Medical Complications of Childhood Obesity

7/30/2019 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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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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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


Obese Fasting lipid levels, ALT, AST

and fasting glucose.

-Repeat every 3-4years if nl


Fasting lipid levels, ALT,

AST and fasting glucose

-Repeat annually if nl



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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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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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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.



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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

Medical Complications of Childhood Obesity

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