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Color Me HealthyColor Me HealthyWIC ConferenceWIC Conference
John Tyler Community CollegeJohn Tyler Community College
Richmond, VARichmond, VA
10-13-1010-13-10
Tipping Point: Childhood Tipping Point: Childhood Obesity From Inception, Obesity From Inception, Conception, and BeyondConception, and Beyond
John Harrington MDJohn Harrington MDAssociate Professor of PediatricsAssociate Professor of PediatricsEastern Virginia Medical SchoolEastern Virginia Medical School
Director of General Academic PediatricsDirector of General Academic PediatricsChildren’s Hospital of The King’s DaughtersChildren’s Hospital of The King’s Daughters
ObjectivesObjectives
Obesity risks before, during, and soon after Obesity risks before, during, and soon after pregnancy pregnancy
Tipping Point StudyTipping Point Study Breast versus BottleBreast versus Bottle Self Regulation of Oral FeedingSelf Regulation of Oral Feeding Guidelines for Feeding, Sleeping and ExerciseGuidelines for Feeding, Sleeping and Exercise Environment and AdvocatingEnvironment and Advocating ConclusionsConclusions
So who contributes to the So who contributes to the weight of the infant mom or weight of the infant mom or
dad?dad?
No such thing as fat spermNo such thing as fat sperm
Mom and DadMom and Dad
Mom’s pre-pregnancy BMI is correlated Mom’s pre-pregnancy BMI is correlated with child’s BMI at age 3.with child’s BMI at age 3.
Dad’s BMI is less correlated in most Dad’s BMI is less correlated in most studiesstudies
Maternal history of Diabetes increases risk Maternal history of Diabetes increases risk of of ↑ BMI↑ BMI
Maternal history of smoking associated Maternal history of smoking associated with obesity in child at age 5with obesity in child at age 5
Opposites do not Opposites do not necessarily attractnecessarily attract
Couple’s riskCouple’s risk
Overweight/Obese female likely to marry Overweight/Obese female likely to marry or procreate with Overweight/obese maleor procreate with Overweight/obese male
Recent study shows overweight/obese Recent study shows overweight/obese girls more likely to start having sex earlier girls more likely to start having sex earlier and to get pregnant.and to get pregnant.
Eating habits inherited, but can be Eating habits inherited, but can be modified by geography (American couple modified by geography (American couple in East Asia)in East Asia)
Obesity in pregnancyObesity in pregnancy
If women gains > than 30-35 pounds for If women gains > than 30-35 pounds for pregnancy 48% more likely to have obese child pregnancy 48% more likely to have obese child by age 7.by age 7. Japanese OB 8-12 kg limit weight gainJapanese OB 8-12 kg limit weight gain
If mom obese baby likely to have some insulin If mom obese baby likely to have some insulin resistance, especially if LGA or SGA resistance, especially if LGA or SGA
Heritability of BMI between 40-70%Heritability of BMI between 40-70% Pre-gestational and gestational DM=increased Pre-gestational and gestational DM=increased
risk for child obesityrisk for child obesity
After birthAfter birth
Babies who are SGA have impaired beta-Babies who are SGA have impaired beta-cell activity in response to glucose cell activity in response to glucose tolerance test.tolerance test.
SGA prone to truncal fat deposition and SGA prone to truncal fat deposition and metabolic syndromemetabolic syndrome
LGA also at increased risk for abnl weight LGA also at increased risk for abnl weight increaseincrease
Rapid weight gain in infancy correlates Rapid weight gain in infancy correlates with obesity.with obesity.
Study at EVMSStudy at EVMS
Identifying the “Tipping Point” Age for Identifying the “Tipping Point” Age for Overweight Pediatric PatientsOverweight Pediatric Patients
John W. Harrington MD,Vu Q. Nguyen, John W. Harrington MD,Vu Q. Nguyen, James F. Paulson PhD,Ruth Garland, James F. Paulson PhD,Ruth Garland, Lawrence, Pasquinelli MD, Donald Lewis Lawrence, Pasquinelli MD, Donald Lewis MDMD
Over 250 charts reviewed in 2 practices of Over 250 charts reviewed in 2 practices of children who were overweight or obese.children who were overweight or obese.
Overweight before age 2
FindingsFindings
Over half the children in study became Over half the children in study became overweight overweight beforebefore age 2. age 2.
All patients were obese or overweight by age 10All patients were obese or overweight by age 10 The rate of gain is approximately The rate of gain is approximately 1 excess BMI 1 excess BMI
unit/yearunit/year, therefore causing most children to be , therefore causing most children to be overweight by age 2. overweight by age 2.
Critical period for preventing childhood obesity in Critical period for preventing childhood obesity in this subset of identified patients is this subset of identified patients is during the during the first 2 years of lifefirst 2 years of life and for many by 3 months of and for many by 3 months of age. age.
Intervention for obesity Intervention for obesity will have to be earlier!!!!will have to be earlier!!!!
But what can we do?But what can we do?
Recognize Early!!!Recognize Early!!!
Growth CurveGrowth Curve
■
■
■
The Rapidly Gaining Infant
2 %iles crossedshould raise a red flag
Do Fat Babies Grow Faster?Do Fat Babies Grow Faster?
Parents always say he is hungry and Parents always say he is hungry and growing (growing (The Buddha BabyThe Buddha Baby)) Overweight/Obese infants and children will Overweight/Obese infants and children will
grow faster due to growth hormone overload.grow faster due to growth hormone overload. The problem is their overall height will be The problem is their overall height will be
unchanged. They just grow faster earlier.unchanged. They just grow faster earlier.
FeedingFeeding
VS
Breast vs Bottle and ObesityBreast vs Bottle and Obesity
Breast feeding is protective- probably due Breast feeding is protective- probably due to the infants ability to “to the infants ability to “self-regulate”self-regulate”
Longer breast feeding more protection up Longer breast feeding more protection up until 1 year.until 1 year. This is an inverse proportionThis is an inverse proportion
• ↑ ↑ in time breastfeeding, ↓ BMIin time breastfeeding, ↓ BMI
Bottle feeding increased risk for obesityBottle feeding increased risk for obesity ↑ ↑ protein in formula may stimulate insulinprotein in formula may stimulate insulin
Warning signs for overfeedingWarning signs for overfeeding
Rapid weight gain in infant (crossing 2 Rapid weight gain in infant (crossing 2 %iles upward from 25 to 75%)%iles upward from 25 to 75%)
Weight outpacing heightWeight outpacing height Parent shows skills of feeding while not Parent shows skills of feeding while not
watching infant- missing satiety cueswatching infant- missing satiety cues Bottle proppingBottle propping
Bottle fedBottle fed
Must watch for infant cues of being fullMust watch for infant cues of being full Head turningHead turning RegurgitantRegurgitant Paced feedingPaced feeding Tongue thrustTongue thrust Drool feedingDrool feeding
Making the diagnosis in infantsMaking the diagnosis in infants
Obese infants in large practice in Texas Obese infants in large practice in Texas 16%16%
Obese child at 6 months 20X more likely Obese child at 6 months 20X more likely to be obese at 24 monthsto be obese at 24 months
Only 10% of infants at 24 months who Only 10% of infants at 24 months who were obese were diagnosed as that in were obese were diagnosed as that in practice practice
Can Intervention Work?Can Intervention Work?
Study done by one solo pediatrician in NY Study done by one solo pediatrician in NY Followed 100 infant pairs to age 2Followed 100 infant pairs to age 2 One group taught to self-regulate intake by 15 One group taught to self-regulate intake by 15
months. Other group did not, parent fed.months. Other group did not, parent fed. Self-regulating group only one BMI > 85%Self-regulating group only one BMI > 85% 42% of non-regulated group with BMI> 85%42% of non-regulated group with BMI> 85% This difference continued even after attempts This difference continued even after attempts
to crossover groupsto crossover groups
Feeding is hard-wired to Feeding is hard-wired to take in the amount of take in the amount of
calories you need.calories you need.
Strong Satiety SignalStrong Satiety Signal
Guidelines for feeding Guidelines for feeding advice in the infant/toddleradvice in the infant/toddler
AgeAge Nutrition Nutrition
RecommendRecommend
Feeding Feeding
BehaviorsBehaviors
Birth-Birth-
6 months6 months
Breast milk Breast milk only – with Vit.only – with Vit.
D supplementD supplement
Review hunger Review hunger and satiety and satiety cuescues
AgeAge Nutrition Nutrition
RecommendRecommend
Feeding Feeding
BehaviorsBehaviors
6-11 6-11 monthsmonths
-Continue-Continue
breastfeedingbreastfeeding
-avoid high salt, -avoid high salt, fat, and fat, and sugar foodssugar foods
- 4-6 oz of - 4-6 oz of 100% juice100% juice
--
-sit in high -sit in high chair at tablechair at table
- - NO TV!NO TV!
AgeAge Nutrition Nutrition
RecommendRecommend
Feeding Feeding
BehaviorsBehaviors
> 12 > 12 months- months- toddler toddler yearsyears
-low fat milk-low fat milk
-no soda or -no soda or sugar drinkssugar drinks
- Fruits and - Fruits and vegetablesvegetables
-eat meals at -eat meals at tabletable
-wean bottle 15 -wean bottle 15 monthsmonths
-parent decides -parent decides food and food and portion: child portion: child decides how decides how muchmuch
And No TV !!!And No TV !!!
At least limitedAt least limited
Obesigenic Society
Solid foodsSolid foods
Later introduction of solids after 6 months Later introduction of solids after 6 months shows correlation with lower BMIshows correlation with lower BMI
Self regulation as early as possibleSelf regulation as early as possible Let the infant/toddler feed themselves by 11-Let the infant/toddler feed themselves by 11-
12 months12 months
AgeAge Nutrition Nutrition
RecommendRecommend
Feeding Feeding
BehaviorsBehaviors
PreschoolPreschool -low fat milk-low fat milk
-3 meals 2 -3 meals 2 snackssnacks
- At table with At table with parent and parent and no TVno TV
- 6 oz fruit 6 oz fruit juicejuice
-Do not use -Do not use food as a food as a reward or reward or punishmentpunishment
Sleeping
SleepSleep
Regular and consistent bedtime routineRegular and consistent bedtime routine Infant who sleeps > 12 hours has less risk Infant who sleeps > 12 hours has less risk
of obesity. This was a negative linear of obesity. This was a negative linear relationship. relationship. Less sleep more obesityLess sleep more obesity
Greater affect on boys versus girlsGreater affect on boys versus girls
Family Dynamics
Three important household routinesThree important household routines
Eating an evening meal as a familyEating an evening meal as a family
Getting 8-10 hours of sleep at nightGetting 8-10 hours of sleep at night
Limited TV/Screen timeLimited TV/Screen time
40% lower obesity40% lower obesity
BMI increase riskBMI increase risk
Subtle neglectSubtle neglect Inadequate supervisionInadequate supervision Poor social engagementPoor social engagement
EthnicityEthnicity African AmericanAfrican American HispanicHispanic American IndianAmerican Indian
What about Exercise?What about Exercise?
Let’s MoveLet’s Move
What we need (0-5 years)What we need (0-5 years)
More physical activity, less screen timeMore physical activity, less screen time Need to actually move!Need to actually move! Need safe parks, playgrounds, and Need safe parks, playgrounds, and
recreational facilities. recreational facilities. Daycares need to be promoting activity Daycares need to be promoting activity
and movement and movement Less energy dense foods and sugar in dietLess energy dense foods and sugar in diet Walking school busesWalking school buses
Many common routes to Many common routes to the same problemthe same problem
ConclusionsConclusions
Obesity prevention starts before pregnancy.Obesity prevention starts before pregnancy. Breast feeding needs to be supported by MDs Breast feeding needs to be supported by MDs
and in the workplaceand in the workplace Limit or eliminate TV and screen time and Limit or eliminate TV and screen time and
enhance physical activityenhance physical activity Parents need to let child regulate intake earlyParents need to let child regulate intake early Physicians need to measure BMI and promote Physicians need to measure BMI and promote
healthy diets through education healthy diets through education
White House Task Force White House Task Force RecommendationsRecommendations
More prenatal care and education for parents More prenatal care and education for parents about appropriate weightabout appropriate weight
Promote breastfeeding via peer counselors, Promote breastfeeding via peer counselors, more accommodations in the work place and more accommodations in the work place and daycaredaycare
Network with child-care to provide healthier food Network with child-care to provide healthier food and better activity for kidsand better activity for kids
Improve food labels and decrease marketing to Improve food labels and decrease marketing to kids of energy dense foods/sugarkids of energy dense foods/sugar
Improve access to healthy affordable food Improve access to healthy affordable food
What we are up againstWhat we are up against
For ExampleFor Example
Widening the roads and a bridge in Widening the roads and a bridge in Chesapeake to include a bike path. Chesapeake to include a bike path. Would increase the cost of the project by Would increase the cost of the project by 1%. The bike path was defeated because 1%. The bike path was defeated because no one thought it was important to have no one thought it was important to have and was an excessive cost. and was an excessive cost.
We wish it were as easy We wish it were as easy as just saying “No” as just saying “No”
Thank You!Thank You!
Questions???Questions???