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


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

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