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Pediatric Obesity and Cardiovascular Health: What We Learned From the Cardiovascular Health Intervention Program (CHIP) Paul S. Visich PhD, MPH, University.

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Presentation on theme: "Pediatric Obesity and Cardiovascular Health: What We Learned From the Cardiovascular Health Intervention Program (CHIP) Paul S. Visich PhD, MPH, University."— Presentation transcript:

1 Pediatric Obesity and Cardiovascular Health: What We Learned From the Cardiovascular Health Intervention Program (CHIP) Paul S. Visich PhD, MPH, University of New England Bill Saltarelli, PhD, Central Michigan University

2 1. Understand the prevalence and implications of pediatric obesity 2. Understanding of the CVD risk factors observed in overweight and obese children along with structural and functional changes in one’s blood vessels. 3. How CVD risk factors are quantified (MetS) 4. Lessons learned from the CHIP 5. How do we alter the course of obesity in children? Is anything working? Objectives

3 1999 Obesity Trends* Among U.S. Adults BRFSS, 1990, 1999, 2009 (*BMI 30, or about 30 lbs. overweight for 5’4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30% BRFSS; Behavioral Risk Factor Surveillance Survey,

4 What About children and adolescents?

5 Trends in Obesity y, 5.0 to 10.4% 6-11y, 6.5 to 19.6% 12-19y, 5.0 to 18.1%

6 Prevalence of Obesity among U.S. Adolescents aged 12-19y of age Ogden, C. and M. Carroll, Division of Health and Nutrition Examination Surveys, June, 2010 Note: Native Americans/American Indians and Alaskan natives were found to have the highest rate of obesity * *

7 Percentage of High School students who were Obese* * Obesity; BMI> to th 95 th % for age and sex. Youth Risk Behavior Survey, 2003 and

8 Geographic Similarities Between Adults and High School Students AdultsHigh School Students

9 State of Maine/ Adults 62.9% overweight (BMI> 25) 26.8% obese (BMI > 30) Vs 35.7% for US Adolescents 15.1% overweight (85 th to < 95 th %) 12.5% obese (> 95 th %) Children (2-<5y of age) 17.1% overweight (85 th to < 95 th %) 14.3% obese (> 95 th %) Vs 12.1% for US in 2010

10 Bottom Line or Waist Line for Children and Adolescents 17% of the US population 2-19y of age are obese Since 1980 prevalence of obesity has almost tripled There are significant racial and ethnic disparities in obesity prevalence among US children and adolescents There was no change in the prevalence of obesity among adults or children from to

11 S.J. Olshansky, etal. A Potential Decline in Life Expectancy in the United States in the 21st Century. N Engl J Med 352(11): , 2005 Life Expectancy Year Born How Much of an Impact is Obesity having on our children’s Health?

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13 Contributing Factors to Obesity Strong4Life, Atlanta Georgia (40% of the children are obese)

14 Meals Away From Home From 1970 to the late 1990’s meals eaten away from home have nearly doubled Ebbeling, CB, etal Lancet, 2002; 360(9331): Typically higher saturated and trans fat, higher glycaemic index, high energy density and larger portion sizes

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16 Portion Sizes 7-Eleven (1976) Gulps (20 ounces) Big Gulps (30 ounces) Super Big Gulps (40 ounces) Double Gulps (64 ounces), 1988 but reduced to 50 ounces this spring, why? Caloric content of Double Gulp with Coca-Cola: 600 calories (25% the recommended caloric Intake for a 30y old, 160 lb. man) Interesting note: Mayor Bloomberg proposed a ban on the sale of large size of sugary drinks in NYC

17 Price of Foods Fruits and vegetables have increased in price 118% from 1985 to 2000 whereas prices for foods high in fats and oils has only increased by 35% Major problem with those with a limited budget!

18 Influence of Technology on Obesity - 26% of US children watched 4h+/day of TV per day - 67% watched at least 2h/day - Non-Hispanic black children had the highest rate of watching TV 4h+/day (42%) - The children that watched 4+h/day had significantly > %fat and BMI Vs those that watched < 2h/day Andersen, R.E., JAMA, March 25, 1998, Vol 279, No. 12

19 Physical Activity and Obesity General consensus (though not consistent) is that moderate/ vigorous activity has a positive benefit in reducing adiposity in overweight/obese youths. Physical activity recommendation: 60 minutes of combined moderate and vigorous activity daily. Problem: only 18.4% of our youth are achieving this recommendation (YRBS, 2009) Daily PE in schools has dropped 33% from 1991 to 2009 (YRBS, 2009) Davis, MM, etal, Pediatrics, 2007

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21 Obesity and Socioeconomic Status in Children Percentage Obese PIR: Poverty Income Ratio (130%= salary of $29,000 for a family of four and 350%= salary of $77,000 for a family of four). Ogden, C.L., NCHS Brief, No. 51, December, 2010

22 Gender Differences with Obesity < 12y of age, very little gender difference 12 to 17y, males more likely to become overweight Possible reason: increased concern in respect to body self-image in females

23 Obesity and Type 2 Diabetes “Adult Onset” Unheard of in children in the mid-1990s With the obesity epidemic we have seen a rise in Type 2 Diabetes in children (10 fold increase in the last two decades) Hannon, TS, etal. Pediatrics. 2005;116(2): % of Type 2 diabetics are overweight or obese 1 in 3 young people born in 2000 will develop Type 2 Diabetes (CDC) Diabetes-Children.aspx

24 What’s the Big Deal? Large percentage of children and adolescents (10-15y old) that are obese turn into obese adults (80%). Prevalence of CHD is estimated to Increase 5-16% by 2035, with more than 100,000 cases of CHD attributed to the predicted increase in obesity. Bibbins-Domingo, K. etal, N Engl J Med. 2007;57(23): The risk of increasing one’s CVD risk factors is significantly higher with obesity (not only in adults but also children)- - hypertension - high cholesterol - low HDL-cholesterol - Type 2 diabetes - insulin resistance - Oxidative stress Additional Health Risks- asthma, sleep apnea, fatty liver disease, formation of gall stones, orthopedic problems Psychosocial Risks- social discrimination; low self-esteem, hinder academic performance, social functioning, etc.

25 Pathophysiology and evidence of blood vessel changes The CVD process has been shown to begin in children as young as 2 years of age (Berenson et al, 1998). Multiple risk factors in children have been shown to persist into adulthood (i.e. tracking) (Boa et al, 1994).

26 Fatty streaks Plaque Bogolossa Direct evidence of blood vessel changes in children Autopsy (Bogulosa Heart Study)

27 Vascular ultrasound evidence

28 Vascular Ultra-sound evidence 1. Carotid artery-Intima-media thickness (IMT) BMI Systolic BP

29 Influence of Diet and Exercise on Individual Cardiovascular Risk Factors in Obese Children (1 Year Program) VariableBaseline1 y Later BMI (kg/m2) *** HDL-C (mg/dl)4650* Trig.s(mg/dl)11192* SBP(mmHg)116108** DBP(mmHg)6255* Glucose (mg/dl)8785 Insulin (mU/L)168* Insulin Resist * IMT (mm).62.55*** Subjects: 56 obese children, median age- 9y old P<.05*, p<.01**, p<.001*** Wunsch, R. etal, Pediatrics118(6): , 2006 Treatment Nutrition and Eating Behavior Course ExerciseTherapy Psychological Family Counseling

30 2. Arterial Compliance Brachial artery reactivity-Flow Mediated Dilation

31 Physiological Process

32 Definition of Metabolic Syndrome “Clustering of CVD risk factors” Children with multiple CVD risk factors (three or more) are more likely to have corresponding blood vessel changes (Strong et al, 1999).

33 METs link between: Insulin resistance (Impaired glucose metabolism) Hypertension Dyslipidemia Obesity And the atherosclerotic process Pediatr Clin N Am 58(2011)

34 Definitions of metabolic syndrome in children

35 IDF definition of metabolic syndrome in children Obesity (waist) plus 2 other factors About 63 cm

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37 Age Total: 4.0% (0.6) Boys: 6.6% (1.3) Girls: 2.1% (0.6) NHANES data 04 Linear rise with age

38 Cardiovascular Health Intervention Program Central Michigan University COLLEGE OF HEALTH PROFESSIONS SCHOOL OF HEALTH SCIENCES Bill Saltarelli, PhD and Paul Visich, PhD, MPH

39 Overall Purpose for Developing the CHIP Awareness: To begin to make children and parents aware and personally responsible of their health by physically participating in a screening program to learn about their individual cardiovascular disease risk factors. Personal Information: If a child and parent(s) knows what their health risks are, they are more likely to consider making changes to improve their health”

40 School Bus To CMU Finch Fieldhouse

41 Station # 1 Blood Lipids and Glucose  Total Cholesterol  HDL Cholesterol  LDL Cholesterol  Triglycerides  Non-HDL Cholesterol  TC/HDL ratio  Blood Glucose

42 Station # 2 Assessment of Body Composition: Height, Weight, Skinfold thickness, waist and hip circumference

43 Station # 3 Heart Rate Monitor (Resting Heart Rate) Station # 4 Resting Blood Pressure

44 Station # 5 Aerobic Capacity Seven Minutes of Stepping to music Recovery HR

45 A Healthy Lunch and Interactive Presentation on Physical Activity and Health Food choices

46 CMU Campus Tour Tour Guide C C

47 CMU Class HSC 586 (2011) Screening CVD risk Factors in children

48 1. Individual Child Reports Are Sent Home 120/80

49 RISK FACTORPercent of Boys at risk Percent of Girls at risk Percent of children at risk BMI (Boys >20, Girls >21) Blood Pressure >90 percentile >119/7 Boys >118/76 Girls Glucose (>100mg/dl) Cholesterol (TCL >170 or HDL <39) Family History (parents or grandparents) Physical Inactivity <5 days/wk/ 60min-all types PA Cardiovascular Disease Risk Factors Total N= 3022Girls N=1550Boys N=1472 Mid-Michigan Children: Age= 11.7y (6th graders)

50 Percent of Children with Multiple CVD Risk Factors Number of CVDRF Percent at Risk CVDRF Total Percent of girls at each # of CVDRF Percent of boys at each # of CVDRF Girls N=1426 * 50% of the children express 3 or more CVDRF Boys N=1441 Mid-Michigan Children: Age= 11.7y (6th graders)

51 Risk factorRisk Criteria % at risk HDL-C<40mg/dl 20% Triglycerides> 110mg/dl 26% Waist Circumference >90th percentile >81.4 cm boys 14% >79.7 cm girls 11% Blood glucose> 110mg/dL.3% Blood pressure90th percentile >119/78 mmHg Boys, 8% >118/76mmHg) Girls 9% Metabolic Syndrome “clustering of CVD risk factors” Criteria for Metabolic syndrome Waist risk plus 2 more CHIP =5.5% NHANES =4.0%

52 Screen lipids of high risk kids (after 2 but before 10 yrs) if: 1. Positive family history of CVD or dyslipidemia (<55 father<65 mother) 2. History is not known 3. BMI > 85 th percentile (overweight or obese) 4. Hypertension >95th percentile 5. Smoker or diabetes To screen or not to screen lipids To treat or not to treat dyslipidemia Pediatrics 2008;122: Treatment 1. Population approach = for all children, healthy diet and increased PA 2. Individual approach = Overweight or obese with high triglyceride ( >150mg/dl) or low HDL (<40mg/dl) = diet and phisical activity counseling 3. > 8 years with LDL>160 with family history or > 2 CVD risk factors or LDL >130 with diabetes = Pharmological intervention

53 Is the school the answer to correct Obesity?

54 Reviewed 51 studies 4 wk-8yr 15 in- school PE 17 health education models 19 combination PE/health Conclusion: No consistency of positive results in reducing obesity have been observed!!!!

55 Prevention/Treatment of Childhood Obesity Through the Developmental Stages Perinatal: good prenatal nutrition, avoid excessive maternal wt. increase, control diabetes, help mothers lose wt. postpartum (nutrition education) Infancy: breast feeding > 6 months of age, delay solid food until 6 months of age, provide balanced diet and avoid high-calorie snacks, follow wt. increase slowly Preschool: develop healthy food preferences, appropriate parental feeding practices, monitor rate of wt. increase, provide child and parent nutrition education Childhood: monitor wt. increase for ht., avoid prepubertal adiposity, nutrition education and encourage daily physical activity Adolescence: prevent excess wt. increase after growth spurt, maintain healthy nutrition as next generation of parents, continue daily physical activity Deckelbaum R., etal, Obesity Research,2001;9:239S-243S

56 Patient-Level Interventions for all children 1.Limit consumption of sugar-sweetened beverages 2.Encourage consumption of recommend fruits and vegetables 3.Limiting screen time 4.Eating breakfast 5.Limit restaurant eating 6.Encouraging family meals 7.Limiting portion size 8.Limiting consumption of energy dense foods 9.Eating diet rich in calcium and fiber 10.Encourage breastfeeding 11.Encourage physical activity 60 min each day of moderate and vigorous Practice and Community level interventions 1.Advocate public policy changes to increase school physical activity 2.Advocate to preserve and enhance community physical activity facilities 3.Make available resources for families to engage in physical activity Addressing Obesity in Clinical Practice EMR

57 15-Minute Obesity Prevention Protocol Step 1 Access and discuss with parent and child BMI Diet Fruits and vegetables, sweetened beverages, fast food, portion size etc. Fast food Family meals Portion size Physical activity Step 2. Set agenda Suggest one or 2 behaviors to be changed Step 3. Assess motivation and confidence to begin change Step 4 Help begin steps to change by suggesting resources Step 5 Schedule a follow-up to evaluate and adjust plan Motivational Interviewing Autonomy-supportive Counseling

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59 American College of Sports Medicine Exercise prescription every patient every time

60 Let’s Go!, a program of The Kids CO-OP at The Barbara Bush Children’s Hospital at Maine Medical Center, is implemented in partnership with MaineHealth. In addition, Let’s Go! and Maine CDC/DHHS have engaged in a public private partnership to improve the health of Youth and families through the work of the Healthy Maine Partnerships.


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