Pediatric Obesity: A Family Affair
Samuel N. Grief, MD
Outline
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Introduction
Definition of childhood overweight/obesity
Scope of Problem
Etiology: Multifactorial
Genetics and obesity
Environment and obesity
Culture and obesity
Taking a pediatric nutrition history
Nutrition recommendations for treating obesity
Practical pointers for all Family Physicians in
dealing with the obese child
Conclusion
Pediatric Obesity: A Family Affair
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Pediatric obesity is rapidly becoming a serious health
epidemic in the united states. Health officials estimate the
percentage of overweight/obese children has risen to 30%
and is climbing.
This symposium will bring the topic of pediatric obesity
into the limelight elucidating:
The severity of this health epidemic,
The multiple causes of pediatric obesity,
The genetic connection,
The latest nutrition recommendations,
A practical approach for family doctors to assess a child’s
nutrition habits in the context of the family unit and
provide sensitive and sound medical advice to help
children and their family members conquer obesity.
Definition of Childhood Overweight/obesity
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Adults: BMI – mild, moderate, severe or
extreme
For children, not clearly established
BMI >85% defined as overweight
BMI >=95% for age and gender
BMI not used for infants
Definition of overweight BMI varies with age
Scope of Pediatric Obesity Problem
NHANES III
NHANES III
Boys
Age/Month
NHANES I
NHANES II
HHANES
2-5
NHANES III
322
6-11
152
47
595
12-23
285
368
101
648
24-35
166
361
116
610
36-47
300
403
113
497
48-59
304
403
126
546
60-71
273
393
116
495
Number of Survey Participants in Sex and Age Groups by Survey
NHANES III
Girls
Age/Month
NHANES I
NHANES II
2-5
HHANES
NHANES III
334
6-11
143
53
576
12-23
267
350
118
635
24-35
129
315
112
591
36-47
286
340
85
545
48-59
281
386
93
532
60-71
314
369
112
554
Number of Survey Participants in Sex and Age Groups by Survey
Prevalence of overweight Based on Percentage of 2-5 year-old children
above the 95% of the weight-for-stature growth reference (NHANES III)
14
12
10
Non Hispanic White
Non Hispanic Black
Mexican American
8
6
4
2
0
Non Hispanic White
Non Hispanic Black
Mexican American
Boys 2-3 Girls 2-3 Boys 4-5 Girls 4-5
1.1
2.8
6.2
2.8
5.6
10.5
2.7
8.5
12
9
11.2
13.2
NHANES I, II, III
6-11 Months
White
Boys
Girls
2.7
7.3
6.5
11.1
NHANES I
NHANES II
NHANES III
9.0
9.5
10.7
Mexican American
HHANES
NHANES III
4.5
12.2
7.3
16.3
NHANES I
NHANES II
NHANES III
Black
NHANES I, II, III
6-11 Months
ALL RACES
NHANES I
NHANES II
NHANES III
Boys
Girls
4.0
7.5
6.2
10.8
NHANES I, II, III
12-23 Months
White
Boys
Girls
NHANES I
NHANES II
NHANES III
Black
8.3
6.6
7.6
5.7
7.5
7.9
NHANES I
NHANES II
NHANES III
3.8
11.8
6.4
8.9
6.8
15.2
Mexican American
HHANES
NHANES III
7.9
13.6
11.3
14.0
NHANES I, II, III
12-23 Months
ALL RACES
NHANES I
NHANES II
NHANES III
Boys
Girls
7.5
7.2
7.5
6.1
7.2
9.5
NHANES I, II, III
2 – 3 Years
White
Boys
Girls
NHANES I
NHANES II
NHANES III
Black
1.9
1.5
2.0
1.6
2.9
4.5
NHANES I
NHANES II
NHANES III
3.4
2.2
3.0
2.2
1.0
6.2
Mexican American
HHANES
NHANES III
5.6
3.0
4.2
6.2
NHANES I, II, III
2 - 3 Years
ALL RACES
NHANES I
NHANES II
NHANES III
Boys
Girls
3.1
2.0
2.1
2.0
2.5
4.8
NHANES I, II, III
4 - 5 Years
White
Boys
Girls
NHANES I
NHANES II
NHANES III
Black
4.0
4.6
4.3
6.0
7.4
11.2
NHANES I
NHANES II
NHANES III
7.0
3.0
8.7
5.0
6.5
12.6
Mexican American
HHANES
NHANES III
4.9
12.0
10.6
13.2
NHANES I, II, III
4 - 5 Years
ALL RACES
NHANES I
NHANES II
NHANES III
Boys
Girls
4.4
4.4
5.0
5.8
7.6
10.8
NHANES III
Percentage of children younger than 3 years above the 95% of
the weight-for-length growth reference, NHANES III
Boys
NHW
NHB
MA
Under 1
9.6
9.1
10.2
Ages 1 & 2
7.5
6.4
8.9
Girls
NHW
12.8
11.0
10.2
13.0
11.5
8.4
NHB
MA
Both Sexes
15.0
15.5
10.3
14.0
16.8
9.4
Assessment of Medical Conditions Related to Obesity
Findings
Potential Conditions
History
Developmental Delay
Genetic Disorders
Poor linear growth
Hypothyroidism, Cushing’s
syndromePrader-Willi syndrome
Headaches
Pseudotumor Cerebri
Nighttime breathing difficulty
Sleep apnea, obesity hypoventilation
syndrome
Daytime somnolence
As above
Abdominal pain
Gallbladder disease
Hip or knee pain
Slipped capital femoral epiphysis
Oligomenorrhea or
amenorrhea
Polycystic ovarian syndrome
Assessment of Medical Conditions
Related to Obesity
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Family History
 Obesity
 NIDDM
 Cardiovascular disease
 Hypertension
 Dyslipidemia
 Gallbladder disease
Social/psychologic history
 Tobacco use
 Depression
 Eating Disorder
Assessment of Medical Conditions
Related to Obesity
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Physical exam
Height, weight, BMI
Triceps skinfold thickness
Truncal obesity
Blood pressure
Dysmorphic features
Acanthosis nigricans
Hirsutism
Violaceous striae
Optic disks
Assessment of Medical Conditions
Related to Obesity
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Tonsils
Abdominal tenderness
Undescended testicle
Limited hip range of motion
Lower leg bowing Risk of cardiovascular
disease; Cushing’s syndrome
Genetic disorders (PW)
NIDDM, insulin resistance
Polycystic ovarian syndrome; Cushing’s syn
Pseudotumor cerebri
Assessment of Medical Conditions
Related to Obesity
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Sleep apnea
Gallbladdeer Disease
Prader-Willi Syndrome
Slipped Capital Femoral Epiphysis
Blount’s Disease
Etiology of Pediatric Obesity:
Multifactorial
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Environmental: Neighborhood, school,
community
Genetic: Inborn diseases, chromosomal
mutations, familial, ethnic predisposition
Cultural: Increased risk with minorities
Societal: Affluent vs. Underserved
Physical: Height and body frame; sick vs.
healthy
Attitude: Family influence on nutrition habits
and physical activity
Medical advice: Doctors not taking an active role
The American way of life!
Genetics and Obesity
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Twin studies
Familial syndromes: Cohen’s, Alstrom’s,
and Bardet-Biedl (look these up!!!)
Ob gene and leptin
POMC
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Pro-opiomelanocortin
 MC4R – a melanocortin receptor
Genetics and obesity
What next?
 Additional leptin to those who are
deficient.
 Ongoing research for pharmacological
manipulation.
 Continued research in rodents is directly
relevant to humans.
Environment and Obesity
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Socioeconomic status and rates of
obesity
Single parent families and risk of obesity
Social support and relevance to pediatric
obesity
School and extracurricular activities
Inner city vs. suburban setting
Western vs. third world setting
Culture and Obesity
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Minorities and increased rates of obesity
African-American
Hispanic
Native Indian
Pacific Islander
White
Asian
European
Other
Culture and Obesity
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Culture and food
Food is a way of life
Learn about different cultures: ASK!
The taste of Chicago…
You deserve a…
BREAK!
Nutrition Exercise
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Split into groups of three
Designate one member as the physician
Designate one member as the parent of an
obese child
Designate one member as the observer
The physician has ten minutes to obtain a
complete nutrition history from the parent
Observer to take notes re:
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Style – effective or not and why?
Open or closed ended questions
Anything missing?
Anything else?
Ready,
set…
GO!
Taking a pediatric nutrition history
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Back to basics!
Methods of assessing dietary intake:
1) 24-Hour recall
2) Usual Intake/Diet history
3) Food frequency questionnaire
4) Family history
5) Past medical history
6) Any diets that have been tried? Successful?
7) Social habits: cigs, caffeine, illicit drugs, ETOH
8) MEDS, vitamins, herbals
9) Food allergies? Lactose intolerance?
10) ROS: Constitutional, GI, GU
Pediatric Nutrition
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Refer to a trusted Registered Dietitian!
Recommendations based on the USDA Food
Guide Pyramid
Most children will need to maintain their current
weight until they reach a lower level BMI
There is no magic wand to wave
The three Es:
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Emphasize proper nutrition,
Encourage an overall family approach to modifying
nutrition habits, and
Empathize with all those concerned.
Medicinal Treatment Options
for Pediatric Obesity
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Few are currently viable
OTCs: Diet pills, ephedra, metabolife, caffeine,
chitosan, hydroxycitric acid, pyruvate, etc.
Methylphenidate, dextroamphetamine, etc.
Diuretics
Thyroid hormone
Growth hormone
Testosterone
Leptin
Metformin
Xenical
Surgical Treatment Options for
Pediatric Obesity
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Useful for adolescents with extreme
obesity
Last resort option for severely obese
adolescents
Choose patients carefully
Obesity and Psychological
Disorders in Children
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Do obese children suffer from greater rates of
depression?
Study of 868 third grade students
KEDS
Results: there is a relationship between depressive
symptoms and BMI in preadolescent girls; not in boys.
Girls express more overweight concerns.
Take home message: when girls present to Family
Docs, assessing overweight concerns with the 5question scale may help identify overweight girls at
highest risk of developing depression, and perhaps
subsequent eating disorders.
Obesity and Eating Disorders
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At any given time, 44% of adolescent girls and
15% of adolescent boys are “dieting”
Prevalence of eating disorders (anorexia and
bulimia) is estimated to be 1-4% of adolescent and
young adult women
Predisposing factors may include: genetic, biological
vulnerability, individual psychopathology, familial
and cultural influences
Survey of women on the most common weight loss
practices: weighing oneself regularly, walking,
fasting, meal skipping, diet pills, cigs
Weight cycling: not related to increased
psychopathology!
Non-dieting approaches for
obese children
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Identify and combat cultural notions that “thinner is
better” and that body weight can be controlled by
willpower
Help participants “stop dieting” by abandoning efforts
to restrict energy intake and avoid certain foods
Help participants identify and eat in response to the
body’s “natural” hunger and satiety signals
Increase self-esteem and positive body image through
self-acceptance rather than weight reduction
Increase awareness about dieting behaviors and their
purported ill effects
Obesity and Children
Miscellaneous
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Early onset of adiposity rebound (AR)
Early onset of puberty related to obesity
in girls
Increased rates of Type 2 diabetes
diagnosed among obese children
Adult food fears impact children
General Approach to Treating
Pediatric Obesity
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Intervention should begin early
The family must be ready for change
Clinicians should educate families about medical
complications of obesity
Clinicians should involve the family and all
caregivers in the treatment program
Treatment programs should institute permanent
changes, not short-term diets or exercise
programs aimed at rapid weight loss
General Approach to Treating
Pediatric Obesity
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As part of the treatment program, a family
should learn to monitor eating and activity
The treatment program should help the family
make small, gradual changes
Clinicians should encourage and emphasize and
not criticize
A variety of experienced professionals can
accomplish many aspects of a weight
management program
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Thank you very much!