height: 6-6
Height: 7-1
Weight: 98 kg
Weight: 154 kg
25
BMI is Age Specific in Children
and Adolescents
24
21
17
Increasing Incidence of
Overweight in Children and
Adolescents
 95th%ile for age and gender
These #s
double when
including
>85%ile
PERCENT OF OBESE CHILDREN WHO
BECOME OBESE ADULTS
80
70
60
50
40
30
20
10
0
Preschool
School-age
Adolescent
Etiology of Obesity
•
•
•
•
Genetic/heritablility
Molecular
Syndromes
Environmental
Multifactorial Condition
Heritability
• Survival advantage to conserve energy
as fat through human evolution
• Humans enriched for genes that
promote energy intake and storage and
minimize expenditure.
• Enhance female fertility and ability to
breastfeed offspring
• In modern industrial environment
– easy access to calorically dense foods
– encourages sedentary lifestyle
• Metabolic consequences of these genes
are maladaptive
Genetic Factors account for 20-40% of
heritability of BMI
• 173 human obesity cases due to single gene
mutations in 10 different genes were reported by
2004 (Perusse, 2005)
• > 600 genes, markers, and chromosomal regions
have been linked with human obesity phenotypes
Familial Risk:
2-3 fold for
moderate obesity
5-8 fold for
severe obesity
Bouchard 01
Buchard 97
Rankinen 02
More than 50 Obesity
Associated Genetic Syndromes
Spina bifida
Down Syndrome
Prader Willi
Bardet-Biedl
Hormones, Neurotransmitters,
Enzyme defects???
• Obesity is not well understood at the
molecular level.
• Discovery of leptin was hoped to
revolutionize the field but its role has
remained obscure
• Role of other hormones,
neurotransmitters, etc
remains unknown
• But doctor, my child must have a low
metabolism….
– Little evidence that metabolic rate is
different (Baker, 05)
– Obese adolescents have a higher total daily
energy expenditure and REE (Bandini, 90)
– There may be small differences in
metabolic efficiency but these are hard to
measure
What is Causing this
Marked Increase in
Overweight??
Obesity is not a genetic shift,
rather it is an environmental shift
Causes of Marked Increase in
Overweight
• Reflects a shift towards positive energy
balance
energy intake = energy expenditure
calories
McDowell 94; Kann 99; Troiano 00,
NHANES II to III
PE
sed act
Increased Energy Intake
• Kids are
– Eating more away from home
– Eating more fast food and snack foods
– Drinking more sodas
• 100 kcal/day above needs = 10 pound
weight gain per year
Physical Activity
• Daily participation in PE declined from
42% to 29% between 1991 and 1999
(www.cdc.gov/HealthyYouth)
• Walking and bicycling dropped 40% in
kids aged 5-15 between 1977 and 1995
• What constitutes “active” these days?
Increase in Sedentary Activity
• Excessive TV watching–
– The average child spent 6 hr/day watching TV or
playing on computers.
– Encourages overeating while viewing
• Influences food choices
– 80% of commercials on children’s programs are for
food
• Lower resting metabolic rate compared to at
rest (Klesges 1993)
• Reduces time available for more active pursuits
Other Contributors to Sedentary
Lifestyles
• Video and computer games
• Parental work schedules
• Unsafe neighborhoods
– discourage parents from allowing children
to play outdoors
– force parents to drive children to school
• Lack of recreational facilities in lowincome neighborhoods
Medical Consequences of Overweight
Cardiovascular
• 60% of OW children have 1 or more
CVD risk factors
• Hyperlipidemia-- LDL and TG,  HDL
– 90% of children with elevated TGs are
overweight
• Hypertension
– Low frequency in children
• 60% with  BP were >120% of IBW
• Obtain fasting lipid profile and blood
pressure on all overweight children.
Type 2 Diabetes
• 95% of teens with Type 2 diabetes have
a BMI >85%ile
• Tremendous public health implications
– Longer duration of disease, > risks of
complications
• Obtain fasting glucose and insulin on all
overweight children, especially those
with..
Dabelea 99; Vinicor 00; Richards 85
• Acanthosis Nigricans
• Hyperpigmented,
velvety plaques in
body folds
• Caused by
hyperinsulinemia
which stimulates
formation
• Associated with
obesity
Other Endocrinological Issues
• Growth
– Taller, advanced bone age, mature earlier
– Early maturation is associated with
• increased fatness and truncal fat distribution in
adulthood
– Short, obese children should be evaluated
for hypothyroidism, Cushing syndrome or
Turner syndrome
More Complications
• Hepatic Steatosis with elevated LFTs
• Cholelithiasis
– 50% of kids with cholecystitis are
overweight
• Orthopedic Problems
Acute Complications that Require
Immediate Medical Attention
• Sleep Apnea
– Occurs in 17% of obese children and teens
(Marcus 1996)
– Deficits in learning, memory, and
vocabulary (Rhodes 1995)
• Obesity hypoventilation syndrome
– rare, potentially fatal disorder
Psychological and Economic Consequences
of Pediatric and Adolescent Obesity
• Discrimination, rejection and low selfesteem (Gortmaker 93), particularly for
females
• Less participation in PE and sports
activities
• Lower college acceptance rates
(Canning 1966)
Who Needs to be Evaluated?
Evaluating For Overweight in a Primary
Care Setting
BMI
Overweight
BMI  95th%
+
In depth medical
assessment
At risk for
Overweight
BMI 85-95th%
Not at risk
BMI  85th%
•Family history
•Blood pressure
•Lipids
•Lg  in BMI
•Concern re wt
Return next yr
for screen

•Note in chart
•No therapy
•Return next yr
Medical Assessment
• r/o genetic syndromes, esp if associated with
mental retardation
• Blood pressure
• Labs to include
– Fasting lipid panel
– Fasting glucose and insulin
• OGTT
– LFTs
– Thyroid fx tests
Back to Anthony—Medical
• PMHx
– chronic otitis media and allergies
– overweight since 7 yrs of age
• Currently c/o headache
• On no chronic meds
• Blood Pressure
– 136/73
– >95th%ile
Social hx
• Only child
• High school sophomore, gets good
grades
• No exercise or organized sports
activities
• Spends 6 hrs/day watching TV and
playing video games
Dietary Information
• Picky eater
• Consumes NO fruits or vegetables
• Mom prepares separate meals for him
24-Hour Recall
• Breakfast--none
• Mid morning--16 oz ginger ale
• Lunch--none
– generally has lunch at school of chocolate
milk, pizza, and french fries
• Dinner--10 beef tacos, 2 cans of soda
What to Do with Anthony?
• Weight goals
– First step is to achieve weight maintenance
– 2-7 years of age
• BMI 85-95%
– Weight maintenance
• BMI >95%
– No complications: weight maintenance
– Complications: weight loss
– 7 and above
• BMI 85-95th%
– No complications--weight maintenance
– Complications—weight loss
• BMI >95th weight loss
What to Do with Anthony?
• Weight goals
– First step is to achieve weight maintenance
– 2-7 years of age
• BMI 85-95%
– Weight maintenance
• BMI >95%
– No complications: weight maintenance
– Complications: weight loss
– 7 and above
• BMI 85-95th%
– No complications--weight maintenance
– Complications—weight loss
• BMI >95th weight loss
General Treatment Goals
• Behavioral goals
– Promote life long healthy eating and
activity behaviors
• Medical goals
– Prevent complications of obesity in
childhood and potentially adulthood
– Improve or resolve existing complications
of obesity
Refer?
• Formal obesity clinic--Team approach
– Physician, therapist, dietitian, exercise
therapist
– Intensive multi-session programs
• Parent and child/teen participate
– Advantages
• Multidisciplinary approach, frequent visits
– Disadvantages
• Expensive, time consuming, require parent
participation
If Going It Alone…
Where Do You Start?
• Assess child’s and family’s willingness to
change
• Negotiate with child/family on specific,
targeted changes
• Develop realistic, achievable goals
• Involve the entire family in making
changes
• Establish a monitoring/assessment tool
Goals for Anthony
• Eat 3 meals per day (establish
regular meals)
• Have 1 piece of fruit each day (introduce new
food groups)
• NO calorie containing beverages except skim
milk (eliminate empty calories)
• Daily exercise (increase energy expenditure)
• Keep a notebook of food intake and exercise
(self-monitoring)
Follow-up
• Weekly visits or as frequent as possible
• lipid profile, HgbA1c, fasting insulin and
glucose, blood pressure
• Identify and reinforce positive changes
• Set new goals based on goals achieved
Anthony’s Lab Data
• Lipid panel
– Total cholesterol
– Triglycerides
– HDL
– LDL
• HgbA1C
• Fasting glucose
• Insulin
156
129
34
96
(<200)
(35-250)
(35-82)
(<100)
5.8 (4.3-5.3)
77
30.3 (0-30)
• Weight
– 97 kg
– Down 53#
• Height
– 179 cm
– Up 4 cm
• BMI
– 30
– Down from 40
Childhood Obesity
Can be prevented
Shaping Habits
That Shape
America’s
Children
PREVENTION: PRECONCEPTION
• Prevention starts prior to conception
– Obese adolescents have an 80%
probability of being obese as adults
– Today's adolescents are tomorrows parents
– Parents are role models for their children
– Obesity risk in a child born to obese
parents is significantly increased
– Educate and intervene at this time to help
prevent obesity in subsequent generations
PREVENTION: POST CONCEPTION
• Routine prenatal care
• Achieve normal weight gain during
pregnancy
– LGA infants and infants of diabetic mothers
have higher rates of subsequent obesity
– SGA infants also at higher risk
• Hediger ML et: Pediatrics 104:e33, 1999
• Promote breast feeding
PREVENTION: SCHOOL
•
•
•
•
Promote physical activity
Provide nutritious meals
Control vending machines
Have nutrition education incorporated
into regular school curriculum.
• Encourage children to walk or bike to
school safely.
PREVENTION: COMMUNITY
• Have safe playgrounds
• Provide safe places for bike riding and
walking
• Promote physical activity outside of
school
PREVENTION: INSURANCE AND
GOVERNMENT
• Acknowledge obesity as a medical
condition for which one can be
reimbursed.
• Provide reimbursement for anticipatory
guidance for nutrition and physical
activity
PREVENTION: PRIMARY CARE
PROVIDER
• Be an advocate
• Provide anticipatory guidance to
families
NUTRITION ANTICIPATORY GUIDANCE
• Beverages
– Encourage water intake
– Limit sweet beverages
• Juice, juice drinks: 120 calories / 8 oz
– No nutritional need for any juice <6 months
of age
– 1-6 years: 4-6 oz
– 7-18 years: 8-12 oz
– Discourage free use of box drinks
– Discourage continuous access to sippy cups
• Soda: 150 calories / 12 oz
NUTRITION ANTICIPATORY GUIDANCE
•
•
•
•
Eat 5 fruits and vegetables a day
Structured meal and snack time
Do not use food as a reward
Know what the child is eating outside
the home: school meals, day care etc.
NUTRITION ANTICIPATORY GUIDANCE
• Encourage child’s autonomy in self-regulation
of food intake
– Parents provide, child decides!
– Do not use the clean the plate rule.
• Provide choice
• Educate parents regarding healthy nutrition
– Healthy snacks
– Consider using pediatric food pyramid
– Portion size: Intake of children >5 years is
dependent on how much they are provided
• Do not skip meals
ACTIVITY ANTICIPATORY GUIDANCE
• Encourage active play for young
children
• Promote physical activity for school age
children and teens
• Encourage participation in organized
sports
ACTIVITY ANTICIPATORY GUIDANCE
• Decrease sedentary activity
– Limit TV, video games and computer to 1-2
hours per day
• > 2 hours a day associated with higher rates of
obesity and hyperlipidemia
– Do not have a TV in the child’s room
• Children with TVs in bedroom watch more TV
BEHAVIORAL ANTICIPATORY GUIDANCE
• Encourage parents to act as role models
– Nutrition
– Activity
• Promote parent child interaction
• Have special “family time” that is
physically active
BEHAVIORAL ANTICIPATORY GUIDANCE
• Limit eating out
– More calorically dense food
– Larger portion sizes
– Less intake of fruits and vegetables
BEHAVIORAL ANTICIPATORY GUIDANCE
• Eat as a family
– Provides “quality time”
– Slows down the eating process
– Parents act as role model
– Parents monitor intake
– Associated with lower fat intake and
greater intake of fruits and vegetables
BEHAVIORAL ANTICIPATORY GUIDANCE
• Do not eat in front of the TV
– Associated with higher intake of fat and
salt
– Lower intake of fruits and vegetables
– Encourages over eating
• 60-80% of commercials on during children
programs are related to food
• Eating without awareness
Summary
• Pediatric obesity is epidemic
• Overweight kids become overweight
adults
• Treatment is difficult
• Prevention is the key