Childhood Obesity: Now What?Childhood Obesity: Now What?

Ann M. Childers, M. D.Ann M. Childers, M. D.Member, American Society of Bariatric Member, American Society of Bariatric PhysiciansPhysiciansand and The Nutrition and Metabolism SocietyThe Nutrition and Metabolism Society

All references to diabetes in All references to diabetes in this presentation refer to this presentation refer to Type II DiabetesType II Diabetes

Once upon a t ime,Once upon a t ime,

19401940

Fifth Grade Class, 1940Fifth Grade Class, 1940

Woodstock 1969

55 thth Grade Class 1969 Grade Class 1969

Then Came the Dietary Then Came the Dietary Recommendations of 1980, Recommendations of 1980, and the and the Food Pyramid of 1992Food Pyramid of 1992

Woodstock 1999Woodstock 1999

Modern ClassroomModern Classroom

The (Un-) Natural The (Un-) Natural History of ManHistory of Man

From This ------------------------------------------- This: 1.8M YrsFrom This -------- This: 35 Yrs

Impact of the Western Impact of the Western Diet Diet

“The change in traditional diets has already led to increased health problems, such as obesity, cardiovascular disease, and diabetes, while the mental health of circumpolar peoples has also declined substantially during the same time period.”

Int J Circumpolar Health, 2003

Health in the Health in the United StatesUnited States

No. 1 in the world for percentage of No. 1 in the world for percentage of obese persons (30.6%)obese persons (30.6%)

No. 1 in the world in total health No. 1 in the world in total health expenditures per capitaexpenditures per capita

No. 22 among industrialized nations No. 22 among industrialized nations for healthy life expectancyfor healthy life expectancy

Source: Nationmaster.comSource: Nationmaster.com

One in Three Children One in Three Children Overweight or ObeseOverweight or Obese

NAFLD: Prevalence estimated at ~10%

Burden of I l lnessBurden of I l lness

Metabolic syndrome is as high as 50% Metabolic syndrome is as high as 50% among severely obese children and among severely obese children and adolescentsadolescents

~44% of American adults have either ~44% of American adults have either metabolic syndrome or diabetesmetabolic syndrome or diabetes

High Insulin StateHigh Insulin State

Chubby CheeksChubby Cheeks

Acanthosis NigricansAcanthosis Nigricans

Nutrit ional ImpactNutrit ional Impact

Low Iron Stores:Low Iron Stores: CognitionCognition Depression/ADHDDepression/ADHD RLSRLS Test: Ferritin (CBC has Test: Ferritin (CBC has

low sensitivity)low sensitivity)

Low Vitamin DLow Vitamin D Test: 25(OH)Vit DTest: 25(OH)Vit D

Body ImageBody Image

81% of 10 year olds polled say they 81% of 10 year olds polled say they are afraid of being fat.are afraid of being fat.

Over ½ of teen girls and 1/3 of teen Over ½ of teen girls and 1/3 of teen boys use unhealthy weight controlboys use unhealthy weight control– Including but not limited to: skipping Including but not limited to: skipping

meals, fasting, cigarettes, vomiting, meals, fasting, cigarettes, vomiting, laxativeslaxatives

History of History of Human Nutrit ionHuman Nutrit ion

If all of human history was condensed into If all of human history was condensed into one year, we only began farming and eating one year, we only began farming and eating grains yesterday, when dental disease grains yesterday, when dental disease became common and we became became common and we became shorter/fatter.shorter/fatter.

We began consuming processed vegetable We began consuming processed vegetable oils & trans fats within the past 10 minutes, oils & trans fats within the past 10 minutes, when heart disease became our No. 1 killer.when heart disease became our No. 1 killer.

Vegetarian Gori l laVegetarian Gori l la

Relative gut proportions for extant hominoids (percentage of total Relative gut proportions for extant hominoids (percentage of total gut volume)gut volume)From: K. Milton, From: K. Milton, Nutritional characteristics of wildNutritional characteristics of wildprimate foods: do the diets of our closest living relatives have primate foods: do the diets of our closest living relatives have lessons for us?lessons for us?, pp. 488-498, pp. 488-498

C. C. E. E. Stevens, Comparat ive physiology of the digest ive system. In Stevens, Comparat ive physiology of the digest ive system. In Dukes Dukes Physiology of Domestic AnimalsPhysiology of Domestic Animals , , 9th edn, M. J. Swenson (Ed.), Comstock, I thaca, 9th edn, M. J. Swenson (Ed.), Comstock, I thaca, NY and London, 1977, pp. 216-232. Note: Images not drawn to scaleNY and London, 1977, pp. 216-232. Note: Images not drawn to scale

Elia Psouni and colleagues analyzed 70 Elia Psouni and colleagues analyzed 70 species of animalspecies of animal

Figure 5. Time to weaning in humans is quantitat ively predictable from a carnivorous diet.Figure 5. Time to weaning in humans is quantitat ively predictable from a carnivorous diet.

Psouni E, Janke A, Garwicz M (2012) Impact of Carnivory on Human Development and Evolution Revealed by a New Unifying Model of Weaning in Mammals. PLoS ONE 7(4): e32452. doi:10.1371/journal.pone.0032452http://www.plosone.org/article/info:doi/10.1371/journal.pone.0032452

How Americans Got How Americans Got Obese: Obese:

the Lipid Hypothesisthe Lipid Hypothesis The Lipid Hypothesis (LH): Dietary fat raises The Lipid Hypothesis (LH): Dietary fat raises

cholesterol and cholesterol causes heart cholesterol and cholesterol causes heart diseasedisease

Promoted by Ancel Keys in early 1950s, via Promoted by Ancel Keys in early 1950s, via his 7 Countries Study. his 7 Countries Study.

Keys had data from 22 countries, but failed Keys had data from 22 countries, but failed to report on 15 that didnto report on 15 that didn ’’t fit his Hypothesis.t fit his Hypothesis.

Left: Data Keys Published Right: Data Keys Had

Ancel Keys/Lipid Ancel Keys/Lipid HypothesisHypothesis

Keys won Keys won AmericaAmerica’’s s confidence confidence – Named Named ““Father of Father of

the Lipid the Lipid HypothesisHypothesis””

– Featured on the Featured on the cover of Time cover of Time (1961) (1961)

MONICA StudyMONICA Study

Began in early-to-mid 1980sBegan in early-to-mid 1980s 10 year study10 year study 22 Countries22 Countries 64,976 men and women, ages 35-6464,976 men and women, ages 35-64 No correlation found between total blood No correlation found between total blood

cholesterol values and death from heart cholesterol values and death from heart diseasedisease

MONICA Data MONICA Data as graphed by Dr. Malcolm as graphed by Dr. Malcolm

KendrickKendrick

Light on Fats, and Light on Fats, and Carbohydrate HeavyCarbohydrate Heavy

USDA Recommendations = USDA Recommendations = Carbohydrate PromotionCarbohydrate Promotion Increased consumption low fat, refined Increased consumption low fat, refined

carbohydrates/sweeteners/processed carbohydrates/sweeteners/processed foods (Snackwells, e.g.)foods (Snackwells, e.g.)– Per AHA, US adults avg. 22 tsps, teens Per AHA, US adults avg. 22 tsps, teens

34 tsps, added sugars per day (fructose, 34 tsps, added sugars per day (fructose, e.g.)e.g.)

Low Fat Dairy: Skim (Low Fat Dairy: Skim (““blueblue””) milk ) milk widely promoted (lactose sugar)widely promoted (lactose sugar)

CHO --> Triglycerides, BSCHO --> Triglycerides, BS

Industry Creates Dietary Confusion:Industry Creates Dietary Confusion:Smart Choices ProgramSmart Choices Program

Endorsed by top Endorsed by top nutritionists at Tufts nutritionists at Tufts University and University and Baylor College of Baylor College of MedicineMedicine

Corporate Corporate sponsored: sponsored: KelloggKellogg’’s, PepsiCo, s, PepsiCo, ConAgra, ConAgra,

Kraft FoodsKraft Foods

Smart Choices Program Smart Choices Program (cont.)(cont.) 44% sugar44% sugar 96% refined 96% refined

carbohydratecarbohydrate Coal tar dyes: Red Dye Coal tar dyes: Red Dye

#40, Yellow Dye #6 #40, Yellow Dye #6 (child hyperactivity)(child hyperactivity)

Seed dye Annatto Seed dye Annatto (allergies)(allergies)

VitaminsVitamins Some fiberSome fiber

whatwhat ’’s next?s next?

You mayYou may

Myth of Whole Wheat?Myth of Whole Wheat?Bread Study,Bread Study,

University of Guelph, CanadaUniversity of Guelph, Canada Whole wheat and whole wheat barley Whole wheat and whole wheat barley

promoted the greatest rises in blood promoted the greatest rises in blood sugarsugar

White bread promoted less White bread promoted less Sourdough bread promoted the very Sourdough bread promoted the very

leastleast

A Calorie is Not a A Calorie is Not a Calorie: Insulin is KeyCalorie: Insulin is Key

What we knew in 1912What we knew in 1912““Skim milk is one of the most valuable adjuncts Skim milk is one of the most valuable adjuncts of the farm for fattening swine. Used with corn, of the farm for fattening swine. Used with corn, kafir corn or any of the common grain by-kafir corn or any of the common grain by-products, an almost ideal ration is formed. products, an almost ideal ration is formed. Hogs like it, and relish rations mixed with it. As Hogs like it, and relish rations mixed with it. As a result of five year’s work in feeding skim milk a result of five year’s work in feeding skim milk at the New York station at Cornell, it is at the New York station at Cornell, it is concluded that the most economical returns are concluded that the most economical returns are secured when the milk is fed with corn meal.”secured when the milk is fed with corn meal.”

FarmerFarmer’s Cyclopedia of Livestock, pg 545’s Cyclopedia of Livestock, pg 545

What My Farmer SaysWhat My Farmer Says

““I want my meat pigs to be pre-diabetic”I want my meat pigs to be pre-diabetic”

Her approach: Grains + Fat Free MilkHer approach: Grains + Fat Free Milk

Control Diet Control Diet vs. vs. Low Carb (20 g CHO per day), High Fat, Ad Lib Low Carb (20 g CHO per day), High Fat, Ad Lib DietDiet

10 obese patients with DMII10 obese patients with DMII

7 days on control diet: Avg 3111 Kcal7 days on control diet: Avg 3111 Kcal

14 days on LC diet: Avg 2164 Kcal14 days on LC diet: Avg 2164 Kcal

Mean 24 hr. plasma glucose normalized.Mean 24 hr. plasma glucose normalized.

1.65 Kg (3.6 lb) weight loss in 14 days1.65 Kg (3.6 lb) weight loss in 14 days

Avg HgA1C declined from 7.3 to 6.8%Avg HgA1C declined from 7.3 to 6.8%

Insulin sensit ivity improved by 75%Insulin sensit ivity improved by 75%

Triglycerides declined 35%Triglycerides declined 35%

Cholesterol declined 10%Cholesterol declined 10%

Ann Intern Med. 2005;142:403-411.

Striking a Balance:Striking a Balance:CHO & Fat CHO & Fat

LeptinLeptin

Cravings? Hunger?Cravings? Hunger?Fat + Protein = SatietyFat + Protein = Satiety

Population StudiesPopulation Studies

3 year study, 12,829 Adolescents: Skim 3 year study, 12,829 Adolescents: Skim and 1% milk, but not dairy fat, associated and 1% milk, but not dairy fat, associated with weight gain with weight gain

(Berkey et. al., Arch Ped Adolesc Med (Berkey et. al., Arch Ped Adolesc Med 2005)2005)

9 yr study: 19,352 Swedish women: In 9 yr study: 19,352 Swedish women: In middle age, one serving full fat milk per middle age, one serving full fat milk per day --> 15% less weight gain; full fat day --> 15% less weight gain; full fat cheese --> 30% less weight gain cheese --> 30% less weight gain

(Rosell, et. al. AJCN 2006) (Rosell, et. al. AJCN 2006)

““ItIt’’s Time to End the s Time to End the Low Fat Myth Low Fat Myth””

In the News:In the News:Brit ish Medical JournalBrit ish Medical JournalObservations: Saturated fat is not the major issueTuesday, October 22, 2013“It is time to bust the myth of the role of saturated fat in heart disease,” argues a British cardiologist.

Food Business News, 4/7/14:Food Business News, 4/7/14:Staying power seen in Staying power seen in

shift from carbohydratesshift from carbohydrates““Health-conscious parents Health-conscious parents have have responded in some responded in some strange ways strange ways such such as preparing unhealthy foods for their as preparing unhealthy foods for their children in the morning, like bacon and children in the morning, like bacon and sausages, sausages, to make sure they are to make sure they are satiated satiated during the dayduring the day””

Fake FoodFake Food

Real FoodReal Food

Less Carbohydrates, More Less Carbohydrates, More Natural Fats & Natural Fats &

High Quality Proteins High Quality Proteins Brain is 60-70% fat & significant Brain is 60-70% fat & significant

cholesterol--fats vital to functioncholesterol--fats vital to function Cholesterol basis steroid hormonesCholesterol basis steroid hormones Fats and proteins block hunger; do not Fats and proteins block hunger; do not

interfere with leptininterfere with leptin Fats promote absorption of vitamins and Fats promote absorption of vitamins and

mineralsminerals Fats slow release of sugar to the blood Fats slow release of sugar to the blood

streamstream

Fats Promote Satiety.Fats Promote Satiety.Fats Do Not Fats Do Not

Promote Promote Insulin.Insulin.

DoesnDoesn ’’t the Brain Need t the Brain Need Carbohydrates?Carbohydrates? Ask any Eskimo: The Ask any Eskimo: The

brain functions well on brain functions well on ketones from ketones from carnivorous dietcarnivorous diet– Ketogenic diet used in Ketogenic diet used in

epileptic childrenepileptic children Gluconeogenesis: Gluconeogenesis:

Proteins converted to Proteins converted to carbohydrates as carbohydrates as neededneeded

Brain functions well on Brain functions well on less than 40% dietary less than 40% dietary carbohydratescarbohydrates

Inuit child fishing with harpoons

Rule of Thumb:Rule of Thumb:If It Promotes Caries & If It Promotes Caries &

Gum Disease, Gum Disease, DonDon ’t Eat It’t Eat It

Highly Fermentable Highly Fermentable Carbohydrates (sticky/sugary Carbohydrates (sticky/sugary

foods, dried fruits, refined grains, foods, dried fruits, refined grains, crackers, potato chips, sodas, crackers, potato chips, sodas, etc.) are cariogenic, promote etc.) are cariogenic, promote

triglycerides, impair metabolism. triglycerides, impair metabolism.

Perfect TeethPerfect TeethPre-AgriculturePre-Agriculture Native American skulls Native American skulls

from US and Canada from US and Canada No tooth decayNo tooth decay Wisdom teeth usefulWisdom teeth useful Broad dental arches, Broad dental arches,

broad cheek bonesbroad cheek bones Fat soluble vitamins Fat soluble vitamins

contribute to tooth & contribute to tooth & bone strength/buildbone strength/build

Dental DiseaseDental DiseasePost-AgriculturePost-Agriculture Head of mummy Head of mummy

Amenhotep III Amenhotep III (1386-1349 BC) (1386-1349 BC)

Front tooth loss Front tooth loss secondary to tooth secondary to tooth infections infections

May contribute to May contribute to death, age ~38 yrs. death, age ~38 yrs.

Impact of WW II on Impact of WW II on Health In JapanHealth In Japan

High Carb, Low Fat High Carb, Low Fat Diets Diets Universally recommended for tx Universally recommended for tx

hyperlipidemia, prevention heart dzhyperlipidemia, prevention heart dz Lower HDLLower HDL Raise triglycerides Raise triglycerides Drive LDL toward Small, DenseDrive LDL toward Small, Dense

– NMR LipoprofileNMR Lipoprofile

Nutrient PoorNutrient Poor

High carbohydrate diets, and high grain High carbohydrate diets, and high grain diets in particular, are nutrient poor.diets in particular, are nutrient poor.

Hunter Gatherer DietHunter Gatherer Diet

Worldwide, 73% of H-G societies derive >55-65% of energy from animal foods

The ProblemThe Problem

Proposed MechanismProposed Mechanism

Insulin = storage hormoneInsulin = storage hormone– ““Bail out” strategy for body under sugar Bail out” strategy for body under sugar

assaultassault– Interferes with energy release from fat Interferes with energy release from fat

cellscells– Interferes with leptin sensitivityInterferes with leptin sensitivity– Too much lowers satiety, increases body Too much lowers satiety, increases body

fat, promotes MetS/DM IIfat, promotes MetS/DM II

What now?What now?

Revert dietary CHO load to 40% or Revert dietary CHO load to 40% or less of diet calories (SAD currently at less of diet calories (SAD currently at 55%)55%)

Discourage the consumption of Discourage the consumption of fermentable carbohydratesfermentable carbohydrates

Discourage marketing of fermentable Discourage marketing of fermentable CHOs to childrenCHOs to children

Encourage adequate protein and Encourage adequate protein and increase dietary fatsincrease dietary fats

For more informationFor more information

Dr. ChildersDr. Childers’’ blog: blog:annchilders.blogspot.comannchilders.blogspot.com

The Nutrition & Metabolism SocietyThe Nutrition & Metabolism Societynmsociety.orgnmsociety.org