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Facts & Fiction about Pediatric Obesity Treatment: Nutrition & Metabolic Health Improvement

Luis A. Rodríguez, RD, CNSC UCSF Benioff Children’s Hospital

& WATCH Clinic May, 2013

Disclosures

•  I have nothing to disclose

Outline

•  Adult and Pediatric Obesity Trends •  Health Consequences Associated with Obesity •  Genetics vs. Environmental Changes •  Fats, Proteins and Carbohydrates (sugars) •  Meal Trends, and Locations •  Screening Obesity and Metabolic Markers •  Nutritional Recommendations •  Other Recommendations •  Summary

1999

Obesity Trends* Among U.S. AdultsBRFSS, 1990, 1999, 2009

(*BMI ≥30, or about 30 lbs. overweight for 5’4” person)

2009

1990

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

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Pediatric Obesity Epidemic

(M. de Onis et al., 2010)

Pediatric Obesity Epidemic

Pediatric Obesity Epidemic Pediatric Obesity Epidemic

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Immediate Health Problems Chronic Health Conditions

•  Asthma •  Sleep Apnea •  Skin Infections •  Joint Pain

•  Hypertension •  Type 2 Diabetes •  Hypercholesterolemia •  Hepatic Steatosis •  Menstrual Abnormalities •  Heart Disease •  PCOS •  Lower Self-Esteem and

Confidence

Health Consequences Associated with Childhood Obesity and Unhealthy Eating

  Genetic Syndromes   Prader-Willi   Laurence-Moon/Bardet-Biedl   Alstrom   Turner’s   Ruvalcaba

Genetics and Hormonal Defects

 Developmental Programming   Prenatal Undernutrition (SGA) (Barker, 2004)

  Dutch Famine Study (Roseboom et al., 2001)

  Prematurity   Overnutrition (LGA, GDM) (Boney et al., 2005)

 Direct relationship of maternal obesity with child obesity.

(Whitaker, 2004)

Genetics and Hormonal Defects Environmental Changes

•  Food Supply Macronutrient Changes •  Fats •  Proteins •  Carbohydrates

•  Meal Trends, and Locations

•  Food Addictions?

•  Decreased Physical Activity Levels

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Dietary Energy in Food Supply

Kcal/day per person

(Putnam, 2002)

↑340 kcal/day

Macronutrient Changes over past 3 Decades

•  Fat •  Total Kcal % decreased from 40% → 30% since 1980’s

•  Protein •  Stable at about 15%

•  Carbohydrate •  Starch 49 → 51% •  Fructose 8 → 12-15%

(Chanmugam et al, 2003)

Fats

Dietary Fat Dietary Source Medicinal Value or Danger

Omega-3 Fatty Acids Wild fish, flaxseed oil Anti-inflammatory, lowers serum TG, repairs membranes

Monounsaturated Fatty Acids Olive and canola oil Stimulates Liver Metabolism, reduces atherogenesis

Polyunsaturated Fatty Acids Vegetable oils Anti-inflammatory, excess amount can cause immune dysfunction

Saturated Fatty Acids Grass-fed animal meats, milk and dairy products, egg yolks

Atherogenic in Familial Hypercholesterolemia

Medium-chain triglycerides Palm oil, coconut oil, palm kernel oil

Energy source, some suggestion of stimulation of atherosclerosis

Omega-6 fatty acids Farm-raised animals and fish (corn and soy fed)

Atherosclerosis, insulin resistance, immune dysfuncion, pro-inflammatory

Trans fats Synthetic, processed food Atherosclerosis, NASH

(Lustig, 2012; Perito et al., 2013)

Fats

•  Women’s Health Initiative •  Randomized controlled, prospective study from

1993-1998. •  ~50,000 post-menopausal women. •  Goal to decrease Fat Calories and increase F/V and

grains. Fat decreased by 8%. •  No significant risk reduction in CHD, stroke or CVD.

(Howard et al, 2006)

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Proteins

•  Branched Chain Amino Acids (L, I, V) •  Essential Amino Acids

•  High concentration in corn

•  Increased insulin resistance d/t bypassing glycogen storage

•  Patients with metabolic syndrome have higher bloodstream levels (Lustig, 2012; Newgard et al., 2009)

Sugar (Fructose)

•  Increases nutrient consumption •  Attenuated Ghrelin response •  Reduced Insulin response, low Leptin rise.

•  NASH pathogenesis and progression •  Liver is primary site for metabolism •  Fructose bypasses rate-limiting step of glycolysis •  Preferentially metabolized to acetyl coA •  Provides substrate for FFA

•  Increases Visceral Fat

(Teff et al., 2004)

(Perito et al., 2013)

(Elliot,2002; Lustig, 2012)

Fructose

•  Increased consumption •  37gm fructose/day (1977-1978) 8% Kcal Intake

•  55gm fructose/day 10.2% Kcal Intake •  78gm fructose/day 12% Kcal Intake (Adolescents) (Vos et al., 2008)

Sugar (Fructose)

•  American Heart Association Recommendation for Optimal Cardiovascular Health •  Women 21gm sugar/day (1,800 Kcal/day) •  Men 38gm sugar/day (2,200 Kcal/day)

(Johnson et al., 2009)

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Fiction

•  “Beating obesity will take action by all of us, based on one simple common sense fact: All calories count, no matter where they come from, including Coca-Cola and everything else with calories…”

-The Coca Cola Company, 2013

Fiction Fact

•  A Calorie is A Calorie •  Calorie output is tightly regulated and dependant on the quantity and quality of ingested calories.

•  A Calorie Burned is a Calorie Burned.

Calories

Where Do People Eat When They Eat Out?

Source: “Factors Influencing Lunchtime Food Choices among Working Americans”. 2009

Fast Food

•  1/3 of U.S adults eat fast food

•  Longitudinal studies show fast food intake predicts weight gain and increased risk for T2D

•  Fast food restaurants overrepresented in poorer neighborhoods; healthy alternatives harder to find •  Prevalence: 2.5/mile2 vs. 1.5/mile2

•  Low SES associated with increased fast food consumption

(Garber, Lustig, 2011)

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Is Fast Food Addictive?

•  Sugar •  Rodent Models demonstrate binging,

withdrawal (teeth chattering, tremors, shakes and anxiety)

•  Seeking and craving

•  Cross-Sensitization

•  Human Studies also suggest sugar is addictive with withdrawal

•  Fructose increases liver and muscle insulin resistance (Sung et al., 2011; Perito et al., 2013)

•  Blocks leptin’s ability to extinguish mesolimbic dopamine signaling

Photo from cbsnews.com

(Garber, Lustig, 2011)

•  Caffeine •  “Flavoring agent”

•  Increases salience of high rewarding beverage.

•  Well established psychological & physiological dependence across age spectrum.

Is Fast Food Addictive?

(Garber, Lustig, 2011)

Photo from: http://www.islandcrisis.net

Is Fast Food Addictive?

•  Environmental Cues •  Required to create addictive patterns •  Powerful external Stimuli trigger reward in animal and human •  Vulnerability to environmental cues may explain differences in

ability to follow a “diet”

•  Ads •  3-5 per 30 minutes during prime time TV.

(Brown, 2002)

(Garber, Lustig, 2011)

Exercise

•  33%

•  Percentage of youth who are actual couch potatoes, engaging in little or no leisure-time physical activity whatsoever

•  2/3

•  Proportion of teens that don’t meet the minimum recommended levels of physical activity of one hour a day of moderate to vigorous activity

•  >2-3

•  Daily number of hours children spend watching TV; more time than on any other single activity except sleeping

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Fiction Facts

•  Exercise alone causes significant weight loss

•  Exercise—even in absence of weight loss—decreases hepatic steatosis, and other lipotoxicity markers.

•  Exercise builds muscle and

stimulates new mitochondrial development and improves insulin sensitivity

•  Increases liver’s Krebs cycle speed

Exercise

(Perito et al. 2013)

(Lustig, 2012)

Screening and Identification of Pediatric Obesity

• Children 0-24 months use WHO Growth Standards •  >97th%ile for weight for length

• Children >2 years use CDC BMI curves •  85-95th%ile: Overweight •  >95th%ile: Obese

Metabolic Markers

• Physical Assessment •  Acanthosis Nigricans (Axilla, neck, flexural areas)

•  Marker of hyperinsulinemia

•  Lab values •  Fasting insulin, fasting BG, HgA1C •  ALT •  Uric Acid •  Fasting Cholesterol Panel

Unhealthy Food Patterns

•  Beverages •  Soda, Juice (any kind), energy drinks, coffee drinks

•  Foods •  Fast food, pre-packaged, processed foods

•  Food environment •  Eating in front of TV, chaotic environment, on the go

•  Stress eating, binge eating, disordered eating

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DIET AND EXERCISE!

Clinical Treatment

…WHAT?

WATCH Clinic (Weight Assessment for Teen and Child Health)

Nutritional Recommendations

•  ½ of your plate non-starchy Vegetables and Fruit

•  ¼ of your plate Whole Grains •  Cereals >5gm fiber/serving •  Breads >3gm fiber/serving •  Other packaged >3gm fiber/~100Kcal

•  ¼ of your plate Proteins High in Fiber or Healthy Fat •  Legumes, Nuts, wild fish, free range beef/poultry, eggs and dairy •  Plain, added-sugar free dairy

•  Healthy Fats •  Olive/Canola Oils

•  Wait 20 minutes before offering 2nd portions

•  Control home environment by limiting “treats”

•  Everyone at home follows same recommendations

•  Remove TV from Child/Teenage Room

•  Enroll in engaging, entertaining, fun, sustainable, regular physical activity

Other Recommendations

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Summary

•  Calories are NOT created equal. Unique nutrients contribute to metabolic disease, even in absence of obesity—trans fats, fructose. •  Follow WATCH Clinic Plate Model •  Avoid processed foods (trans fats, low fiber, high sugar) •  Avoid all sweetened beverages; only drink water, plain milk or

plain milk substitutes, and plain teas

•  Exercise improves cardiometabolic health, even in the absence of weight loss.

References

•  A. K. Garber, Lustig R. H. (2011) “ Is Fast Food Addictive?” Curr. Drug Abuse Rev. 4, 146-162.

•  Basu S, Yoffe P, Hills N, Lustig RH (2013) The Relationship of Sugar to Population-Level Diabetes Prevalence: An Econometric Analysis of Repeated Cross-Sectional Data. PLoS ONE 8(2): e57873.

•  Brown JD, Witherspoon EM. The mass media and American adolescents’ health. J Adoles Health. 2002 Dec;31 (6 Suppl): 153-70.

•  B. V. Howard et al., “Low-Fat Dietary Pattern and Risk of Cardiovascular Disease: The Women’s Health Initiative Randomized Controlled Dietary Modification Trial,” JAMA 295 (2006): 655-66; B. V. Howard et al., “Low-Fat Dietary Pattern and Weight Change over 7 Years: The Women’s Health Initiative Dietary Modification Trial,” JAMA 295 (2006) 39-49.

•  C. B. Newgard et al., “A Branched-Chain Amino Acid-Related Metabolic Signature That Differentiates Obese and Lean Humans and Contributes to Insulin Resistance,” Cell Metab. 9 (2009): 311-26.

•  C. M. Boney et al., “Metabolic Syndrome in Childhood: Association with Birth Weight, Maternal Obesity, and Gestational Diabetes,” Pediatrics 115 (2005): e290-e96.

References

•  D. J. Barker, “The Development Origins of Chronic Adult Disease,” Acta Paediatr. Supp. 93 (2004): 26-33.

•  K. C. Sung et al., “Interrelationship Between Fatty Liver and Insulin Resistance in the Development of Type 2 Diabetes,” J. Clin. Endocrinol. Metab. 96 (2011): 1093-97.

•  M. B. Vos et al., “Dietary Fructose Consumption Among US Children and Adults: The Third National Health and Nutrition Examination Survey,” Medscape J. Med. 10, (2008): 160.

•  M. de Onis et al., “Global Prevalence and Trends of Overweight and Obesity Among Preschool Children,” Am. J. Clin. Nutr. 92 (2010): 1257-64.

•  P. Chanmugam et al., “Did Fat Intake in the United States Really Decline Between 1989-1991 and 1994-1996?” J. Am. Diet Assoc. 103 (2003): 867-72.

•  Perito ER, Rodriguez LA, Lustig RH. “Dietary management of non-alcoholic steatohepatitis.” Current Opinion in Gastroenterology, March 2013. Invited review, submitted November 2012.

•  R.J.F. Loos et al., “Genome-wide Association Studies and Human Population Obesity,” in Obesity Before Birth, R.H. Lustig ed. (New York: Springer, 2010), pp. 95-112.

References

•  R.K. Johnson et al., “Dietary Sugars Intake and Cardiovascular Health: A Scientific Statement From the American Heart Association. Circulation.” 2009 Sep 15; 120 (11):1011-20.

•  Robert H. Lustig, Fat Chance: Beating the Odds Against Sugar, Processed Food, Obesity, and Disease. New York: Penguin, 2012.

•  P. Chanmugam et al., “Did Fat Intake in the United States Really Decline Between 1989-1991 and 1994-1996?” J. Am Diet. Assoc. 103 (2003): 867-72.

•  S. J. Olshansky et al., “A Potential Decline in Life Expectancy in the United States in the 21st Century,” New Engl. J. Med. 352 (2005): 1138-45.

•  Teff K, et al. Dietary Fructosse Reduces Circulating Insulin and Leptin, Attenuates Posprandial Suppression of Ghrelin, and increases Triglycerides in Women. J Clin Endocr Metab (2004): 89:2963-2972.

•  T. J. Roseboom et al., “Effects of Prenatal Exposure to the Dutch Famine on Adult Disease in Later Life: An Overview,” Mol. Cell. Endocrinol. 185 (2001): 93-98.

•  Whitaker, R. “Predicting Preschooler Obesity at Birth: The Role of Maternal Obesity in Early Pregnancy,” Pediatrics. (2004): 114; e29.