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Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
Childhood Overweight Childhood Overweight and Type 2 Diabetes ...
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Childhood Overweight Childhood Overweight and Type 2 Diabetes ...

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  • 1. Childhood Overweight and Type 2 Diabetes Turning the Titanic and other Sisyphean tasks Terry Raymer MD, CDE Alaska Native Diabetes Program twraymer@anmc.org
  • 2. Overweight in Childhood • Brief overview of epidemiology and etiology childhood • Evaluation of overweight in children • Medical Consequences • Management recommendations and communication with families regarding overweight in childhood & case study • Briefly (if time permits): roles of society – Community and Schools
  • 3. Obesity Trends* Among U.S. Adults BRFSS, 1991, 1996, 2003 (*BMI ≥30, or about 30 lbs overweight for 5’4” pe rson) 1991 1996 2003 “the average weight gain among subjects (20-40 years old) in the population is 1.8 to 2.0 pounds/year.” Science. 299:7;853-855 (2003) No Data <10% 10%–14% 15%–19% 20%–24% ¡ 25% Source: Behavioral Risk Fac tor Surveil lance System, CDC.
  • 4. Prevalence of Overweight Among U.S. Children and Adolescents Ages 6-19 Years 18 15.8 16.1 16 3 Fold 14 Increase 12 11 11 Percent 10 8 7 6 6 5 5 4 4 4 2 0 1963-70 1971-74 1976-80 1988-94 1999-02 6-11 Years 12-19 Years SOURCE: CDC/NCHS, NHES and NHANES
  • 5. ANMC Overweight Prevalence Report 2004-2007 80 70 60 50 Percent 40 30 20 10 0 2-4 5-14 15-19 20-24 25-44 45-64 65-74 BMI over 25 BMI over 30 Combined RPMS Data BMI is for adult population, for ages 2-19…
  • 6. Defining overweight in Children • Ages 2-19: 'At Risk for Overweight' is defined as BMI >=85th% but <95th% • 'Overweight' is defined as BMI >= 95th% • National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion (2000).
  • 7. Percentage of Overweight Children and Youth who become overweight Adults 100 90 80 80 70 Percentage 60 50 50 40 35 30 20 10 10 0 s t e l nt en oo Ag fa sc ch ol In le es ho do Pr Sc A Preventive Medicine 1993; Vol. 22:pp. 167-177 Arch Pediatr Adolesc Med Vol. 158 May 2004 pp. 449-452
  • 8. Pima Indians Current Prevalence of Type 2 Diabetes in Children 10-14 years 22.3/1000 15-19 years 50.9/1000 Prevalence for all American Indian children 4.5/1000 Prevalence for all 0 – 19 y/o children in US 1.7/1000
  • 9. Childhood Overweight Behavioral Risk Factors • Altered Dietary Intake • Decreased Physical Activity • Increased Sedentary Behaviors • Parenting Styles • Gestational Diabetes Genes are not destiny
  • 10. A small behavior change over time can prevent some weight problems. Energy Input vs Energy Output 2% Error Leads to Overweight 125 kj /day or 15 Minutes of Play Instead of Television Michael Goran , Am J Clin Nutr 1999;70
  • 11. Infant & Toddler Overweight Behavioral Risk Factors • Breastfeeding rates at 12 months of age are 7% • 17% of infants consume juice before 6 months • 10% of infants consume French fries and soda before 12 months of age • WIC toddlers consume more 100% juice and less whole fruit than non-WIC toddlers • WIC toddlers consume 40% more calories than their energy requirements Pediatrics October 2004, Vol 114,No. 4 pp. 1146-1173 Feeding Infants and Toddlers Survey (FITS) 2004
  • 12. Why pick on soda? Billboard on the edge of the Navajo Reservation Courtesy of Tim Gilbert/ANTHC
  • 13. Clear Evidence of Negative effects • Children’s Hospital in Boston – Increased consumption definitively linked to weight, increased calories (~300 a day) • HFCS (sweetener) may contribute to the development of diabetes, particularly in children due to “carbonyl” formation • Higher insulin resistance and fasting blood levels of insulin even in healthy adults • Evidence that “diet sodas” are not protective
  • 14. Childhood Overweight Behavioral Risk Factors • The average consumption of soft drinks by 12- 19 year olds is over 20 ounces per day • 80% of 5th, 7th and 9th graders in California fail to meet the minimum fitness standards. • More than 25% of children in CA reported averaging > 4 hours of TV watching per day • In California, of 7th, 9th and 11th graders surveyed less than half reported eating fruits or vegetables at least once per day in past week.
  • 15. Fitness and Academic Performance 2001 Grade 7 SAT 9 and Physical Fitness 70 66 60 60 54 50 SAT 9 Percentile 50 44 41 40 3436 3132 Reading 30 26 28 Math 20 10 0 1 2 3 4 5 6 Number of Fitness Standards Achieved California Department of Education 12/10/02 http://www.cde.ca.gov/news/releases2002/rel37.asp
  • 16. Determining the BMI • (First you gotta) Measure BMI Annually • Measure BMI at Well Child Care Visits 2-18 years (hint – plot on growth chart) • BMI (English):[ weight (lb) ÷ height (in) ÷ height (in) ] x 703 • BMI (metric):[ weight (kg) ÷ height (cm) ÷ height (cm) ] x 10,000 • Calculation Tools: www.cdc.gov/ and www.nhlbisupport.com/bmi/
  • 17. Determine the Diagnosis Make a weight diagnosis using BMI percentile for age: • < 5%-ile Underweight • 5-84%-ile: “Healthy Weight” • 85-94%-ile: “at risk for overweight” • > 95%-ile: “Overweight”
  • 18. BMI BMI Boys: 2 to 20 years Measurement example: Age=3 y 3 wks Height=100.8 cm (39.7 in) Weight=18.6 kg (41 lb) BMI=18.3 BMI-for-age= >95th%-ile “Overweight” BMI BMI
  • 19. Shape of BMI-for-Age BMI BMI Growth Curve: “Adiposity” Boys: 2 to 20 years Rebound • Risk factor for Adult overweight • Linked to Parental weight • A Key Intervention Age Example: Early AR Age (mos) BMI 26 18.2 BMI BMI 32 17.4 BMI 38 18.5 41 18.7
  • 20. Conveying the Diagnosis For Patient Communication... • Weight or Excess Weight • Body Mass Index (BMI) • Emphasize weight “stabilization” • Focus on healthy habits, not weight loss • Risk for Diabetes & Heart Disease • Better to assign risk, non-pejorative terms
  • 21. Childhood Overweight Medical Assessment: Medical History • Developmental delay (Genetic disorders) • Poor linear growth (Hypothyroidism, Cushing’s, Prader-Willi syndrome) • Headaches (Pseudotumor cerebri) • Daytime somnolence (Sleep apnea, hypoventilation) • Nighttime breathing difficulty (Sleep apnea) • Abdominal pain (Gall bladder disease) • Hip or knee pain (Slipped capital femoral epiphysis) • Oligomenorrhea or amenorrhea (Polycystic ovary syndrome)
  • 22. Medical Assessment: Family History • Overweight • Hypertension • Type 2 Diabetes • Dyslipidemia • Cardiovascular disease • Gall bladder disease
  • 23. Medical Assessment: Exam • Height, weight, Blood pressure and BMI • Truncal obesity (Risk of cardiovascular disease; Cushing’s syndrome) • Acanthosis nigricans (Type 2 DM, insulin resistance) • Hirsutism (Polycystic ovary syndrome; Cushing’s syndrome) • Tonsils (Sleep apnea) • Limited hip range of motion (Slipped capital femoral epiphysis)
  • 24. Acanthosis Nigricans on the Neck
  • 25. Acanthosis Nigricans
  • 26. Laboratory Assessment • BMI 85-94%-ile Without Risk Factors – Fasting Lipid Profile + Insulin? • BMI 85-94%-ile Age 10 Years or puberty & Older With Risk Factors Every 2 Years – Fasting Lipid Profile – ALT and AST – Fasting Glucose • BMI >= 95%ile Age 10 Years & Older Every 2 Years – Fasting Lipid Profile – ALT and AST – Fasting Glucose – Other Tests as Indicated by Health Risks
  • 27. Testing for Diabetes in Kids* • Asymptomatic, age 10 or puberty with BMI > 85%-ile with any 2 of the following: – Family History: type 2 DM in a 1st or 2nd degree relative – Ethnic Group: Native American, African American, Hispanic, Asian/Pacific Islander – Signs of Insulin Resistance: acanthosis nigricans, hypertension, dyslipidemia, PCOS – Maternal History of GDM (consider LGA) * Diabetes Care, volume 31, Supplement 1; January 2008: S14
  • 28. Testing for Diabetes in Kids* • Preferred test is a Fasting Plasma Glucose • Diagnostic Criteria: plasma glucose – Fasting (8+ hour) > 126 mg/dl – Oral glucose tolerance test: 2-hour plasma glucose > 200 mg/dl – Casual (random) plasma glucose > 200 mg/dl WITH symptoms • Confirm on subsequent day/test * Diabetes Care, volume 31, Supplement 1; January 2008: S14
  • 29. Laboratory evaluation • Other tests based on history and physical... • Family History, Symptoms or Signs of Thyroid Disease • TSH • Oligomenorrhea or Amenorrhea • Free Testosterone • LH • FSH • TSH • Prolactin
  • 30. Medical Complications of Overweight Pulmonary disease: Idiopathic intracranial obstructive sleep apnea hypertension, pseudotumor c. Liver disease: steatosis Insipient CVD Steatohepatitis, NAFLD Hypertension Dyslipidemia Gall bladder Diabetes disease Pancreatitis Gynecologic: Cancer Risk Increase PCOS, Infertility Joints: Arthritis, Slipped Capital Femoral Epiphysis Skin Phlebitis: venous stasis
  • 31. Overweight Associated Psychological Conditions • Depression • Anxiety • Low self esteem • Teasing/Bullying • Adverse socioeconomic outcome • Other social prejudices
  • 32. “The Metabolic Syndrome” Type 2 diabetes Adiposity, visceral Hypertension Dyslipidemia Insulin Impaired Resistance glucose tolerance Polycystic Acanthosis ovary disease nigricans Adapted from Consensus Development Conference of the American Diabetes Association, Diabetes Care, 1997
  • 33. Childhood Hypertension Predicts Adult Hypertension • 20%-30% of overweight children have high blood pressure • Overweight adolescents have 8.5 fold risk of hypertension as adults.** – Cardiac hypertrophy/LVH on ultrasound. – Long term risk of CVD and stroke. • Treatment – Weight loss, low salt diet, pharmacotherapy **Srinivasan Metab 1996;45:235-240.
  • 34. Adolescent Overweight Predicts Adult Hyperlipidemia Overweight during adolescence associated with: • 2.4 X increase in prevalence of cholesterol > 240mg/dl, • 3 X increase in LDL-C values >160mg/dl • 8 X increase in HDL-C values < 35 mg/dl in adults 27-31 yo. Srinivasan Metab 1996;45:235-240.
  • 35. Atherosclerosis begins in Childhood: Autopsy Studies • Bogalusa Heart Study: 2-15 yo • Pathological Determinants of Atherosclerosis in Youth (PADY): 15-30 • Raised coronary lesions in – 7% Bogalusa – 24% PADY • Correlates of coronary atherosclerosis – Body mass index – VLDL, LDL-C, HDL-C, triglycerides – Blood pressure Berenson GS, et.al. N Engl J Med Jun 4; 338(23):1650-1656. Malcolm GT, Oalmann MC,. Annals New York Academy of Sciences pp 179-188
  • 36. Treatment and Prevention “It’s hard to know if you’re failing unless you set yourself some goals…” Yogi Berra
  • 37. Recommended Weight Goals Weight loss approx. 1 pound/month Weight goal: BMI< 85% Sarah E. Barlow and William H. Dietz, Obesity Evaluation and Treatment: Expert Committee Recommendations, Pediatrics 1998 102: e29 http://www.pediatrics.org/cgi/content/full/102/3/e29
  • 38. AMA Prevention Strategies • Annually, measure height, weight, and calculate BMI plus BMI percentile (level of evidence, C). • Encourage all children to participate in at least 60 minutes of moderate to vigorous physical activity on most, and preferably all, days of the week (level of evidence, A). • Advise no more than 1 serving per day of sweetened beverages, such as fruit juice, fruit drinks, regular-calorie soft drinks, sports drinks, energy drinks, sweetened or flavored milk, or sweetened iced tea (level of evidence, B).
  • 39. AMA Prevention Strategies • Advise families to limit children's television viewing and other screen time to 2 hours per day or less (level of evidence, B). • Recommend that children's fast-food consumption be limited to no more than once per week (level of evidence, C). • Advise families to eat meals together as often as possible, on most, and preferably all, days of the week (level of evidence, C).
  • 40. Prevention of Pediatric Overweight and Obesity: American Academy of Pediatrics Policy Statement • Prevention Summary: http://www.pediatrics.org/cgi/content/full /120/Supplement_4/S229 • Very similar Strategies to AMA recommendations • Treating GDM may reduce risk as well* *Diabetes Care. 2007;30:2287-2292.
  • 41. And now for something completely different…
  • 42. “75210” • Eat Breakfast 7 days a week – Could add eat together 7 days a week • Eat 5 servings of Fruits and Veggies • Limit screen time to 2 hours or less daily • Participate in 1 hour of Physical Activity daily • Drink 0 sodas or sweetened beverages on a typical day* *Yes, you can exclude the Chuck E Cheese birthday parties…
  • 43. AMA: Treatment Stages • Stage I (Prevention-Plus Protocol): Make specific dietary and physical activity recommendations, with monthly follow-up. If BMI does not improve in 3 to 6 months, consider stage II. • Stage II (Structured Weight Management Protocol). Low–energy-dense, balanced diet; structured meals; supervised physical activity of at least 60 minutes daily; limiting television-watching and other screen time to 1 hour per day or less; and use of logs to self- monitor these behaviors. Family clinicians may require assistance from allied care professionals to implement this step, and children should be followed up as often as needed. If BMI does not improve in 3 to 6 months, stage III is appropriate.
  • 44. AMA: Treatment Stages • Stage III (Comprehensive, Multidisciplinary Intervention) and Stage IV (Tertiary-Care Intervention) More intensive interventions administered by highly trained teams expert in overweight management. Specialized centers can provide effective, intensive counseling programs that promote behavior modification for overweight children. Especially indicated for severely overweight children and for those with co-morbidities. • Stage IV: tertiary care referral. • Many recommendations can be carried out by family physicians for treatment and prevention. These include advice to limit consumption of sweetened beverages and fast food, limit screen time, engage in physical activity for at least 60 minutes per day, and encourage family meals on most (if not all) days of the week.
  • 45. Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: • Summary: http://www.pediatrics.org/cgi/content/full/120/Supplement _4/S164 • Assessment: http://www.pediatrics.org/cgi/content/full/120/Supplement _4/S193 • Treatment: http://www.pediatrics.org/cgi/content/full/120/Supplement _4/S254
  • 46. Medications and Surgery?? • None Approved for Children Under 16, experimental only • Orlistat (Xenical®) • Lipase inhibitor: decreased fat absorption • Adverse reactions: flatus, diarrhea • Sibutramine (Meridia®) • Serotonin and norepinephrine reuptake inhibitor • Promotes feeling of fullness, increase calorie expenditure • Adverse reactions: increases heart rate, increases BP • Adolescents 13-17 years: sibutramine + behavior therapy lost 7.8 kg at 6 months compared to 3.2 kg for placebo and behavior therapy . • Bariatric Surgery for Severely Overweight JAMA. 2003;289:1805-1812
  • 47. Overweight Children and Your Practice • How will you improve the care of overweight children in your practice? • What tools will you need? • What training will be needed? • How will measure the success of your efforts?
  • 48. Cultural Considerations Native Americans/Alaska Natives • Child Rearing – Anglo-American: parent-focused responsibility – Native American: community-focused child rearing - children are to be shared; discipline and nurturing responsibility of all • Education – Anglo-American: formal education stressed, individual achievement is stressed – Native American: education occurs in all facets of life, individuals should learn from one another • Implications for Intervention: Community based, Health Aides No cultural advice applies to everyone in a particular culture Pediatrics Vol. 91 (5) Supp, May 1993 pp. 1063-1070
  • 49. Cultural/Group Support • Pima Pride/Action -DPP pilot study People randomized to “Action” group: -Structured diet/exercise meetings People randomized to “Pride” control group: -Unstructured activities emphasizing Pima culture and history - “Pima Pride” group showed more positive outcomes on every biological parameter measured Narayan et al, Diabet Med 1998;15:66-72 Ann Bullock MD
  • 50. Adolescents and Dieting • Overweight adolescents have been shown to be more likely to skip breakfast and consume a few large meals per day than their leaner counterparts. (1) • Although medically supervised weight control may be beneficial for overweight youths, some research suggests that for many adolescents, dieting to control weight is not only ineffective, it may actually promote weight gain. (2) (1) J Am Diet Assoc. Vol. 101, 2001, pp. 798-802 (2) Pediatrics Vol. 112 (4) 2003, pp. 900-906
  • 51. Overweight Children and Your Practice • Do you routinely provide advice or counseling for overweight children and their parents? • What communication techniques do you use? • How effective is your counseling?
  • 52. Overweight Sensitivity “First Do no harm” • “Obesity” • Overweight • Ideal Weight • Healthier Weight • Personal • Family Improvement Improvement • Focus on Lifestyle • Focus on Weight • Healthier Food • Diets or “Bad Foods” Choices • Exercise • Play or Activity
  • 53. Stages of Behavior Change Integrated Action Behavior Maintenance Preparation Relapse & Recycle Contemplation Pre-contemplation Prochaska & Di Clemente: Transtheoretical Model of Behavior Change
  • 54. Positive Family Attitudes • Over a healthy weight is not a fault. • Avoid classifying “good” food or “bad” food. • Emphasize staying physically active rather than “exercising” • There is no ideal weight or body shape.
  • 55. Parents’ Responsibilities • Have [pleasant?!] family meals. • Purchase and offer healthy foods and portion sizes. • Role model good eating and activity behaviors. • Avoid using food as a reward. • Set limits on TV and video games. • Be flexible and understanding. • Encourage and show affection.
  • 56. Childs’ Responsibilities • To eat as much or as little as they need of the foods available • To eat 3 meals a day with healthy snacks • To make activity fun • To try to be active every day • To be responsible for TV and video game limits • To do things that they enjoy, give joy • To choose goals and areas to improve on
  • 57. How do you talk with parents who do not consider their child overweight? • “National experts have recommended using BMI to identify children who are overweight.” • Show child’s BMI on BMI-for-age growth curve. “This means your child is at increased risk of becoming overweight as an adult and developing diabetes.” • Ask them: “What do you think?” • “The good news is that making simple changes in eating and physical activity can really reduce this risk. Are you interested in talking more about making family changes?”
  • 58. Additional Key Messages for Parents of Overweight Toddlers • Change to low-fat or non-fat milk at 2 years old. • Avoid telling your child to “clean the plate”. • Do not use food as a reward. • Keep offering foods that your child refuses to eat. Praise your child for trying new foods. • Wean from the bottle at 12-18 months. No bottle in bed.
  • 59. Case Study: Where from success?? • 14 y/o BMI 40.3 (Ht = 5’ 1”, Wt = 213 lb) • 40.3 = BMI >>> 95%-ile • Acanthosis Nigricans • Both parents with type 2 diabetes • Seen in March of 2004, discussed healthy eating habits, physical activity • Very soft sell, scheduled f/u 3 months • “Lost to follow up”
  • 60. Case Study: Where from success?? • Presented with mother following Spring • Lost 80 pounds, Acanthosis – gone! • BMI now 22.9 or 85%-ile • Stopped drinking sodas • Made modest changes in his own eating habits • Voluntarily increased his physical activity – Activities he enjoyed, martial arts • Engaged family in his changes
  • 61. Treatment of Type 2 in children? • MNT and Lifestyle changes • Insulin: always the safe first alternative • Metformin: approved, use enough • Other oral agents?? Byetta? • Beware the Type 1/Type 2 conundrum – Check antibodies and C-peptide (later)
  • 62. Case Study: Type 1 vs Type 2? • 16 year old presents in DKA • Treated with i.v. insulin, responds well • BMI 39.1, >> 95%-ile • Acanthosis Nigricans • Grandfather, type 2 diabetes, mom s/p gastric bypass, BMI > 40.
  • 63. Case Study: Type 1 vs Type 2? • Further work-up: + Islet Cell antibodies • Marginal BG’s on insulin, but markedly improved metabolic balance • Addition of Metformin (titrated) resulted in further BG improvement, decrease in basal insulin requirements • What kind of diabetes does he have?
  • 64. What about Lipids? AAP says: • “For patients 8 years and older with an LDL concentration of 190 mg/dL (or 160 mg/dL with a family history of early heart disease or 2 additional risk factors present or 130 mg/dL if diabetes mellitus is present), pharmacologic intervention should be considered.” • Goal = 160 mg/dl, 110-130 mg/dl if FHx CVD • Treatment options: Fibrates, Niacin, Statins • http://www.pediatrics.org/cgi/content/full/122/ 1/198
  • 65. Childhood Overweight The Role of Schools and Communities
  • 66. Overweight Prevention in Schools An Opportunity for Parent Advocacy • Salad bars and other low cost healthy meal options. • Bans on soda contracts. • More PE (200 minutes every 10 school days). • More fun PE, non-competitive activities. • Walk to school events (www.cawalktoschool.com) • Integrate health promotion into curriculum. • Link activities – school and home.
  • 67. Preventing childhood obesity by reducing consumption of carbonated drinks: Cluster Randomized Controlled Trial • Setting: Six primary schools in southwest England. • Participants: 644 children aged 7-11 years • Intervention: Focused educational program on nutrition over one school year. • Results: Consumption of carbonated drinks over three days decreased by 0.6 glasses in the intervention group but increased by 0.2 glasses in the control group. At 12 months the percentage of overweight children increased in the control group by 7.5%, compared with a decrease in the intervention group of 0.2%. BMJ 2004;328:1237 (22 May)
  • 68. Prevention of Overweight and Type 2 Diabetes • Multifaceted, multi-sector interventions may be more effective (schools, communities, health care, work-site). • Evidence based strategies with local adaptation may be an effective approach. • Sustained interventions (over 5 years) may be needed. • Key intervention strategies include: • Increasing physical activity and breastfeeding. • Decreasing sedentary behavior and sweetened beverage consumption. • Evaluation, sustainability and dissemination need to be considered. • Behavior change strategies can be augmented with policy and built environment changes. Pediatrics Vol. 112 No. 4 October 2003, pp. e328-346 Pediatrics Vol. 115 No. 4 April 2005, pp. 1142-1147
  • 69. Questions? Final thoughts… “You've got to be careful if you don't know where you're going, because you might not get there.” So… “…if you get to a fork in the road, take it.” Yogi Berra

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