Pediatric Obesity and Cardiovascular Health: What We Learned From the Cardiovascular Health Intervention Program (CHIP) Paul S. Visich PhD, MPH, University.

Pediatric Obesity and Cardiovascular Health: What We Learned From the

Cardiovascular Health Intervention Program (CHIP)

Paul S. Visich PhD, MPH, University of New EnglandBill Saltarelli, PhD, Central Michigan University

1. Understand the prevalence and implications of pediatric obesity

2. Understanding of the CVD risk factors observed in overweight andobese children along with structural and functional changes in one’sblood vessels.

3. How CVD risk factors are quantified (MetS)

4. Lessons learned from the CHIP

5. How do we alter the course of obesity in children? Is anything working?

Objectives

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%

BRFSS; Behavioral Risk Factor Surveillance Survey, www.cdc.gov/brfss

What About children and adolescents?

Trends in Obesity

1976 - 20082-5y, 5.0 to 10.4%

6-11y, 6.5 to 19.6% 12-19y, 5.0 to 18.1%

http://www.cdc.gov/obesity/childhood/index.html

Prevalence of Obesity among U.S. Adolescents aged 12-19y of age

Ogden, C. and M. Carroll, Division of Health and Nutrition Examination Surveys, June, 2010

Note: Native Americans/American Indians and Alaskan natives were found to have the highest rate of obesity

*

*

Percentage of High School students who were Obese*

* Obesity; BMI> to th 95th% for age and sex. Youth Risk Behavior Survey, 2003 and 2011

2003

2011

Geographic Similarities Between Adults and High School Students

Adults High School Students

State of Maine/2010

http://www.cdc.gov/brfsshttp://www.cdc.gov/HealthyYouth/yrbs/index.htmhttp://www.cdc.gov/pednss/pednss_tables/tables_health_indicators.htm

Adults62.9% overweight (BMI> 25)26.8% obese (BMI > 30) Vs 35.7% for US 2009-2010

Adolescents15.1% overweight (85th to < 95th%)12.5% obese (> 95th%)

Children (2-<5y of age)17.1% overweight (85th to < 95th%)14.3% obese (> 95th%) Vs 12.1% for US in 2010

Bottom Line or Waist Line for Children and Adolescents

17% of the US population 2-19y of age are obese

Since 1980 prevalence of obesity has almost tripled

There are significant racial and ethnic disparities inobesity prevalence among US children and adolescents

There was no change in the prevalence of obesity amongadults or children from 2007-2008 to 2009-2010

http://www.cdc.gov/obesity/childhood/index.html

S.J. Olshansky, etal. A Potential Decline in Life Expectancy in the United States in the 21st Century. N Engl J Med 352(11):1138-1144, 2005

Life

Exp

ecta

ncy

Year Born

How Much of an Impact is Obesity having on our children’s Health?

Contributing Factors to Obesity

Strong4Life, Atlanta Georgia (40% of the children are obese)

Meals Away From Home

From 1970 to the late 1990’s meals eaten away from home have nearly doubled

Ebbeling, CB, etal Lancet, 2002; 360(9331):473-482

Typically higher saturated and trans fat, higher glycaemic index, high energy density and larger portion sizes

Portion Sizes7-Eleven (1976)Gulps (20 ounces)Big Gulps (30 ounces)Super Big Gulps (40 ounces)Double Gulps (64 ounces), 1988 but reduced to 50 ounces this spring, why?

Caloric content of Double Gulp with Coca-Cola:600 calories (25% the recommended caloricIntake for a 30y old, 160 lb. man)

Interesting note:Mayor Bloomberg proposed a ban on the sale

of large size of sugary drinks in NYC

Price of Foods

Fruits and vegetables have increased inprice 118% from 1985 to 2000 whereas

prices for foods high in fats and oils has only increased by 35%

Major problem with those with a limited budget!

Influence of Technology on Obesity

- 26% of US children watched 4h+/day of TV per day- 67% watched at least 2h/day - Non-Hispanic black children had the highest rate of watching TV 4h+/day (42%)- The children that watched 4+h/day had significantly > %fat and BMI Vs those that watched < 2h/day

Andersen, R.E., JAMA, March 25, 1998, Vol 279, No. 12

Physical Activity and ObesityGeneral consensus (though not consistent) is that moderate/vigorous activity has a positive benefit in reducing adiposity in overweight/obese youths.

Physical activity recommendation: 60 minutes of combined moderate and vigorous activity daily. Problem: only 18.4% of our youth are achieving this recommendation (YRBS, 2009)

Daily PE in schools has dropped 33% from 1991 to 2009 (YRBS, 2009)

Davis, MM, etal, Pediatrics, 2007

Obesity and Socioeconomic Status in Children

Boys 2-19y

Girls 2-19y

0 5 10 15 20 25

PIR < 130%130%< PIR <350%PIR >350%

Percentage Obese

PIR: Poverty Income Ratio (130%= salary of $29,000 for a familyof four and 350%= salary of $77,000 for a family of four).Ogden, C.L., NCHS Brief, No. 51, December, 2010

Gender Differences with Obesity

< 12y of age, very little gender difference

12 to 17y, males more likely to become overweight

Possible reason: increased concern in respect to body self-image in females

Obesity and Type 2 Diabetes“Adult Onset”

Unheard of in children in the mid-1990s

With the obesity epidemic we have seen a rise in Type 2 Diabetes in children (10 fold increase in the last two decades)Hannon, TS, etal. Pediatrics. 2005;116(2):473-480

80% of Type 2 diabetics are overweight or obese

1 in 3 young people born in 2000 will develop Type 2 Diabetes (CDC)

http://www.kaiserhealthnews.org/Storeis/2011/March/22/Obesity-Type2-Diabetes-Children.aspx

What’s the Big Deal?Large percentage of children and adolescents (10-15y old) that are obese turn into obese adults (80%).

Prevalence of CHD is estimated to Increase 5-16% by 2035, with more than 100,000 cases of CHD attributed to the predicted increase in obesity. Bibbins-Domingo, K. etal, N Engl J Med.2007;57(23):2371-2379

The risk of increasing one’s CVD risk factors is significantlyhigher with obesity (not only in adults but also children)-

- hypertension- high cholesterol- low HDL-cholesterol- Type 2 diabetes- insulin resistance- Oxidative stress

Additional Health Risks- asthma, sleep apnea, fatty liver disease, formation of gall stones,orthopedic problems

Psychosocial Risks- social discrimination; lowself-esteem, hinder academic performance, social functioning, etc.

Pathophysiology and evidence of blood vessel changes

• The CVD process has been shown to begin in children as young as 2 years of age (Berenson et al, 1998).

• Multiple risk factors in children have been shown to persist into adulthood (i.e. tracking) (Boa et al, 1994).

Fatty streaks Plaque

Bogolossa

Direct evidence of blood vessel changes in children

Autopsy (Bogulosa Heart Study)

Vascular ultrasound evidence

Vascular Ultra-sound evidence1. Carotid artery-Intima-media thickness (IMT)

BMISystolic BP

Influence of Diet and Exercise on Individual Cardiovascular Risk Factors in Obese Children

(1 Year Program)

Variable Baseline 1 y Later

BMI (kg/m2) 24.6 22.4***

HDL-C (mg/dl) 46 50*

Trig.s(mg/dl) 111 92*

SBP(mmHg) 116 108**

DBP(mmHg) 62 55*

Glucose (mg/dl) 87 85

Insulin (mU/L) 16 8*

Insulin Resist. 3.5 1.9*

IMT (mm) .62 .55***

Subjects: 56 obese children, median age- 9y old

P<.05*, p<.01**, p<.001***

Wunsch, R. etal, Pediatrics118(6): 2334-2340, 2006

TreatmentNutrition and EatingBehavior Course

ExerciseTherapy

Psychological Family Counseling

2. Arterial ComplianceBrachial artery reactivity-Flow Mediated

Dilation

Physiological Process

Definition of Metabolic Syndrome“Clustering of CVD risk factors”

Children with multiple CVD risk factors (three or more) are more likely to have corresponding blood vessel changes (Strong et al, 1999).

METs link between: Insulin resistance

(Impaired glucose metabolism)Hypertension DyslipidemiaObesity

And the atherosclerotic process

Pediatr Clin N Am 58(2011) 1241-1255

Definitions of metabolic syndrome in children

IDF definition of metabolic syndrome in children Obesity (waist) plus 2 other factors

About 63 cm

Age 12-17 Total: 4.0% (0.6) Boys: 6.6% (1.3) Girls: 2.1% (0.6)

NHANES data 04Linear rise with age

Cardiovascular Health Intervention Program

Central Michigan UniversityCOLLEGE OF HEALTH PROFESSIONS

SCHOOL OF HEALTH SCIENCES

Bill Saltarelli, PhD and Paul Visich, PhD, MPH

Overall Purpose for Developing the CHIP

Awareness:To begin to make children and parents aware and personally responsible of their health by physically participating in a screening program to learn about their individual cardiovascular disease risk factors.

Personal Information:If a child and parent(s) knows what their health risks are, they are more likely to consider making changes to improve their health”

School Bus To CMU Finch Fieldhouse

Station # 1 Blood Lipids and

Glucose

Total Cholesterol HDL Cholesterol LDL Cholesterol Triglycerides Non-HDL

Cholesterol TC/HDL ratio Blood Glucose

Station # 2Assessment of Body Composition:

Height, Weight, Skinfold thickness, waist and hip circumference

Station # 3Heart Rate Monitor

(Resting Heart Rate)

Station # 4Resting Blood

Pressure

Station # 5Aerobic Capacity

Seven Minutes of Stepping to musicRecovery HR

A Healthy Lunch and Interactive Presentation on Physical Activity and Health Food choices

CMU Campus Tour

Tour Guide

CC

CMU Class HSC 586 (2011)

Screening CVD risk

Factors in children

1. Individual Child Reports Are Sent Home

120/80

RISK FACTOR Percent of Boys at

risk

Percent of Girls at

risk

Percent of children at

risk

BMI (Boys >20, Girls >21) 43.3 41.2 42.2Blood Pressure>90 percentile>119/7 Boys >118/76 Girls

28.8 28.1 28.6

Glucose (>100mg/dl) 28.2 21.5 28.6Cholesterol(TCL >170 or HDL <39)

63.1 61.2 62.1

Family History (parents or grandparents)

27.7 27.0 27.3

Physical Inactivity <5 days/wk/ 60min-all types PA

66.6 76.1 71.5

Cardiovascular Disease Risk Factors 2005-2008

Total N= 3022 Girls N=1550 Boys N=1472Mid-Michigan Children: Age= 11.7y (6th graders)

Percent of Children with Multiple CVD Risk Factors

Number of

CVDRF

Percent at Risk

CVDRFTotal

Percent of girls at each #

of CVDRF

Percent of boys at each #

of CVDRF

0 3.8 3.6 4.0

1+ 96.2 96.4 95.9

2+ 79.4 79.8 78.9

3+ 50.2 49.4 50.9

4+ 23.3 22.4 24.2

5+ 6.7 6.3 7.0

Girls N=1426

* 50% of the children express 3 or more CVDRF

Boys N=1441

Mid-Michigan Children: Age= 11.7y (6th graders)

Risk factor Risk Criteria % at risk

HDL-C <40mg/dl 20%

Triglycerides > 110mg/dl 26%

Waist Circumference

>90th percentile >81.4 cm boys 14%>79.7 cm girls 11%

Blood glucose > 110mg/dL .3%

Blood pressure 90th percentile>119/78 mmHg Boys, 8%>118/76mmHg) Girls 9%

Metabolic Syndrome“clustering of CVD risk factors”

Criteria for Metabolic syndromeWaist risk plus 2 more

CHIP=5.5%

NHANES=4.0%

Screen lipids of high risk kids (after 2 but before 10 yrs) if:1. Positive family history of CVD or dyslipidemia (<55 father<65 mother)2. History is not known3. BMI > 85th percentile (overweight or obese)4. Hypertension >95th percentile5. Smoker or diabetes

To screen or not to screen lipidsTo treat or not to treat dyslipidemia

Pediatrics 2008;122:198-208

Treatment 1. Population approach = for all children, healthy diet and increased PA2. Individual approach =

Overweight or obese with high triglyceride ( >150mg/dl) or low HDL (<40mg/dl) = diet and phisical activity counseling

3. > 8 years with LDL>160 with family history or > 2 CVD risk factors or LDL >130 with diabetes

= Pharmological intervention

Is the school the answer to correctObesity?

Reviewed 51 studies 4 wk-8yr15 in- school PE 17 health education models19 combination PE/health

Conclusion:No consistency of positive resultsin reducing obesity have been observed!!!!

Prevention/Treatment of Childhood Obesity Through the Developmental Stages

Perinatal: good prenatal nutrition, avoid excessive maternal wt. increase, control diabetes, help mothers lose wt. postpartum (nutrition education)

Infancy: breast feeding > 6 months of age, delay solid food until 6 months of age, provide balanced diet and avoid high-calorie snacks, follow wt. increase slowly

Preschool: develop healthy food preferences, appropriate parental feeding practices, monitor rate of wt. increase, provide child and parent nutritioneducation

Childhood: monitor wt. increase for ht., avoid prepubertal adiposity, nutrition education and encourage daily physical activity

Adolescence: prevent excess wt. increase after growth spurt, maintain healthy nutrition as next generation of parents, continue daily physical activity

Deckelbaum R., etal, Obesity Research,2001;9:239S-243S

Patient-Level Interventions for all children

1. Limit consumption of sugar-sweetened beverages2. Encourage consumption of recommend fruits and vegetables3. Limiting screen time4. Eating breakfast5. Limit restaurant eating6. Encouraging family meals7. Limiting portion size8. Limiting consumption of energy dense foods9. Eating diet rich in calcium and fiber10. Encourage breastfeeding11. Encourage physical activity 60 min each day of moderate and vigorous

Practice and Community level interventions

1. Advocate public policy changes to increase school physical activity 2. Advocate to preserve and enhance community physical activity facilities3. Make available resources for families to engage in physical activity

Addressing Obesity in Clinical Practice

EMR

15-Minute Obesity Prevention Protocol

Step 1 Access and discuss with parent and childBMI Diet

Fruits and vegetables, sweetened beverages, fast food, portion size etc.

Fast foodFamily mealsPortion size

Physical activity

Step 2. Set agendaSuggest one or 2 behaviors to be changed

Step 3. Assess motivation and confidence to begin change

Step 4 Help begin steps to change by suggesting resources

Step 5 Schedule a follow-up to evaluate and adjust plan

Motivational InterviewingAutonomy-supportive Counseling

American College of Sports Medicine

Exercise prescription every patient every time

Let’s Go!, a program of The Kids CO-OP at The Barbara Bush Children’s Hospital at Maine Medical Center, is implemented in partnership with MaineHealth. In addition, Let’s Go! and Maine CDC/DHHS have engaged in a public private partnership to improve the health of Youth and families through the work of the Healthy Maine Partnerships.