The Skinny on Childhood Obesity and Type 2 Diabetes

1
The Skinny on Childhood Obesity and Type 2
Diabetes

• Ryan Brown, MD

2
Introduction

• Prevalence of Obesity in US
• How to calculate BMI
• Basic introduction to the pathophysiology of type
  2 diabetes in children
• How to screen and diagnose type 2 diabetes in
  children

3
OBESITY
4
Obesity in the Media
5
(No Transcript)
6
Body Mass Index (BMI)

• Calculated as
• kg/m2 OR (lbs/inches2)x 703
• Used to define overweight and obesity
• Correlates well with more accurate measure of
  body fatness
• Correlates with obesity-related co-morbid
  conditions

7
Body Mass Index

• Category BMI for age
• Underweight lt 5th percentile
• Normal Between 5th and
• 84th percentile
• Overweight Betweeen 85th-
• 94th percentile
• Obese 95th-99th percentile
• Severely Obese gt99th percentile

8
(No Transcript)
9
Prevalence of Overweight Among U.S. Children and
Adolescents(Aged 219 Years)
Source CDC/NCHS and NHANES
10
Prevalence of Overweight1 Among U.S. Children and
Adolescents(Aged 2 19 Years)National Health
and Nutrition Examination Surveys
11
How we compare to the Nation

• Children 10-17 years old (BMI 95th percentile)
• 1- Washington, DC
• 17- Oklahoma
• 51- Utah
• Adults (BMI 30)
• 1- Mississippi
• 8- Oklahoma/Arkansas
• 51- Colorado
• F as in Fat, Trust for Americas Health report,
  2008

12
Dr. Pepper-1885 Coke-1886 1st McDonalds-1955
Doritos
HFCS introduced
MTV hits the air
Pong introduced
13
Timeline

• 1885- Dr. Pepper invented(Coca-Cola-1886
  Pepsi-1902)
• 1930- Twinkies invented
• 1946- Regular TV Broadcasting
• 1955- First McDonalds Opens
• 1966- Doritos invented
• 1975- First drive thru McDonalds Opens
• 1975- High fructose Corn Syrup hits the market
• 1976- Pong video game hits
• 1981- MTV debuts
• 1982- PC becomes mainstream
• 1994- Internet becomes mainstream
• 2000- Cellphones become mainstream

14
Percentage of high school students who were
overweight-2003 (based on the Youth Risk
Behavioral Survey)
15
Percentage of high school students who were
overweight-2005 (based on the Youth Risk
Behavioral Survey)
16
Youth Risk Behavior Survey-Oklahoma

• 2003 2005
• At risk for becoming overweight 14 16
• Overweight 11 15
• Largest increase of any participating state
• Ate healthy fruit/vegetable lt5/d
• during the past 7 days 86 84
• Had not participated in any vigorous
• or moderate physical activity in the
• past 7 days 8 12

17
How we compare to the Nation(based on Youth Risk
Behavior Survey-2005)
18
(No Transcript)
19
Percentage of overweight children told by a
doctor or health professional that they were
overweightAge group (yrs) Percentage2-5 1
7.46-11 32.612-15 39.616-19 51.6
Children begin to respond to environmental
cues regarding dietary patterns by age 5 Early
onset of childhood obesity is associated with
higher BMI in adulthoodCenters for Disease
Control MMWR 200554848-849.Rolls BJ, et al.
Serving portion size influences 5 year old but
not 3 year old childrens food intakes. J Am Diet
Assoc. 2000 100232-234.Freedman DS, et al.
Relationship of childhood obesity to coronary
heart disease risk factors in adulthood the
Bogalusa Heart Study. Pediatrics 2001108712-8.
20
Problems Associated with Obesity

• Hypercholesterolemia
• Dyslipidemia
• Hypertension
• Hyperinsulinism
• Insulin resistance
• Impaired glucose tolerance
• Type 2 Diabetes
• Menstrual irregularity
• Genu varum

• Slipped capital femoral epiphysis
• Nonalcoholic steatohepatitis
• Microalbuminuria
• Depression
• Low self esteem
• Obstructive sleep apnea
• Asthma

American Academy of Pediatrics Policy Statement.
Prevention of Pediatric Overweight and Obesity.
Pediatrics 2003112424-430.
21
Abdominal Fat

• Associated with
• High blood pressure
• Glucose intolerance/Type 2 diabetes
• Abnormal cholesterol triglycerides
• Rule of Thumb
• Your waist should be equal to or less than
  one-half your height

22
Maternal obesity surgery results in fewer obese
offspring

• 45 children born before bypass surgery (Mean
  maternal BMI-48)
• 172 children born after bypass surgery (Mean
  maternal BMI-31)
• Normal weight
• 36 for kids born to mothers before surgery vs.
  57 for kids born after surgery
• Therefore, Birth after surgery decreased
  prevalence of obesity by 52 and severe obesity
  by 45

23
DIABETES
24
Classification

• Type 1 (10)
• -The body does not make insulin
• -AKA Juvenile onset, Insulin dependent
• Type 2 (90)
• - Relative insulin resistance
• -AKA Adult onset, Non-insulin dependent
• Gestational diabetes affects about 4 of all
  pregnancies

25
Diabetes Definition

• Syndrome characterized by inappropriate fasting
  and postprandial hyperglycemia due to a
  disturbance in the metabolism of carbohydrate,
  protein, and fat resulting from a deficiency of
  insulin secretion or its action.
• Most common endocrine disorder of childhood and
  adolescence.

26
Type 2 Diabetes in Children-timeline

• Rare, prior to 1990s (about 4)
• By 1994, up to 16 of new cases were type 2 (J
  Pediatr, 128608, 1996)
• By 1999, 8-45 of all new cases in US were type 2
  (Diabetes Care, 22345, 1999)
• About 1 out of every 3 new cases!

27
And How Big of a Problem is it, Really?

• For a US child born in 2000, the overall lifetime
  risk of getting diabetes is..

Narayan, V, et al,Lifetime Risk for Diabetes
Mellitus in the United States, JAMA, October 8,
2003Vol 290, No. 14
28
Male Female 32.8 38.8

• Hispanic
• Male Female
• 45.4 52.5

• Black
• Male Female
• 40.2 49.0

29
If you are 50 years old today, and do not yet
have diabetes, your risk of getting it is..
30
Male Female 25.5 28.2

• Black
• Male Female
• 36.1 40.8

• Hispanic
• Male Female
• 40.3 43.6

31
How does this compare to other health problems?

• Breast Cancer 1 in 8 women
• Coronary Heart Disease 1 in 2 men
• 1 in 3 women
• Diabetes gt 1 in 3 women
• almost 1 in 3 men

32
Oklahoma

• In our OKC clinic, approximately 1 in 3 new-onset
  patients with diabetes is DM2
• Among OK Medicaid patients, gt50 of children with
  diabetes are DM2
• In Native American communities, gt50 of children
  with diabetes are DM2, and 75 of new-onsets are
  DM2

33
(No Transcript)
34
Diabetes Trends Among Adults in the
U.S.,(Includes Gestational Diabetes) BRFSS
1995-96
Obesity Trends Among U.S. AdultsBRFSS, 1995-96
Source Mokdad et al., Diabetes Care
2000231278-83.
Diabetes
Obesity
35
Diabetes Trends Among Adults in the
U.S.,(Includes Gestational Diabetes) BRFSS 1990
Obesity Trends Among U.S. AdultsBRFSS, 1990
Diabetes
Source Mokdad et al., Diabetes Care
2000231278-83.
Obesity
36
Diabetes Trends Among Adults in the
U.S.,(Includes Gestational Diabetes) BRFSS 2000
Obesity Trends Among U.S. AdultsBRFSS, 2000
Source Mokdad et al., J Am Med Assoc 200128610.
Diabetes
Obesity
37
Diabetes Trends Among Adults in the
U.S.,(Includes Gestational Diabetes) BRFSS 2001
Obesity Trends Among U.S. AdultsBRFSS, 2001
Source Mokdad et al., J Am Med Assoc 200128610.
Diabetes
Obesity
38
Type 2 Diabetes-etiology
Decreased physical activity
Increased visceral fat
Puberty
Calorie dense diet
Gender
Hyperinsulinemia
Insulin resistance
Genetic predisposition
39
Type 2 diabetes is a complex metabolic disorder
of heterogeneous etiology with social,
behavioral, and environmental risk factors
unmasking the effects of genetic susceptibility

• (Diabetes Care 200023381-389.)

40
Recommendations of the OU Childrens Diabetes
Center

• The child at high risk for DM2 should be screened
  every 2 years after age 10 or at the onset of
  puberty.
• Type 2 diabetes risk factors include
• Overweight,with a BMI greater than the 85th
  percentile for age and sex
• Plus any two of the following three risk factors
• 1.  Signs of insulin resistanceacanthosis
  nigricans, polycystic ovary syndrome,
  dyslipidemia, hypertension.
  
  
  2.  Family history of type 2 diabetes, including
  having a mother who experienced gestational
  diabetes.
• 3.  EthnicityNative American, African American,
  Hispanic, Asian/Pacific Islander

41
Recommendations of the OU Childrens Diabetes
Center (contd)

• What tests should be ordered in patients who are
  at-risk?
• Draw a random plasma blood glucose immediately in
  any at-risk patient who has symptoms.
• Perform 2 hour OGTT or obtain a 2 hour
  post-prandial plasma glucose, with fasting (1)
  plasma glucose, (2) insulin, (3) HbA1c, and (4)
  lipid profile drawn at baseline.
• Call us at any time for advice and questions
  [phone]

42
Criteria for Diagnosis

• Symptoms of diabetes (polyuria, polydipsia,
  polyphagia) plus casual plasma glucose
  concentration 200 mg/dl
• Or
• Fasting plasma glucose 126 mg/dl
• Or
• Two hour plasma glucose 200 mg/dl during an
  OGTT(WHO criteria 75g load)
• (Diabetes Care 200023381-389.)

43
Recommendations of the OU Childrens Diabetes
Center (contd)
Definitions Fasting Serum Glucose Normal
70-100 mg/dl Impaired Fasting Glucose
100-125 mg/dl Diabetes gt126 mg/dl Two
Hour Glucose Tolerance Test Normal lt139
mg/dl Impaired Glucose Tolerance 140-199
mg/dl Diabetes gt200 mg/dl
44
Recommendations of the OU Childrens Diabetes
Center (contd)

• If diabetes is present (FBS gt 126 mg/dl random
  or 2 hr PP or OGTT gt 200 mg/dl), refer
  immediately for management.

45
Recommendations of the OU Childrens Diabetes
Center (contd)

• If diabetes is not yet present..
• Dietary counsel
• Start with pop.drink water!
• Program of physical activity (no TV/video games
  until 30 min/day exercise completed)
• Lifestyle change
• Involve the whole family
• Praise, praise, praise
• Frequent contact (weekly or monthly weights)

46
More suggestions

• Leave the cordless phone on station
• No TV during meal times
• No Junk food in the house-go out for ice cream
• Eat as a family when possible-in the mini van on
  the way to practice doesnt count
• Park away from the store entrance
• Move during favorite TV show
• Plan your weekly menu ahead of time
• Have a shopping list and dont deviate

47
Bariatric Surgery (age 15-19)

• 1996-2000
• 996
• 2001-2003
• 1747

Arch Pediatr Adolesc Med. 2007 161217-221.
48
(No Transcript)
49
(No Transcript)
50
(No Transcript)
51
Fun Facts

• Big Mac, large fries, and a large Coke 1372
  calories
• Average walking speed 3 miles/hr
• For a 120 lbs child, walking one hour would burn
  215 calories
• SO, you would have to walk for over 6 hours
  straight (or nearly 20 miles) to burn off the
  meal!

52
Fun Facts

• ONE 20 oz Coca-Cola 270 kcals
• 1 lbs of fat 3500 kcals
• If a someone drinks on the average two 20 oz
  cokes a day without compensatory diet and
  exercise, they would gain ONE POUND A WEEK
  (That is over 50 lbs in one year)

53
Fun Facts

• By consuming 100 less calories/day, a person can
  lose 10 pounds a year.
• The reverse is also true
• By consuming 100 more calories/day, a person
  could gain 10 pounds a year.

54
Fun Facts

• Milk
• 1 cup whole 146 calories
• 1 cup 2 122 calories
• 1 cup skim 91 calories
• Coffee 1 cup regular ground 2 calories
• Sugar- 1 level teaspoon 16 calories
• Half and half creamer- 1 tablespoons 20 calories
• Mayonnaise
• 1 tablespoon regular 100 calories
• 1 tablespoon fat free 12 calories
• Cheese
• 1 oz slice of American 112 calories
• 1 oz slice of 2 American 50 calories

55
Juice A Hidden Culprit

• 100 Grape Juice (8 ounces)
• 164 calories
• 41 grams carbohydrates
• 100 Apple Juice (8 ounces)
• 124 calories
• 31 grams carbohydrates
• Red Bull (8.3 ounces)
• 115 calories
• 28 grams carbohydrates
• Coca Cola (8 ounces)
• 108 calories
• 27 grams carbohydrates
• Gatorade (lemon-lime) (8.1 ounces or ¼ bottle)
• 50 calories
• 14 grams carbohydrates

56
AAP Guidelines

• Juice should not be introduce before 6 months of
  age
• Limit juice intake to on 4-6 oz/d for kids age
  1-6 years old and 8-12 oz/d for children
  adolescents 7-18 years old
• Fruit juice offers no nutritional benefits over
  whole fruit, and it does not contain the fiber
  fruit does

AAP. The use and misuse of fruit juice in
pediatrics. Pediatrics 20011071210-1213.
57
AAP Recommendations

• Calculate and plot BMI once a year in all
  children and adolescents
• Use change in BMI to identify rate of excessive
  weight gain relative to linear growth
• Encourage and support breastfeeding
• Limitation of television and video time to a
  maximum of 2 hours per day
• Help those who influence youth to discuss health
  habits, NOT BODY HABITUS, as part of their
  efforts to control overweight and obesity

American Academy of Pediatrics Policy Statement.
Prevention of Pediatric Overweight and Obesity.
Pediatrics 2003112424-430.
58
(No Transcript)
59
Fast Food Capital of the US

• Oklahoma City-Ranked number 15 in Americas
  Fattest Cities by Mens Fitness
• In 2006, 55 of fast food patrons dined at
  restaurant at least 12 times per month

60
THANK YOU

• QUESTIONS??

Ryan-Brown_at_ouhsc.edu