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Impact of Obesity on Adolescents with CKD: From Diagnosis ...

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    • 1. Impact of Obesity on Adolescents With CKD: From Diagnosis Through Transplant Lauren Graf, MS, RD Montefiore Medical Center
    • 2. Prevalence of Overweight Among U.S. Children
      • 17% of children and adolescents are obese in the U.S. today
      • Over the past 20 years, the proportion of overweight children age 6-11years of age has nearly tripled
      • The rate of overweight adolescents age 12-19 has more than tripled.
      Information obtained from National Center for Health Statistics Available at: http://www.cdc.gov/nchs/products/pubs/pubd/hestats/overweight/overwght_child_03.htm
    • 3. Adopted from National Center for Health Statistics Available at: http://www.cdc.gov/nchs/products/pubs/pubd/hestats/overweight/overwght_child_03.htm
    • 4. Impact of Obesity on the Kidney Fat cell Kidney Microalbuminuria/proteinuria Glomerulopathy Fat secretes inflammatory cytokines Increased renal plasma flow (RPF) Enhances progression of other renal diseases Diabetic nephropathy Reduced renal survival after transplant Rutkowski et al. J Ren Nutr. 2006;16:216-223
    • 5. Incidence of Kidney Failure (per million population, 1990 by HSA unadjusted) Adopted from NKDEP, available at: http://www.nkdep.nih.gov/resources/nkdep_ckd_presentation.ppt
    • 6. Incidence of Kidney Failure (Per Million Population, 2000, per HSA unadjusted ) Adopted from NKDEP, available at: http://www.nkdep.nih.gov/resources/nkdep_ckd_presentation.ppt
    • 7. Obesity-Related Glomerulopathy (ORG)
      • ORG has distinct findings on biopsy including glomerular hyperfiltration, increased accumulation of extracellular matrix and renal hypertrophy
      • May lead to ESRD
      • Prevalence has increased 10-fold over past 15 years
      Percen t Wu et al. Endocrinology.2006;147:44-50, Kambham et al. Kidney Int. 2002;59:1498-1509, Chagnac et al. J Am Soc Nephrol;14:1480-1486
    • 8. Weight Loss May Reverse ORG
      • Weight loss may reverse or delay the progression of renal insufficiency
      • Studies have found that weight loss in obese patients results in a significant reduction in GFR, RPF and albuminuria
      • These improvements in renal parameters are seen with significant weight loss even if a normal BMI is not achieved
      Tran, Med J Aust.2006;184:367, Chagnac et al. J Am Soc Nephrol.2003;14:1480-1486
    • 9. Risks of Obesity Throughout the Course of Kidney Disease
      • The number of patients starting dialysis with a BMI greater than 35 has increased 64% over the past decade
      • If this continues, it is predicted that 20% of all patients will initiate dialysis in this already obese state
      • Intervention and attempts to prevent obesity before ESRD is beneficial
      Kramer et al. Curr Opin Nephrol Hypertens.2007;16:237-41
    • 10. Obesity and Transplant
      • Receiving a transplant with a BMI of
      • greater than 35 is associated with a
      • significantly higher incidence of
      • new onset transplant diabetes mellitus
      • wound complications post-transplant
      • post-transplant weight gain
      Kent.. J Ren Nutr. 2007;17:107-113
    • 11. Interventions to Help These Patients: Children
      • For children under 12 years old, treatment should be family oriented
      • Children under age 7 are cognitively able to grasp only simple nutrition concepts (e.g. food groups)
      • Bulk of the responsibility for making diet changes should be directed toward the parents
      • The goal at this stage is developing good nutrition habits and exposure to healthful foods.
    • 12. Interventions to Help Teens
      • In teenagers, parents remain involved but individual counseling is also critical
      • Teens have much more autonomy and often on their own after school or during dinner
      • The goal is to encourage teenagers to take responsibility for their health and food choices, thus preparing them for adulthood
    • 13. What Kind of Interventions are Available?
      • Nutrition counseling with an RD can
      • Provide diet education
      • Help identify diet pitfalls and provide strategies or suggestions for how to overcome them
      • Provide support and act as a coach
      • Social Work or Psychological Counselor
      • Help work through psychological issues related to overeating
      • Motivational Interviewing
      Doyle et al. Adv Chronic Kidney Dis. 2006;13:386-393
    • 14. Programs Available in the Community
      • Dr. Iman Sharif, MD, MPH of Montefiore runs a program in the South Bronx targeted towards young children and parents. It involves both nutrition classes and exercise
      • B’N Fit is an obesity program at Montefiore targeted for teenagers. Nutrition classes and group sessions are run by an RD and MSW
      • Teens are taken to the gym several times per week.
      • An 8-week summer day camp is also offered through B’N Fit. Days are filled with hiking, swimming and other physical activities
    • 15. CKD Case Study for Patient C.S.
      • 15 year old African American girl with morbid obesity is an outpatient at Montefiore.
      • Weight: 139.8 kg, Height: 170.5 cm, BMI: 48
      • C.S. was referred to the B’N Fit Program at Montefiore by her PMD in the spring of 2006
      • During her physical she was found to have proteinuria, elevated creatinine and HTN.
    • 16. Case Study for Patient C.S. Continued
      • Referred to our renal clinic. A kidney biopsy revealed obesity related FSGS. GFR = 70, stage II CKD
      • She attended 4 sessions at the B’N Fit Program and received individual nutrition counseling and follow-up with renal RD.
      • After 4 sessions, she abruptly stopped participating in B’N Fit and has failed to show up for several appointments at the renal clinic
      • One year later, she has regained all the weight she lost.
    • 17. Growth Chart with BMI
      • Normal BMI ranges
      • differ in children and
      • adolescents based on age and sex
      • BMI is plotted against age on the growth chart
    • 18. What has worked to help C.S. ?
      • Unsuccessful Attempts
      • In May 2007, the renal RD
      • and social worker attempted
      • to reach out to her through:
      • Follow up counseling visits
      • Email (food diary)
      • Phone calls
      • The above failed due to poor
      • follow-up
      • B’N Fit was not an option at
      • this time because of conflicts
      • with school
      • Successful Attempts
      • C.S. has agreed to attend
      • the B’N Fit Camp program
      • this summer for 8 weeks
      • Camp involves intense
      • physical activity each day
      • with healthy meals
      • provided
    • 19. Transplant Patient Case Study: Patient R.M.
      • 13 year-old boy with ESRD secondary to
      • FSGS. He received a kidney transplant in
      • the spring of 2005
      • Pre-transplant anthropometrics:
      • Wt: 58.9 kg, ht: 154.6 cm BMI: 24.6
      • Two years later post-transplant at age 15:
      • Wt: 106.5 kg, ht: 162 cm, BMI: 40.5
    • 20. Challenges With Patient R.M.
      • Weight steadily increases at each visit to transplant clinic
      • Family history of obesity- R.M.’s mom is morbidly obese
      • Very low income family with poor access to food and safe places to exercise
      • The family has not been receptive to counseling from RD or social worker regarding weight loss.
      • Has refused referrals to weight loss/nutrition programs
    • 21. Adopted from www.lapietra.edu The Childhood Obesity Cycle
    • 22. Future Directions
      • Ways to Help Patients As Clinicians
      • Provide ongoing nutrition/psychological counseling for patients that need it
      • Be aware of programs/support groups in the area and make appropriate referrals
      • Public Health- efforts to help
      • Reaching out to change cultural beliefs- increase the perception that overweight and obese pose significant health risks
      • Marketing campaigns to reach low income groups- ads, billboards, health fairs etc.
      • More programs like B’N Fit for teens and children

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