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Obesity in AdolescentsObesity in Adolescents
Gilberto A. Velez-Domenech, M.D.Gilberto A. Velez-Domenech, M.D.
New York Medical CollegeNew York Medical College
Department of PediatricsDepartment of Pediatrics
Division of Adolescent MedicineDivision of Adolescent Medicine
OutlineOutline DefinitionsDefinitions EpidemiologyEpidemiology Etiology and Influencing FactorsEtiology and Influencing Factors PubertyPuberty Influence and Effects on HealthInfluence and Effects on Health PreventionPrevention TherapyTherapy ResourcesResources
Overweight and ObesityOverweight and Obesity
Body weight above an arbitrary standardBody weight above an arbitrary standard
Excess body fatExcess body fat
Often defined in relation to heightOften defined in relation to height
Body Mass Index (BMI)Body Mass Index (BMI)
BMI=Wt(Kg)/Ht(m)BMI=Wt(Kg)/Ht(m)22
Expert Committee on Clinical Guidelines Expert Committee on Clinical Guidelines for Overweight in Adolescent Preventive for Overweight in Adolescent Preventive Services (Himes and Dietz, 1994)Services (Himes and Dietz, 1994)
Correlation of 0.7 to 0.8 with body fat Correlation of 0.7 to 0.8 with body fat contentcontent
Children and AdolescentsChildren and Adolescents
At risk for Overweight = BMI above the At risk for Overweight = BMI above the 8585thth and up to the 95 and up to the 95thth percentile for age percentile for age
Overweight = BMI above the 95Overweight = BMI above the 95thth percentile for agepercentile for age
Young Adults and AdultsYoung Adults and Adults
BMI > 25 kg/mBMI > 25 kg/m22
ChartsCharts
Standard CDC ChartsStandard CDC Charts
Methods that use just height and weight Methods that use just height and weight are cheap and easy to use but do not are cheap and easy to use but do not reflect regional body fat distribution.reflect regional body fat distribution.
Skin fold measurements are susceptible to Skin fold measurements are susceptible to inter-observer error.inter-observer error.
Highly technical methods are precise but Highly technical methods are precise but expensive and limited to research settingsexpensive and limited to research settings
SummarySummary
EpidemiologyEpidemiology
60 to 70% of obese adolescents are female60 to 70% of obese adolescents are female 80 to 85% of obese adolescents will become 80 to 85% of obese adolescents will become
obese adults.obese adults. If a child is obese at age 12 the odds are 4:1 If a child is obese at age 12 the odds are 4:1
against attaining IBW as adultsagainst attaining IBW as adults If a child is obese after adolescence the odds If a child is obese after adolescence the odds
are 28:1 against attaining IBW as adultsare 28:1 against attaining IBW as adults
EpidemiologyEpidemiology
Serdula, 1995. National Study: 44% of Serdula, 1995. National Study: 44% of female students and 15% of male students female students and 15% of male students were trying to loose weight.were trying to loose weight.
ExerciseExercise: 51% female / 30% of male: 51% female / 30% of male Skipping MealsSkipping Meals: 49% female / 18% male: 49% female / 18% male Diet PillsDiet Pills: 4% female / 2% male: 4% female / 2% male VomitingVomiting: 3% female / 1% male: 3% female / 1% male
National Health and Nutrition National Health and Nutrition Examination Survey (NHANES)Examination Survey (NHANES)
Age GroupNHES 2
1963-1965NHES 3
1966-1970NHANES I1971-1974
NHANES II1976-1980
NHANES III1988-1994
NHANES1999-2000
Total 5.0 5.0 7.2 10.4
Male 5.0 4.7 6.1 9.9
Female 4.9 5.3 8.2 11.0
Total 4.2 4.0 6.5 11.3 15.3
Male 4.0 4.3 6.6 11.6 16.0
Female 4.5 3.6 6.4 11.0 14.5
Total 4.6 6.1 5.0 10.5 15.5
Male 4.5 6.1 4.8 11.3 15.5
Female 4.7 6.2 5.3 9.7 15.5
12-19
2-5
6-11
Trends in Overweight for Children Trends in Overweight for Children by Age Groupby Age Group
NHES 21963-1965 NHES 3
1966-1970 NHANES I1971-1974 NHANES II
1976-1980 NHANES III1988-1994 NHANES
1999-2000
2-5
6-11
12-190.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
Percent
Trends in Overweight for Male Trends in Overweight for Male Children by Age GroupChildren by Age Group
NHES 21963-1965 NHES 3
1966-1970 NHANES I1971-1974 NHANES II
1976-1980 NHANES III1988-1994 NHANES
1999-2000
2-5
6-11
12-190.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
Percent
Survey
Trends in Overweight for Female Trends in Overweight for Female Children by Age GroupChildren by Age Group
NHES 21963-1965 NHES 3
1966-1970 NHANES I1971-1974 NHANES II
1976-1980 NHANES III1988-1994 NHANES
1999-2000
2-5
6-11
12-190.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
Percent
Survey
Overweight Children by Age and Overweight Children by Age and Race/Ethnicity: NHANES 1999-2000Race/Ethnicity: NHANES 1999-2000
2-5
6-11
12-19
Non-Hispanic White
Non-Hispanic Black
Mexican American
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
45.0
Percent
Age Group
Overweight Male Children by Age & Overweight Male Children by Age & Race/Ethnicity: NHANES 1999-2000Race/Ethnicity: NHANES 1999-2000
2-5
6-11
12-19
Non-Hispanic White
Non-Hispanic Black
Mexican American
0.0
5.0
10.0
15.0
20.0
25.0
30.0
Percent
Age Group
2-5
6-11
12-19
Non-Hispanic White
Non-Hispanic Black
Mexican American
0.0
5.0
10.0
15.0
20.0
25.0
30.0
Percent
Age Group
Overweight Female Children by Age & Overweight Female Children by Age & Race/Ethnicity: NHANES 1999-2000Race/Ethnicity: NHANES 1999-2000
Etiology & Influencing FactorsEtiology & Influencing Factors
Cause still unclearCause still unclear 5% of Obese Children and Adolescents 5% of Obese Children and Adolescents
have an underlying specific causehave an underlying specific cause 3% = Endocrine3% = Endocrine
HypothyroidismHypothyroidism Cushing SyndromeCushing Syndrome HypogonadismHypogonadism
2% Rare Syndromes (Prader-Willi et. al.)2% Rare Syndromes (Prader-Willi et. al.)
Familial or GeneticFamilial or Genetic
Swedish Twin StudiesSwedish Twin Studies 1 Parent Obese = 30% Risk1 Parent Obese = 30% Risk 2 Parents Obese = 70% Risk2 Parents Obese = 70% Risk
Stunkard (1986)Stunkard (1986) BMI correlation between adoptees and BMI correlation between adoptees and
biological parentsbiological parents No correlation with adoptive parentsNo correlation with adoptive parents
Stunkard (1990)Stunkard (1990) High correlation BMI between twinsHigh correlation BMI between twins
Fat Cell TheoryFat Cell Theory
Fat cells gained early in life and during Fat cells gained early in life and during puberty cannot be lost, only reduced in puberty cannot be lost, only reduced in size.size.
Overfeeding early in first year of life and Overfeeding early in first year of life and during puberty increases the number of fat during puberty increases the number of fat cellscells
Adolescents who have propensity to Adolescents who have propensity to obesity have increased number of fat cellsobesity have increased number of fat cells
Activity and Energy ExpenditureActivity and Energy Expenditure
Dietz (1993) stated that the most powerful Dietz (1993) stated that the most powerful predictor of the development of obesity in predictor of the development of obesity in adolescence was the time that a child 6 to adolescence was the time that a child 6 to 11 years of age spends viewing television, 11 years of age spends viewing television, even after controlling for other variables.even after controlling for other variables.
BehaviorBehavior Eating FastEating Fast Skipping breakfast and/or lunch and eating Skipping breakfast and/or lunch and eating
the majority of calories at night.the majority of calories at night. Eating when not hungry but when food is Eating when not hungry but when food is
availableavailable Eating when appetite is stimulated by Eating when appetite is stimulated by
environmental cuesenvironmental cues Eating when depressed or anxiousEating when depressed or anxious Eating in association with other activitiesEating in association with other activities Overindulging in “Fast Foods”Overindulging in “Fast Foods”
Central Regulation TheoryCentral Regulation Theory
The hunger or satiety center in the The hunger or satiety center in the hypothalamus may not function properly in hypothalamus may not function properly in suppressing appetite.suppressing appetite.
Psychological TheoryPsychological Theory
Obese individuals are depressed or Obese individuals are depressed or anxious and use eating as a means to anxious and use eating as a means to alter their mood.alter their mood.
Body Image TheoryBody Image Theory
Obese adolescents have a distorted fat Obese adolescents have a distorted fat body image.body image.
One cannot achieve weight change until One cannot achieve weight change until one has visualized a smaller body image one has visualized a smaller body image and become comfortable with it.and become comfortable with it.
Hormonal TheoryHormonal Theory
LeptinLeptin Encoded by the obese geneEncoded by the obese gene Produced by the adipose tissueProduced by the adipose tissue Signal satiety and alter eating behaviorSignal satiety and alter eating behavior Monitors and controls body fat and energy Monitors and controls body fat and energy
balancebalance
Pubertal Changes: Effects of Pubertal Changes: Effects of Puberty on Body CompositionPuberty on Body Composition
Lean Body Mass increases in Both SexesLean Body Mass increases in Both Sexes More in Male than in Females because of the More in Male than in Females because of the
greater increase in skeletal muscle mass under greater increase in skeletal muscle mass under the effect of testosterone.the effect of testosterone.
Maximum increase in muscle mass occurs at the Maximum increase in muscle mass occurs at the time of PHV in both sexestime of PHV in both sexes
Maximum fat deposition occurs 2 years before Maximum fat deposition occurs 2 years before PHV and in females it continues throughout PHV and in females it continues throughout pubertypuberty
Ultimately female adults have more body fat Ultimately female adults have more body fat than males than males
Pubertal Changes: Effects of Pubertal Changes: Effects of Obesity on PubertyObesity on Puberty
Taller and larger in skeletal mass and Taller and larger in skeletal mass and more advanced in skeletal development.more advanced in skeletal development.
Earlier sexual maturation and menarche.Earlier sexual maturation and menarche.
Higher levels of hemoglobin/hematocrit.Higher levels of hemoglobin/hematocrit.
Menstrual Irregularities Menstrual Irregularities
Influence and Effects on Health Influence and Effects on Health Psychosocial ConsequencesPsychosocial Consequences
Poor Body ImagePoor Body Image Social Isolation for fear of rejection and non-Social Isolation for fear of rejection and non-
acceptance by peersacceptance by peers Gortmaker, 1993. 7-year Study of 16-24 y/oGortmaker, 1993. 7-year Study of 16-24 y/o
Obese Obese ♀ ♀ completed fewer years of schoolcompleted fewer years of school Less likely to be marriedLess likely to be married Lower household incomesLower household incomes Higher rates of povertyHigher rates of poverty
Low self-esteemLow self-esteem DepressionDepression
Influence and Effects on Health Influence and Effects on Health General Morbidity and MortalityGeneral Morbidity and Mortality
Obese adolescents who become obese Obese adolescents who become obese adults will have more severe obesity than adults will have more severe obesity than those adults whose obesity began in those adults whose obesity began in adulthood.adulthood.
Greater morbidity and mortality due to Greater morbidity and mortality due to cardiovascular diseasecardiovascular disease
Effect of adolescent obesity on adult Effect of adolescent obesity on adult morbidity and mortality is independent of the morbidity and mortality is independent of the effect of adolescent obesity on adult weight.effect of adolescent obesity on adult weight.
Influence and Effects on HealthInfluence and Effects on Health
HypertensionHypertension Cerebrovascular DiseaseCerebrovascular Disease Cardiovascular DiseaseCardiovascular Disease Serum LipidsSerum Lipids Diabetes Mellitus (Type 2)Diabetes Mellitus (Type 2) Polycystic Ovary SyndromePolycystic Ovary Syndrome CancerCancer Skeletal Deformity and ArthritisSkeletal Deformity and Arthritis
PreventionPrevention
1.1. During PregnancyDuring Pregnancy Moderate weight gain during 3Moderate weight gain during 3rdrd trimester trimester
2.2. During Infancy and ChildhoodDuring Infancy and Childhood Breast feed in first year of lifeBreast feed in first year of life Delay cereals until 3 to 4 months of ageDelay cereals until 3 to 4 months of age Be sensitive to the deceleration of growth at Be sensitive to the deceleration of growth at
18 months of age18 months of age
PreventionPrevention
3.3. During Puberty and AdolescenceDuring Puberty and Adolescence Encourage healthy nutritional practices in Encourage healthy nutritional practices in
early puberty (Remember the fat cells)early puberty (Remember the fat cells)
Encourage lifestyle of activity and Encourage lifestyle of activity and participation through role modelingparticipation through role modeling
Discourage TV, DVD and videotape Discourage TV, DVD and videotape watching and video game use.watching and video game use.
PreventionPrevention
Reducing television, videotape,Reducing television, videotape,
DVD and video game use may beDVD and video game use may be
the most promising populationthe most promising population
based approach to prevention ofbased approach to prevention of
childhood obesity.childhood obesity.
Treatment: General AspectsTreatment: General Aspects
HUGE CHALLENGE!!!HUGE CHALLENGE!!! Determine who is at greater riskDetermine who is at greater risk
In the absence of complications obesity is In the absence of complications obesity is clinically significant when Wt is over 20 – 30% clinically significant when Wt is over 20 – 30% IBW for height and age.IBW for height and age.
If complications are present it is always If complications are present it is always clinically significant.clinically significant.
Focus on control, not cureFocus on control, not cure Ascertain Ascertain motivationmotivation..
Treatment: Critical AreasTreatment: Critical Areas
MotivationMotivation
Supportive Social and Family FrameworkSupportive Social and Family Framework
Willingness to increase physical activityWillingness to increase physical activity
Realistic GoalsRealistic Goals
Diet: General PrinciplesDiet: General Principles
Deficit of 500 kcal/day = 1 lb wt loss/weekDeficit of 500 kcal/day = 1 lb wt loss/week Food typesFood types Eating habits (Patient and Family)Eating habits (Patient and Family) Situation-dependent eatingSituation-dependent eating Family and cultural preferencesFamily and cultural preferences Good nutritional balance among food Good nutritional balance among food
groups.groups.
Diets: General PrinciplesDiets: General Principles
Energy NeedsEnergy Needs Males = [900 + (10 x W0] x Activity FactorMales = [900 + (10 x W0] x Activity Factor Females = [800 + (7 x W)] x Activity FactorFemales = [800 + (7 x W)] x Activity Factor
Activity FactorActivity Factor Low Activity = 1.2Low Activity = 1.2 Moderate Activity = 1.4Moderate Activity = 1.4 High Activity = 1.6High Activity = 1.6
Energy required to maintain each Kg of Energy required to maintain each Kg of body weight = 22 Kcalbody weight = 22 Kcal
DietsDiets
KetogenicKetogenic Very-low-calorie (< 400 Kcal/day)Very-low-calorie (< 400 Kcal/day) Glycemic IndexGlycemic Index Prolonged fastingProlonged fasting Special food combinations (Steak and Special food combinations (Steak and
Grapefruit Diet)Grapefruit Diet) Balanced Low-calorie (~1200 Kcal/day)Balanced Low-calorie (~1200 Kcal/day)
Balanced DietBalanced Diet
Foods from five groups: dairy, meat, Foods from five groups: dairy, meat, bread, fruits and vegetablesbread, fruits and vegetables
Three meals per dayThree meals per day Eat less food or calories than previouslyEat less food or calories than previously Instructions for food preparationInstructions for food preparation Instructions for food substitution (L vs H)Instructions for food substitution (L vs H) Instructions for food shoppingInstructions for food shopping
Physical ActivityPhysical Activity
Walking instead of riding the car or busWalking instead of riding the car or bus
Stairs instead of elevatorsStairs instead of elevators
Not using the channel flipperNot using the channel flipper
Exercise prescription: Over 30 min per day Exercise prescription: Over 30 min per day / 4 days per week of anything acceptable/ 4 days per week of anything acceptable
Cognitive Behavioral TherapyCognitive Behavioral Therapy
1.1. Contract and reward systemContract and reward system2.2. Initial food diaryInitial food diary
Time spent eatingTime spent eating PlacePlace Hunger ratingHunger rating MoodMood Associated activityAssociated activity Food consumedFood consumed AmountAmount
Cognitive Behavioral TherapyCognitive Behavioral Therapy
3.3. Behavior ChangeBehavior Change Eat three regular mealsEat three regular meals Eat favorite dish firstEat favorite dish first For a particular food eat favorite part firstFor a particular food eat favorite part first Eat defensively: Avoid “junk food”Eat defensively: Avoid “junk food” Eat slowly, chew – swallow – reloadEat slowly, chew – swallow – reload Do not keep “weakness food”Do not keep “weakness food” Eat where eating is meant to occurEat where eating is meant to occur
Cognitive Behavioral TherapyCognitive Behavioral Therapy
3.3. Behavior Change (Cont.)Behavior Change (Cont.) Do not watch TV while eatingDo not watch TV while eating Do not eat on the goDo not eat on the go Learn difference between Appetite & HungerLearn difference between Appetite & Hunger Eat when hungry, not when food is availableEat when hungry, not when food is available Have a breakout activity when depressed, Have a breakout activity when depressed,
anxious or unhappyanxious or unhappy Be honest about lapses in controlBe honest about lapses in control
GroupsGroups
Encouragement and supportEncouragement and support Release of feelingsRelease of feelings Peer contact and acceptancePeer contact and acceptance Non-commercialNon-commercial
TOPSTOPS Overeaters AnonymousOvereaters Anonymous
CommercialCommercial Weight WatchersWeight Watchers Diet WorkshopDiet Workshop Jenny CraigJenny Craig Richard Simmons SlimmonsRichard Simmons Slimmons
OtherOther
Anorexigenic drugsAnorexigenic drugs
Bariatric surgeryBariatric surgery
ResourcesResources
1.1. BooksBooks The Hilton Head Diet for Children and Teenagers: The Hilton Head Diet for Children and Teenagers:
The Safe and Effective Program That Helps Your The Safe and Effective Program That Helps Your Child Overcome Weight Problems for Good,Child Overcome Weight Problems for Good, by by Peter M. Miller (Warner Books, Inc., 1993)Peter M. Miller (Warner Books, Inc., 1993)
Girl Power in the Mirror: A Book about Girls, Their Girl Power in the Mirror: A Book about Girls, Their Bodies and Themselves,Bodies and Themselves, by H. Cordes (Lerner by H. Cordes (Lerner Publishing Group, 1999)Publishing Group, 1999)
Safe Dieting for Teens,Safe Dieting for Teens, by Linda Ojeda and Lisa by Linda Ojeda and Lisa Lee (Hunter House, Inc., 1992)Lee (Hunter House, Inc., 1992)
ResourcesResources
2.2. Web SitesWeb Sites http://www.niddk.nih.gov/health/nutrit/pubs/chohttp://www.niddk.nih.gov/health/nutrit/pubs/cho
ose.htmose.htm. Choosing a safe weight reduction program . Choosing a safe weight reduction program from NIHfrom NIH
http://www.health.gov/dietaryguidelines/http://www.health.gov/dietaryguidelines/. . Dietary GuidelinesDietary Guidelines
http://www.niddk.nih.gov/health/nutrit/pubs/preshttp://www.niddk.nih.gov/health/nutrit/pubs/presmeds.htmmeds.htm. Prescription medications for obesity. Prescription medications for obesity
http://www.niddk.nih.gov/health/nutrit/win.htmhttp://www.niddk.nih.gov/health/nutrit/win.htm. . Weight-control Information NetworkWeight-control Information Network
