Color Me HealthyColor Me HealthyWIC ConferenceWIC Conference

John Tyler Community CollegeJohn Tyler Community College

Richmond, VARichmond, VA

10-13-1010-13-10

Tipping Point: Childhood Tipping Point: Childhood Obesity From Inception, Obesity From Inception, Conception, and BeyondConception, and Beyond

John Harrington MDJohn Harrington MDAssociate Professor of PediatricsAssociate Professor of PediatricsEastern Virginia Medical SchoolEastern Virginia Medical School

Director of General Academic PediatricsDirector of General Academic PediatricsChildren’s Hospital of The King’s DaughtersChildren’s Hospital of The King’s Daughters

ObjectivesObjectives

Obesity risks before, during, and soon after Obesity risks before, during, and soon after pregnancy pregnancy

Tipping Point StudyTipping Point Study Breast versus BottleBreast versus Bottle Self Regulation of Oral FeedingSelf Regulation of Oral Feeding Guidelines for Feeding, Sleeping and ExerciseGuidelines for Feeding, Sleeping and Exercise Environment and AdvocatingEnvironment and Advocating ConclusionsConclusions

So who contributes to the So who contributes to the weight of the infant mom or weight of the infant mom or

dad?dad?

No such thing as fat spermNo such thing as fat sperm

Mom and DadMom and Dad

Mom’s pre-pregnancy BMI is correlated Mom’s pre-pregnancy BMI is correlated with child’s BMI at age 3.with child’s BMI at age 3.

Dad’s BMI is less correlated in most Dad’s BMI is less correlated in most studiesstudies

Maternal history of Diabetes increases risk Maternal history of Diabetes increases risk of of ↑ BMI↑ BMI

Maternal history of smoking associated Maternal history of smoking associated with obesity in child at age 5with obesity in child at age 5

Opposites do not Opposites do not necessarily attractnecessarily attract

Couple’s riskCouple’s risk

Overweight/Obese female likely to marry Overweight/Obese female likely to marry or procreate with Overweight/obese maleor procreate with Overweight/obese male

Recent study shows overweight/obese Recent study shows overweight/obese girls more likely to start having sex earlier girls more likely to start having sex earlier and to get pregnant.and to get pregnant.

Eating habits inherited, but can be Eating habits inherited, but can be modified by geography (American couple modified by geography (American couple in East Asia)in East Asia)

Obesity in pregnancyObesity in pregnancy

If women gains > than 30-35 pounds for If women gains > than 30-35 pounds for pregnancy 48% more likely to have obese child pregnancy 48% more likely to have obese child by age 7.by age 7. Japanese OB 8-12 kg limit weight gainJapanese OB 8-12 kg limit weight gain

If mom obese baby likely to have some insulin If mom obese baby likely to have some insulin resistance, especially if LGA or SGA resistance, especially if LGA or SGA

Heritability of BMI between 40-70%Heritability of BMI between 40-70% Pre-gestational and gestational DM=increased Pre-gestational and gestational DM=increased

risk for child obesityrisk for child obesity

After birthAfter birth

Babies who are SGA have impaired beta-Babies who are SGA have impaired beta-cell activity in response to glucose cell activity in response to glucose tolerance test.tolerance test.

SGA prone to truncal fat deposition and SGA prone to truncal fat deposition and metabolic syndromemetabolic syndrome

LGA also at increased risk for abnl weight LGA also at increased risk for abnl weight increaseincrease

Rapid weight gain in infancy correlates Rapid weight gain in infancy correlates with obesity.with obesity.

Study at EVMSStudy at EVMS

Identifying the “Tipping Point” Age for Identifying the “Tipping Point” Age for Overweight Pediatric PatientsOverweight Pediatric Patients

John W. Harrington MD,Vu Q. Nguyen, John W. Harrington MD,Vu Q. Nguyen, James F. Paulson PhD,Ruth Garland, James F. Paulson PhD,Ruth Garland, Lawrence, Pasquinelli MD, Donald Lewis Lawrence, Pasquinelli MD, Donald Lewis MDMD

Over 250 charts reviewed in 2 practices of Over 250 charts reviewed in 2 practices of children who were overweight or obese.children who were overweight or obese.

Overweight before age 2

FindingsFindings

Over half the children in study became Over half the children in study became overweight overweight beforebefore age 2. age 2.

All patients were obese or overweight by age 10All patients were obese or overweight by age 10 The rate of gain is approximately The rate of gain is approximately 1 excess BMI 1 excess BMI

unit/yearunit/year, therefore causing most children to be , therefore causing most children to be overweight by age 2. overweight by age 2.

Critical period for preventing childhood obesity in Critical period for preventing childhood obesity in this subset of identified patients is this subset of identified patients is during the during the first 2 years of lifefirst 2 years of life and for many by 3 months of and for many by 3 months of age. age.

Intervention for obesity Intervention for obesity will have to be earlier!!!!will have to be earlier!!!!

But what can we do?But what can we do?

Recognize Early!!!Recognize Early!!!

Growth CurveGrowth Curve

■

■

■

The Rapidly Gaining Infant

2 %iles crossedshould raise a red flag

Do Fat Babies Grow Faster?Do Fat Babies Grow Faster?

Parents always say he is hungry and Parents always say he is hungry and growing (growing (The Buddha BabyThe Buddha Baby)) Overweight/Obese infants and children will Overweight/Obese infants and children will

grow faster due to growth hormone overload.grow faster due to growth hormone overload. The problem is their overall height will be The problem is their overall height will be

unchanged. They just grow faster earlier.unchanged. They just grow faster earlier.

FeedingFeeding

VS

Breast vs Bottle and ObesityBreast vs Bottle and Obesity

Breast feeding is protective- probably due Breast feeding is protective- probably due to the infants ability to “to the infants ability to “self-regulate”self-regulate”

Longer breast feeding more protection up Longer breast feeding more protection up until 1 year.until 1 year. This is an inverse proportionThis is an inverse proportion

• ↑ ↑ in time breastfeeding, ↓ BMIin time breastfeeding, ↓ BMI

Bottle feeding increased risk for obesityBottle feeding increased risk for obesity ↑ ↑ protein in formula may stimulate insulinprotein in formula may stimulate insulin

Warning signs for overfeedingWarning signs for overfeeding

Rapid weight gain in infant (crossing 2 Rapid weight gain in infant (crossing 2 %iles upward from 25 to 75%)%iles upward from 25 to 75%)

Weight outpacing heightWeight outpacing height Parent shows skills of feeding while not Parent shows skills of feeding while not

watching infant- missing satiety cueswatching infant- missing satiety cues Bottle proppingBottle propping

Bottle fedBottle fed

Must watch for infant cues of being fullMust watch for infant cues of being full Head turningHead turning RegurgitantRegurgitant Paced feedingPaced feeding Tongue thrustTongue thrust Drool feedingDrool feeding

Making the diagnosis in infantsMaking the diagnosis in infants

Obese infants in large practice in Texas Obese infants in large practice in Texas 16%16%

Obese child at 6 months 20X more likely Obese child at 6 months 20X more likely to be obese at 24 monthsto be obese at 24 months

Only 10% of infants at 24 months who Only 10% of infants at 24 months who were obese were diagnosed as that in were obese were diagnosed as that in practice practice

Can Intervention Work?Can Intervention Work?

Study done by one solo pediatrician in NY Study done by one solo pediatrician in NY Followed 100 infant pairs to age 2Followed 100 infant pairs to age 2 One group taught to self-regulate intake by 15 One group taught to self-regulate intake by 15

months. Other group did not, parent fed.months. Other group did not, parent fed. Self-regulating group only one BMI > 85%Self-regulating group only one BMI > 85% 42% of non-regulated group with BMI> 85%42% of non-regulated group with BMI> 85% This difference continued even after attempts This difference continued even after attempts

to crossover groupsto crossover groups

Feeding is hard-wired to Feeding is hard-wired to take in the amount of take in the amount of

calories you need.calories you need.

Strong Satiety SignalStrong Satiety Signal

Guidelines for feeding Guidelines for feeding advice in the infant/toddleradvice in the infant/toddler

AgeAge Nutrition Nutrition

RecommendRecommend

Feeding Feeding

BehaviorsBehaviors

Birth-Birth-

6 months6 months

Breast milk Breast milk only – with Vit.only – with Vit.

D supplementD supplement

Review hunger Review hunger and satiety and satiety cuescues

AgeAge Nutrition Nutrition

RecommendRecommend

Feeding Feeding

BehaviorsBehaviors

6-11 6-11 monthsmonths

-Continue-Continue

breastfeedingbreastfeeding

-avoid high salt, -avoid high salt, fat, and fat, and sugar foodssugar foods

- 4-6 oz of - 4-6 oz of 100% juice100% juice

--

-sit in high -sit in high chair at tablechair at table

- - NO TV!NO TV!

AgeAge Nutrition Nutrition

RecommendRecommend

Feeding Feeding

BehaviorsBehaviors

> 12 > 12 months- months- toddler toddler yearsyears

-low fat milk-low fat milk

-no soda or -no soda or sugar drinkssugar drinks

- Fruits and - Fruits and vegetablesvegetables

-eat meals at -eat meals at tabletable

-wean bottle 15 -wean bottle 15 monthsmonths

-parent decides -parent decides food and food and portion: child portion: child decides how decides how muchmuch

And No TV !!!And No TV !!!

At least limitedAt least limited

Obesigenic Society

Solid foodsSolid foods

Later introduction of solids after 6 months Later introduction of solids after 6 months shows correlation with lower BMIshows correlation with lower BMI

Self regulation as early as possibleSelf regulation as early as possible Let the infant/toddler feed themselves by 11-Let the infant/toddler feed themselves by 11-

12 months12 months

AgeAge Nutrition Nutrition

RecommendRecommend

Feeding Feeding

BehaviorsBehaviors

PreschoolPreschool -low fat milk-low fat milk

-3 meals 2 -3 meals 2 snackssnacks

- At table with At table with parent and parent and no TVno TV

- 6 oz fruit 6 oz fruit juicejuice

-Do not use -Do not use food as a food as a reward or reward or punishmentpunishment

Sleeping

SleepSleep

Regular and consistent bedtime routineRegular and consistent bedtime routine Infant who sleeps > 12 hours has less risk Infant who sleeps > 12 hours has less risk

of obesity. This was a negative linear of obesity. This was a negative linear relationship. relationship. Less sleep more obesityLess sleep more obesity

Greater affect on boys versus girlsGreater affect on boys versus girls

Family Dynamics

Three important household routinesThree important household routines

Eating an evening meal as a familyEating an evening meal as a family

Getting 8-10 hours of sleep at nightGetting 8-10 hours of sleep at night

Limited TV/Screen timeLimited TV/Screen time

40% lower obesity40% lower obesity

BMI increase riskBMI increase risk

Subtle neglectSubtle neglect Inadequate supervisionInadequate supervision Poor social engagementPoor social engagement

EthnicityEthnicity African AmericanAfrican American HispanicHispanic American IndianAmerican Indian

What about Exercise?What about Exercise?

Let’s MoveLet’s Move

What we need (0-5 years)What we need (0-5 years)

More physical activity, less screen timeMore physical activity, less screen time Need to actually move!Need to actually move! Need safe parks, playgrounds, and Need safe parks, playgrounds, and

recreational facilities. recreational facilities. Daycares need to be promoting activity Daycares need to be promoting activity

and movement and movement Less energy dense foods and sugar in dietLess energy dense foods and sugar in diet Walking school busesWalking school buses

Many common routes to Many common routes to the same problemthe same problem

ConclusionsConclusions

Obesity prevention starts before pregnancy.Obesity prevention starts before pregnancy. Breast feeding needs to be supported by MDs Breast feeding needs to be supported by MDs

and in the workplaceand in the workplace Limit or eliminate TV and screen time and Limit or eliminate TV and screen time and

enhance physical activityenhance physical activity Parents need to let child regulate intake earlyParents need to let child regulate intake early Physicians need to measure BMI and promote Physicians need to measure BMI and promote

healthy diets through education healthy diets through education

White House Task Force White House Task Force RecommendationsRecommendations

More prenatal care and education for parents More prenatal care and education for parents about appropriate weightabout appropriate weight

Promote breastfeeding via peer counselors, Promote breastfeeding via peer counselors, more accommodations in the work place and more accommodations in the work place and daycaredaycare

Network with child-care to provide healthier food Network with child-care to provide healthier food and better activity for kidsand better activity for kids

Improve food labels and decrease marketing to Improve food labels and decrease marketing to kids of energy dense foods/sugarkids of energy dense foods/sugar

Improve access to healthy affordable food Improve access to healthy affordable food

What we are up againstWhat we are up against

For ExampleFor Example

Widening the roads and a bridge in Widening the roads and a bridge in Chesapeake to include a bike path. Chesapeake to include a bike path. Would increase the cost of the project by Would increase the cost of the project by 1%. The bike path was defeated because 1%. The bike path was defeated because no one thought it was important to have no one thought it was important to have and was an excessive cost. and was an excessive cost.

We wish it were as easy We wish it were as easy as just saying “No” as just saying “No”

Thank You!Thank You!

Questions???Questions???