4/18/2013 Disclosures Facts & Fiction about Pediatric Obesity Treatm ent: Nutrition & Metabolic Health Im provem ent I have nothing to disclose Luis A. Rodríguez, RD, CNSC UCSF Benioff Children’s Hospital & WATCH Clinic May 20 13 Obesity Trends* Am ong U.S. Adults Outline BRFSS, 1 9 9 0 , 1 9 9 9 , 2 0 0 9 ( * BMI 3 0 , or about 3 0 lbs. overw eight for 5 ’4 ” person) 1990 1999 Adult and Pediatric Obesity Trends Health Consequences Associated with Obesity Genetics vs. Environmental Changes Fats, Proteins and Carbohydrates (sugars) 2009 Meal Trends, and Locations Screening Obesity and Metabolic Markers Nutritional Recommendations Other Recommendations Summary No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥ 30% Pediatric Obesity Epidemic Pediatric Obesity Epidemic (M. de Onis et al., 2010) 1
4/18/2013 Pediatric Obesity Epidemic Pediatric Obesity Epidemic Health Consequences Associated with Genetics and Hormonal Defects Childhood Obesity and Unhealthy Eating Im m ediate Health Im m ediate Health Chronic Health Conditions Chronic Health Conditions Problem s Problem s Genetic Syndromes Asthma Hypertension Prader-Willi Type 2 Diabetes Sleep Apnea Laurence-Moon/Bardet-Biedl Hypercholesterolemia Skin Infections Alstrom Hepatic Steatosis Turner’s Joint Pain Menstrual Abnormalities Ruvalcaba Heart Disease PCOS Lower Self-Esteem and Confidence Genetics and Hormonal Defects Environmental Changes Developmental Programming Food Supply Macronutrient Changes Prenatal Undernutrition (SGA) (Barker, 2004) Fats Dutch Famine Study (Roseboom et al., 2001) Proteins Prematurity Carbohydrates Overnutrition (LGA, GDM) (Boney et al., 2005) Meal Trends, and Locations Direct relationship of maternal Food Addictions? obesity with child obesity. Decreased Physical Activity Levels (Whitaker, 2004) 2
4/18/2013 Dietary Energy in Food Supply Macronutrient Changes over past 3 Decades Fat Total Kcal % decreased from 40% 30% since 1980’s Protein Kcal/ day ↑ 340 kcal/day per Stable at about 15% person Carbohydrate Starch 49 51% Fructose 8 12-15% (Chanmugam et al, 2003) (Putnam, 2002) Fats Fats Dietary Fat Dietary Source Medicinal Value or Danger Women’s Health Initiative Omega-3 Fatty Acids Wild fish, flaxseed oil Anti-inflammatory, lowers serum TG, repairs membranes Randomized controlled, prospective study from Monounsaturated Fatty Acids Olive and canola oil Stimulates Liver Metabolism, 1993-1998. reduces atherogenesis Polyunsaturated Fatty Acids Vegetable oils Anti-inflammatory, excess ~50,000 post-menopausal women. amount can cause immune dysfunction Goal to decrease Fat Calories and increase F/V and Saturated Fatty Acids Grass-fed animal meats, milk and Atherogenic in Familial dairy products, egg yolks Hypercholesterolemia grains. Fat decreased by 8%. Medium-chain triglycerides Palm oil, coconut oil, palm kernel Energy source, some suggestion oil of stimulation of atherosclerosis No significant risk reduction in CHD, stroke or CVD. Omega-6 fatty acids Farm-raised animals and fish Atherosclerosis, insulin (corn and soy fed) resistance, immune dysfuncion, pro-inflammatory (Howard et al, 2006) Trans fats Synthetic, processed food Atherosclerosis, NASH (Lustig, 2012; Perito et al., 2013) Proteins Sugar (Fructose) Increases nutrient consumption ● Branched Chain Amino Acids (L, I, V) Attenuated Ghrelin response Essential Amino Acids ● Reduced Insulin response, low Leptin rise. ● High concentration in corn (Teff et al., 2004) NASH pathogenesis and progression ● Increased insulin resistance d/t bypassing glycogen storage Liver is primary site for metabolism ● Fructose bypasses rate-limiting step of glycolysis ● Patients with metabolic syndrome have Preferentially metabolized to acetyl coA higher bloodstream levels ● Provides substrate for FFA (Perito et al., 2013) ● Increases Visceral Fat ● (Lustig, 2012; Newgard et al., 2009) (Elliot,2002; Lustig, 2012) 3
4/18/2013 Fructose Sugar (Fructose) Increased consumption 37gm fructose/day (1977-1978) 8% Kcal Intake American Heart Association Recommendation for Optimal Cardiovascular Health 55gm fructose/day 10.2% Kcal Intake 78gm fructose/day 12% Kcal Intake (Adolescents) Women 21gm sugar/day (1,800 Kcal/day) (Vos et al., 2008) Men 38gm sugar/day (2,200 Kcal/day) (Johnson et al., 2009) Fiction Calories “Beating obesity will take action by all of us, based Fiction Fiction Fact Fact on one simple com m on sense fact: All calories count, no matter where they come from, including A Calorie is A Calorie Calorie output is tightly Coca-Cola and everything else with calories…” regulated and -The Coca Cola Company, 2013 dependant on the quantity and quality of ingested calories. A Calorie Burned is a Calorie Burned. Fast Food Where Do People Eat When They Eat Out? 1/3 of U.S adults eat fast food 50% 45% Longitudinal studies show fast food 40% 35% intake predicts weight gain and 30% increased risk for T2D 25% 20% 15% 10% Fast food restaurants overrepresented in 5% 0% poorer neighborhoods; healthy alternatives harder to find Prevalence: 2.5/mile 2 vs. 1.5/mile 2 Low SES associated with increased fast food consumption Source: “Factors Influencing Lunchtime Food (Garber, Lustig, 2011) Choices among Working Americans”. 2009 4
4/18/2013 Is Fast Food Addictive? Is Fast Food Addictive? Sugar Caffeine Rodent Models demonstrate binging, “Flavoring agent” withdrawal (teeth chattering, tremors, shakes and anxiety) Increases salience of high rewarding Seeking and craving beverage. Well established psychological & physiological Cross-Sensitization dependence across age spectrum. Human Studies also suggest sugar is addictive with withdrawal Fructose increases liver and muscle insulin resistance ( Sung et al., 2011; Perito et al., 2013) Photo from cbsnews.com Blocks leptin’s ability to extinguish mesolimbic dopamine signaling Photo from: http://www.islandcrisis.net (Garber, Lustig, 2011) (Garber, Lustig, 2011) Is Fast Food Addictive? Exercise 33% Environmental Cues Percentage of youth who are actual couch Required to create addictive patterns potatoes, engaging in little or no leisure-time physical activity whatsoever Powerful external Stimuli trigger reward in animal and human Vulnerability to environmental cues may explain differences in 2/ 3 Proportion of teens that don’t meet the ability to follow a “diet” minimum recommended levels of physical activity of one hour a day of moderate to (Garber, Lustig, 2011) vigorous activity >2-3 Ads Daily number of hours children spend watching TV; more time than on any other 3-5 per 30 minutes during prime time TV. single activity except sleeping (Brown, 2002) <6% Percentage of high schools requiring daily PE Screening and Identification of Pediatric Obesity Exercise Fiction Fiction Facts Facts Children 0-24 months use WHO Growth Standards Exercise—even in absence of Exercise alone causes >97 th %ile for weight for length weight loss—decreases hepatic significant weight loss steatosis, and other lipotoxicity Children >2 years use CDC BMI curves markers. (Perito et al. 2013) 85-95 th %ile: Overweight Exercise builds muscle and >95 th %ile: Obese stimulates new mitochondrial development and improves insulin sensitivity Increases liver’s Krebs cycle speed (Lustig, 2012) 5
4/18/2013 Unhealthy Food Patterns Metabolic Markers Physical Assessment Acanthosis Nigricans (Axilla, neck, flexural areas) Beverages Marker of hyperinsulinemia Soda, Juice (any kind), energy drinks, coffee drinks Foods Lab values Fast food, pre-packaged, processed foods Fasting insulin, fasting BG, HgA1C Food environment ALT Eating in front of TV, chaotic environment, on the go Uric Acid Stress eating, binge eating, disordered eating Fasting Cholesterol Panel WATCH Clinic (Weight Assessment for Teen and Child Health) Clinical Treatment D I E T AN D E X E R CI S E ! …W H AT? Nutritional Recommendations Meals Breakfast ½ of your plate non-starchy Vegetables and Fruit Veggie Omelet, fruit, whole grain toast ¼ of your plate Whole Grains Old Fashion oatmeal, nuts, banana, milk Cereals >5gm fiber/serving Lunch Breads >3gm fiber/serving Cold Sandwich on whole grain bread, chicken breast/roast Other packaged >3gm fiber/~100Kcal beef, vegetables, cheese, fruit, water to drink Mixed greens salad with olive oil and vinegar, beans, ¼ of your plate Proteins High in Fiber or Healthy Fat tomatoes, cucumbers, whole grain bread Legumes, Nuts, wild fish, free range beef/poultry, eggs and dairy Dinner Plain, added-sugar free dairy Wild salmon/free range beef or poultry, brown rice, mixed sautéed vegetables Healthy Fats Whole grain pasta with tomatoes, bell peppers, onion, grilled Olive/Canola Oils chicken, mixed greens salad with olive oil/vinegar 6
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