This conference focused on the causes of childhood obesity and possible interventions, with an examination of obesity from the perspectives of dental health, psychology, occupational therapy and pharmacy

Jobst, Erin E.

Miller, Catherine

English

CommonKnowledge

Pediatric Obesity
What can WE do to help?
Interdisciplinary Case Conference
Pacific University
College of Health Professions
April 2007 
fHow are overweight and obesity de ined?
• Obesity: chronic metabolic disease 
resulting from an imbalance between 
energy intake and energy output. 
– Defining feature is excess body fat
• Body mass Index (BMI): mass in kg/height 
in m2
• BMI: published tables to determine weight 
status
– Underweight:  BMI < 18.5 kg/m2
– Normal: BMI 18.5-24.9 kg/m2
– Overweight:   BMI 25-29.9 kg/m2
– Obese: BMI ≥ 30 kg/m2
2
Why become involved in curbing the obesity epidemic?
• > 60% of American adults are now       
overweight or obese, predisposing 
them to a host of chronic diseases.
• Age-adjusted prevalence of combined    
overweight and obesity in ethnic 
minorities - especially in minority 
women - is generally higher than in 
hitw es.
– Non-Hispanic White women: 57.2%
– Mexican-American women: 71.7%
– Non-Hispanic Black women: 77.2%
• Total economic cost:  $122.9 billion
3(Data from Weight-control information network, NIH)
Data shown in the following maps were collected through CDC’s 
Behavioral Risk Factor Surveillance System (BRFSS) Each year
NOTE:
     .  , 
state health departments use standard procedures to collect data 
through series of monthly telephone interviews with U.S. adults. 
During past 20 years there has been dramatic increase in obesity 
in US In 1985 only few states were participating in the CDC's .  ,         
Behavioral Risk Factor Surveillance System (BRFSS) and 
providing obesity data. In 1990, 4 states had obesity prevalence 
rates of 15–19 percent and no states had rates at or > 20%. In 
1995 obesity prevalence in each of 50 states was < 20% In,          .  
2000, 28 states had obesity prevalence rates < 20%. In 2005, only 
4 states had obesity prevalence rates < 20%, while 17 states had 
prevalence rates equal  to or > 25%, with 3 of those having 
prevalences equal to or > 30 %(Louisiana Mississippi West     , ,  
Virginia).
4
Obesity Trends* Among U.S. Adults
BRFSS 1994, 
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
5
No Data           <10%          10%–14% 15%–19% 
Obesity Trends* Among U.S. Adults
BRFSS 1995, 
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
6
No Data           <10%          10%–14% 15%–19% 
Obesity Trends* Among U.S. Adults
BRFSS 1996, 
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
7
No Data           <10%          10%–14% 15%–19% 
Obesity Trends* Among U.S. Adults
BRFSS 1997, 
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
8
No Data          <10%           10%–14% 15%–19%          ≥20%
Obesity Trends* Among U.S. Adults
BRFSS 1998, 
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
9
No Data          <10%           10%–14% 15%–19%          ≥20%
Obesity Trends* Among U.S. Adults
BRFSS 1999, 
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
10
No Data          <10%           10%–14% 15%–19%          ≥20%
Obesity Trends* Among U.S. Adults
BRFSS 2000, 
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
11
No Data          <10%           10%–14% 15%–19%          ≥20%
Obesity Trends* Among U.S. Adults
BRFSS 2001, 
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
12
No Data          <10%           10%–14% 15%–19%           20%–24%        ≥25%
Obesity Trends* Among U.S. Adults
BRFSS 2002
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
, 
13
No Data          <10%           10%–14% 15%–19%           20%–24%        ≥25%
Obesity Trends* Among U.S. Adults
BRFSS 2003, 
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
14
No Data          <10%           10%–14% 15%–19%           20%–24%        ≥25%
Obesity Trends* Among U.S. Adults
BRFSS 2004, 
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
15
No Data          <10%           10%–14% 15%–19%           20%–24%        ≥25%
Obesity Trends* Among U.S. Adults
BRFSS 2005, 
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
16
No Data          <10%           10%–14% 15%–19%           20%–24%          25%–29%           ≥30%
How is “obesity” measured in children?
BMI-for-age: gender and age specific
Underweight BMI-for-age <5th percentile
BMI-for-age 5th to 85th
Healthy
    
percentile
BMI f 85 til t
At risk for overweight
- or-age  percen e o 
<95th percentile
Overweight
BMI-for-age ≥95th percentile
17Percentiles from CDC
Based on growth charts developed by CDC & contain series of curved lines representing different percentiles.
Term “childhood obesity” is commonly used; however , theCDC refrains from using the term- instead, refers to the condition 
as “overweight”.
Th t t f hildh d b ite ex en o  c oo  o es y
• Percentage of teens overweight 
has more than tripled since 
1980.
• 1/5 children (ages 6 – 11) are 
obese, an increase of 147% 
from 1971 to 1994.   
• ~60% of overweight children 
become overweight or obese 
adults…
18
Th i t f hildh d b ite mpac o  c oo  o es y
• Prevalence of type 2 diabetes mellitus in children is expected to           
exceed that of type 1 diabetes mellitus within the next 10 years.
• People who develop type 2 diabetes before the age of 20, as 
d t l t t t i k f d t l di doppose  o a er, are a  grea er r s  o  en -s age rena  sease an  
death before the age of 55 (Pavkov et al., July 2006).
• In a study of >100,000 women, those who were overweight at age 
18 were more likely to die prematurely in middle age (van Dam et 
al., 2006).
(van Dam et al., Annals of Internal Medicine, 2006)
(Pavkov et al JAMA July 2006)
19
 ., ,  
Health complications of overweight/obesity 
in children 
• Insulin resistance
• Type 2 diabetes  
• Hypertension
• Cardiovascular disease
• Dental caries
• Early onset of puberty
• Polycystic ovary syndrome 
• Cholecystitis
Depression•
• Eating disorders
• Sleep apnea
• Stroke
• Possible increased risk of cancer
• Decreased quality of life, self-esteem, social competence
• Premature death in women
20
A b t hildh d b itwareness a ou  c oo o es y
Research!America poll: Americans ARE aware of the•        
scope of the problem 
– > 1/3 of Americans say most American children are overweight
O l b 1 % f hild ( d 2 19 ) i h– n y a out 7  o  c ren age  -  years  are overwe g t
• IOM 2006 report- call to action in childhood obesity 
prevention
• Numerous local, regional, and national programs 
addressing the problem
– MoveOn, ShapeUp, Go for Health!, Y B FIT!, GoGirlGo!…
21
R i l di iti i hildh d b itac a  spar es n c oo  o es y
• African American and Hispanic children and 
adolescents have higher prevalence rates of 
overweight/obesity than do white 
children/adolescents, but they receive less care      
(Ogden and Flegal, JAMA, 2002).
– These children are also at greater risk for obesity-
associated complications (type 2 diabetes) than are white        
children (Rosenbloom et al., 1999).
22
C f hildh d b itauses o  c oo  o es y
• Increase in TV/computer use   
• Proliferation of fast-food restaurants
• Marketing of junk food to children by media
• Increase in consumption of fatty high fructose corn syrup laden    ,    -  
foods (displayed at “kid’s-eye view”)
• Schools offering junk food and soda 
• Decreased physical education classes in schools     
• Reduced affordable access to fresh foods
• Working parents unable to cook healthy meals or supervise 
outdoor activities 
• Less walking to school and more driving
• Suburban sprawl and urban crime preventing children from 
outdoor games and exercise
23
• And the list goes on…
Parameters included in successful intervention     
programs for childhood obesity
• Interdisciplinary multi-component approach
– Dietary component
– Behavioral modification
• Contracting 
• Self-monitoring
• Social reinforcement with participants and family to decrease fatty 
food consumption and increase activity level
– Parental involvement
24
Obesity and Oral Health
M ik Al SDHon a corn, 
Brandy Peer, SDH
Pacific University
Dental Health Science
25
  
Ob it d O l H lthes y an  ra  ea
• Nutrition is a key component of both oral and 
systemic health.
• Diet and nutrition have direct effects on 2 oral 
diseases.
– Dental caries (tooth decay)
– Periodontal disease
26
N t itiu r on 
• Obesity has been shown to have a link to food 
and lifestyle choices (IJAHSP, 2007).
E i i t k f d f t bl• xcess ve n a e o  sugars an  ermen a e 
carbohydrates increases susceptibility to tooth 
decay.
• Increasing body fat may heighten the 
inflammatory response associated with 
periodontitis as well as diabetes.
27
The Acid Attack  
•The formula:
Bacteria + Carbohydrate + Tooth Decay
(fermentable)
•After each meal or snack containing a carbohydrate, 
bacteria release an acidic byproduct which bathes the 
h i id f 20 i f h lteet  n ac  or up to  m nutes a ter t e mea .
•The more frequent the snacks, the more acid attacks on 
the teeth .
28
Dental Caries 
• Dental decay is one of the most chronic 
conditions affecting children today.
• It is now considered an epidemic by many 
health experts .
• 52% of American children by 8 years of 
age have caries (School Nurse News     , 
2007).
29
Why are dental caries important?    
• Untreated caries lead to:  
– Pain
Difficulty eating and poor food choices–      
– Low self-esteem due to appearance
Missed school days–   
– Inability to concentrate
D d d i f– ecrease  aca em c per ormance
30
This is a Preventable Disease    
• Oral health education is vital.
• Regular oral self-care and dental visits can 
maintain health and function.
• The mouth and body are interconnected.
– Oral disease negatively impacts the body.
I f ti d t i l ff t d– n ec on can sprea  o prev ous y una ec e  areas 
within the body.
31
Obesity and Periodontitis
“Obesity is a significant predictor for periodontal 
disease, no matter what your age, sex, race, or ethnic 
background.”
American Dental Association (ADA, 2006)
Ob it Ri k F t f P i d tities y - s  ac or or er o on s
Ob ti t h hi h t f• ese pa en s ave a g er ra e o  
periodontitis.
Increased percent of body fat is associated with a–          
higher level of inflammatory response
– Decreased vascularity to the periodontal structures
33
Periodontal Disease
• Inflammation of the gingiva
 
   
• Resulting in loss of supporting tooth structure 
(bone and tooth attachment to bone)
• Ultimately teeth are lost
34
Periodontal Disease
E b d b b d d i d• xacer ate  y ur ene  mmune system an  
systemic diseases
Ob it• es y
• Diabetes
f• Part o  a complex cycle with interrelated cause 
and effect
Obesity
Periodontal DiseaseDiabetes
35
 
Nutrition          Obesity          Diabetes
“The CDC predicts American children born      
in 2000 face an alarming 1 in 3 chance of 
developing diabetes” .
The Dental Hygienist’s Guide to Nutritional Care, 2005
36
Di b ta e es
• Obesity - major risk factor for Type 2 diabetes       
• Delayed healing response + increased 
inflammatory response = periodontal infections
• Affects all aspects of cardiovascular health, 
including blood vessels that supply the 
i d tiper o on um
37
Th R l f N t itie o e o  u r on
Di t h i h f d ff t l• e ary c o ces ave a pro oun  e ec  on ora  
health and overall health.
Di t h bit th t d t i t l t l h lth• e ary a s a  are e r men a  o ora  ea  
can be identified by a dietary analysis.
• Making practical dietary changes can     
dramatically improve both oral and overall 
health.
38
Assessing Nutrition
5 D F d Di
Example Day 1 Day 2 Day 3 Day 4 Day 5
 ay oo  ary
Breakfast Bowl 
cheerios
Milk
Morning 
Snacks
6 soda 
crackers
Peanut 
butter
Lunch Hamburger
French fries
Coke
Afternoon 
Snacks
Apple
Hershey 
bar
Dinner Fried 
chicken
salad/ranch
dressing
white roll
applesauce
39
Evening 
Snacks
1 scoop 
vanilla ice 
cream
Assessing Nutrition 
24 Hour Food Diary
Food/Beverage Serving Size 
(estimated)
Example Coke
Banana
12 oz can
Whole
Snickers
Vegetable Soup
1 King size
1 Cup
Breakfast
Morning Snacks
Lunch
Afternoon Snacks
Dinner
40Evening Snacks
Summary
Nutrition
Patients see their dental
practitioners more frequently
Dental hygienists are often
the first line of diagnosis  
than their physicians.
     
and treatment for patients.
Dental Health
Science
Oral Health Obesity
41
Behavior Modification 
Catherine Miller, Ph.D.
S h l f P f i lc oo  o  ro ess ona  
Psychology (SPP)
Th P bl f P di t i Ob ite ro em o  e a r c es y
• Weight gain and poor health are generally 
considered negative consequences that most 
people would like to avoid    .  
• Why, then, do children continue to exhibit 
behaviors such as overeating fatty foods and,       
engaging in sedentary activities, that lead to 
these negative consequences?  
43
Th P bl f P di t i Ob ite ro em o  e a r c es y
C• ommon answers:
– The child is lazy or has no will power
– Something happened in the child’s past which is affecting current 
behavior
• Main problems with these answers:
Blames the child rather than focusing on solutions–        
– Discourages action
• Instead, learning principles may help to determine what 
may be maintaining the behaviors that lead to obesity
44
L i P i i learn ng r nc p es
Principle 1: Behavior that is reinforced is more likely to be•            
repeated, while behavior that is punished is less likely to be 
repeated
• Principle 2: Reinforcement can be either positive or 
negative
A li ti t di t i b it• pp ca on o pe a r c o es y:
– Eating fatty foods and engaging in sedentary activities are reinforcing
– Positive reinforcement:  Fatty food tastes good
– Negative reinforcement:  Physical activity hurts and/or requires effort
45
L i P i i learn ng r nc p es
Principle 3: Immediate consequences have a MUCH•         
larger effect on behavior than delayed consequences
• Application to pediatric obesity: Good-tasting food and        
avoidance of physical exertion are immediate 
consequences, which are much more powerful than 
delayed weight gain or threat of long-term health        
problems
46
I t ti B d L i P i i ln erven ons ase  on earn ng r nc p es
f f f• Reduce opportunity or rein orcement o  sedentary 
behaviors and overeating
– Intervention:  Stimulus (or environmental) control 
– Remove fatty foods in the house, eat only at the dinner table, 
remove videogames from the home
• Increase reinforcement of healthy behaviors, such as 
increased consumption of healthy foods and increased 
physical activity
– Intervention:  Behavioral contracting
47
C id ti h C t tions era ons w en on rac ng
Sh t l ll i ti• or -range goa s; sma  approx ma ons
• Negotiation, not imposition
• Constructive language: focus on behavioral 
deficits rather than behavioral excesses
W itt f t• r en orma
48
El t f C t tiemen s o  on rac ng
• Behavior
• Length of contract
C• onsequences
– Positive reinforcements
Aversive consequences–  
• Method of data collection
• Review of progress  
• Signatures
49
Diffi lti h C t ticu es w en on rac ng 
S tti th t t i ht b h i ?• e ng e arge : we g  or e av or
• Specification of target
• Achievability of goals
• Availability and administration of reinforcers
• Accuracy of data collection
• Phases:  baseline, treatment, revisions
50
E l f C t tixamp e o  on rac ng
I t d th f ll i• , ______, agree o o e o ow ng:
– Walk the dog 2 times per week for 10 minutes each 
time
– Ride my bike to school 1 day per week
– Eat one serving of vegetables 1 day per week
– Eat one serving of fruit 1 day per week
• Mom will keep track of all of these; I will also 
k t k f lki d bik idieep rac  o  my wa ng an  e r ng.
51
E l f C t tixamp e o  on rac ng
• Possible reinforcers: Play videogames for 10       
minutes, play board game with mom
• Bonus: If I do all of them I can go to the mall on      ,        
Saturday.
• If I don’t meet my goals I will lose videogame     ,     
privileges for the weekend.
• This contract will be reviewed and possibly       
revised next week.
• Signatures
52
R h C t tiesearc  on on rac ng
B h i t ti ff ti th• e av or con rac ng more e ec ve an no 
treatment or attention-only controls
B h i t ti ff ti th• e av or con rac ng more e ec ve an 
nutrition education
• Parent involvement in contracting important for      
long-term maintenance (10-year follow-up data)
53
Pharmacologic and surgical 
interventions
• Reserved for patients that have increased 
risk from co-morbid conditions
Drug therapy–  
• Sibutramine (Meridia)
• Orlistat (Xenical, Alli)
• Metformin (Glucophage) 
– Bariatric surgery
• Safety and long-term outcomes
54
NOT the silver bullets   
55
Resources for Managing 
Pediatric Obesity
• Patient education
– Pamphlets
– Multi-media
• Clinical tools
• Professional information
• Advocacy
56
NIH Obesity Education Initiative –   
57
http://www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/index.htm
Meal Planner Tool  
58
Portion Distortion 
59
60
61http://discoveryhealthcme.discovery.com/childhoodobesity/childhoodobesity.html
Agency for Healthcare 
Research and Quality (AHRQ)
62http://www.ahrq.gov/child/dvdobesity.htm
63
64http://www.aap.org/obesity/
65
What’s new? 
66
Pediatric Obesity Research
• Harvard Growth Study
• Healthy People 2010
• Healthy Start
• Youth Risk Behavior Survey
67
Psychosocial Research
• Evaluating quality of life in research, includes 
social, emotional, physical, and school 
performance in children  
68
Treatment Research
• Appetite suppressants (e.g., Sibutramine)
• Diet
• Exercise
• Behavioral therapy
• Problem-solving
• Lifestyle changes for both child and family
69
Etiology Research
• Diet
• Media:  television, computers, videogames
• Genetics
• Parental lifestyle choices
• Exercise and physical fitness
70
f OFuture o  Pediatric besity
• Diet
• Media:  television, computers, videogames
• Parental lifestyle choices
• Exercise and physical fitness
71


The Growing Problem of Pediatric Obesity

https://commons.pacificu.edu/cgi/viewcontent.cgi?article=1005&amp;context=icc

The Growing Problem of Pediatric Obesity

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