Sarah Hallberg, D.O., M.S.
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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
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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
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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
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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
Obesity is hiding hunger for many kids
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1 of 3 low income children are obese or
overweight before their 5th birthday
Ped NSS data 2009
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High calorie and nutrient poor foods
◦ This is what is in our food banks
◦ Cheap, calorie dense foods
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Fruits and non-corn veggies
www.fruitsandveggiesmatter.gov/health
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Identification, assessment, prevention and
early intervention
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%BMI instead of BMI
Plot on graph
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Less than 5%
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Underweight
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5% - 85%
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Healthy Weight
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85% to <95%
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Overweight
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95% to <99%
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Obese
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>99%
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Severely obese
Percentile Range (% BMI)
Weight Status Category
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Either BMI% >95%
OR
BMI > 30
Whichever is LOWER
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Medical Risk
Behavioral Risk
Attitudes
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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
Kindergarteners would rather sit next to a
child with a physical handicap over one with
obesity
Neumark-Aztainer D. J Nutr Educ.
1999
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BMI 85 – 94% - Lipid always
◦ If risk factors than fasting glucose, ast, alt
◦ Measure q 2 years for >10 years of age
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BMI > 95% - lipid, fasting glucose, alt, ast
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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
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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
<2 years – Prevention counseling
2 – 5 years
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85 – 94% weight maintenance or slow gain
>95% maintenance or loss up to 1# per month
6 – 11 years
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85 -94% maintenance
95 – 99% gradual loss 1#/month
>99% average 2#/wk
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12 – 18 years
• 85 – 94% maintenance or gradual loss
• 95 – 99% weight loss, average 2#/wk
• >99% weight loss average 2#/wk
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Mood stabilizers
Antipsychotics (Geodon the best)
?Add topamax if on antipsychotics
?Add metformin if on antipsychotics
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Shown to improve body composition, fasting
insulin, fatty liver in obese kids and
adolescents
500mg qd to start up to 1000mg XR best
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ID problem behaviors
Praise if no problems identified
Patient and family counseling about behavior
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Stage I - Prevention Plus
Stage II -Structured weight management
Stage III -comprehensive multidisciplinary
intervention
Stage IV -Tertiary Care
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PCP office
Visit for this alone
Establish goals
If no progress in 3 – 6 months than stage II
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Planned diet and snacks
Planned activity
Dietician
Counselor
Monthly visits
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Structured and monitored
Negative energy balance
Parent home training
Weight management program
◦ Meds
◦ Meal replacements
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Tertiary care
◦ VLCD
◦ Surgery
◦ Appetite suppressants
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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
http://www.aap.org/obesity/pdf/obesitycodin
gfactsheet0208.pdf
Don’t Feed it Soda!!
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Non Alcohol Fatty Liver Disease
◦ 1/3 of overweight kids have this
◦ How many normal weight kids do?
Mallort GB. J Pediatr. 1989
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Pathologically the same as alcohol liver
disease
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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
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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
Robert H. Lustig, MD
Journal of the American Dietetic Association – Vol
110, Issue 9 Sept 2010
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Look for it
Be comfortable with discussions
Allied Health Professionals
Broader scope- policy changes
No soda