1. Obesity in Children and Adolescents
A Pediatrician’s Role in Shaping the Future

2. Disclosures
We have no financial relations to disclose.

3. Objectives Discuss current epidemiology Review normal growth
Define obesity in childhood
Discuss causes
Discuss complications
What can we do as physicians?

4. According to the CDC in 2015, the percentage of children classified as overweight and obese in the United states is ______.
13%
21%
32%
40%
47%

5. What is the recommended amount of physical activity for children by the American Heart Association?
60 minutes per day, 7 days per week
60 minutes per day, 5 days per week
45 minutes per day, 7 days per week
45 minutes per day, 5 days per week
30 minutes per day, 5 days per week

6. What is the percentage of type 2 diabetes in all new onset diabetes in children?
15%
25%
35%
45%
50%

7. Fasting glucose and lipid panel
Kyle is a 13 year old male presenting to your office for a well child check. His height is at the 85th percentile, his weight is at the 98th percentile, and his BMI is at the 96th percentile. What screening labs should be performed at this visit?
Fasting glucose and lipid panel
Fasting glucose, lipid panel, AST, and ALT
Fasting glucose, lipid panel, AST, ALT, TSH, and Free T4
Fasting glucose, lipid panel, TSH, and Free T4

8. Worldwide Statistics
Childhood obesity is one of the most important global health problems of the 21st century.
Prevalence increasing at an alarming rate.
In 2010, WHO estimated 43 million children < 5 years of age are overweight.
It is estimated that by 2020, >60% of global disease burden while be due to obesity related diseases .
Primary prevention of pediatric obesity is essential.

9. United States Statistics
Overweight or Obesity
BMI-for-age >/= 85th percentile
Obesity
BMI-for-age >/= 95th percentile
All
31.8%
16.9%
2-5 year olds
22.8%
8.4%
6-11 year olds
34.2%
17.7%
12-19 year olds
34.5%
20.5%
All Females 2-19 years old
31.6%
17.2%
White (non-Hispanic)
29.2%
15.6%
Black (non-Hispanic)
36.1%
Hispanic
37.0%
20.6%
All Males 2-19 years old
32.0%
16.7%
27.8%
12.6%
34.4%
19.9%
40.7%
24.1%

10. South Carolina Statistics
17% of adolescents were overweight
14% of adolescents were obese
46% of students grades 9-12 ate fruit or drank 100% fruit juice < 1 time daily
46% of students grades 9-12 consumed vegetables < 1 time daily
78% of adolescents drank a can, bottle, or glass of regular soda during the 7 days prior to the survey
20% of adolescents received < 1 day of 60 minutes of physical activity
33% of adolescents watched 3 or more hours of TV on an average school day

11. Defining Obesity Excess of body fat CDC 2000 growth charts
Body Mass Index [weight (kg)/ height (m)]
2-18 years of age
Obese: BMI at or greater than the 95th percentile of BMI for age
Overweight: BMI at the 85th but less than the 95th percentile of BMI for age
Less than 2 years of age
Overweight: at or greater than the 95th percentile of weight-for-length

12. Normal Growth
Infants typically loss 5-8% of their birth weight in the days following birth
Back at birth weight by 2 weeks of age
Double birth weight by 6 months
Triple birth weight by 12 months
Quadruple birth weight by 2 years of age
Average weight gain of 2kg/year between 2year of age and puberty

13. Body Fat Proportion of body fat increases rapidly from birth to 12mos
Slow fall occurs until preadolescence
Slow rise again until puberty
After puberty, percentage stabilizes

14. BMI changes from 2-18
BMI decreases from age 2 years of age to 5-6 years of age and then increase thereafter.
V-Shaped Pattern in early childhood has been termed “adiposity rebound”

17. The Cause of Obesity is Multifactorial

18. The Genetic Role Obesity tends to run in families
Risk is 2-8 times greater with a family history of obesity
Little is known regarding the specific genes that contribute to obesity
What is clear: Genetic factors identified thus far account for only a small portion of obesity risk.
Specific Genetic Conditions linked to obesity
Bardet-Biedl and Cohen Syndromes
Prader Willi

19. >1/3 of kids eat fast food on any given day
FAST Food Consumption
>1/3 of kids eat fast food on any given day

20. Soft drink consumption accounts for 1/3 of added sugar in the US diet.
Sugary Beverages
Soft drink consumption accounts for 1/3 of added sugar in the US diet.

21. Portion Sizes

22. Activity Level
Only 22% of American children meet basic activity level requirements.
PE programs in schools are reduced or eliminated
Safe places to play outside are limited in some areas
Increased screen time

23. Complications

24. Endocrine Impaired Glucose Tolerance (Pre-Diabetes)
10-30% of children and adolescents have IGT
Insulin resistance- increased lipid accumulation and reduced sensitivity of the Beta-cell
Majority of this population have normal fasting glucose levels
Type 2 Diabetes
45% of all new onset diabetes in adolescents
Often occurs in the 2nd decade of life
Positive family history in 1st or 2nd degree relative in >75%
Biggest risk factor is overweight or obesity

25. Endocrine Hyperandrogenemia Polycystic Ovarian Syndrome
Early puberty in girls

26. Cardiovascular Hypertension
37% of hypertensive children are overweight or obese
Dyslipidemia
High LDL and Triglycerides, Low HDL
Early Development of Atherosclerosis

28. Metabolic Syndrome
Type 2 diabetes, hypertension, dyslipidemia, and a prothrombotic inflammatory vascular environment
Incidence of 30% in overweight adolescents
Increases risk for cardiovascular disease

29. Gastrointestinal NAFLD Most common liver disease in the US
Affects 10% of all children and 38% of obese children
Obesity alone and obesity related diseases increase risk
Can progress to fibrosis leading to cirrhosis
Cholelithiasis

30. Pulmonary Obstructive Sleep Apnea
Occurs in up to 60% of obese children
Increases risk of cardiovascular and metabolic syndrome
Obesity Hypoventilation Syndrome
Asthma

31. Musculoskeletal Higher risk for fractures Early Arthritis
Slipped Capital Femoral Epiphysis
Blount’s Disease
Pes Planus

32. Other Systems Neuro: Pseudotumor Cerebri
Integumentary: Chronic irritation and infection of skin folds

33. Psychosocial Stress triggering “emotional” eating
Neglect or Maltreatment
Living situation lacking consistency, limit-setting, and supervision
Food as a reward
Food as a part of socializing

34. What can we do as Physicians?

35. Expert Committee Recommendations
Expert committee is comprised of representatives from 15 different professionals organizations
First meeting in 1997
Initial recommendations published in 1998
Second meeting in 2007 and revision to initial recommendations published.
Serves as a guide for physicians in managing childhood obesity

36. Medical Assessment
Identify any underlying syndromes or secondary complications
History and Physical

38. History
Dietary Assessment
Physical Activity Assessment
Family History

39. Symptom
Possible Causes
Anxiety, school avoidance, social isolation
Depression
Severe recurrent headaches
Pseudotumor cerebri
Shortness of breath, exercise intolerance
Asthma, lack of physical conditioning
Snoring, apnea, daytime sleepiness
Obstructive sleep apnea, obesity hypoventilation syndrome
Sleepiness or wakefulness
Abdominal pain
Gastroesophageal reflux disease, constipation, gallbladder disease, NAFLDa
Hip pain, knee pain, walking pain
Slipped capital femoral epiphysis, musculoskeletal stress from weight (may be barrier to physical activity)
Foot pain
Musculoskeletal stress from weight (may be barrier to physical activity)
Irregular menses (<9 cycles per y)
Polycystic ovary syndrome; may be normal if recent menarche
Primary amenorrhea
Polycystic ovary syndrome, Prader-Willi syndrome
Polyuria, polydipsia
Type 2 diabetes mellitusa
Unexpected weight loss
Nocturnal enuresis
Obstructive sleep apnea
Tobacco use
Increased cardiovascular risk; may be used as form of weight control

40. Physical Exam Vitals: BP, Weight, Height, BMI General: Body Habitus
Neck: Acanthosis Nigricans, Thyromegaly, Buffalo Hump
HEENT: Moon facies, Tonsillar Hypertrophy
CV: Murmur
Abdomen: Hepatomegaly, RUQ tenderness
GU: Early puberty
MSK: Bowing of legs, Limited ROM of Hip, Limp
Skin: Hirsutism, Excessive Acne, Violaceous Striae I

41. Screening for Obesity Related Conditions
Overweight individuals (BMI of 85th-94th percentile) at age 10 or onset of puberty should have a lipid panel performed and, if risk factors are present, a fasting glucose, AST, and ALT should be performed.
Obese individuals (BMI at the 95th percentile or greater at age 10 or onset of puberty should have a lipid panel, fasting glucose, AST, and ALT performed regardless of risk factors
The Endocrine Society recommends obese children have a 25-OH vitamin D performed
Repeat every 2 years

44. Individual based Testing
Tonsillar hypertrophy + snoring, daytime sleepiness  Sleep Study  OSA?
RUQ pain after eating + RUQ tenderness  RUQ Abdominal US Cholelithiasis?
Knee pain or limp + limited ROM of hip  AP and Frog Leg Xrays  SCFE?

45. Treatment of Childhood Obesity
Behavior Changes!

46. Counseling Use sensitivity and compassion
Obesity is an important medical condition that can be treated
Ask questions in an objective, non-accusatory fashion
Try to avoid words that may have a negative connotation

47. Motivational Interviewing
Patient-centered method for enhancing intrinsic motivation to change health behavior by exploring and resolving ambivalence.
Elicit-Provide-Elicit
Importance and Confidence Scale
Positive results in health behavior and weight loss
Reduces physician stress and frustration in obesity counseling
Increases odds of success!

48. Ineffective Communication
Doctor: We need to talk about John’s weight and diet. His BMI percentile classifies him as obese. You state that he eats little to no vegetables or fruit and that his diet consists of mainly hot dogs, chicken nuggets, fries, and juice. You should increase the vegetables and fruit that John eats and reduce the high calorie, processed foods in his diet. John should also only drink 4-6oz of juice per day.
Mother: Well I am a single mother that works a full time job. Fresh fruits and vegetables are more expensive and take more time to prepare. For our lifestyle, his current diet is more feasible.

49. Effective Communication
Doctor: Would it be okay if we discussed John’s diet and weight today?
Mother: I guess so.
Doctor: The diet of many young kids today consists of a large amount of processed foods such as hot dogs, chicken nuggets, and fries. These foods are high in calories and low in nutritional value which can cause children to be overweight and deficient in vitamins and minerals. They also contain a large amount of salt that isn’t good for the heart. Most children drink more juice than recommended. We recommend no more than 4-6oz of juice per day because it contains a large amount of sugar and calories. How do feel about the information I’ve provided?
Mother: Well after hearing all of that information and when I look closer at John’s diet, maybe we do need to make some changes.

50. Doctor: On a scale of 1-10, with 10 being the highest, how important is making a change in John’s diet to you?
Mother: I guess I’d say an 8.
Doctor: Using this same scale, how confident are you that you can make these changes?
Mother: I think an 8.
Doctor: Great! Well let’s talk about the changes you would like to make and the strategies you can use to achieve those changes.

51. 4 stages of Treatment Stage 1: Prevention Plus
Stage 2: Structured Weight Management
Stage 3: Comprehensive Multidisciplinary Intervention
Stage 4: Tertiary Care Intervention

52. Additional Tips for Counseling
Make 1 change at a time.
Encourage parents not to expect children to make healthy choices on their own.
Food should not be used as a reward.
Encourage positive behavior changes for the entire family.
Emphasize health not weight.

53. Summary
Childhood obesity can be a difficult and frustrating disease to treat.
Every child should be screened for obesity and risk factors for obesity and obesity-related disorders.
Counsel on preventive measures at every visit.
Primary prevention is key!

54. According to the CDC in 2015, the percentage of children classified as overweight and obese in the United states is ______.
13%
21%
32%
40%
47%

55. What is the recommended amount of physical activity for children by the American Heart Association?
60 minutes per day, 7 days per week
60 minutes per day, 5 days per week
45 minutes per day, 7 days per week
45 minutes per day, 5 days per week
30 minutes per day, 5 days per week

56. What is the percentage of type 2 diabetes in all new onset diabetes in children?
15%
25%
35%
45%
50%

57. Fasting glucose and lipid panel
Kyle is a 13 year old male presenting to your office for a well child check. His height is at the 85th percentile, his weight is at the 98th percentile, and his BMI is at the 96th percentile. What screening labs should be performed at this visit?
Fasting glucose and lipid panel
Fasting glucose, lipid panel, AST, and ALT
Fasting glucose, lipid panel, AST, ALT, TSH, and Free T4
Fasting glucose, lipid panel, TSH, and Free T4

58. Resources
Herouvi, Despina, Evangelos Karanasios, Christina Karayianni, and Kyriaki Karavanaki. "Cardiovascular disease in childhood: the role of obesity." European Journal Pediatrics 172 (2013):  PubMed. Web. 3 Jan. 2016
McCrindle, Brian W. "Cardiovascular Complications of Childhood Obesity." Canadian Cardiovascular Society 31.2 (2014):  PubMed. Web. 3 Jan
Indra Narang and Jospeh L. Mathew, “Childhood Obesity and Obstructive Sleep Apnea,” Journal of Nutrition and Metabolism, vol. 2012, Article ID , 8 pages, doi: /2012/134202
Andrew J. Walley, Alexandra I.F. Blakemore, and Philippe Froguel. Genetics of obesity and the prediction of risk for health. Hum. Mol. Genet. (2006) 15 (suppl 2): R124-R130 doi: /hmg/ddl21
Burt Solorzano, Christine M., and Christopher R. McCartney. “Obesity and the Pubertal Transition in Girls and Boys.” Reproduction (Cambridge, England)140.3 (2010): 399–410. PMC. Web. 6 Jan
Schuman, Andrew J. "Making a Difference: Point of care screening for hyperlipidemia." Contemporary Pediatrics (2013). Web. 9 Jan. 2016
Kelishadi, Roya, and Fatemeh Azizi-Soleiman. "Controlling Childhood Obesity: A Systematic Review on Strategies and Challenges." Journal of Research in Medical Sciences (2014):  PubMed. Web. 14 Jan. 2016
Krebs, Nancy F., and John H. Himes. "Assessment of Child and Adolescent Overweight and Obesity." Journal of Research in Medical Sciences (2007):  PubMed. Web. 14 Jan
Vikraman, Sundeep, and Cheryl Fryar. "Caloric Intake From Fast Food Among Children and Adolescents in the United States, " CDC. N.p., Sept Web. 14 Jan
Golden, Neville H., and Steven A. Abrams. "Optimizing Bone Health in Children and Adolescents." Pediatrics 134.4 (2014). Web. 14 Jan

59. Resources
Barlow, Sarah E. "Expert Committee Recommendations Regarding Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report." Pediatrics 120 (2015): Web. 14 Jan. 2016
Barlow, Sarah E., and William H. Dietz. "Obesity Evaluation and Treatment: Expert Committee Recommendations." Pediatrics102 (1998). Web. 14 Jan
file:///C:/Users/Rebecca/Downloads/ObesityMgmt-PocketGuide%20(1).pdf

60. Thank You!