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Nutrition and Obesity

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Title: Nutrition and Obesity


1
Nutrition and Obesity
  • David Freestone, DO
  • PGY 1 UNSOM
  • Dept. of Pediatrics

2
ACGME
  • Patient Care
  • Medical Knowledge
  • Practice Based Learning and Improvement
  • Systems Based Practice
  • Professionalism
  • Interpersonal Skills and Communication

3
Objectives
  • Brief 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

4
Nutrition
  • Who here has taken a course on nutrition?
  • A class?
  • A lecture?
  • Heard the word nutrition in medical school?

5
Nutrition
  • Yet who feels that good nutrition correlates
    with good health?
  • Who here feels that they have a healthy lifestyle
    with good nutrition?

6
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

7
(No Transcript)
8
The Western Diet
  • Processed Foods
  • Refined grains
  • Saturated fats and transfats
  • Lots of meat
  • High starch
  • Low fiber
  • High fructose corn syrup in everything

9
The Western Diet
  • Google 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

10
Diet Related Conditions (Not an all encompassing
list)
  • Behavior
  • Allergies
  • Malnutrition/deficiencies
  • Cancers
  • CAD
  • Obesity
  • Metabolic syndrome

11
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.

12
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. Whats 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

13
Nutrition Research
  • Where 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.

14
AAP Guidelines
  • Nutrition 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

15
Obesity
16
Obesity
Skin Acanthosis nigricans
17
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 ß oxidation.

18
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 ß oxidation.

19
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

20
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.
21
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 lt2 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

22
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
  • Dont treat obesity like AOM
  • Use the chronic care model

23
Chronic Care Model
Environment Family School Worksite Community
Medical System Information systems Decision
support Delivery system design Self-management
support
Family/Patient Self Management
24
Expert Committee
  • Studies 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 wont know if it works unless we try

25
Management programs
  • Lets 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

26
Local Resources Healthy Hearts Program Children'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

27
Criteria for referral
  • BMI gt 95th percentile (obesity not a diagnosis)
  • (Metabolic syndrome)
  • Hyperlipidemia
  • Hypertension
  • Family history of cardiac risk factors
  • Cardiac Rehab
  • Ages
  • Nutrition consult 0-18 years
  • 12-week program ages 7-18

28
Laboratory Markers
  • Glucose
  • LFTs
  • Fasting lipid panel
  • Insulin
  • HgA1C
  • Thyroid panel
  • High Sensitivity (Cardio) CRP

29
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

30
Summery
  • We 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.

31
Things to watch for
  • AAP Committee on Nutrition will release statement
    on nutrition recommendations for children 4 yrs
    for preventing obesity in the coming months.

32
References

  • Cox P, Balik M. Plants, People, and Culture The
    Science of Ethnobotany. New York Scientific
    American Library1997
  • 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
    20058134154.
  • www.google.com rewestern 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.
    115496-506, 2005.
  • Barlow SE. Expert Committee Recommendations
    Regarding the Prevention, Assessment, and
    Treatment of Child and Adolescent Overweight and
    Obesity Summary Report. Pediatrics vol.
    120S164-192, 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
    vol1122061-2075, 2005
  • AAP Committee on Nutrition Prevention of
    Pediatric Overweight and Obesity. Pediatrics vol.
    112424-30, 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. 1171834-42,
    2006.
  • Bremer AA, Mietus-Snyder M, Lustig R. Toward a
    unifying Hypothesis of Metabolic Syndrome.
    Pediatrics vol. 129557-570, 2012.
  • Lustig R. Fructose Metabolic, Hedonic, and
    Societal Parallels with Ethanol. Journal of the
    American Dietetic Association vol 1101307-21,
    2010.
  • Johnson T, Weed LD, Touger-Decker R. School-based
    interventions for overweight and obesity in
    minority school children. J Sch Nurs. 2012
    Apr28(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

33
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