Childhood Obesity: Assessments,

Cardiometabolic Risk, and

Interventions

Can We Predict Prediabetes

and Cardiac Risk Profile in
Overweight African
American Adolescents
Patricia A. Cowan, PhD, RN
University of Tennessee Health Science Center
Funded by NIH-NINR and GCRC
 Obesity: A Worldwide
Concern
Worldwide there are 1 billion
overweight or obese adults.
In the United States, 65% of adults are
overweight or obese---The prevalence
has doubled since 1980.
Parental obesity associated with
childhood obesity.

(2004). ObesityBig is beautiful? The Globalist: retrieved March 1, 2003

from www.theglobalist.com/DBWeb/printStoryId.aspx?StoryId=3326
 Obesity Trends: U.S. Adults
BRFSS, 1990

(*BMI 30, or ~ 30 lbs overweight for 5 4 person)

No Data <10% 10%14%

 Obesity Trends: U.S. Adults
BRFSS, 2008

TN
#2 Adult
obesity

#6 Childhood
obesity
(*BMI 30, or ~ 30 lbs overweight for 5 4 person)
No Data <10% 10%14% 15%19% 20%24% 25%29% 30%
 Prevalence of Overweight &
Obesity Among Youth in the
United States (1999-2008)
Overweight Obese
Year (BMI for age 85%) (BMI for age 95%)

1999-2000 28.2 13.9

2001-2002 30.0 15.4

2003-2004 33.6 17.1

2007-2008 31.7 16.9

Ogden, C.L., et al. (2006). JAMA, 295 (13), 1549-1555 and Ogden et al (2010)
JAMA, 303(3):242-249.
 Disparities in Obesity and
Overweight Among 6-19 Year
Olds in 2007-2008
Groups Boys Girls
Overweight Obese Overweight Obese
% % % %
Total 35.3 20.1 34.1 17.3
Caucasian 33.4 18.2 31.6 15.6
African 34.4 18.9 43.3 25.9
American
Hispanic 43.1 26.7 40.5 19.5
American

Ogden, C.L., et al. (2010). JAMA, 303(3):242-249

 Why the Concern?
Childhood obesity persists into adulthood
Linked to subsequent morbidity &
mortality, including type 2 diabetes and
cardiovascular disease
Costly--$129 billion directly attributed to
obesity
Escalation in costs if development of
diabetes and cardiovascular diseases
 Evolution of Childhood Type 2 Diabetes
in the Greater-Memphis Area
120
Since 1990, in the Memphis area, 10-fold increase in
100 diagnosis of type 2 diabetes mellitus in children.

80 In children, shorter latency period from prediabetes

to diabetes.
60
The NHANES 1999-2000 data revealed an 11%
prevalence of prediabetes in children.
40
ADA estimates 2 million teens (or 1 in 6 overweight
20 adolescents) aged 12-19 have pre-diabetes.

0
1990 1992 1994 1996 1998 2000 2002 2006 2008
 Cardiovascular Risk (CVR)
Factors in Obese Youth
Current screening recommendations for
obese youth include fasting insulin and
glucose, blood pressure, and lipid profile
if family history of hyperlipidemia.

Typically clinicians refer older, more

severely obese youth with a family history
of diabetes for metabolic evaluation

Perception that diabetes drove the

development of CVR factors in youth.
 Who Should be Screened?
Inadequate resources to screen all
overweight youth for diabetes and CVR
factors.

Need to identify which youth are at

greater risk for developing metabolic and
cardiovascular abnormalities.

Determine whether current screening

recommendations relevant across ethnic
groups.
 Diabetes Screening: 150
Overweight or Obese Children
155

145

135

125
Ctrl
GLU0

115
OB-NGT
105 OB_IGT

95

85

75

65
80 100 120 140 160 180 200 220

GLU120

66% of youth who had IGT (pre-diabetes or diabetes

based on OGTT) had normal fasting blood glucose
 Similar Cardiovascular Risk Factors in Obese AA
Teens with T2DM and Obese AA Non-DM Teens

60
T2DM Non-DM

40
Percent

20
*

0
FIB >400 CRP >0.5 BP>95th% Chol >170 LDL>110 TRI >150 HDL <35

*p<0.05 between groups

 Purpose
Examine the interaction of severity
of obesity, physical activity (fitness),
diet, insulin resistance and family
history in predicting pre-diabetes
and a cardiac risk profile in
overweight-obese AA adolescents.
 Design & Sample
Descriptive, correlational
122 overweight-obese 11-18 year
African-American (AA) adolescents
(age=14.8 2.1 yr), 57% female
Non-diabetic, no medications that
affect glucose tolerance, females-
negative pregnancy test. 97% had
acanthosis nigrican
 Methods: Demographics
and Family History
Age
Gender
Tanner Stage
Parental report of family history of
type 2 diabetes or early myocardial
infarction in childs parents or
blood relatives.
 Methods: Obesity Severity
Body Mass Index (BMI)
BMI= Weight in kg
Height in m

Relative BMI= BMI x 100

50th% BMI
Whole body DXA scan (Hologics)
with segment measures of fat,
bone, and lean mass.
 Methods: Prediabetes
Oral glucose tolerance test (1mg/kg,
75 gm maximum)

Prediabetes =
Fasting blood glucose > 100 mg/dl or
2-hr post load glucose > 140 mg/dl
 Methods: Insulin Resistance
Fasting and OGTT derived indices

QUICKI = 1/(log FI U/ml+ log FBG)

CISI= 10000 / [SQRT (FI x FBG) x

(mean insulin (0-120 min) x mean
glucose (0-120 min)]
 Methods: CVR Factors
Fasting blood samples for
Homocysteine (>12 mcg/M)
High-sensitivity C-reactive Protein (>2 mg/L)
Fibrinogen (>350 mg/dl)
PAI-1 (>43 ng/ml)
Standard lipid profile: triglycerides >150 mg/dl;
cutpoints for total cholesterol, LDL-cholesterol,
HDL-cholesterol based on age and gender
normative data (Jolliffe 2006)
Lp(a) (>20 mg/dl)
LDL particle size (<25.9=Pattern B)
Blood pressure (per NHLBI guidelines)
Self-report of tobacco use.
 Methods: Dietary Intake
3-day diet diary analyzed for micro
and macronutient content using
Nutribase Clinical Nutritional
dietary software program.
Multi-pass approach with the use of
food models and queries.
 Methods: Activity/Fitness

7-Day physical activity recall

Days/week of > 30 minutes of
moderate or more intense physical
activity
Sit hours per day
Maximal cardiopulmonary exercise
testing (VO2 peak)
 Statistical Analysis
Data log-transformed if not normally
distributed
Logistic regression to predict pre-
diabetes
Multiple regression to predict cardiac risk
profile
Substitution of DXA for BMI measures of
obesity severity and fitness for physical
activity in models.
 Results: Anthropometrics
BMI 36.4 7.9

Relative BMI 185.1 40.4

Percent fat mass 42.4 7.4

Percent trunk mass 42.2 8.3

activity (day/week)
 Physical Activity and Fitness
VO2peak (mg/kg/min): 21.5 6.3
> 30 min moderate+ 2.6 1.8
activity (day/week)
Sit (hours/day) 10.5 2.7
Walk (min/day) 81.9 62.8
Only 4 youth (3.3%) engaged in
recommended amounts of physical activity.
97% had very poor or poor levels of fitness
 Results: Macronutrients
Energy intake 1791 626 kcal/day;
estimated underreporting of 940 kcal/day

Kcal/day Percent of
(Mean SD) Intake
Protein 268 99 15.2 3.1

Carbohydrates 865 333 48.3 6.2

Fat 657 246 36.5 5.5

 Physical Activity and Fitness
VO2peak (mg/kg/min): 21.5 6.3
> 30 min moderate+ 2.6 1.8
activity (day/week)
Sit (hours/day) 10.5 2.7
Walk (min/day) 81.9 62.8
Only 4 youth (3.3%) engaged in
recommended amounts of physical activity.
97% had very poor or poor levels of fitness
 Results: Pre-diabetes
OGTT on 119
28 (23.5%) had prediabetes

8 of these youth had normal fasting, but

abnormal 2 hr glucose
Thus, 29% of youth with prediabetes
would have been missed if the OGTT had
not been performed.
 Results: Insulin Resistance
CISI < 2.0 77 (69.4%)

QUICKI <0.3 68 (57.1%)

Some degree of acanthosis nigricans in

97%.
 Results: CVR factors
CVR Factor Abnormal CVR Factor Abnormal
N (%) N (%)
Lp(a) 94 (78.3) Tobacco Use 9 (7.3)
CRP-hs 71 (59.2) Homocysteine 7 (5.8)
Fibrinogen 71 (59.2) LDL-cholesterol 7 (5.8)
PAI-1 60 (50.4) Total 4 (2.3)
cholesterol
HDL- 58 (47.5) Small LDL 1 (0.8)
cholesterol particle size
Hypertension 32 (29) Triglycerides 1 (0.8)
 Results: CVR Factors

# of CVR factors 3.9 1.6

36% had five or more CVR factors
 Model: Pre-diabetes
Logistic regression to predict
prediabetes

Variables entered: Obesity severity

(BMI, RBMI or fat mass), physical
activity or fitness, family history, insulin
indices, diet, adjusting for tanner stage,
age, and gender

Model did not predict prediabetes

 Model: Cardiac Profile
Backwards multiple regression for
cardiac profile.

Higher severity of obesity and positive

family history of MI predicted cardiac
profile retained in all models.

Age (younger), Tanner score (lower),

obesity severity, insulin resistance
(greater), and positive family history of
MI predicted 33% of the variance in the
cardiac profile.
 Discussion
Compared to NHANES data:
prediabetes was more common in these
predominantly sedentary, overweight
AA adolescents.
emerging cardiac risk factors were more
prevalent
Contrary to the literature, fitness and
physical activity did not predict pre-
diabetes nor the cardiac profile.
 Research Conclusions
Current screening recommendation
underestimate metabolic and cardiac
risk of obese AA adolescents.

Because neither age, severity of obesity,

or family history of T2DM predicted
prediabetes in overweight AAA, these
demographics should not be used to
limit screening for prediabetes in this
population.
 Research Conclusions
Future studies are needed to determine
the interactions between biomarkers,
behaviors, and obesity severity to
predict early CVD in obese AA
adolescents.
Childhood Obesity
Treatments
 Target Factors Contributing
to Obesity in Youth
Nutritional Factors
Physical Inactivity
 Consider Other Factors
Contributing to Childhood
Obesity
Medical Conditions
Pharmacological Treatments
Genetic Conditions
Other (Abuse, etc)
 Lifestyle and Behavioral
Interventions
Family-based behavioral weight-management
interventions have generally yielded positive results
in children (McLean, 2003; Epstein, 1994; Reinehr,
Brylak, Alexy, Kersting, and Andler, 2003).
Parents strongly influence their childrens dietary
intake and level of activity through modeling and
reinforcement of eating and lifestyle habits.
Additionally parents determine food options and
opportunities for physical activity (Morgan, 2002 ).
 Dietary-Behavioral-Physical
Activity Interventions
Three month duration effectively decreased BMI

Exercise minimally 3 x week 45 minutes

Balanced hypocaloric diet
Counseling
Modest BMI reductions -1.7 vs. a gain of 0.6
for the control group
 Inpatient (Immersion)
Programs?
2006 study
Diet-based on RDA for age and low fitness level
Physical activity-90 minutes 3x week or more
Cognitive behavioral therapy: modification-
individual and group sessions
Impressive BMI decline!!
-Girls-38.4 4.1 down to 28.4 4.1
-Boys-34.5 3.2 down to 25.5 2.3
2011 review: 191% greater reductions in %
overweight at post-treatment and 130%
greater reduction at 12month follow-up

Kelly, K. P., & Dirschenbaum, D. S. (2011). Obesity Reviews, 12(1):37-49.

Challenges with Home
Lifestyle Behavioral
Treatments
Portion Sizes
 How Much Exercise Is
Needed?
Physical activity 60
minutes everyday
Limit physical
inactivity
Issues with length of
school day, homework,
technology (computer,
gaming, TV), safety
concerns
 Anti-Obesity Medications
Anti-obesity medications are usually
reserved for those patients who have
failed diet, exercise, and behavioral
interventions (Kaplan, 2005).

Approved by the Federal Drug

Administration for weight loss in adults:
appetite depressant (phentermine,
sibutramine), and inhibitors of fat
absorption (orlistat).

(Ionnides-Demos, Proietto, & McNeil, 2005)

 In Overweight Youth with
Impaired Glucose Tolerance
Impaired glucose tolerance is characterized by insulin
resistance with high levels of insulin production (beta-
cell function is preserved)
Treatment should be geared toward improving insulin
sensitivity (decreasing insulin resistance) while
preserving beta-cell function.
Treatment focus is on diet, weight loss, increase physical
activity, medications to improve insulin sensitivityalso
look at other risk factors that may need intervention
Additional Treatments if
Associated Co-Morbidities
Metformin and other insulin-
lowering drugs
Lipid-lowering drugs
High blood pressure medicines

Ornstein, R.M. & Jacobson, M.S. (2006). Adolescent Medicine

Clinics, 17 (3), 565-587.
 Bariatric Surgery for Obese
Youth
Medically supervised weight loss management Failed at 6 months
BMI 40 with serious obesity-
related co-morbidities
or BMI 50 with less severe
co- morbidities
Physiologic maturity Attained or nearly attained
Medical and Psychological evaluations Demonstrated commitment
before and after surgery
Agreement to avoiding Pregnancy At 1 year postoperatively
Informed consent Must provide
Decisional Capacity Must provide
Family environment Supportive
_____________________________________________________________________________
Inge et al., 2004. Serious obesity-related co-morbities (Diabetes type 2, obstructive sleep apnea, and pseudotumor cerebri); less severe
co-morbidities (hypertension, dyslipidemia, nonalcoholic steatohepatitis, venous stasis disease, significant impairment in activities of daily
living, interiginous soft-tissue infections, stress urinary incontinence, gastroesophageal reflux disease, weight-related arthropaties that
impair physical activity, and obesity related psychosocial distress
 Evidence for
Management
Multidisciplinary approach
Family involvement
Behavioral/Lifestyle remains key
component
Medication MAY be used as adjunct
Bariatric surgerylast resort
 COFFEE
20 Years Ago Today

Coffee Mocha Coffee

(with whole milk and sugar) (with steamed whole
milk and mocha syrup)

45 calories How many calories

8 ounces are in today's coffee?
 COFFEE
20 Years Ago Today

Coffee Mocha Coffee

(with whole milk and sugar) (with steamed whole
milk and mocha syrup)

45 calories 350 calories

8 ounces 16 ounces

Calorie Difference: 305 calories

Maintaining a Healthy Weight is a
Balancing Act: Calories In = Calories Out

How long will you have to walk in

order to burn those extra 305
calories?*

*Based on 130-pound person

Calories In = Calories Out

If you walk 1 hour and 20 minutes,

you will burn approximately 305
calories.*

*Based on 130-pound person

 MUFFIN
20 Years Ago Today

210 calories
How many calories
1.5 ounces
are in todays
muffin?
 MUFFIN
20 Years Ago Today

210 calories 500

1.5 ounces calories
4 ounces

Calorie Difference: 290 calories

Maintaining a Healthy Weight is a
Balancing Act: Calories In = Calories Out

How long will you have to vacuum in

order to burn those extra 290
calories?*
*Based on 130-pound person
Calories In = Calories Out

If you vacuum for 1 hour and 30

minutes you will burn approximately 290
calories.*

*Based on 130-pound person

CHICKEN CAESAR SALAD
20 Years Ago Today

390 calories How many calories are

1 cups in todays chicken
Caesar salad?
CHICKEN CAESAR SALAD
20 Years Ago Today

390 calories 790 calories

1 cups 3 cups

Calorie Difference: 400 calories

Maintaining a Healthy Weight is a Balancing Act
Calories In = Calories Out

How long will you have to walk the dog

in order to burn those extra 400
calories?*

*Based on 160-pound person

 Calories In = Calories Out

If you walk the dog for 1 hour and 20

minutes, you will burn approximately 400
calories.*