Overweight Children Prevalence, Problems, and Solutions (?) David L. Gee, PhD FCSN 547 – Nutrition Update Summer 2004

Overweight ChildrenPrevalence, Problems, and Solutions

(?)

David L. Gee, PhDFCSN 547 – Nutrition Update

Summer 2004

Assessment of Overweight in Children 1997 Expert Panel

The Maternal and Child Health Bureau, Health Resources and Services Administration, the Department of Health and Human Services

PEDIATRICS Vol. 102 No. 3 September 1998, p. e29 Recommends that BMI be routinely used to

screen children for overweight Defined

Overweight as a BMI for age over the 95th percentile

Risk for overweight as a BMI for age between the 85th and 95th percentile

Is a child’s BMI useful in predicting adult obesity?

Prevalence of Overweight Children in the US

Prevalence of Overweight and Obesity Among US

Children, Adolescents, and Adults, 1999-2002

A. Hedley et al.JAMA 2004; 291: 2847-2850

(June 16)

Prevalence of Overweight and Obesity Among US Children, Adolescents, and

Adults, 1999-2002

NHANES 1999-2000

N=4115 adults N=4018 children

2001-2002 N=4390 adults N=4258 children

Adult prevalence 65.1% overweight or obese 30.4% obese 5.1% extreme obese (BMI>40)

Prevalence of Overweight and Obesity Among US Children, Adolescents, and

Adults, 1999-2002

Children 6-19 yrs 31% at risk for overweight or overweight 16% overweight

At risk for overweight or overweight by age 2-5 = 22.6% 6-11 = 31.2% 12-19 = 30.9%

Prevalence of Overweight and Obesity Among US Children, Adolescents, and Adults, 1999-2002

At risk for overweight or overweight by gender Boys = 31.8% Girls = 30.3%

At risk for overweight or overweight By ethnicity White = 28.2% (29.2%b, 27%g) Black = 35.4% (31%b, 40%g) Mexican-American = 39.9% (42.8%b, 36.6%g)

Type 2 Diabetes in the Young

The evolving epidemic(review article)

Z. BloomgardenDiabetes Care 2004 (Apr);

27:998-1010

Type 2 Diabetes in the YoungThe evolving epidemic

Prevalence

NHANES III (1988-1994) ~3000 subjects, 12-19 yo IFG: 17.6 per 1000 HbA1c>6%: 3.9 per 1000 Diabetes (all types): 4.1 per 1000 Extrapolate: ~600,000 US adolescents

with some degree of glycemic abnormality

How many with Type 2 diabetes?


Prevalence

Sinha et al., NEJM 346:802-810, 2002 167 obese adolescents and children 4% prevalence of Type 2 DM

All in Hispanic and black adolescents IGT

16% obese white 27% obese black 26% obese Hispanic

(UK study found risk of Type 2 DM 13.5 times greater in Asian than white children)

Prevalence of T2 diabetes has increased significantly (2-3X)among Indian children in the past 30 years.


Prevalence Trends

10 fold increase from 1982-1994 in Cincinnati J. Ped. 128:608-615, 1996

% of diabetic children w/ T2 increased from 9.4% (1994) to 20% (1998) (Florida) Pub. Health Rep. 117:373-379, 2002

~1/3rd of children w/ diabetes have T2 in OH, AR, CA(Hispanics) Diabetes Care 22:345-354, 1999


Prevalence

Other factors: Gender

Girls 1.7 times more likely than boys Diabetes Care 22:345-354, 1999

Family History 2/3rd of children w/ T2DM with at least

one parent with T2DM Diabetes Care 23:381-389, 2000


Prevalence Other factors (1998 study from India)

Low birthweight High prepubertal weight


Screening Prevalence of T2DM in young low but

growing Prevalence of overweight growing rapidly Screening of all children not cost effective

~$10,000 per case found (Japan/Taiwan study) ADA/AAP Consensus Position

Diabetes Care 2000 Testing >10yr if BMI > 85th pct with 1o or 2o

relative with DM, at risk ethnic group, or signs of insulin resistance (metabolic syndrome)

Obesity and the Metabolic Syndrome in Children and

Adolescents

R. Weiss et al.NEJM 350:2362-74,2004

Obesity and the Metabolic Syndrome in Children and

Adolescents Metabolic Syndrome

Cluster of metabolic abnormalities associated with insulin resistance

Diagnosis of Metabolic Syndrome in Adults Three or more of the following: Abdominal Obesity

men > 40” waist circumference women > 35” waist circumference

Hypertriglyceridemia (>150 mg/dl) Low HDL

men < 40 mg/dl women < 50 mg/dl

Pre-hypertension (>130/>85 mmHg) Pre-diabetes (> 110 mg/dl)

Obesity and the Metabolic Syndrome in Children and Adolescents

Methods 439 obese children/adolescents 31 overweight siblings 20 non-obese siblings 41% white, 31% black, 27% Hispanic

Administered oral GTT Measured BP, plasma lipids, C-

reactive protein


Criteria for Metabolic Syndrome in Children

Obesity (instead of waist circumference) Obese = z-score >2.0 for BMI

Moderate Obese = z-score 2.0-2.5 Severe Obese = z-score > 2.5

Metabolic values TG: > 95th pct HDL-C: < 5th pct Glucose intolerance following OGTT Insulin resistance = [fasting glu]x[fasting plasma

insulin]/22.5


Anthropometric & Metabolic Characteristics

Non-obese Overweight

Moderate Obese

Severe Obese

BMI 18.4 24.5 33.4 40.6Glucose(mg/dl,<0.05)

87.4 86.8 90.5 90.2

InsulinuU/ml,<.001

10.3 14.6 31.3 38.6

Insulin resistance<.001

2.2 3.12 7.05 8.69

TriglyceridesMg/dl, <.001

48.4 83.1 104.6 96.5


Anthropometric & Metabolic Characteristics

Non-obese Overweight

Moderate Obese

Severe Obese

HDL-CMg/dl,<.001

58.5 46.7 41.1 39.9

LDL-CMg/dl, p=.41

92.2 95.5 98.1 97.3

Systolic BPmmHg,<.001

106 116 121 124

IGT%, .01

0 3.23 14.4 19.9

CRPMg/dl, .001

.01 .05 .13 .33


Prevalence

Overall 38.7% in moderately obese 49.7% in severely obese

39% in severely obese blacks

“…metabolic syndrome is far more common among children and adolescents than previously reported…prevalence increases directly with the degree of obesity.”

Prevalence of metabolic syndrome increases with degree of insulin resistance

Health-Related Quality of Life of Severely Obese

Children and Adolescents

J. Schwimmer et alJAMA 289:1813-1819 (Apr 9,

2003)

Health-Related Quality of Life of Severely Obese Children and

Adolescents

Health-related QOL Physical functioning Emotional functioning Social functioning School functioning

106 children & adolescents mean age = 12 yrs (+3) Mean BMI = 34.9 (+9.3) (z-score=2.6) Compared with 401 healthy and 106 cancer

pediatric patients

Obese children and adolescents reported significantly lower health-related QOL in all domains compared with healthy controls.

Obese children were more likely to have impaired health-related QOL than healthy controls and were similar to children and adolescents with cancer.

Health-Related Quality of Life of Severely Obese Children and

AdolescentsConclusions:

Obese children and adolescents reported impairment of total and all domains of QOL Likelihood of impaired QOL was 5.5 times

greater in obese than healthy Obese children and adolescents reported

similar impairment of QOL as in cancer patients undergoing chemotherapy Lower than children with rheumatoid arthritis,

type 1 diabetes, congenital heart disease.

Children’s Food Consumption Patterns Have Changed over Two

Decades (1973-1994): The Bogalusa Heart Study

T. Nicklas et al., JADA 104:1127-1140 (2004)

Children’s Food Consumption Patterns Have Changed over Two Decades (1973-1994): The Bogalusa Heart Study

One 24-hr dietary recall Seven surveys of 10 yr-olds 1584 children surveyed

Amount of food consumed at schools and restaurants

Increased, while the amount consumed in ‘other’ decreased.

Grams of food consumed by source of consumption

0

200

400

600

800

1000

1200

1400

1600

1800

2000

1970 1975 1980 1985 1990 1995

Home

School***

Restaurant***

Other***

Total**

The amount of dessert and candy consumed decreased,While the amount of salty snacks increased.

0

10

20

30

40

50

60

70

80

90

100

Desserts**** Candy**** Condiments**** Salty snacks*** Seafood

gram

s/da

y 1974

1994

Egg and pork consumption decreased, while consumption of cheese, beef and poultry increased.

0

10

20

30

40

50

60

70

80

Egg*** Pork** Cheese**** Beef Poultry****

gram

s pe

r day 1974

1994

Consumption of fats/oils and breads/cereals decreased,while consumption of fruits/juices and mixed meats increased.

0

50

100

150

200

250

Fats/Oils* Fruits/Juices** Veg Bread/Grains* Mixed Meats****

gram

s pe

r day 1974

1994

Milk consumption decreased while consumption of sweetened beverages increased.

0

50

100

150

200

250

300

350

400

450

500

Milk** Sw eet Bev**

gram

s pe

r day 1974

1994

Total consumption and consumption at lunch and dinnerIncreased, while consumption of snacks decreased.

Amount consumed by meal

0

200

400

600

800

1000

1200

1400

1600

1800

Breakfast Lunch**** Dinner**** Snacks**** Total**

gram

s pe

r day 1974

1994



Findings that may contribute to childhood obesity

More food consumed at restaurants More fruits and fruit juices More cheese, mixed meat, beef, and

poultry More salty snacks More sweetened beverages and less milk More food consumed at lunch and dinner More total food consumed



Surprising findings Less food consumed at places other

than home, school, restaurants Less fats and oils Less dessert and candy Less food consumed outside of

meals (snacks)

Parent Weight Change as a Predictor of Child Weight Change

in Family-Based Behavioral Obesity Treatment

B. Wrotniak et al.Arch. Pediatr. Adolesc. Med.158: 342-347 (Apr. 2004)

Parent Weight Change as a Predictor of Child Weight Change in Family-Based Behavioral

Obesity Treatment

Family-based behavioral treatment Parenting techniques

Reinforcement Stimulus control Environmental restructuring

Obese parents make similar behavioral changes

Parent Weight Change as a Predictor of Child Weight Change in Family-Based Behavioral Obesity Treatment

Participants 142 obese children (8-12yo) and at

least one parent attended family-based weight control program

2-year study with measurements at 6, 12, and 24 months


Both child and parents lost significant amounts of weight over 6 and 24 months


Parents who lost the most weight had children who lost the most weight.


Conclusions: “Parent z-BMI change was a

significant predictor of child z-BMI change over 6 and 24 months.”

“…youth benefit the most from parents who lose the most weight in family-based behavioral programs.”

“…support the inclusion of parents into family-based programs for their children.”

Reducing children’s television viewing to prevent obesity: A randomized controlled trial.

T. RobinsonJAMA 282:1561-1567 (1999)

Reducing children’s television viewing to prevent obesity: A randomized controlled

trial.

Many observational studies have found associations between television viewing and child/adolescent adiposity.

Reviewed in AAP’s Policy Statement Pediatrics 112:424-430 (2003) 25% children watch >4hrs TV/day BMI of children who watch >4hrs per day

significantly greater than those watching < 2hrs per day

TV in child’s bedroom significant predictor of overweight


192 3rd & 4th grade children in two matched public elementary school

Intervention group 18-lesson, 6-month classroom

curriculum to reduce TV, videotape, and videogame use

Measures at 0 and 8 months


Compared to controls, children in intervention group had statistically significant relative decreases in BMI, TSF, waist circumference, and W/H ratio.


The intervention significantly decrease children’s television viewing and video game use.


However, reducing television viewing did not significantly reduce: Frequency of snacking in front of TV Daily servings of high-fat foods

Or increase Overall physical activity Fitness

“Reducing television… may be a promising, population-based approach to help prevent childhood obesity.”

Useful references American Academy of Pediatrics – Policy

Statement Pediatrics 112:424-430(2003)

Society for Nutrition Education Guidelines for Childhood Obesity Prevention

Programs: Promoting Healthy Weight in Children J. Nutr. Ed. Behav. 35:1-3 (2003)

Childhood and Adolescent Overweight: The Health Professional’s Guide to Identification, Treatment, and Prevention. M Mullen & J Shield ADA 2004

Addressing the issues of childhood and adolescent

obesityJuly 25, Monday class debate

You are either a group of RD’s lobbying in support

for population-based approaches for preventing and treating overweight in children

Nay-sayers who support status quo and believe strongly in personal responsibility and individual freedom



On Thursday, July 22, RD’s must provide a brief list of their proposed population-based approaches to the naysayers.

Debate format 10 minute presentation by RD’s 3-5 minute rebuttal by naysayers 3-5 minute response by RD’s



School Board RDs: DO, AC, ED SQ: NA, KW

Community RDs: KL, CV, LenaG SQ: KD, LK

State/Federal RD’s: NS, LauraG, SL, SC SQ: DK, RS

Documents

Overweight Children Prevalence, Problems, and Solutions (?) David L. Gee, PhD FCSN 547 – Nutrition Update Summer 2004