Medical Complications of Childhood Obesity
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Transcript of Medical Complications of Childhood Obesity
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Childhood Obesity: Complications,Predictors and Prevention
Anshu Gupta, MD
Assistant Professor,
Division of Pediatric Endocrinology
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Objectives
1. Know the most common
complications of obesity in childhood.
2. Know predictors of childhood obesity.
3. Know ways to prevent childhood
obesity.
4.Discuss role of breastfeeding in
obesity.
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Definition of childhood obesity
Add NIH growth chart
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Complications of obesity
Financial burden
Immediate
Long-term
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Consequences and complications
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Immediate consequences
Psychosocial1,2
Greater risk of discrimination
6-11 year olds rank overweight peers lowest in
preference to play with among children withvarious handicaps
Associate obesity with laziness and sloppiness
Poor self-esteem, which can continue into
adulthood. Typically during adolescence
1.Dietz W. Health consequences of obesity in youth: Childhood predictors of
adult disease. Pediatrics 1998;101:518525.
2.Swartz MB and Puhl R. Childhood obesity: a societal problem to solve. ObesiReviews 2003; 4(1):5771.
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Weight Stigma
Fosters blame and intolerance
Interferes with health care
Interferes with patients quality of life*
Teasing linked to disordered eating, unhealthy
weight control practices, depression, bodyimage concerns and suicidal thoughts
Less physically active
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Cardiovascular
Metabolic
syndrome
High BloodPressure
High cholesterol
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Respiratory issues
Apnea
Asthma: 52% increased risk in children
and 60% in adolescents.
Gilliland FD et al. Obesity and the risk of
newly diagnosed asthma in school-age
children. American Journal of Epidemiology,
158(5): 406-415, 2003.
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Gastrointestinal issues
Gallstones
Fatty liver disease
Gastroesophageal reflux
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Orthopedic problems
Blounts disease
Joint pain
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Endocrine
Diabetes
15% new cases of diabetes in teens type 2
Overrepresented: Blacks, Hispanics,
American Indians
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Long-term consequences
Obesity in childhood tracks toadulthood
Stronger for older children
24- 90% of obese adolescents becomeoverweight/obese adults
In one study, 87% of obese adolescents
were obese adults and 39% of obese
adolescents were severely obese adults
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Summary
A childhood obesity crisis exists in the
United States
It has a tremendous financial burden
and associated with increased risk of
co-morbidities
Highest disparities noted in Hispanic
and Afro-american populations.
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Predictors and prevention of obesity
Genetic
Energy
imbalance
Environment
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Average daily energy excess (kcal/day)
between 1988-1994 and 1999-2002
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What race/ethnicities are most affected in the
adolescent population?
http://www.cdc.gov/nchs/data/hestat/obesity_child_07_08/Figures3.pnghttp://www.cdc.gov/nchs/data/hestat/obesity_child_07_08/Figures2.png -
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Environmental factors
Food options
Increased cost of
healthy foods
Junk foods cheap and
easily available
Bigger portion size
Increased school
vending and ala carte
options
Physical activity School transport
Increased TVtime
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Socioeconomic status
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Changes in physical activity
mode of transport to school
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Impact of TV time on childhood obesity
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Excess Health Risks Associated with
Not Breastfeeding Outcome Excess Risk* (%)
Among full-term infants
Acute ear infection (otitis media) 100
Diarrhea and vomiting (gastrointestinal infection) 178
Infant hospitalization for pneumonia (LRTI) 257
Asthma, with family history 67
Asthma, no family history 35
Childhood obesity 32
Type 2 diabetes mellitus 64
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Excess Health Risks Associated with Not
Breastfeeding Outcome Excess Risk* (%)
Acute lymphocytic leukemia 23
Acute myelogenous leukemia 18
Sudden infant death syndrome 56
Among preterm infants
Necrotizing enterocolitis 138
Among mothers
Breast cancer 4
Ovarian cancer 27
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Breastfeeding and child adiposity
Obesity in later life
Ever breastfeeders: 0.76 (95%CI 0.67-0.86)
Never breastfeeders: 0.93 (95%CI: 0.880.99) 1
Duration of breastfeeding Negatively associated with risk of overweight
Each month of breastfeeding associated with 4
percent decrease in risk of overweight.2
1.Arenz 2004, Owen 2006
2. Harder 2005
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Hypotheses
Satiety Bottle fed babies 2 times more likely to
empty the cup than breastfed babies.
Different gut microbiomes
Exclusively breastfed infants :probiotic
bacteria like bifidobacteria and
ruminococci, which thrive on the
particular oligosaccharides in humanmilk. Formula-fed infants : various
bacterial species in their guts, including
species associated with disease.
Ley, 2006: Morelli 2008
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Breastfeeding and mother
Average 4.4 lb greater loss at 3
months with breastfeeding
Cumulative 12 months of
breastfeeding led to 32 % reduction inobesity risk in white mothers but no
change in Black mothers.(?)
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Introduction of solid foods
Prospective pre-birth cohort study,
obesity at 3 years of age. The primary
exposure was the timing of
introduction of solid foods,categorized as
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Introduction of solid foods
Among breastfed infants, the timing of
solid food introduction was not
associated with odds of obesity
Among formula-fed infants,introduction of solid foods before 4
months was associated with a six-fold
increase in odds of obesity at age 3years; the association was not
explained by rapid early growth.
Huh 2011
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Prevention
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Role of medical provider
Individual: identify, counsel, treat
Family: counseling
Community: advocate
Society: advocate, leader in policy
change
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Beware of your own biases!!
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Weight Stigma in Healthcare
Physicians, nurses, medical students, and dieteticinterns report that obese patients are:
Non-compliant
Dishonest
Lazy
Lacking in self-control
Weak-willed
Unsuccessful
Sloppy
Awkward
Unattractive
Berryman et al., 2006
Campbell et al., 2000
Fogelman et al., 2002Foster, 2003
Hebl & Xu, 2001
Kristeller & Hoerr, 1997
McArthur et al., 1997
Oberreider et al., 1995
Price et al., 1987
Puhl & Heuer, 2009
Teachman and Brownell, 2001
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All patients
Focused family history for risk factors
Deliver 95210 message consistently
Identify any unhealthy behaviours and
counsel.
Listen respectfully.
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Principal targets
Prenatal/pregnancy counselling:
Pre-pregnancy weight
Weight gain
Diabetes
Smoking
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Strategies to support BF
Extra BF support for all moms by:
Reducing obstacles in the immediate
postpartum
Reducing obstacles in the
homecoming
Reducing obstacles over time
Improving alternative feeding
practices
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Effective strategy for counseling
How to give the advice? Empathize/Assess
Discussing weight with patients
Ask patients for permission to discuss weight
Ask patients for preferred terms to describe their obesity (e.g.,weight or BMI)
Avoid hurtful or offensive descriptors of weight (e.g., fatness
and weight problem)
You childs ___ put him/her at an increased risk for developing
diabetes and heart disease at an early age. What are yourthoughts about this?
Assess readiness to change (1-10 scale)
Assess motivation to change (1-10 scale)
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Effective strategy for counseling
Elicit:
How can we help support you as you try to
change?
Usually requires:
Written goals/plan
SPECIFIC and made with parents!!!!!
No more than 3-4 goals at a time
Family should put these goals up on
refrigerator so they have to see them daily close follow up to reevaluate and come up with a
new plan if needed.
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Effective strategy for counseling
Provide Information/advice
Provide facts and see what parent(s) think
here are some things that often work if you are
interested in trying to change .
What are 2-3 things you think you would bewiling to try to change?
** remember 9-5-2-1-0 framework as you create
plan
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Reduction of high energy intake/
Increasing energy expenditure
9 hours or more of sleep
5 or more servings of fruits and
vegetables
2 hours or less of recreational screen
time (keep TV out of bedroom)
1 hour or more physical activity daily
0 sweetened beverages
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Encourage healthy choices for snacks
and celebration
Encourage water and low fat milkinstead of SSB
Discourage use of food as a reward
Use physical activity as a reward
Reduction of high energy intake/
Increasing energy expenditure
A staged approach to treating obesity per AAP recs
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A staged approach to treating obesity per AAP recs
Stage 1 Prevention Plus: for
all overweight and
obese patients 1st
step!
Primary Care Office 6 months: visits
should be every 1-
3 months
Stage 2 Structured Weight
Management
Primary care office w
support (can add
nutritionist, exercise
trainer and/or
psychologist)
6 months: visits
should be every 1-
2 months
Stage 3 Comprehensive,
Multidisciplinary
Intervention
Multidisciplinary team
w expertise in obesity
6 months: visits
are often every 1-2
weeks
Stage 4 Tertiary Care
Intervention
Obesity Specialized
Program (may include
meds and or
consideration of
surgery)
Ongoing - until
patient drops
below 95% BMI
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Goals of preventive interventionAge BMI 85-94%
and no risks
BMI 85-94%
and + risks
BMI 95-98% BMI >99%
2-5yo Nl weight
velocity for
age
Decrease wt
velocity or
maintain
current wt
Maintain
current wt
Gradual wt
loss of up to
1lb/month
6-11yo Nl weightvelocity for
age
Decrease wtvelocity or
maintain
current wt.
Maintaincurrent wt or
wt loss of
1lb/month
Wt loss waverage of
2lbs/week
12-18yo Nl weight
velocity for
age
Decrease wt
velocity or
maintain
current wt.
Wt loss w
average of
2lbs/week
Wt loss w
average of
2lbs/week
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When to order labs & what labs to order
2 yo 10yo 10 yo 18yo
Overweight (85%-95%) &
no family or personal risk
factors
Fasting lipid levels:
- Repeat in 3-4 yrs if nl
- If abnormal consider
referral to specialist
and repeat annually
Fasting lipid levels
- Repeat every 2 yrs if
nl
- If abnormal consider
referral to specialist
and repeat annuallyOverweight with family or
personal risk factors
Fasting lipid levels and
consider ALT, AST, and
fasting glucose
-Repeat in 3-4 yrs if nl
-Same as above if abnormal
Fasting lipid levels, ALT, AST
and fasting glucose
-Repeat every 1-2 years if
nl
-Same as above if abnormal
Obese Fasting lipid levels, ALT, AST
and fasting glucose.
-Repeat every 3-4years if nl
-Same as above if abnormal
Fasting lipid levels, ALT,
AST and fasting glucose
-Repeat annually if nl
-Same as above if abnormal
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What if behavior interventions dont
work?
The following medicines and
procedures should be decidedupon by family and a tertiary
care center that specializes in
Obesity
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Approved medications
Sibrutamine (serotonin reuptakeinhibitor)
FDA approved in adolescents >16yo ALONG WITH exercise anddiet interventions
Orlistat (causes fatmalabsorption)
FDA approved in patients > 12yoALONG WITH exercise and dietinterventions
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Surgical procedures
Gastric Bypass or Gastric Banding
Only to be done as a last resort in severelyobese adolescents
Can only be done once physical and cognitivematurity has been reached
Should only be done by surgeons associatedwith a Pediatric Obesity Center
There are stringent guidelines about whatevaluations must be done before thesesurgeries can be considered.
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Can you do it alone?
No!!
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The challenge
Community and society wide changesneeded
Decrease Energy intake
Increase Physical activity
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Reducing energy intake
Rudd Report. Soft Drink Taxes. www.yaleruddcenter.org
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Reducing energy intake
Policies that eliminate the use of SSBsin child care and after school programs
Increased availability of water in
public venues
Competitive pricing in vending
machines that increase the price of
SSBs, and using that revenue tosubsidize and lower the price of
healthier beverages
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Reducing energy intake
Decrease consumption of high caloriefoods
Menu labeling
Changing procurement policies
Childrens food and beverage initiative
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Access to healthy foods 23.5 million Americans live in food
deserts
Low income, communities of color, ruraland urban neighbourhoods.
Reducing energy intake
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Increase physical activity
Safe routes to school
Public transport, walking, biking
Quality physical education programs
Improve community infrastructure to
support physical activity