1. Childhood Obesity Dennette Fend, NP William Beaumont Hospital Nutrition and Preventive Medicine Outpatient Breastfeeding Clinic March 28, 2014 Health Outcomes of Breastfeeding

2. Outline Obesity Epidemics Etiology of Obesity Medical and Psychosocial Consequences Efforts to Reverse the Epidemic – Health Outcomes of Breast feeding

4. Obesity Trends* Among U.S. Adults BRFSS, 1989 No Data <10% 10%–14% (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

5. Obesity Trends* Among U.S. Adults BRFSS, 1991 No Data <10% 10%–14% 15%–19% (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

6. Obesity Trends* Among U.S. Adults BRFSS, 1993 No Data <10% 10%–14% 15%–19% (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

7. Obesity Trends* Among U.S. Adults BRFSS, 1995 No Data <10% 10%–14% 15%–19% (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

8. Obesity Trends* Among U.S. Adults BRFSS, 1997 No Data <10% 10%–14% 15%–19% ≥20% (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

9. Obesity Trends* Among U.S. Adults BRFSS, 1999 No Data <10% 10%–14% 15%–19% ≥20% (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

10. Obesity Trends* Among U.S. Adults BRFSS, 2001 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

11. Obesity Trends* Among U.S. Adults BRFSS, 2003 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

12. Obesity Trends* Among U.S. Adults BRFSS, 2005 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

13. Obesity Trends* Among U.S. Adults BRFSS, 2007 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

14. Obesity Trends* Among U.S. Adults BRFSS, 2009 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

15. 2000 Obesity Trends* Among U.S. Adults Obesity Trends* Among U.S. Adults BRFSS, 1990, 2000, 2010 (*BMI 30, or about 30 lbs. overweight for 5’4” person) 2010 1990 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30% Obesity: 35% Overweight and Obesity: 68%

16. Childhood Obesity (ages 10-17) Childhood obesity has more than tripled over the past 3 decades. Obesity: 17% Overweight & obesity: 35%

17. Race/Ethnicity and Childhood Obesity

18. Body Mass Index (BMI) BMI (kg/m 2 ) Risk of Comorbidities Healthy Weight18.5 – 24.9Normal Overweight25.0 – 29.9Increased Obese Class I30.0 – 34.9High Obese Class II35.0 – 39.9Very High Obese Class III> 40.0Extremely High Adapted from the World Health Organization. Obesity: Preventing and Managing the Global Epidemic. Geneva: WHO; 2000. Weight (kg) Height (m 2 ) Weight (kg) Height (m 2 ) BMI =

19. Child Obesity BMI > 95 th % Child Overwt BMI > 85 th % and < 95 th % Defining Childhood/Adolescent Overweight and Obesity

20. Outline Obesity Epidemics Etiology of Obesity Medical and Psychosocial Consequences Efforts to Reverse the Epidemic

21. Positive Energy Balance Leads to Weight Gain Fat Stores Basal metabolic rate, Physical activity Food, Drinks

22. Saving and Overconsuming Energy

24. Contributing Factors to Childhood Obesity Nutrition and Eating Habits: Eating less fruits and vegetables than recommended Increases in snacking, especially on less healthy food Larger portion sizes of food and beverages Increases in consumption of sugar sweetened drinks More food eaten away from home Lack of access to healthy foods at neighborhood stores Centers for Disease Control

25. How many calories today? 320 calories Portion Distortion 30 Years AgoToday

26. 500 Calorie Difference 820 calories320 calories Portion Distortion 30 Years AgoToday

27. How many calories today? 85 Calories 6.5 ounces Portion Distortion 30 Years AgoToday

28. 250 Calories 20 ounces 85 Calories 6.5 ounces Portion Distortion 30 Years AgoToday 170 Calorie Difference

29. 140 calories 3-inch diameter How many calories today? BAGEL 30 Years Ago Today Portion Distortion

30. 140 calories 3-inch diameter Calorie Difference: 210 calories 350 calories 6-inch diameter BAGEL 30 Years Ago Today Portion Distortion

31. Portion Sizes for Americans Aged 2 years and Older et al., JAMA 2003; 289:450-453. JAMA, 2003; 289: 450-453

32. Soft Drinks: “Liquid Candy” Sugar drinks are the largest source of added sugar and an important contributor of calories in the diets of children in the United States. High consumption of sugar drinks, which have few, if any, nutrients, has been associated with obesity. On a typical day, 80% of youth drink sugar drinks. Reedy J, J Am Diet Assoc 2010;110(10):1477—84. Vartanian LR, Am J Public Health 2007;97(4):667—675. Wang YC, Pediatrics 2008;121(6):e1604—1614.

33. The School Environment ~55 million children are enrolled in schools across the United States > 50% of U.S. middle and high schools still offer sugar drinks and less healthy foods for purchase Children have access to sugar drinks and less healthy foods at school throughout the day from vending machines and school stores, as well as fundraising events, school parties, and sporting events. Snyder TD, National Center for Education Statistics; 2009. CDC. Children's Food Environment State Indicator Report, 2011.

34. Michigan Youth Health Risk Behavior Survey: High School Students, 2011 During the 7 days before the survey –5% did not eat fruit or drink 100% fruit juices –6% did not eat vegetables –9% drank a can, bottle, or glass of soda or pop three or more times per day www.cdc.gov/yrbss

35. Contributing Factors to Childhood Obesity Physical Inactivity: Spending more time in front of a screen (television, video games, computers) Less physical activity in schools and at home Less walking/biking to school and in the community Communities designed for driving, not walking or biking Centers for Disease Control

36. Television and Media 8 to18 year-olds spend an average of 7.5 hours a day using entertainment media (TV, computers, video games, cell phones, and movies) 83% of children 6 months to <6 years old view TV or videos about 1 hour and 57 minutes a day Rideout VJ, A Kaiser Family Foundation Study; 2010. Rideout V, The Henry J. Kaiser Family Foundation; 2006.

37. TV and Childhood Obesity Takes away from the time children spend in physical activities Leads to increased energy intake through snacking and eating meals in front of the TV Influences children to make unhealthy food choices through exposure to food advertisements Zimmerman FJ, Am J Public Health 2010;100(2):334—40. Robinson TN. Pediatr Clin North Am 2001;48(4):1017—25..

38. Physical Activity in Schools At least 60 minutes of aerobic physical activity each day is recommended Only 18% of students in grades 9 -12 met this recommendation in 2007. Daily, quality physical education in school could help students meet the guidelines. However, in 2009 only 33% attended daily physical education classes. U.S. Department of Health and Human Services. 2008. Youth Risk Behavior Surveillance System. http://www.cdc.gov/HealthyYouth/yrbs/pdf/us_physical_trend_yrbs.pdf

39. Michigan Youth Health Risk Behavior Survey: High School Students, 2011 Physical Inactivity –66% did not attend physical education (PE) classes in an average week when they were in school. –29% watched television 3 or more hours per day on an average school day. –27% used computers 3 or more hours per day on an average school day. www.cdc.gov/yrbss

40. Outline Obesity Epidemics Etiology of Obesity Medical and Psychosocial Consequences Efforts to Reverse the Epidemic

41. Health Risks of Childhood Obesity The current generation of young people could be the first in U.S. history to live sicker and die younger than their parents’ generation. Nearly one-third of children and teens are currently obese or overweight, which is putting them at higher risks for developing a range of diseases and developing them earlier in life.

42. Health Risks of Childhood Obesity Children who are obese are more than twice as likely to die before the age of 55 as children with normal BMI Around 70% of obese youths have at least one additional risk factor for cardiovascular disease, such as: –Elevated total cholesterol –Elevated triglycerides –Elevated insulin –Elevated blood pressure

43. Health Risks of Childhood Obesity Sleep apnea Asthma Gallstones Type 2 diabetes Hypertension Orthopedic/joint problems Fatty liver Cancer Poor self esteem/depression Victims of bullying and social stigma Eating Disorders

44. 1 out of 3 children born in the year 2000 will be diabetic during their lifetime.

45. Risk of Adult Obesity Children who are obese after the age of 6 are 50% more likely to be obese as adults. For overweight tweens and teens (10 – 15 years old), 80% will be obese as adults.

46. Psychosocial Consequences Overweight and obese children and teens face a higher risk for: –more severe and frequent bullying –are rejected by their peers more often –are chosen less as friends –generally not as well-liked as healthy-weight children Weight-based teasing is related to increased susceptibility to depression.

47. Perceptions

50. Financial Costs of Obesity >25% of all U.S. health care costs are related to obesity and inactivity. (Anderson, et al 2005) 1979 and 1999: Obesity-associated hospital costs for children tripled from $35 million to $127 million. (Wang and Dietz, 2002) Physical inactivity costs $128 per person. (Garrett, 2004) Adult obesity costs $2.9 billion in Michigan. (BRFS 2008)

51. Outline Obesity Epidemics Etiology of Obesity Medical and Psychosocial Consequences Efforts to Reverse the Epidemic

55. Reducing Childhood Obesity Reducing and preventing childhood obesity is critical to improving the future health of the country, and consequently would help to lower health care costs and improve productivity. Research supports the concept that focusing on children and getting them on a healthy path early in life is one of the areas where the greatest successes can be achieved.

56. Breastfeeding & Obesity Breast feeding during infancy has been shown to reduce the risk of infants developing overweight and/or obesity in childhood. The risk of overweight in children decreases by 30% with 9 months or more of breastfeeding and each month of breastfeeding was associated with a 4% decrease in the risk of overweight into childhood. Tawia, S. Breastfeeding Review. 2013

57. Long term health benefits Dose response gradient- better with prolonged, exclusive breastfeeding! Gunderson, EP. 2008. Curr Diab Rep.

58. Why does BF protect against obesity ? Feeding from the breast prevents over feeding (feeding beyond satiety)– babies do not take in more than they need. BREAST FEEDING rather than BREAST MILK protects against obesity in later life. SELF-REGULATION! Baby led weaning: babies continue to self-regulate their intake. »Li, R. Arch Pediatric Adolesc Med. 2012

59. How? Baby led weaning provides infants, from about 6 months, the opportunity to continue to self-regulate their food intake – very successfully! Babies who are breastfed less likely to over consume calories compared to formula fed infants = less likely to become overweight/obese as they grow older. BF babies are not encouraged to “finish the bottle”. They learn self-regulation of caloric intake more closely suited to their needs. Substances pass from mom to baby - such as the appetite-regulating hormone leptin. AICR. August 2012. Issue 73.

60. Definition of LEPTIN : a peptide hormone that is produced by fat cells and plays a role in body weight regulation by acting on the hypothalamus to suppress appetite and burn fat stored in adipose tissue http://www.merriam-webster.com/medical/leptin

61. Babies drink more from bottle than breast Why? 1. Working moms: pumped milk is costly – finish bottle. 2. Sharing in responsibility of feeding. 3. Empty bottle/clean plate satisfying to parents/caregivers. 4. Infants with slow initial weight gain more likely to receive formula for risk of under nutrition 5. Want to know how much child is eating. »Li, R. Arch Pediatric Adolesc Med. 2012

62. Appetite regulation STUDY: Does feeding human milk from breast or bottle lead to better appetite regulation in childhood? Children aged 3-6 y/o categorized into directly, exclusively BF, bottle fed human milk, or bottle fed formula in first 3 months Direct BF associated with greater appetite regulation Children bottle fed human milk 67% less likely to have high satiety response compared to those directly BF »DeSantis, K. (2011). Int’l Journal of Behavioral Nutrition and Physical Activity.

63. Childhood obesity October 13 - Japanese study showed exclusive breastfeeding at 6-7 months was associated with decreased risk of being overweight and obesity compared to formula feeding. Results effective through 7-8 years of age among Japanese schoolchildren. Yamakawa, M. JAMA. 2013.

64. BF reduces obesity BF reduces body size, visceral fat, subcutaneous fat, and protects against central fat patterning of youths at higher fat levels. »Crume et al. (2012). Int’l Journal of Obesity

65. Delaying Solid Food Analyses of breastfeeding practice combinations revealed that when children were not breastfed, obesity odds decreased when solid foods postponed until 4 months of age. Obesity odds were further decreased when solid food delay was combined with breastfeeding. Consistent increases in delaying complementary foods = consistently and substantially lower likelihood of obesity.

66. Prevention of Type 1 Diabetes Most studies indicate that BF:  Offers a protective effect against development T1DM  Shorter duration of BF could be a modifiable risk factor in development of T1DM.  Duration of BF and age at intro to bottle feeding are inversely associated with T1DM (>5 months compared to <2 weeks). »J Pediatr (Rio J). 2013 Oct 16. pii: S0021- 7557(13)00178-2

67. Breast vs formula Why do breast-fed babies have a decreased risk of developing T1DM? –Due to a cell mediated response to a specific cow’s milk protein (beta-casein) which may be involved in the pathogenesis of type 1 diabetes mellitus

68. Prevention of T1DM Pooled data 43 studies:  Overall risk reduction of DM after exclusive BF for >2 weeks  Association for >3 months a bit weaker, but results vary  No association after non-exclusive BF for >2 weeks or >3 months  Author cites marked variation in effect and possible biases »Cardwell, CR et al. Diabetes Care. 2012 Nov;35(11):2215-25.

69. Early nutrition matters! Risk of T1DM increased if:  Starting solids 6 months  Safest age to introduce solids 4-5 months  BF while introducing new foods may decrease risk T1DM Frederiksen, B. JAMA Pediatr. 2013 Sep;167(9):808-15.

70. PHYSIOLOGY Believed that human milk contains substances that promote maturation of the immune system, protective against T1DM. BM has bioactive substances that promote: –satiety (leptin) –energy balance – preventing excess weight gain during childhood – protection against development of T2DM.

71. Questions? Contact info: Dennette Fend, MSN, NP, IBCLC dfend@beaumont.edu

72. Thank you