1. Obesity in Adolescents Gilberto A. Velez-Domenech, M.D. New York Medical College Department of Pediatrics Division of Adolescent Medicine

2. Outline Definitions Definitions Epidemiology Epidemiology Etiology and Influencing Factors Etiology and Influencing Factors Puberty Puberty Influence and Effects on Health Influence and Effects on Health Prevention Prevention Therapy Therapy Resources Resources

3. Overweight and Obesity Body weight above an arbitrary standard Body weight above an arbitrary standard Excess body fat Excess body fat Often defined in relation to height Often defined in relation to height

4. Body Mass Index (BMI) BMI=Wt(Kg)/Ht(m) 2 BMI=Wt(Kg)/Ht(m) 2 Expert Committee on Clinical Guidelines for Overweight in Adolescent Preventive Services (Himes and Dietz, 1994) Expert Committee on Clinical Guidelines for Overweight in Adolescent Preventive Services (Himes and Dietz, 1994) Correlation of 0.7 to 0.8 with body fat content Correlation of 0.7 to 0.8 with body fat content

5. Children and Adolescents At risk for Overweight = BMI above the 85 th and up to the 95 th percentile for age At risk for Overweight = BMI above the 85 th and up to the 95 th percentile for age Overweight = BMI above the 95 th percentile for age Overweight = BMI above the 95 th percentile for age Young Adults and Adults BMI > 25 kg/m 2 BMI > 25 kg/m 2

6. Charts Standard CDC Charts Standard CDC Charts

7. Methods that use just height and weight are cheap and easy to use but do not reflect regional body fat distribution. Methods that use just height and weight are cheap and easy to use but do not reflect regional body fat distribution. Skin fold measurements are susceptible to inter-observer error. Skin fold measurements are susceptible to inter-observer error. Highly technical methods are precise but expensive and limited to research settings Highly technical methods are precise but expensive and limited to research settings Summary

8. Epidemiology 60 to 70% of obese adolescents are female 60 to 70% of obese adolescents are female 80 to 85% of obese adolescents will become obese adults. 80 to 85% of obese adolescents will become obese adults. If a child is obese at age 12 the odds are 4:1 against attaining IBW as adults If a child is obese at age 12 the odds are 4:1 against attaining IBW as adults If a child is obese after adolescence the odds are 28:1 against attaining IBW as adults If a child is obese after adolescence the odds are 28:1 against attaining IBW as adults

9. Epidemiology Serdula, 1995. National Study: 44% of female students and 15% of male students were trying to loose weight. Serdula, 1995. National Study: 44% of female students and 15% of male students were trying to loose weight. Exercise: 51% female / 30% of male Exercise: 51% female / 30% of male Skipping Meals: 49% female / 18% male Skipping Meals: 49% female / 18% male Diet Pills: 4% female / 2% male Diet Pills: 4% female / 2% male Vomiting: 3% female / 1% male Vomiting: 3% female / 1% male

10. National Health and Nutrition Examination Survey (NHANES)

11. Trends in Overweight for Children by Age Group

12. Trends in Overweight for Male Children by Age Group

13. Trends in Overweight for Female Children by Age Group

14. Overweight Children by Age and Race/Ethnicity: NHANES 1999-2000

15. Overweight Male Children by Age & Race/Ethnicity: NHANES 1999-2000

16. Overweight Female Children by Age & Race/Ethnicity: NHANES 1999-2000

17. Etiology & Influencing Factors Cause still unclear Cause still unclear 5% of Obese Children and Adolescents have an underlying specific cause 5% of Obese Children and Adolescents have an underlying specific cause 3% = Endocrine 3% = Endocrine Hypothyroidism Hypothyroidism Cushing Syndrome Cushing Syndrome Hypogonadism Hypogonadism 2% Rare Syndromes (Prader-Willi et. al.) 2% Rare Syndromes (Prader-Willi et. al.)

18. Familial or Genetic Swedish Twin Studies Swedish Twin Studies 1 Parent Obese = 30% Risk 1 Parent Obese = 30% Risk 2 Parents Obese = 70% Risk 2 Parents Obese = 70% Risk Stunkard (1986) Stunkard (1986) BMI correlation between adoptees and biological parents BMI correlation between adoptees and biological parents No correlation with adoptive parents No correlation with adoptive parents Stunkard (1990) Stunkard (1990) High correlation BMI between twins High correlation BMI between twins

19. Fat Cell Theory Fat cells gained early in life and during puberty cannot be lost, only reduced in size. Fat cells gained early in life and during puberty cannot be lost, only reduced in size. Overfeeding early in first year of life and during puberty increases the number of fat cells Overfeeding early in first year of life and during puberty increases the number of fat cells Adolescents who have propensity to obesity have increased number of fat cells Adolescents who have propensity to obesity have increased number of fat cells

20. Activity and Energy Expenditure Dietz (1993) stated that the most powerful predictor of the development of obesity in adolescence was the time that a child 6 to 11 years of age spends viewing television, even after controlling for other variables. Dietz (1993) stated that the most powerful predictor of the development of obesity in adolescence was the time that a child 6 to 11 years of age spends viewing television, even after controlling for other variables.

21. Behavior Eating Fast Eating Fast Skipping breakfast and/or lunch and eating the majority of calories at night. Skipping breakfast and/or lunch and eating the majority of calories at night. Eating when not hungry but when food is available Eating when not hungry but when food is available Eating when appetite is stimulated by environmental cues Eating when appetite is stimulated by environmental cues Eating when depressed or anxious Eating when depressed or anxious Eating in association with other activities Eating in association with other activities Overindulging in Fast Foods Overindulging in Fast Foods

22. Central Regulation Theory The hunger or satiety center in the hypothalamus may not function properly in suppressing appetite. The hunger or satiety center in the hypothalamus may not function properly in suppressing appetite.

23. Psychological Theory Obese individuals are depressed or anxious and use eating as a means to alter their mood. Obese individuals are depressed or anxious and use eating as a means to alter their mood.

24. Body Image Theory Obese adolescents have a distorted fat body image. Obese adolescents have a distorted fat body image. One cannot achieve weight change until one has visualized a smaller body image and become comfortable with it. One cannot achieve weight change until one has visualized a smaller body image and become comfortable with it.

25. Hormonal Theory Leptin Leptin Encoded by the obese gene Encoded by the obese gene Produced by the adipose tissue Produced by the adipose tissue Signal satiety and alter eating behavior Signal satiety and alter eating behavior Monitors and controls body fat and energy balance Monitors and controls body fat and energy balance

26. Pubertal Changes: Effects of Puberty on Body Composition Lean Body Mass increases in Both Sexes Lean Body Mass increases in Both Sexes More in Male than in Females because of the greater increase in skeletal muscle mass under the effect of testosterone. More in Male than in Females because of the greater increase in skeletal muscle mass under the effect of testosterone. Maximum increase in muscle mass occurs at the time of PHV in both sexes Maximum increase in muscle mass occurs at the time of PHV in both sexes Maximum fat deposition occurs 2 years before PHV and in females it continues throughout puberty Maximum fat deposition occurs 2 years before PHV and in females it continues throughout puberty Ultimately female adults have more body fat than males Ultimately female adults have more body fat than males

27. Pubertal Changes: Effects of Obesity on Puberty Taller and larger in skeletal mass and more advanced in skeletal development. Taller and larger in skeletal mass and more advanced in skeletal development. Earlier sexual maturation and menarche. Earlier sexual maturation and menarche. Higher levels of hemoglobin/hematocrit. Higher levels of hemoglobin/hematocrit. Menstrual Irregularities Menstrual Irregularities

28. Influence and Effects on Health Psychosocial Consequences Poor Body Image Poor Body Image Social Isolation for fear of rejection and non- acceptance by peers Social Isolation for fear of rejection and non- acceptance by peers Gortmaker, 1993. 7-year Study of 16-24 y/o Gortmaker, 1993. 7-year Study of 16-24 y/o Obese completed fewer years of school Obese completed fewer years of school Less likely to be married Less likely to be married Lower household incomes Lower household incomes Higher rates of poverty Higher rates of poverty Low self-esteem Low self-esteem Depression Depression

29. Influence and Effects on Health General Morbidity and Mortality Obese adolescents who become obese adults will have more severe obesity than those adults whose obesity began in adulthood. Obese adolescents who become obese adults will have more severe obesity than those adults whose obesity began in adulthood. Greater morbidity and mortality due to cardiovascular disease Greater morbidity and mortality due to cardiovascular disease Effect of adolescent obesity on adult morbidity and mortality is independent of the effect of adolescent obesity on adult weight. Effect of adolescent obesity on adult morbidity and mortality is independent of the effect of adolescent obesity on adult weight.

30. Influence and Effects on Health Hypertension Hypertension Cerebrovascular Disease Cerebrovascular Disease Cardiovascular Disease Cardiovascular Disease Serum Lipids Serum Lipids Diabetes Mellitus (Type 2) Diabetes Mellitus (Type 2) Polycystic Ovary Syndrome Polycystic Ovary Syndrome Cancer Cancer Skeletal Deformity and Arthritis Skeletal Deformity and Arthritis

31. Prevention 1. During Pregnancy Moderate weight gain during 3 rd trimester Moderate weight gain during 3 rd trimester 2. During Infancy and Childhood Breast feed in first year of life Breast feed in first year of life Delay cereals until 3 to 4 months of age Delay cereals until 3 to 4 months of age Be sensitive to the deceleration of growth at 18 months of age Be sensitive to the deceleration of growth at 18 months of age

32. Prevention 3. During Puberty and Adolescence Encourage healthy nutritional practices in early puberty (Remember the fat cells) Encourage healthy nutritional practices in early puberty (Remember the fat cells) Encourage lifestyle of activity and participation through role modeling Encourage lifestyle of activity and participation through role modeling Discourage TV, DVD and videotape watching and video game use. Discourage TV, DVD and videotape watching and video game use.

33. Prevention Reducing television, videotape, DVD and video game use may be the most promising population based approach to prevention of childhood obesity.

34. Treatment: General Aspects HUGE CHALLENGE!!! HUGE CHALLENGE!!! Determine who is at greater risk Determine who is at greater risk In the absence of complications obesity is clinically significant when Wt is over 20 – 30% IBW for height and age. In the absence of complications obesity is clinically significant when Wt is over 20 – 30% IBW for height and age. If complications are present it is always clinically significant. If complications are present it is always clinically significant. Focus on control, not cure Focus on control, not cure Ascertain motivation. Ascertain motivation.

35. Treatment: Critical Areas Motivation Motivation Supportive Social and Family Framework Supportive Social and Family Framework Willingness to increase physical activity Willingness to increase physical activity Realistic Goals Realistic Goals

36. Diet: General Principles Deficit of 500 kcal/day = 1 lb wt loss/week Deficit of 500 kcal/day = 1 lb wt loss/week Food types Food types Eating habits (Patient and Family) Eating habits (Patient and Family) Situation-dependent eating Situation-dependent eating Family and cultural preferences Family and cultural preferences Good nutritional balance among food groups. Good nutritional balance among food groups.

37. Diets: General Principles Energy Needs Energy Needs Males = [900 + (10 x W0] x Activity Factor Males = [900 + (10 x W0] x Activity Factor Females = [800 + (7 x W)] x Activity Factor Females = [800 + (7 x W)] x Activity Factor Activity Factor Activity Factor Low Activity = 1.2 Low Activity = 1.2 Moderate Activity = 1.4 Moderate Activity = 1.4 High Activity = 1.6 High Activity = 1.6 Energy required to maintain each Kg of body weight = 22 Kcal Energy required to maintain each Kg of body weight = 22 Kcal

38. Diets Ketogenic Ketogenic Very-low-calorie (< 400 Kcal/day) Very-low-calorie (< 400 Kcal/day) Glycemic Index Glycemic Index Prolonged fasting Prolonged fasting Special food combinations (Steak and Grapefruit Diet) Special food combinations (Steak and Grapefruit Diet) Balanced Low-calorie (~1200 Kcal/day) Balanced Low-calorie (~1200 Kcal/day)

39. Balanced Diet Foods from five groups: dairy, meat, bread, fruits and vegetables Foods from five groups: dairy, meat, bread, fruits and vegetables Three meals per day Three meals per day Eat less food or calories than previously Eat less food or calories than previously Instructions for food preparation Instructions for food preparation Instructions for food substitution (L vs H) Instructions for food substitution (L vs H) Instructions for food shopping Instructions for food shopping

40. Physical Activity Walking instead of riding the car or bus Walking instead of riding the car or bus Stairs instead of elevators Stairs instead of elevators Not using the channel flipper Not using the channel flipper Exercise prescription: Over 30 min per day / 4 days per week of anything acceptable Exercise prescription: Over 30 min per day / 4 days per week of anything acceptable

41. Cognitive Behavioral Therapy 1. Contract and reward system 2. Initial food diary Time spent eating Time spent eating Place Place Hunger rating Hunger rating Mood Mood Associated activity Associated activity Food consumed Food consumed Amount Amount

42. Cognitive Behavioral Therapy 3. Behavior Change Eat three regular meals Eat three regular meals Eat favorite dish first Eat favorite dish first For a particular food eat favorite part first For a particular food eat favorite part first Eat defensively: Avoid junk food Eat defensively: Avoid junk food Eat slowly, chew – swallow – reload Eat slowly, chew – swallow – reload Do not keep weakness food Do not keep weakness food Eat where eating is meant to occur Eat where eating is meant to occur

43. Cognitive Behavioral Therapy 3. Behavior Change (Cont.) Do not watch TV while eating Do not watch TV while eating Do not eat on the go Do not eat on the go Learn difference between Appetite & Hunger Learn difference between Appetite & Hunger Eat when hungry, not when food is available Eat when hungry, not when food is available Have a breakout activity when depressed, anxious or unhappy Have a breakout activity when depressed, anxious or unhappy Be honest about lapses in control Be honest about lapses in control

44. Groups Encouragement and support Encouragement and support Release of feelings Release of feelings Peer contact and acceptance Peer contact and acceptance Non-commercial Non-commercial TOPS TOPS Overeaters Anonymous Overeaters Anonymous Commercial Commercial Weight Watchers Weight Watchers Diet Workshop Diet Workshop Jenny Craig Jenny Craig Richard Simmons Slimmons Richard Simmons Slimmons

45. Other Anorexigenic drugs Anorexigenic drugs Bariatric surgery Bariatric surgery

46. Resources 1. Books The Hilton Head Diet for Children and Teenagers: The Safe and Effective Program That Helps Your Child Overcome Weight Problems for Good, by Peter M. Miller (Warner Books, Inc., 1993) The Hilton Head Diet for Children and Teenagers: The Safe and Effective Program That Helps Your Child Overcome Weight Problems for Good, by Peter M. Miller (Warner Books, Inc., 1993) Girl Power in the Mirror: A Book about Girls, Their Bodies and Themselves, by H. Cordes (Lerner Publishing Group, 1999) Girl Power in the Mirror: A Book about Girls, Their Bodies and Themselves, by H. Cordes (Lerner Publishing Group, 1999) Safe Dieting for Teens, by Linda Ojeda and Lisa Lee (Hunter House, Inc., 1992) Safe Dieting for Teens, by Linda Ojeda and Lisa Lee (Hunter House, Inc., 1992)

47. Resources 2. Web Sites http://www.niddk.nih.gov/health/nutrit/pubs/cho ose.htm. Choosing a safe weight reduction program from NIH http://www.niddk.nih.gov/health/nutrit/pubs/cho ose.htm. Choosing a safe weight reduction program from NIH http://www.niddk.nih.gov/health/nutrit/pubs/cho ose.htm http://www.niddk.nih.gov/health/nutrit/pubs/cho ose.htm http://www.health.gov/dietaryguidelines/. Dietary Guidelines http://www.health.gov/dietaryguidelines/. Dietary Guidelines http://www.health.gov/dietaryguidelines/ http://www.niddk.nih.gov/health/nutrit/pubs/pres meds.htm. Prescription medications for obesity http://www.niddk.nih.gov/health/nutrit/pubs/pres meds.htm. Prescription medications for obesity http://www.niddk.nih.gov/health/nutrit/pubs/pres meds.htm http://www.niddk.nih.gov/health/nutrit/pubs/pres meds.htm http://www.niddk.nih.gov/health/nutrit/win.htm. Weight-control Information Network http://www.niddk.nih.gov/health/nutrit/win.htm. Weight-control Information Network http://www.niddk.nih.gov/health/nutrit/win.htm