The document discusses childhood obesity and its causes. It notes that obesity rates have risen sharply over the past few decades due to dietary changes. Recommendations in the 1980s to reduce fat intake and emphasize carbohydrates have paradoxically contributed to weight gain and associated health issues like diabetes. Current research suggests dietary fat and protein are more satiating than carbohydrates and do not raise insulin levels in the same way. A balanced, less carbohydrate-focused diet may help address obesity and related diseases.

1. Childhood Obesity: Now What?Childhood Obesity: Now What?
Ann M. Childers, M. D.Ann M. Childers, M. D.
Member, American Society of BariatricMember, American Society of Bariatric
PhysiciansPhysicians
andand
The Nutrition and Metabolism SocietyThe Nutrition and Metabolism Society

2. All references to diabetes inAll references to diabetes in
this presentation refer tothis presentation refer to
Type II DiabetesType II Diabetes

3. Once upon a time,Once upon a time,

4. 19401940

5. Fifth Grade Class, 1940Fifth Grade Class, 1940

6. Woodstock 1969

7. 55thth
Grade Class 1969Grade Class 1969

8. Then Came the DietaryThen Came the Dietary
Recommendations of 1980,Recommendations of 1980,
and theand the
Food Pyramid of 1992Food Pyramid of 1992

10. Woodstock 1999Woodstock 1999

11. Modern ClassroomModern Classroom

13. The (Un-) NaturalThe (Un-) Natural
History of ManHistory of Man
From This ------------------------------------------- This: 1.8M Yrs
From This -------- This: 35 Yrs

14. Impact of the WesternImpact of the Western
DietDiet
 “The change in traditional diets has
already led to increased health
problems, such as obesity,
cardiovascular disease, and
diabetes, while the mental health
of circumpolar peoples has also
declined substantially during the same
time period.”
Int J Circumpolar Health, 2003

15. Health in theHealth in the
United StatesUnited States
 No. 1 in the world for percentage ofNo. 1 in the world for percentage of
obese persons (30.6%)obese persons (30.6%)
 No. 1 in the world in total healthNo. 1 in the world in total health
expenditures per capitaexpenditures per capita
 No. 22 among industrialized nationsNo. 22 among industrialized nations
for healthy life expectancyfor healthy life expectancy
Source: Nationmaster.comSource: Nationmaster.com

16. One in Three ChildrenOne in Three Children
Overweight or ObeseOverweight or Obese
NAFLD: Prevalence estimated at ~10%

17. Burden of IllnessBurden of Illness
 Metabolic syndrome is as high as 50%Metabolic syndrome is as high as 50%
among severely obese children andamong severely obese children and
adolescentsadolescents
 ~44% of American adults have either~44% of American adults have either
metabolic syndrome or diabetesmetabolic syndrome or diabetes

18. High Insulin StateHigh Insulin State

19. Chubby CheeksChubby Cheeks

22. Acanthosis NigricansAcanthosis Nigricans

23. Nutritional ImpactNutritional Impact
Low Iron Stores:Low Iron Stores:
CognitionCognition
Depression/ADHDDepression/ADHD
RLSRLS
Test: Ferritin (CBC hasTest: Ferritin (CBC has
low sensitivity)low sensitivity)
Low Vitamin DLow Vitamin D
Test: 25(OH)Vit DTest: 25(OH)Vit D

24. Body ImageBody Image
 81% of 10 year olds polled say they81% of 10 year olds polled say they
are afraid of being fat.are afraid of being fat.
 Over ½ of teen girls and 1/3 of teenOver ½ of teen girls and 1/3 of teen
boys use unhealthy weight controlboys use unhealthy weight control
– Including but not limited to: skippingIncluding but not limited to: skipping
meals, fasting, cigarettes, vomiting,meals, fasting, cigarettes, vomiting,
laxativeslaxatives

25. History ofHistory of
Human NutritionHuman Nutrition
 If all of human history was condensed intoIf all of human history was condensed into
one year, we only began farming and eatingone year, we only began farming and eating
grains yesterday, when dental diseasegrains yesterday, when dental disease
became common and we becamebecame common and we became
shorter/fatter.shorter/fatter.
 We began consuming processed vegetableWe began consuming processed vegetable
oils & trans fats within the past 10 minutes,oils & trans fats within the past 10 minutes,
when heart disease became our No. 1 killer.when heart disease became our No. 1 killer.

26. Vegetarian GorillaVegetarian Gorilla

27. Relative gut proportions for extant hominoids (percentage of totalRelative gut proportions for extant hominoids (percentage of total
gut volume)gut volume)
From: K. Milton,From: K. Milton, Nutritional characteristics of wildNutritional characteristics of wild
primate foods: do the diets of our closest living relatives haveprimate foods: do the diets of our closest living relatives have
lessons for us?lessons for us?, pp. 488-498, pp. 488-498

29. C.C. E.E. Stevens, Comparative physiology of the digestive system. InStevens, Comparative physiology of the digestive system. In DukesDukes
Physiology of Domestic AnimalsPhysiology of Domestic Animals ,, 9th edn, M. J. Swenson (Ed.), Comstock, Ithaca,9th edn, M. J. Swenson (Ed.), Comstock, Ithaca,
NY and London, 1977, pp. 216-232. Note: Images not drawn to scaleNY and London, 1977, pp. 216-232. Note: Images not drawn to scale

30. Elia Psouni and colleagues analyzed 70Elia Psouni and colleagues analyzed 70
species of animalspecies of animal

31. Figure 5. Time to weaning in humans is quantitatively predictable from a carnivorous diet.Figure 5. Time to weaning in humans is quantitatively predictable from a carnivorous diet.
Psouni E, Janke A, Garwicz M (2012) Impact of Carnivory on Human Development and Evolution Revealed by a New Unifying
Model of Weaning in Mammals. PLoS ONE 7(4): e32452. doi:10.1371/journal.pone.0032452
http://www.plosone.org/article/info:doi/10.1371/journal.pone.0032452

32. How Americans GotHow Americans Got
Obese:Obese:
the Lipid Hypothesisthe Lipid Hypothesis
 The Lipid Hypothesis (LH): Dietary fat raisesThe Lipid Hypothesis (LH): Dietary fat raises
cholesterol and cholesterol causes heartcholesterol and cholesterol causes heart
diseasedisease
 Promoted by Ancel Keys in early 1950s, viaPromoted by Ancel Keys in early 1950s, via
his 7 Countries Study.his 7 Countries Study.
 Keys had data from 22 countries, but failedKeys had data from 22 countries, but failed
to report on 15 that didnto report on 15 that didn’’t fit his Hypothesis.t fit his Hypothesis.

33. Left: Data Keys Published Right: Data Keys Had

34. Ancel Keys/LipidAncel Keys/Lipid
HypothesisHypothesis
 Keys wonKeys won
AmericaAmerica’’ss
confidenceconfidence
– NamedNamed ““Father ofFather of
the Lipidthe Lipid
HypothesisHypothesis””
– Featured on theFeatured on the
cover of Timecover of Time
(1961)(1961)

35. MONICA StudyMONICA Study
 Began in early-to-mid 1980sBegan in early-to-mid 1980s
 10 year study10 year study
 22 Countries22 Countries
 64,976 men and women, ages 35-6464,976 men and women, ages 35-64
 No correlation found between total bloodNo correlation found between total blood
cholesterol values and death from heartcholesterol values and death from heart
diseasedisease

36. MONICA DataMONICA Data
as graphed by Dr. Malcolmas graphed by Dr. Malcolm
KendrickKendrick

37. Light on Fats, andLight on Fats, and
Carbohydrate HeavyCarbohydrate Heavy

38. USDA Recommendations =USDA Recommendations =
Carbohydrate PromotionCarbohydrate Promotion
 Increased consumption low fat, refinedIncreased consumption low fat, refined
carbohydrates/sweeteners/processedcarbohydrates/sweeteners/processed
foods (Snackwells, e.g.)foods (Snackwells, e.g.)
– Per AHA, US adults avg. 22 tsps, teensPer AHA, US adults avg. 22 tsps, teens
34 tsps, added sugars per day (fructose,34 tsps, added sugars per day (fructose,
e.g.)e.g.)
 Low Fat Dairy: Skim (Low Fat Dairy: Skim (““blueblue””) milk) milk
widely promoted (lactose sugar)widely promoted (lactose sugar)
 CHO --> Triglycerides, BSCHO --> Triglycerides, BS

39. Industry Creates Dietary Confusion:Industry Creates Dietary Confusion:
Smart Choices ProgramSmart Choices Program
 Endorsed by topEndorsed by top
nutritionists at Tuftsnutritionists at Tufts
University andUniversity and
Baylor College ofBaylor College of
MedicineMedicine
 CorporateCorporate
sponsored:sponsored:
KelloggKellogg’’s, PepsiCo,s, PepsiCo,
ConAgra,ConAgra,
Kraft FoodsKraft Foods

40. Smart Choices ProgramSmart Choices Program
(cont.)(cont.)
 44% sugar44% sugar
 96% refined96% refined
carbohydratecarbohydrate
 Coal tar dyes: Red DyeCoal tar dyes: Red Dye
#40, Yellow Dye #6#40, Yellow Dye #6
(child hyperactivity)(child hyperactivity)
 Seed dye AnnattoSeed dye Annatto
(allergies)(allergies)
 VitaminsVitamins
 Some fiberSome fiber

41. whatwhat’’s next?s next?
You mayYou may

43. Myth of Whole Wheat?Myth of Whole Wheat?
Bread Study,Bread Study,
University of Guelph, CanadaUniversity of Guelph, Canada
 Whole wheat and whole wheat barleyWhole wheat and whole wheat barley
promoted the greatest rises in bloodpromoted the greatest rises in blood
sugarsugar
 White bread promoted lessWhite bread promoted less
 Sourdough bread promoted the verySourdough bread promoted the very
leastleast

44. A Calorie is Not aA Calorie is Not a
Calorie: Insulin is KeyCalorie: Insulin is Key

45. What we knew in 1912What we knew in 1912
““Skim milk is one of the most valuable adjunctsSkim milk is one of the most valuable adjuncts
of the farm for fattening swine. Used with corn,of the farm for fattening swine. Used with corn,
kafir corn or any of the common grain by-kafir corn or any of the common grain by-
products, an almost ideal ration is formed.products, an almost ideal ration is formed.
Hogs like it, and relish rations mixed with it. AsHogs like it, and relish rations mixed with it. As
a result of five year’s work in feeding skim milka result of five year’s work in feeding skim milk
at the New York station at Cornell, it isat the New York station at Cornell, it is
concluded that the most economical returns areconcluded that the most economical returns are
secured when the milk is fed with corn meal.”secured when the milk is fed with corn meal.”
FarmerFarmer’s Cyclopedia of Livestock, pg 545’s Cyclopedia of Livestock, pg 545

46. What My Farmer SaysWhat My Farmer Says
““I want my meat pigs to be pre-diabetic”I want my meat pigs to be pre-diabetic”
Her approach: Grains + Fat Free MilkHer approach: Grains + Fat Free Milk

50. Control DietControl Diet
vs.vs.
Low Carb (20 g CHO per day), High Fat, Ad LibLow Carb (20 g CHO per day), High Fat, Ad Lib
DietDiet
 10 obese patients with DMII10 obese patients with DMII
 7 days on control diet: Avg 3111 Kcal7 days on control diet: Avg 3111 Kcal
 14 days on LC diet: Avg 2164 Kcal14 days on LC diet: Avg 2164 Kcal
 Mean 24 hr. plasma glucose normalized.Mean 24 hr. plasma glucose normalized.
 1.65 Kg (3.6 lb) weight loss in 14 days1.65 Kg (3.6 lb) weight loss in 14 days
 Avg HgA1C declined from 7.3 to 6.8%Avg HgA1C declined from 7.3 to 6.8%
 Insulin sensitivity improved by 75%Insulin sensitivity improved by 75%
 Triglycerides declined 35%Triglycerides declined 35%
 Cholesterol declined 10%Cholesterol declined 10%
Ann Intern Med. 2005;142:403-411.

51. Striking a Balance:Striking a Balance:
CHO & FatCHO & Fat

52. LeptinLeptin

53. Cravings? Hunger?Cravings? Hunger?
Fat + Protein = SatietyFat + Protein = Satiety

54. Population StudiesPopulation Studies
 3 year study, 12,829 Adolescents: Skim3 year study, 12,829 Adolescents: Skim
and 1% milk, but not dairy fat, associatedand 1% milk, but not dairy fat, associated
with weight gainwith weight gain
(Berkey et. al., Arch Ped Adolesc Med(Berkey et. al., Arch Ped Adolesc Med
2005)2005)
 9 yr study: 19,352 Swedish women: In9 yr study: 19,352 Swedish women: In
middle age, one serving full fat milk permiddle age, one serving full fat milk per
day --> 15% less weight gain; full fatday --> 15% less weight gain; full fat
cheese --> 30% less weight gaincheese --> 30% less weight gain
(Rosell, et. al. AJCN 2006)(Rosell, et. al. AJCN 2006)

55. ““ItIt’’s Time to End thes Time to End the
Low Fat MythLow Fat Myth””

56. In the News:In the News:
British Medical JournalBritish Medical Journal
Observations: Saturated fat is not
the major issue
Tuesday, October 22, 2013
“It is time to bust the myth of the role of
saturated fat in heart disease,” argues a
British cardiologist.

57. Food Business News, 4/7/14:Food Business News, 4/7/14:
Staying power seen inStaying power seen in
shift from carbohydratesshift from carbohydrates
““Health-conscious parentsHealth-conscious parents havehave
responded in someresponded in some strange waysstrange ways suchsuch
as preparing unhealthy foods for theiras preparing unhealthy foods for their
children in the morning, like bacon andchildren in the morning, like bacon and
sausages,sausages, to make sure they areto make sure they are
satiatedsatiated during the dayduring the day””

58. Fake FoodFake Food

59. Real FoodReal Food

60. Less Carbohydrates, MoreLess Carbohydrates, More
Natural Fats &Natural Fats &
High Quality ProteinsHigh Quality Proteins
 Brain is 60-70% fat & significantBrain is 60-70% fat & significant
cholesterol--fats vital to functioncholesterol--fats vital to function
 Cholesterol basis steroid hormonesCholesterol basis steroid hormones
 Fats and proteins block hunger; do notFats and proteins block hunger; do not
interfere with leptininterfere with leptin
 Fats promote absorption of vitamins andFats promote absorption of vitamins and
mineralsminerals
 Fats slow release of sugar to the bloodFats slow release of sugar to the blood
streamstream

61. Fats Promote Satiety.Fats Promote Satiety.
Fats Do NotFats Do Not
PromotePromote Insulin.Insulin.

62. DoesnDoesn’’t the Brain Needt the Brain Need
Carbohydrates?Carbohydrates?
 Ask any Eskimo: TheAsk any Eskimo: The
brain functions well onbrain functions well on
ketones fromketones from
carnivorous dietcarnivorous diet
– Ketogenic diet used inKetogenic diet used in
epileptic childrenepileptic children
 Gluconeogenesis:Gluconeogenesis:
Proteins converted toProteins converted to
carbohydrates ascarbohydrates as
neededneeded
 Brain functions well onBrain functions well on
less than 40% dietaryless than 40% dietary
carbohydratescarbohydrates
Inuit child fishing with harpoons

63. Rule of Thumb:Rule of Thumb:
If It Promotes Caries &If It Promotes Caries &
Gum Disease,Gum Disease,
DonDon’t Eat It’t Eat It
Highly FermentableHighly Fermentable
Carbohydrates (sticky/sugaryCarbohydrates (sticky/sugary
foods, dried fruits, refined grains,foods, dried fruits, refined grains,
crackers, potato chips, sodas,crackers, potato chips, sodas,
etc.) are cariogenic, promoteetc.) are cariogenic, promote
triglycerides, impair metabolism.triglycerides, impair metabolism.

64. Perfect TeethPerfect Teeth
Pre-AgriculturePre-Agriculture
 Native American skullsNative American skulls
from US and Canadafrom US and Canada
 No tooth decayNo tooth decay
 Wisdom teeth usefulWisdom teeth useful
 Broad dental arches,Broad dental arches,
broad cheek bonesbroad cheek bones
 Fat soluble vitaminsFat soluble vitamins
contribute to tooth &contribute to tooth &
bone strength/buildbone strength/build

65. Dental DiseaseDental Disease
Post-AgriculturePost-Agriculture
 Head of mummyHead of mummy
Amenhotep IIIAmenhotep III
(1386-1349 BC)(1386-1349 BC)
 Front tooth lossFront tooth loss
secondary to toothsecondary to tooth
infectionsinfections
 May contribute toMay contribute to
death, age ~38 yrs.death, age ~38 yrs.

66. Impact of WW II onImpact of WW II on
Health In JapanHealth In Japan

68. High Carb, Low FatHigh Carb, Low Fat
DietsDiets
 Universally recommended for txUniversally recommended for tx
hyperlipidemia, prevention heart dzhyperlipidemia, prevention heart dz
 Lower HDLLower HDL
 Raise triglyceridesRaise triglycerides
 Drive LDL toward Small, DenseDrive LDL toward Small, Dense
– NMR LipoprofileNMR Lipoprofile

69. Nutrient PoorNutrient Poor
High carbohydrate diets, and high grainHigh carbohydrate diets, and high grain
diets in particular, are nutrient poor.diets in particular, are nutrient poor.

70. Hunter Gatherer DietHunter Gatherer Diet
Worldwide, 73% of H-G societies derive >55-65% of energy from animal foods

71. The ProblemThe Problem

72. Proposed MechanismProposed Mechanism
 Insulin = storage hormoneInsulin = storage hormone
– ““Bail out” strategy for body under sugarBail out” strategy for body under sugar
assaultassault
– Interferes with energy release from fatInterferes with energy release from fat
cellscells
– Interferes with leptin sensitivityInterferes with leptin sensitivity
– Too much lowers satiety, increases bodyToo much lowers satiety, increases body
fat, promotes MetS/DM IIfat, promotes MetS/DM II

73. What now?What now?
 Revert dietary CHO load to 40% orRevert dietary CHO load to 40% or
less of diet calories (SAD currently atless of diet calories (SAD currently at
55%)55%)
 Discourage the consumption ofDiscourage the consumption of
fermentable carbohydratesfermentable carbohydrates
 Discourage marketing of fermentableDiscourage marketing of fermentable
CHOs to childrenCHOs to children
 Encourage adequate protein andEncourage adequate protein and
increase dietary fatsincrease dietary fats

74. For more informationFor more information
Dr. ChildersDr. Childers’’ blog:blog:
annchilders.blogspot.comannchilders.blogspot.com
The Nutrition & Metabolism SocietyThe Nutrition & Metabolism Society
nmsociety.orgnmsociety.org