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2	Children of the Corn Syrup
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4	Type 2 Diabetes: The “Family Disease” of the 21^st Century
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7	Pediatric Overweight/Obesity 2006
8	Pediatric Overweight/Obesity 2010
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10	We are obsessed with weight!
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14	Americans are more accepting of heavier bodies
15	Too big to hang, killer dies in prison
16	"More laparoscopic procedures" More laparoscopic procedures More T&A’s for Obstructive Sleep Apnea (OSA) More orthopedic procedures Altering surgical practices and equipment needs (operating tables, scanners)
17	Cholecystectomies at DCH
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19	Increase in % overweight prevalence by ethnicity
20	This problem doesn’t treat itself
21	Treatment failure is common without good follow up
22	“Profile” of the typical overweight child Began gaining weight between ages 3-5 years Frequent fast food consumer Drinks most of his/her excess calories May skip one or more meals each day, then start to graze Watches 4 or more hours of TV each day Tall for age (above the 50%tile)
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25	Case study 3 16 year old 530 pounds Hypertensive Normal OGTT AN on neck Normal lipogram Osteotomy R leg Referred for bariatric therapy
26	Case study 4 10 year 11 month old 401 pounds Normal OGTT AN Severe OSA Chief complaint: “He can’t tie his shoes”
27	Obstructive Sleep Apnea: possible Signs/Symptoms Obesity Snoring Restless nighttime sleep Daytime sleepiness (falls asleep in car on short rides) Bedwetting Morning headaches Difficult behavior Poor school performance
28	Non-endocrine effects of obesity Cardiovascular Respiratory Orthopedic Dermatologic Immunologic Gastrointestinal Neurologic
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31	Acanthosis Nigricans referrals
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41	13 y.o. girl diagnosed with T2DM by MD after Positive School AN screening
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45	Impact of obesity on pubertal onset
46	Anatomy of the problem Early weight gain Tall for age “Appropriate” final height Heavy liquid calorie consumers Family history of overweight/obesity
47	36.7%* of doctors talk directly to parents about overweight kids. Why? They don’t properly identify them at well child visits like they should Some docs may fear a “negative” response Some may not know what to say or how to say it
48	But like Diabetes, Obesity is a result or outcome with many possible causes Multiple definitions Multiple causes Multiple therapies Significant confusion
49	With one “final common pathway”
50	But, I only eat like a bird!
51	Yes, but….
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53	The familial nature of obesity One parent: 50% risk of having obese child Both parents: 66% chance of having obese child Neither parent: ~10% risk of having obese child
54	But what about the environment? Plays a “permissive” role
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56	Newton’s First Law of Thermodynamics “Energy is neither created or destroyed” 3,500 calories = 1 pound Calories in (food) = calories out (activity) + weight gain Only a 0.15% daily caloric “excess” results in obesity within 5 years
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58	Weight control systems Our bodies are “designed” to protect more against weight loss than weight gain (“hard-wired” to eat) This represents an evolutionary adaptation to scarcity It’s the main reason why many of us are here today
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60	But don’t forget the “final common pathway”
61	The four “kid” food groups Soft drinks (e.g., colas, sport drinks, kool aid) Fast foods (e.g., McDonald’s, Burger King, KFC) Sugared cereals (e.g., Fruit loops, Cocoa Puffs) Candy (e.g., Baby Ruth, Nerds, Snickers)
62	Common nutritional “blind spots” Sport drinks and juices are good for you, no matter how much. “Snacks don’t count” Portion sizes Caloric density
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64	The Supersizing phenomenon
65	The SUV’s of Fast Foods
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67	Coming to a theater near you! May 1, 2006
68	What We’re Up Against
69	What We’re Up Against
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71	Big Food Strikes Back!
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74	Humongous-Size Me?
75	Distortion of “normal”
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78	6 year referred for “poor growth” Height 50% Weight 50%
79	Can we be fat…and healthy?
80	Metabolic effect of frequent snacking
81	Metabolic effect of frequent snacking
82	What is the daily caloric requirement for an average child 1-2 years of age? 750 calories 950 calories 1150 calories 1350 calories 1550 calories
83	What is the most commonly consumed vegetable in toddlers aged 15-24 months? Carrots Green beans Squash French fries Mashed potatoes
84	For a child 1 to 6 years of age, what is the daily fruit juice recommendation by the AAP? 2-4 oz 4-6 oz 8-12 oz 12-16 oz 16-20 oz
85	True or False: 12 ounces of regular Sprite has fewer calories than 12 ounces of Coca Cola True False
86	What percent of children eat a balanced diet as described by the USDA’s Food Guide Pyramid? 1% 5% 10% 25% 50%
87	www.mypyramid.gov
88	Which of the following is the official name for “sugar”, according to the FDA? Glucose Fructose Lactose Sucrose Dextrose
89	What percentage of teenage girls get their RDA for calcium? 3% 13% 33% 53% 63%
90	How many pounds will an average person GAIN each year from drinking ONE 12 ounce regular soda pop each day? 4 pounds 8 pounds 16 pounds 32 pounds 48 pounds
91	What percentage of American children have TV sets in their bedrooms? 15% 25% 40% 65% 75%
92	Celebrity marketing
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100	Getting the message: at a price?
101	Up to how many times does a new vegetable choice need to be offered to a toddler before giving up? Twice 3 times 7 times 15 times 30 times
102	Feeding Infants and Toddlers Study (FITS) Soda is now served to children as young as 7 months of age by many parents Nearly 25% of 19-24 month old babies are not eating a single fruit or vegetable in a day By 19-24 months, most toddlers consumed sweets, desserts or salty snacks at least once a day.
103	Over the past 20 years… Milk intake has decreased 40% Soda intake has increased 300% 40% of children’s calories now come from fat and sugars
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105	Lead and Ancient Rome. Ancient Romans used lead in… Water pipes Cooking utensils Water tanks Storage vessels Wine preparation (flavor enhancer and preservative) Cosmetics
106	Chronic lead poisoning was one reason cited for the decline of the Roman Empire* “Apathy and gluttony” Apathy attributed to the lead in the food water and wine City dwellers were more likely to suffer “gouts”, “dropsies” and “colics” High infant mortality rates occurred Surviving offspring were “underachievers”
107	A Plague of Blessings?
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110	A Provocative Thesis The rapid rise of fructose in the food supply is resulting in an earlier onset of insulin resistance and its sequelae in the population in general…and in at-risk groups in particular.
111	In animals, high fructose intake results in… Insulin resistance Impaired glucose tolerance Hyperinsulinemia Hypertriacylglycerolemia Hypertension
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113	Metabolic effects of fructose DOES NOT induce insulin release DOES NOT trigger LEPTIN Increases ghrelin release
114	However, in larger amounts, fructose… Increases liver triacylglycerol production (de novo lipogenesis) Is lipogenic (Fat-producing)
115	High fructose corn syrup Processed from hydrolyzed corn starch (1966) Contains fructose and sucrose 75% sweeter than table sugar (sucrose) Less expensive than sugar Mixes well with many foods First appeared in the early 1970’s 14% fructose, 43% dextrose, 31% disaccharides and 12% “other” products (composition) Daily intake has skyrocketed over the past 20 years
116	Just two 12 ounce regular sodas… Provide ~ 50 grams fructose (200 kcal) > 10% of the daily energy needs for an average weight woman This doesn’t consider other sources of dietary fructose
117	Soda Pop may increase women’s blood pressure
118	HFCS: hiding in plain sight? Sodas Juices Sport drinks Chocolate milk Candies Baked goods Cookies Syrups Soups Ketchup Breakfast cereals Pasta sauces Baby foods Baked beans Yogurts Barbecue sauce Desserts
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133	What about fruit and vegetable sources of fructose?
134	HFCS facts Increase in HFCS parallels a decrease in sucrose intake in the US 4,000% increase in HFCS consumption between 1970-2003) The percentage of fructose in the diet continues to increase
135	Insulin resistance: several contributors Aggravated by high saturated fat intake (human and animal studies) Dietary fructose has been shown to induce weight gain, insulin resistance, hyperlipidemia and hypertension (animal studies)
136	Analysis of human studies In all human studies to date, fructose or sucrose (50% fructose) feedings do not result in a reduction of ad lib energy (food) intake from other sources. In other words: these extra calories don’t lessen overall appetite! YOU DON’T COMPENSATE (EAT LESS) FOR THE NUMBER OF CALORIES YOU TAKE IN THE FORM OF FRUCTOSE!!!!
137	Means, Motive and Opportunity? High fructose intake is shown to aggravate weight gain and promote metabolic changes resulting in insulin resistance The body does a poor job in recognizing fructose based calories: we generally eat more as a result! Corn syrup sweeteners are virtually everywhere in the American diet!
138	U.S. per capita HFCS deliveries (in pounds) ; T2DM at DCH ; Cholecystectomies at DCH
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141	Corn is the most heavily subsidized (5.5 Billion/year) crop in the United States
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144	Summary: Fructose In small amounts, has positive effects, but in large amounts… Does not stimulate insulin production from insulin producing beta cells Reduces serum leptin levels Is lipogenic (fat-producing) in the liver Induces high blood pressure (hypertension) May cause insulin resistance by several mechanisms
145	High Fructose Corn Syrup…? Is a part of our lives because of the over-abundance of corn in the US (and world) food supply Is readily available to all sectors of our society, especially very young children May have a role in obesity that is direct and/or indirect Direct: impact on daily caloric intake and metabolism Indirect: in contributing to increased portion sizes due to its lower cost than sugar (e.g., 20 ounce sodas, soda dispensers in front on the fast food counter instead of behind the counter)
146	When did soda dispensers move out from behind the counters?
147	So…is fructose the “smoking gun”?
148	Remember when???
149	Did we do that ?
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151	Reading a nutrition facts label Serving size Servings per container Calories per serving Total fat Trans fat Sodium Carbohydrates
152	Walk Like the Amish? 96 members of an Old Order Amish community near Ontario, Canada Men walked an average of 18,000 steps a day Women walked an average of 14,000 steps a day NO Men were obese Only 2 women were obese 26% overweight Diet consists of meat, potatoes, gravy, eggs, vegetables, pies and cakes Pre WWII rural diet high in fat and refined sugar
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155	Percent Maximum VO₂ and Percent Maximum Heart Rate during Weight Bearing Exercise in Children with Increasing Levels of Obesity
156	Observations from the front line Weight gain in at risk children starts in early childhood: BEFORE starting school Extra calories intake in toddlers almost always is in the form of LIQUIDS (milk, juice, sodas, sport drinks, etc…) One “red flag” for possible endocrine or genetic problems in kids is short stature and obesity
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159	Definition of “overweight”
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161	Identifying those “at-risk”
162	Size matters… Children born large for gestational age (LGA) may be prone to accumulating excess fat in early childhood
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164	“Cuando en la tina del bano el agua se derrama, la primera medida es cerrar la llave del agua”
165	Why PRIMARY prevention is so important Cost to effectively treat childhood obesity is ~ $11,000 per child per year* Once an older child leaves an obesity management program, he/she gains most of the weight back* Success rates for successful long term treatment of morbidly overweight teens is extremely low ^†(<10%) Access to any effective program is geographic-limited, time-limited and cost-limited to most at-risk (e.g., Medicaid, CHIP) children.
166	Is adolescence too late?
167	In teens, nutrition information does not change fast food ordering behavior
168	Boy and girl BMI charts
169	Adiposity rebound?
170	“Normal” adiposity rebound
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173	Simple Changes Drink 8 glasses of water a day Buy a pedometer: 10,000 steps a day. Stop regular colas, switch to sugar-free Beware of sport drinks (e.g., Gatorade)
174	The 5 minute obesity consult Soft drinks Switch diet for regular sodas Discuss sport drinks 8 glasses of water After Meal Snacking Reduce grazing Eat 3 meals a day Snacks add calories! Fast foods Reduce frequency Don’t supersize! Diet sodas or water Exercise Reduce TV viewing Pedometer? (10,000 steps a day! Walk Encourage family involvement
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178	S.A.F.E./S.A.N.A. brochures
179	S.A.F.E./ S.A.N.A. Fridge magnet
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181	What about the “diet of the month”?
182	Just a few of the “diets” out there
183	But, how many diets… Allow unlimited regular soft drink consumption? Encourage frequent, large aftermeal snacks? Recommend you eat lots of fast foods? Don’t feel exercise is very important?
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187	17 teaspoons of sugar!
188	35 teaspoons of sugar!
189	53 teaspoons of sugar!
190	Sugar vs. artificial sweeteners
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192	Time is the enemy
193	Readiness to change? If parents don’t feel their child’s weight is a problem, or… If they don’t feel it can be changed, Then…delay initiation of therapy And focus on parental education and counseling
194	Promote greater self esteem Promote a positive approach at each encounter Patients must be set up to succeed Use praise generously Remember, it’s a lifelong effort
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197	Weight goals Prevent further weight gain Weight maintenance for any child not at final adult height Normal weight may not be achieved, but positive behaviors should be viewed as a success
198	Lifestyle Guidelines Limit media time Ban the remote Exercise during ads No TV for kids < 2 yrs No TV in kids bedroom Encourage 30-60 min unstructured play/day Exercise together! Diversify activity to avoid boredom
199	Other suggestions… Place S.A.F.E. (or S.A.N.A.) posters in each examination room and/or waiting room. “Passive” education tools increase questions from parents about eating, exercise and weight. Use of S.A.F.E. prescription pads convey stronger message to parents
200	Other practical suggestions… Show parents the BMI plot and what it means Post BP standards in measuring area for quick reference Make healthy lifestyle messages a part of well baby care. Specifically, steer families away from soft drinks and fast foods for infants and toddlers BEFORE THEY START. Remember that excess juice and sport drink consumption are often not appreciated for their role in obesity
201	When to act? Ideally, at well child visits Start at birth (or before) Incorporate messages into vaccine visits
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203	Pharmacologic therapy? Xenical Meridia
204	Bariatrics? Generally: Must be over 18 years of age Some academic centers now performing these: Girls: Post-menarchal Boys: Tanner 4 or 5 Attempt ONLY after failed medical management
205	Promote breast feeding!
206	Weight loss “fallout”?
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210	Having one (or two) obese parents
211	Sleeping less than 10.5 hours a night at age 3
212	Watching more than 4 hours of TV a week at age 3
213	Being in the highest quarter of weight at ages 8 months and 18 months
214	Gaining weight at a high rate in the first year of life
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216	Having “catch-up” growth between birth and age 2
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