1. Sarah Hallberg, D.O., M.S.

2.  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

3.  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

4.  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

5. 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

6. Obesity is hiding hunger for many kids

7.  1 of 3 low income children are obese or overweight before their 5 th birthday Ped NSS data 2009

8.  High calorie and nutrient poor foods ◦ This is what is in our food banks ◦ Cheap, calorie dense foods

9.  Fruits and non-corn veggies  www.fruitsandveggiesmatter.gov/health

10.  Identification, assessment, prevention and early intervention

12.  %BMI instead of BMI  Plot on graph

13. Percentile Range (% BMI) Weight Status Category Less than 5% 5% - 85% 85% to <95% 95% to <99% >99% Underweight Healthy Weight Overweight Obese Severely obese

14.  Either BMI% >95% OR  BMI > 30 Whichever is LOWER

15.  Medical Risk  Behavioral Risk  Attitudes

16.  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

17. Kindergarteners would rather sit next to a child with a physical handicap over one with obesity Neumark-Aztainer D. J Nutr Educ. 1999

18.  BMI 85 – 94% - Lipid always ◦ If risk factors than fasting glucose, ast, alt ◦ Measure q 2 years for >10 years of age  BMI > 95% - lipid, fasting glucose, alt, ast

19.  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

20. 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

21. <2 years – Prevention counseling 2 – 5 years  85 – 94% weight maintenance or slow gain  >95% maintenance or loss up to 1# per month 6 – 11 years  85 -94% maintenance  95 – 99% gradual loss 1#/month  >99% average 2#/wk

22.  12 – 18 years 85 – 94% maintenance or gradual loss 95 – 99% weight loss, average 2#/wk >99% weight loss average 2#/wk

23.  Mood stabilizers  Antipsychotics (Geodon the best)  ?Add topamax if on antipsychotics  ?Add metformin if on antipsychotics

24.  Shown to improve body composition, fasting insulin, fatty liver in obese kids and adolescents  500mg qd to start up to 1000mg XR best

26.  ID problem behaviors  Praise if no problems identified  Patient and family counseling about behavior

27.  Stage I - Prevention Plus  Stage II -Structured weight management  Stage III -comprehensive multidisciplinary intervention  Stage IV -Tertiary Care

28.  PCP office  Visit for this alone  Establish goals  If no progress in 3 – 6 months than stage II

29.  Planned diet and snacks  Planned activity  Dietician  Counselor  Monthly visits

30.  Structured and monitored  Negative energy balance  Parent home training  Weight management program ◦ Meds ◦ Meal replacements

31.  Tertiary care ◦ VLCD ◦ Surgery ◦ Appetite suppressants

32.  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

33. http://www.aap.org/obesity/pdf/obesitycodin gfactsheet0208.pdf

38. Don ’ t Feed it Soda!!

39.  Non Alcohol Fatty Liver Disease ◦ 1/3 of overweight kids have this ◦ How many normal weight kids do? Mallort GB. J Pediatr. 1989

40.  Pathologically the same as alcohol liver disease

41.  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

42.  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

43. Robert H. Lustig, MD Journal of the American Dietetic Association – Vol 110, Issue 9 Sept 2010

44.  Look for it  Be comfortable with discussions  Allied Health Professionals  Broader scope- policy changes  No soda