Nutrition and ObesityDavid Freestone, DOPGY 1 UNSOM Dept. of Pediatrics

ACGMEPatient Care

Medical Knowledge

Practice Based Learning and Improvement

Systems Based Practice

Professionalism

Interpersonal Skills and Communication

ObjectivesBrief overview of general nutrition

Understand consequences of poor diet

Understand what components of diet most contribute to obesity in pediatrics

Know what AAP guidelines are regarding prevention and treatment of obesity

Know local resources available to us in helping overweight/obese in Las Vegas

NutritionWho here has taken a course on nutrition?

A class?

A lecture?

Heard the word nutrition in medical school?

NutritionYet who feels that “good nutrition” correlates with “good health”?

Who here feels that they have a healthy lifestyle with good nutrition?

Why I am interested in nutrition

Undergraduate Ethnobotany

Study of culture and botany

A whole new world opened up to me describing how we use plants with focus on agriculture and medicine

Shamans use of plants and herbs for healing is basis for a lot of medicinal compounds used today.

Instead of a pill they would use mixtures of plants in belief that there would be a synergistic effect to the desired primary healing component.

This really made me think about what I put in my body

The Western DietProcessed Foods

Refined grains

Saturated fats and transfats

Lots of meat

High starch

Low fiber

High fructose corn syrup in everything

The Western DietGoogle search:

How Western Diets are Making the World Sick

Western Diet Ups Heart, Diabetes Risk

The western diet and lifestyle and diseases of civilization

Western Diet Tied to Intestinal Disease and Allergies

Western diet changes gut bacteria and triggers colitis in those at risk

Western Diet Linked to Inflammatory Bowel Disease

Diet Related Conditions(Not an all encompassing list)

Behavior

Allergies

Malnutrition/deficiencies

Cancers

CAD

Obesity

Metabolic syndrome

Government Recommendations (USDA)

SuperTracker: 

My foods. Get your personalized nutrition and physical activity plan.

My fitness. Track your foods and physical activities to see how they stack up.

My health. Get tips and support to help you make healthier choices and plan ahead.

Government Recommendations

“The thing to keep in mind about the USDA [recommendations] is that it comes from the Department of Agriculture, the agency responsible for promoting American agriculture, not from agencies established to monitor and protect our health…. What’s good for some agricultural interests is not necessarily good for the people who eat their products.” – Chair of the Department of Nutrition at Harvard School of Public Health

Nutrition & ResearchWhere does nutrition fit?

NIH distributes funds for research.

Out of 27 institutes and centers…

Nothing is dedicated to nutrition alone.

Under Health information on Child and Teen the closest topic to nutrition is “Alcohol abuse”.

AAP GuidelinesNutrition and obesity-related Policy Statements:

Breastfeeding and the Use of Human Milk

Expert Committee Recommendations on Prevention, Assessment and Treatment of Child and Adolescent Overweight and Obesity

Dietary Recommendations for Children and Adolescents (By AHA endorsed by AAP)

Prevention of Pediatric Overweight and Obesity

Active Healthy Living

Bright Bodies – Promoting Healthy Nutrition

These are a few of many helpful documents

Obesity

Obesity

Skin Acanthosis nigricans

Major dietary contributors of obesity and metabolic syndrome

Toward a Unifying Hypothesis of Metabolic Syndrome. Pediatrics. Feb. 2012

Branched Chain Amino Acids, Trans-fats, Ethanol

Fructose

Consumption trends parallel raise of obesity and metabolic syndrome

Partially converted to glucose, mainly converted to Fructose-1-phosphate (insulin independent)

Lipogenic precursors are created in liver leading to steatosis.

All 4 macronutrients overwhelm mitochondrial function resulting in ROS generation, excessive Denovo Lipogenesis, and impaired β oxidation.

Major dietary contributors of obesity and metabolic syndrome

Toward a Unifying Hypothesis of Metabolic Syndrome. Pediatrics. Feb. 2012

Branched Chain Amino Acids, Trans-fats, Ethanol

Fructose

Consumption trends parallel raise of obesity and metabolic syndrome

Partially converted to glucose, mainly converted to Fructose-1-phosphate (insulin independent)

Lipogenic precursors are created in liver leading to steatosis.

All 4 macronutrients overwhelm mitochondrial function resulting in ROS generation, excessive Denovo Lipogenesis, and impaired β oxidation.

Prevention of Metabolic Syndrome

Decrease substrate consumption

Particularly lipogenic substrate

Reduction in hepatic substrate flux

Increase fiber

↓Glycemic load (glycemic index × CHO(gm)/100)

↓lipogenesis and hepatic lipid export

Increase substrate clearance

Exercise

DRI Macronutrient Requirements

Age/Group Carbohydrates (g/d) Fiber (g/d) Fat (g/d) Protein (g/d)

0-6 mo 60 ND 31 9.1

6-12 mo 95 ND 30 11

1-3 y 130 19 ND 13

4-8 y 130 25 ND 19

Male 3-13 y 130 31 ND 34

14-18 y 130 38 ND 52

Female 9-13 y 130 26 ND 34

14-18 y 130 26 ND 46

ND = Not determinable due to lack of data of adverse effects in this age group and concern with regard to lack of ability to handle excess amounts. Source of intake should be from food only to prevent high levels of intake.

Expert Committee Recommendations:Eating, physical activity, and sedentary behaviors

Limit consumption of sugar-sweetened beverages

Encourage 9 servings a day of fruits and vegetables

limit screen time. (AAP recommends <2 hours)

Eat breakfast daily

Limit eating out

Encourage family meals

Limit portion size

Include high fiber diet

Balance macronutrient intake

60 minutes of moderate to vigorous activity daily

Limit consumption of energy-dense foods

Expert Committee Recommendations:Primary care providers

Assess obesity risk of all patients

Provide anticipatory guidance on healthy behavior

Check BMI at each well-child visit

Don’t treat obesity like AOM

Use the chronic care model

Chronic Care Model

Family/PatientSelf Management

EnvironmentFamilySchool

WorksiteCommunity

Medical SystemInformation systemsDecision supportDelivery system designSelf-management support

Expert CommitteeStudies since recommendations show that there is mixed adherence

Mainly surveys and no RCT

Obesity programs are following the expert committee recommendations while primary care is about 50%

No data to support effectiveness of recommendations, but a lot of data are used to create recommendations

We won’t know if it works unless we try

Management programs

Let’s Move

Bright Bodies

Smart Moves

5, 2, 1, 0

Focus on a Fitter Future: A Survival Guide to Planning, Sustaining, and Building a Pediatric Obesity Program.

Study assessing these programs declared:

“Effectiveness was greater when program objectives were specific, implemented across the school environments, extended into the community, and were culturally relevant”

Local ResourcesHealthy Hearts ProgramChildren's Heart Center

Guide To A Healthy Lifestyle

Achieving A Healthy Weight

Healthy Meals In Minutes

Recommended Reading For Parents

What Do Healthy People Do?

What's A Parent To Do?

Preventive Cardiology For Children

Healthy Lifestyles Newsletter

Criteria for referralBMI > 95th percentile (obesity not a diagnosis)

(Metabolic syndrome)HyperlipidemiaHypertensionFamily history of cardiac risk factorsCardiac RehabAges

Nutrition consult: 0-18 years12-week program: ages 7-18

Laboratory MarkersGlucoseLFT’sFasting lipid panelInsulinHgA1CThyroid panelHigh Sensitivity (Cardio) CRP

How it works…Referred to CHC by pediatrician

OV with pediatric cardiologist(EKG, Echo, Labs)

Nutrition Consult with R.D.

F/U x 3 months with R.D. Enroll into 12-week program

SummeryWe have patients who are overweight, obese, and/or at risk of becoming overweight or obese.

We need to be able to identify these patients

We need to educate on proper nutrition and healthy lifestyle.

We need to know resources available to us.

We need to constantly reevaluate how our methods are working for our patients.

Things to watch forAAP Committee on Nutrition will release statement on nutrition recommendations for children ≤4 yrs for preventing obesity in the coming months.

ReferencesCox P, Balik M. Plants, People, and Culture: The Science of Ethnobotany. New York : Scientific American Library;1997

Cordain L, Eaton SB, Sebastian A, et al. Origins and evolution of the Western diet: health implications for the 21st centery. Am J Clin Nutr 2005;81:341–54.

www.google.com re:western diet

Greene A. Feeding Baby Green – The Earth-Friendly Program for Healthy, Safe Nutrition During Pregnancy, Childhood, and Beyond. San Francicso: Jossey-Bass; 2009.

McCann D, Barrett A, Cooper A, et al. Food additives and hyperactive behaviour in 3-year-old and 8/9-year-old children in the community: a randomised, double-blinded, placebo-controlled trial(2007) Lancet, 370 (9598), pp. 1560-1567.

Environmental and Nutritional Diseases. In: Robbins SL, Kumar V, Abbas AK, Cotran RS, Fausto N. Robbins and Cotran: Pathologic Basis of Disease ed. 8. Philadelphia: W.B. Saunders Company, 2010. eBook.

http://www.choosemyplate.gov/

http://www.nih.gov/icd/

AAP Policy Statement: Breastfeeding and the Use of Human Breast Milk. Pediatrics vol. 115:496-506, 2005.

Barlow SE. Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report. Pediatrics vol. 120:S164-192, 2007.

Gidding SS, Dennison BA, Birch LL et al. Dietary Recommendations for Children and Adolescents, A Guide for Practitioners, Consensus Statement from the American Heart Association. Circulation vol112:2061-2075, 2005

AAP Committee on Nutrition: Prevention of Pediatric Overweight and Obesity. Pediatrics vol. 112:424-30, 2003.

AAP Council on Sport Medicine and Fitness and Council on School Health. Active Healthy Living: Prevention of Childhood Obesity Through Increased Physical Activity. Pediatrics. vol. 117:1834-42, 2006.

Bremer AA, Mietus-Snyder M, Lustig R. Toward a unifying Hypothesis of Metabolic Syndrome. Pediatrics vol. 129:557-570, 2012.

Lustig R. Fructose: Metabolic, Hedonic, and Societal Parallels with Ethanol. Journal of the American Dietetic Association vol 110:1307-21, 2010.

Johnson T, Weed LD, Touger-Decker R. School-based interventions for overweight and obesity in minority school children. J Sch Nurs. 2012 Apr;28(2):116-23. Epub 2011 Oct 24.

Kranz S, Brauchla M, Slavin JL, and Miller KB. What Do We Know about Dietary Fiber Intake in Children and Health? The Effects of Fiber Intake on Constipation, Obesity, and Diabetes in Children. Adv Nutr January 2012 Adv Nutr vol. 3: 47-53, 2012.

Eisenmann JC. Assessment of Obese Children and Adolescents: A Survey of Pediatric Obesity-Management Programs. PEDIATRICS Vol. 128 No. S51-58, 2011

Rausch JC, Perito ER, Hametz P. Obesity Prevention, Screening, and Treatment: Practices of Pediatric Providers Since the 2007 Expert Committee Recommendations. CLIN PEDIATR vol. 50: 434-441, 2011

Questions?