Obesity in Adolescents Gilberto A. Velez-Domenech, M.D. New York Medical College Department of...

Obesity in AdolescentsObesity in Adolescents

Gilberto A. Velez-Domenech, M.D.Gilberto A. Velez-Domenech, M.D.

New York Medical CollegeNew York Medical College

Department of PediatricsDepartment of Pediatrics

Division of Adolescent MedicineDivision of Adolescent Medicine

OutlineOutline DefinitionsDefinitions EpidemiologyEpidemiology Etiology and Influencing FactorsEtiology and Influencing Factors PubertyPuberty Influence and Effects on HealthInfluence and Effects on Health PreventionPrevention TherapyTherapy ResourcesResources

Overweight and ObesityOverweight and Obesity

Body weight above an arbitrary standardBody weight above an arbitrary standard

Excess body fatExcess body fat

Often defined in relation to heightOften defined in relation to height

Body Mass Index (BMI)Body Mass Index (BMI)

BMI=Wt(Kg)/Ht(m)BMI=Wt(Kg)/Ht(m)22

Expert Committee on Clinical Guidelines Expert Committee on Clinical Guidelines for Overweight in Adolescent Preventive for Overweight in Adolescent Preventive Services (Himes and Dietz, 1994)Services (Himes and Dietz, 1994)

Correlation of 0.7 to 0.8 with body fat Correlation of 0.7 to 0.8 with body fat contentcontent

Children and AdolescentsChildren and Adolescents

At risk for Overweight = BMI above the At risk for Overweight = BMI above the 8585thth and up to the 95 and up to the 95thth percentile for age percentile for age

Overweight = BMI above the 95Overweight = BMI above the 95thth percentile for agepercentile for age

Young Adults and AdultsYoung Adults and Adults

BMI > 25 kg/mBMI > 25 kg/m22

ChartsCharts

Standard CDC ChartsStandard CDC Charts

Methods that use just height and weight Methods that use just height and weight are cheap and easy to use but do not are cheap and easy to use but do not reflect regional body fat distribution.reflect regional body fat distribution.

Skin fold measurements are susceptible to Skin fold measurements are susceptible to inter-observer error.inter-observer error.

Highly technical methods are precise but Highly technical methods are precise but expensive and limited to research settingsexpensive and limited to research settings

SummarySummary

EpidemiologyEpidemiology

60 to 70% of obese adolescents are female60 to 70% of obese adolescents are female 80 to 85% of obese adolescents will become 80 to 85% of obese adolescents will become

obese adults.obese adults. If a child is obese at age 12 the odds are 4:1 If a child is obese at age 12 the odds are 4:1

against attaining IBW as adultsagainst attaining IBW as adults If a child is obese after adolescence the odds If a child is obese after adolescence the odds

are 28:1 against attaining IBW as adultsare 28:1 against attaining IBW as adults

EpidemiologyEpidemiology

Serdula, 1995. National Study: 44% of Serdula, 1995. National Study: 44% of female students and 15% of male students female students and 15% of male students were trying to loose weight.were trying to loose weight.

ExerciseExercise: 51% female / 30% of male: 51% female / 30% of male Skipping MealsSkipping Meals: 49% female / 18% male: 49% female / 18% male Diet PillsDiet Pills: 4% female / 2% male: 4% female / 2% male VomitingVomiting: 3% female / 1% male: 3% female / 1% male

National Health and Nutrition National Health and Nutrition Examination Survey (NHANES)Examination Survey (NHANES)

Age GroupNHES 2

1963-1965NHES 3

1966-1970NHANES I1971-1974

NHANES II1976-1980

NHANES III1988-1994

NHANES1999-2000

Total 5.0 5.0 7.2 10.4

Male 5.0 4.7 6.1 9.9

Female 4.9 5.3 8.2 11.0

Total 4.2 4.0 6.5 11.3 15.3

Male 4.0 4.3 6.6 11.6 16.0

Female 4.5 3.6 6.4 11.0 14.5

Total 4.6 6.1 5.0 10.5 15.5

Male 4.5 6.1 4.8 11.3 15.5

Female 4.7 6.2 5.3 9.7 15.5

12-19

2-5

6-11

Trends in Overweight for Children Trends in Overweight for Children by Age Groupby Age Group

NHES 21963-1965 NHES 3

1966-1970 NHANES I1971-1974 NHANES II

1976-1980 NHANES III1988-1994 NHANES

1999-2000

2-5

6-11

12-190.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

Percent

Trends in Overweight for Male Trends in Overweight for Male Children by Age GroupChildren by Age Group

NHES 21963-1965 NHES 3

1966-1970 NHANES I1971-1974 NHANES II

1976-1980 NHANES III1988-1994 NHANES

1999-2000

2-5

6-11

12-190.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

Percent

Survey

Trends in Overweight for Female Trends in Overweight for Female Children by Age GroupChildren by Age Group

NHES 21963-1965 NHES 3

1966-1970 NHANES I1971-1974 NHANES II

1976-1980 NHANES III1988-1994 NHANES

1999-2000

2-5

6-11

12-190.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

Percent

Survey

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

2-5

6-11

12-19

Non-Hispanic White

Non-Hispanic Black

Mexican American

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

Percent

Age Group

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

2-5

6-11

12-19

Non-Hispanic White

Non-Hispanic Black

Mexican American

0.0

5.0

10.0

15.0

20.0

25.0

30.0

Percent

Age Group

2-5

6-11

12-19

Non-Hispanic White

Non-Hispanic Black

Mexican American

0.0

5.0

10.0

15.0

20.0

25.0

30.0

Percent

Age Group

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

Etiology & Influencing FactorsEtiology & Influencing Factors

Cause still unclearCause still unclear 5% of Obese Children and Adolescents 5% of Obese Children and Adolescents

have an underlying specific causehave an underlying specific cause 3% = Endocrine3% = Endocrine

HypothyroidismHypothyroidism Cushing SyndromeCushing Syndrome HypogonadismHypogonadism

2% Rare Syndromes (Prader-Willi et. al.)2% Rare Syndromes (Prader-Willi et. al.)

Familial or GeneticFamilial or Genetic

Swedish Twin StudiesSwedish Twin Studies 1 Parent Obese = 30% Risk1 Parent Obese = 30% Risk 2 Parents Obese = 70% Risk2 Parents Obese = 70% Risk

Stunkard (1986)Stunkard (1986) BMI correlation between adoptees and BMI correlation between adoptees and

biological parentsbiological parents No correlation with adoptive parentsNo correlation with adoptive parents

Stunkard (1990)Stunkard (1990) High correlation BMI between twinsHigh correlation BMI between twins

Fat Cell TheoryFat Cell Theory

Fat cells gained early in life and during Fat cells gained early in life and during puberty cannot be lost, only reduced in puberty cannot be lost, only reduced in size.size.

Overfeeding early in first year of life and Overfeeding early in first year of life and during puberty increases the number of fat during puberty increases the number of fat cellscells

Adolescents who have propensity to Adolescents who have propensity to obesity have increased number of fat cellsobesity have increased number of fat cells

Activity and Energy ExpenditureActivity and Energy Expenditure

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

BehaviorBehavior Eating FastEating Fast Skipping breakfast and/or lunch and eating Skipping breakfast and/or lunch and eating

the majority of calories at night.the majority of calories at night. Eating when not hungry but when food is Eating when not hungry but when food is

availableavailable Eating when appetite is stimulated by Eating when appetite is stimulated by

environmental cuesenvironmental cues Eating when depressed or anxiousEating when depressed or anxious Eating in association with other activitiesEating in association with other activities Overindulging in “Fast Foods”Overindulging in “Fast Foods”

Central Regulation TheoryCentral Regulation Theory

The hunger or satiety center in the The hunger or satiety center in the hypothalamus may not function properly in hypothalamus may not function properly in suppressing appetite.suppressing appetite.

Psychological TheoryPsychological Theory

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

Body Image TheoryBody Image Theory

Obese adolescents have a distorted fat Obese adolescents have a distorted fat body image.body image.

One cannot achieve weight change until One cannot achieve weight change until one has visualized a smaller body image one has visualized a smaller body image and become comfortable with it.and become comfortable with it.

Hormonal TheoryHormonal Theory

LeptinLeptin Encoded by the obese geneEncoded by the obese gene Produced by the adipose tissueProduced by the adipose tissue Signal satiety and alter eating behaviorSignal satiety and alter eating behavior Monitors and controls body fat and energy Monitors and controls body fat and energy

balancebalance

Pubertal Changes: Effects of Pubertal Changes: Effects of Puberty on Body CompositionPuberty on Body Composition

Lean Body Mass increases in Both SexesLean Body Mass increases in Both Sexes More in Male than in Females because of the More in Male than in Females because of the

greater increase in skeletal muscle mass under greater increase in skeletal muscle mass under the effect of testosterone.the effect of testosterone.

Maximum increase in muscle mass occurs at the Maximum increase in muscle mass occurs at the time of PHV in both sexestime of PHV in both sexes

Maximum fat deposition occurs 2 years before Maximum fat deposition occurs 2 years before PHV and in females it continues throughout PHV and in females it continues throughout pubertypuberty

Ultimately female adults have more body fat Ultimately female adults have more body fat than males than males

Pubertal Changes: Effects of Pubertal Changes: Effects of Obesity on PubertyObesity on Puberty

Taller and larger in skeletal mass and Taller and larger in skeletal mass and more advanced in skeletal development.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

Influence and Effects on Health Influence and Effects on Health Psychosocial ConsequencesPsychosocial Consequences

Poor Body ImagePoor Body Image Social Isolation for fear of rejection and non-Social Isolation for fear of rejection and non-

acceptance by peersacceptance by peers Gortmaker, 1993. 7-year Study of 16-24 y/oGortmaker, 1993. 7-year Study of 16-24 y/o

Obese Obese ♀ ♀ completed fewer years of schoolcompleted fewer years of school Less likely to be marriedLess likely to be married Lower household incomesLower household incomes Higher rates of povertyHigher rates of poverty

Low self-esteemLow self-esteem DepressionDepression

Influence and Effects on Health Influence and Effects on Health General Morbidity and MortalityGeneral Morbidity and Mortality

Obese adolescents who become obese Obese adolescents who become obese adults will have more severe obesity than adults will have more severe obesity than those adults whose obesity began in those adults whose obesity began in adulthood.adulthood.

Greater morbidity and mortality due to Greater morbidity and mortality due to cardiovascular diseasecardiovascular disease

Effect of adolescent obesity on adult Effect of adolescent obesity on adult morbidity and mortality is independent of the morbidity and mortality is independent of the effect of adolescent obesity on adult weight.effect of adolescent obesity on adult weight.

Influence and Effects on HealthInfluence and Effects on Health

HypertensionHypertension Cerebrovascular DiseaseCerebrovascular Disease Cardiovascular DiseaseCardiovascular Disease Serum LipidsSerum Lipids Diabetes Mellitus (Type 2)Diabetes Mellitus (Type 2) Polycystic Ovary SyndromePolycystic Ovary Syndrome CancerCancer Skeletal Deformity and ArthritisSkeletal Deformity and Arthritis

PreventionPrevention

1.1. During PregnancyDuring Pregnancy Moderate weight gain during 3Moderate weight gain during 3rdrd trimester trimester

2.2. During Infancy and ChildhoodDuring Infancy and Childhood Breast feed in first year of lifeBreast feed in first year of life Delay cereals until 3 to 4 months of ageDelay cereals until 3 to 4 months of age Be sensitive to the deceleration of growth at Be sensitive to the deceleration of growth at

18 months of age18 months of age

PreventionPrevention

3.3. During Puberty and AdolescenceDuring Puberty and Adolescence Encourage healthy nutritional practices in Encourage healthy nutritional practices in

early puberty (Remember the fat cells)early puberty (Remember the fat cells)

Encourage lifestyle of activity and Encourage lifestyle of activity and participation through role modelingparticipation through role modeling

Discourage TV, DVD and videotape Discourage TV, DVD and videotape watching and video game use.watching and video game use.

PreventionPrevention

Reducing television, videotape,Reducing television, videotape,

DVD and video game use may beDVD and video game use may be

the most promising populationthe most promising population

based approach to prevention ofbased approach to prevention of

childhood obesity.childhood obesity.

Treatment: General AspectsTreatment: General Aspects

HUGE CHALLENGE!!!HUGE CHALLENGE!!! Determine who is at greater riskDetermine who is at greater risk

In the absence of complications obesity is In the absence of complications obesity is clinically significant when Wt is over 20 – 30% clinically significant when Wt is over 20 – 30% IBW for height and age.IBW for height and age.

If complications are present it is always If complications are present it is always clinically significant.clinically significant.

Focus on control, not cureFocus on control, not cure Ascertain Ascertain motivationmotivation..

Treatment: Critical AreasTreatment: Critical Areas

MotivationMotivation

Supportive Social and Family FrameworkSupportive Social and Family Framework

Willingness to increase physical activityWillingness to increase physical activity

Realistic GoalsRealistic Goals

Diet: General PrinciplesDiet: General Principles

Deficit of 500 kcal/day = 1 lb wt loss/weekDeficit of 500 kcal/day = 1 lb wt loss/week Food typesFood types Eating habits (Patient and Family)Eating habits (Patient and Family) Situation-dependent eatingSituation-dependent eating Family and cultural preferencesFamily and cultural preferences Good nutritional balance among food Good nutritional balance among food

groups.groups.

Diets: General PrinciplesDiets: General Principles

Energy NeedsEnergy Needs Males = [900 + (10 x W0] x Activity FactorMales = [900 + (10 x W0] x Activity Factor Females = [800 + (7 x W)] x Activity FactorFemales = [800 + (7 x W)] x Activity Factor

Activity FactorActivity Factor Low Activity = 1.2Low Activity = 1.2 Moderate Activity = 1.4Moderate Activity = 1.4 High Activity = 1.6High Activity = 1.6

Energy required to maintain each Kg of Energy required to maintain each Kg of body weight = 22 Kcalbody weight = 22 Kcal

DietsDiets

KetogenicKetogenic Very-low-calorie (< 400 Kcal/day)Very-low-calorie (< 400 Kcal/day) Glycemic IndexGlycemic Index Prolonged fastingProlonged fasting Special food combinations (Steak and Special food combinations (Steak and

Grapefruit Diet)Grapefruit Diet) Balanced Low-calorie (~1200 Kcal/day)Balanced Low-calorie (~1200 Kcal/day)

Balanced DietBalanced Diet

Foods from five groups: dairy, meat, Foods from five groups: dairy, meat, bread, fruits and vegetablesbread, fruits and vegetables

Three meals per dayThree meals per day Eat less food or calories than previouslyEat less food or calories than previously Instructions for food preparationInstructions for food preparation Instructions for food substitution (L vs H)Instructions for food substitution (L vs H) Instructions for food shoppingInstructions for food shopping

Physical ActivityPhysical Activity

Walking instead of riding the car or busWalking instead of riding the car or bus

Stairs instead of elevatorsStairs instead of elevators

Not using the channel flipperNot using the channel flipper

Exercise prescription: Over 30 min per day Exercise prescription: Over 30 min per day / 4 days per week of anything acceptable/ 4 days per week of anything acceptable

Cognitive Behavioral TherapyCognitive Behavioral Therapy

1.1. Contract and reward systemContract and reward system2.2. Initial food diaryInitial food diary

Time spent eatingTime spent eating PlacePlace Hunger ratingHunger rating MoodMood Associated activityAssociated activity Food consumedFood consumed AmountAmount

Cognitive Behavioral TherapyCognitive Behavioral Therapy

3.3. Behavior ChangeBehavior Change Eat three regular mealsEat three regular meals Eat favorite dish firstEat favorite dish first For a particular food eat favorite part firstFor a particular food eat favorite part first Eat defensively: Avoid “junk food”Eat defensively: Avoid “junk food” Eat slowly, chew – swallow – reloadEat slowly, chew – swallow – reload Do not keep “weakness food”Do not keep “weakness food” Eat where eating is meant to occurEat where eating is meant to occur

Cognitive Behavioral TherapyCognitive Behavioral Therapy

3.3. Behavior Change (Cont.)Behavior Change (Cont.) Do not watch TV while eatingDo not watch TV while eating Do not eat on the goDo not eat on the go Learn difference between Appetite & HungerLearn difference between Appetite & Hunger Eat when hungry, not when food is availableEat when hungry, not when food is available Have a breakout activity when depressed, Have a breakout activity when depressed,

anxious or unhappyanxious or unhappy Be honest about lapses in controlBe honest about lapses in control

GroupsGroups

Encouragement and supportEncouragement and support Release of feelingsRelease of feelings Peer contact and acceptancePeer contact and acceptance Non-commercialNon-commercial

TOPSTOPS Overeaters AnonymousOvereaters Anonymous

CommercialCommercial Weight WatchersWeight Watchers Diet WorkshopDiet Workshop Jenny CraigJenny Craig Richard Simmons SlimmonsRichard Simmons Slimmons

OtherOther

Anorexigenic drugsAnorexigenic drugs

Bariatric surgeryBariatric surgery

ResourcesResources

1.1. BooksBooks The Hilton Head Diet for Children and Teenagers: The Hilton Head Diet for Children and Teenagers:

The Safe and Effective Program That Helps Your The Safe and Effective Program That Helps Your Child Overcome Weight Problems for Good,Child Overcome Weight Problems for Good, by by Peter M. Miller (Warner Books, Inc., 1993)Peter M. Miller (Warner Books, Inc., 1993)

Girl Power in the Mirror: A Book about Girls, Their Girl Power in the Mirror: A Book about Girls, Their Bodies and Themselves,Bodies and Themselves, by H. Cordes (Lerner by H. Cordes (Lerner Publishing Group, 1999)Publishing Group, 1999)

Safe Dieting for Teens,Safe Dieting for Teens, by Linda Ojeda and Lisa by Linda Ojeda and Lisa Lee (Hunter House, Inc., 1992)Lee (Hunter House, Inc., 1992)

ResourcesResources

2.2. Web SitesWeb Sites http://www.niddk.nih.gov/health/nutrit/pubs/chohttp://www.niddk.nih.gov/health/nutrit/pubs/cho

ose.htmose.htm. Choosing a safe weight reduction program . Choosing a safe weight reduction program from NIHfrom NIH

http://www.health.gov/dietaryguidelines/http://www.health.gov/dietaryguidelines/. . Dietary GuidelinesDietary Guidelines

http://www.niddk.nih.gov/health/nutrit/pubs/preshttp://www.niddk.nih.gov/health/nutrit/pubs/presmeds.htmmeds.htm. Prescription medications for obesity. Prescription medications for obesity

http://www.niddk.nih.gov/health/nutrit/win.htmhttp://www.niddk.nih.gov/health/nutrit/win.htm. . Weight-control Information NetworkWeight-control Information Network