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

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

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

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

• 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

1 of 3 low income children are obese or overweight before their 5th birthday

Ped NSS data 2009

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

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

Identification, assessment, prevention and early intervention

%BMI instead of BMI Plot on graph

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

Either BMI% >95%OR

BMI > 30

Whichever is LOWER

Medical Risk Behavioral Risk Attitudes

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

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

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

• 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 counseling2 – 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

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

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

Shown to improve body composition, fasting insulin, fatty liver in obese kids and adolescents

500mg qd to start up to 1000mg XR best

ID problem behaviors Praise if no problems identified Patient and family counseling about

behavior

Stage I - Prevention Plus Stage II -Structured weight management Stage III -comprehensive multidisciplinary

intervention Stage IV -Tertiary Care

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

Planned diet and snacks Planned activity Dietician Counselor Monthly visits

Structured and monitored Negative energy balance Parent home training Weight management program

◦ Meds◦ Meal replacements

Tertiary care◦ VLCD◦ Surgery◦ Appetite suppressants

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/obesitycodingfactsheet0208.pdf

Don’t Feed it Soda!!

Non Alcohol Fatty Liver Disease◦ 1/3 of overweight kids have this◦ How many normal weight kids do?

Mallort GB. J Pediatr. 1989

Pathologically the same as alcohol liver disease

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

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, MDJournal of the American Dietetic Association –

Vol 110, Issue 9 Sept 2010

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