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: 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 high-risk 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 non-Hispanic white boys, and non-Hispanic black girls were significantly more likely to be obese than non-Hispanic 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: Obesity Dyslipidemia High blood pressure Insulin resistance Faster early postnatal growth leads to: 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: 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 6-month 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 take-home 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 (13-19) 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?