10/22/20

Pitfall in Pediatric
Obesity Management

Dr. dr. Maria Mexitalia SpA(K)

Pediatrics Department
Faculty of Medicine Diponegoro University /
Dr. Kariadi Hospital Semarang

Sub Topics
• Early adiposity rebound
• Gene-environment interaction in childhood
obesity
• Sugar- SSB and Glycemic index
• Diet recommendation
• Physical activity in youth and adolescents

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What is adiposity rebound (AR) ?

§ In general, BMI rapidly increases during the first

year of life……

What is adiposity rebound (AR) ?

…..then subsequently
decreases and reaches a
nadir at around 6 years of
age.

Adiposity Rebound :
The second rise of BMI
throughout childhood,
after reaches a nadir.

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Trend in the timing of AR in the 21st century

Kang MJ, Korean J Pediatr 2018

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CASE 1
Fat child at 1 year,
remained fat after an
early adiposity
rebound (2 years)

CASE 2
Fat child at 1 year,
did not stay fat after
a late adiposity
rebound (8 years);

Rolland-Cachera MF et al. Int J Obes 2006

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CASE 3
Lean child at 1 year,
became fat after an
early adiposity
rebound (4.5 years);

CASE 4
Lean child at 1 year,
remained lean after
a late adiposity
rebound (8 years)

Rolland-Cachera MF et al. Int J Obes 2006

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Early
Adiposity
Rebound

the higher
the centile,
the earlier the
rebound.

Cole TJ, BMC

Pediatric 2004

British 1990 girls BMI

chart.
The adiposity rebound for each
of 5 hypothetical subjects A to
E, defined by three
measurements over four years
where the outer two are the
same BMI.
The older subjects AA to EE
show the same patterns of BMI
centile crossing as subjects A
to E respectively.

Cole TJ, BMC

Pediatric 2004
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The data of Figure A replotted on the BMI SD score scale. The centiles curves
of figure A appear as horizontal and equally spaced straight lines.
For each subject A to E the BMI SD score changes linearly over time, indicating
a constant rate of centile crossing. Subjects AA to EE show the same
patterns as A to E respectively, but starting at age 13.

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Peto's "horse racing effect”

Childhood is a horse race,

and race position corresponds to BMI rank
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In a horse race, horses near the front of the field and/

or overtaking others have a better chance of
winning.
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Peto's "horse racing effect”

• This explains why the age at rebound predicts

adult BMI when adjusted for BMI at rebound.
• But is no longer predictive when adjusted for
BMI at age 7 or 8.
• The horse's position early in the race becomes
irrelevant once its position later in the race is
known.

Cole TJ, BMC

Pediatric 2004

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Summary of the article

• The adiposity rebound is the second rise in BMI that
occurs between 3 and 7 years, and an early age at
adiposity rebound is known to be a risk factor for later
obesity.
• Two aspects of the BMI centile curve :
• The BMI centile and the rate of BMI centile
crossing, determine a child's age at rebound.
• A high centile and upward centile crossing are both
associated separately with an early rebound, while
a low centile and/or downward centile crossing
correspond to a late rebound.
Cole TJ, BMC
Pediatric 2004

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Summary of the article

• An early rebound is a risk factor for later fatness

because it identifies children whose BMI centile is high
and/or crossing upwards. Such children are likely to
have a raised BMI later in childhood and adulthood.
This is the "horse racing effect”.
• The association of centile crossing with later obesity is
statistical not physiological, and it applies at all ages
not just at rebound, so adiposity rebound cannot be
considered a critical period for later obesity.

Cole TJ, BMC

Pediatric 2004

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Risk factors of Early Adiposity Rebound

Ethnicity
Lower
Birth
weight Metabolic
Early syndrome
Gestational Adiposity Obesity
age Rebound Diabetes
Parental
obesity

Social
economy
status
Protein
intake ? Lowe J, Centre for Longitudinal
Studies, UCL London 2016

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üThe mean age at AR was 5.5 years, and 15% of the

cohort was obese in young adulthood.
üAdult obesity rates were higher in those with early
versus late AR (25% vs 5%), those who were heavy
versus lean at AR (24% vs 4%), those with heavy
versus lean mothers (25% vs 5%), and those with
heavy versus lean fathers (21% vs 5%).
üAfter adjusting for parent BMI and BMI at AR, the odds
ratio for adult obesity associated with early versus late
AR was 6.0 (95% CI, 1.3–26.6).

Pediatrics 1998;101(3)

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Koyama et al. Pediatrics

2013

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Koyama et al. Pediatrics

2013

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Koyama et al. Pediatrics

2013

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Gene-environment
interaction in childhood
obesity

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How to diagnose Obesity in children

BMI = weight / (height)2
Weight (kg), Length / Height (m)

Children < 2 years (WHO 2006 chart)

BMI > +3 SD obese
BMI > + 2 SD overweight

Children 2 – 18 years (CDC 2000 chart)

• BMI > p95 : obese
• BMI < 95 and ≥ 85 : overweight
UKK NPM IDAI

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Characteristic and etiology of obesity

Idiophatic obesity Endogenous obesity

>90% cases <10% kasus

Tall stature (usually Height for Age Perawakan pendek (umumnya
> P50) TB/U < P50)
Usually, family history of obesity is Usually, there is no family history of
obtained obesity
Normal mental function Mental retarded
Normal or advanced bone age Delayed bone age

Physical appearance is generally There are stigmata on physical

normal examination

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The Impact of Familial Predisposition to Obesity and

Cardiovascular Disease on Childhood Obesity

• Familial predisposition to obesity and obesity-related

complications and its impact on obesity in children is
an important marker of the complex interplay between
genetic and environmental factors, which could,
potentially, serve as a preventive and predictive marker
in the struggle against childhood obesity.

Nielsen LA, et al. Obes Facts 2015;8:319–328

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N Engl J Med 2010;363:2339-50.

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Genetic Susceptibility to Obesity and Related

Traits in Childhood and Adolescence

CONCLUSIONS

Most obesity susceptibility loci

identified by GWA studies in
adults are already associated
with anthropometric traits in
children/adolescents. Whereas
the association of some
variants may differ with age,
the cumulative effect size is
similar.

den Hoed et al. Diabetes 2010;2980-8

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Latar belakang Rentan secara Mutasi gen

genetik normal genetik tunggal

asupan dan pengeluaran Lingkungan

energi normal

asupan energi tinggi

asupan energi tinggi dan

pengeluaran energi rendah

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Congenital Leptin Deficiency

Prader Willi syndrome

Bardet-biedel syndrome

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How to prevent and manage

obesity in childhood ?

vRoutinely anthropometry monitoring (weight,

height)
vPlotting in appropriate growth chart
vCalorie intake should be calculated based on
Ideal body weight / height (RDA)
vStop high calorie and high glycemic index
vPhysical activity

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Sugar - SSB
Glycemic index and
glycemic load

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Glucose homeostasis

Starch provides glucose directly,

while fructose (from dietary
sucrose) and galactose (from
dietary lactose) are
absorbed and also converted into
glucose in the liver

Insulin is the principal hormone

affecting blood glucose levels.
Some amino acids (e.g. leucine),
fatty acids and ketone bodies
also promote insulin secretion.

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Glycemic Index (GI)

• A scale that ranks

carbohydrate by how much
they raise blood glucose
levels compared to reference
food.
• Foods with a high GI are
those which are rapidly
digested, absorbed and
metabolised and result in
marked fluctuations in blood
sugar (glucose) levels.

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High fructose corn syrup

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REKOMENDASI :

Konsumsi gula pada anak ≤25 g (100 kal

or ≈6 sendok teh) per hari.
Hindari pemberian gula untuk anak di
bawah 2 tahun.

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• Rerata konsumsi gula sehari pada anak perempuan 54,3

g dan laki-laki 46,6 g (p <0.001), sebagian besar dari
makanan olahan.
• Asupan gula dari susu dan buah menurunkan risiko
obesitas pada anak perempuan (OR 0,42 95% CI 0,23-
0,79), sedangkan SSB tidak berhubungan dengan
obesitas.

These results suggest that total sugars and SSB intake in

Asian children and adolescents remains relatively low and
sugar intake from milk and fruits is associated with a
decreased risk of overweight or obesity, especially in
girls.

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• Remaja yang mengkonsumsi SSB > 350 ml/hari

mempunyai risiko resistensi insulin (yang diukur dengan
HOMA-IR) lebih tinggi dibanding yang tidak
mengkonsumsi SSB.

J Pediatr 2016;171:90-6

Other investigations have shown that fat consumption especially

cholesterol and trans/saturated fatty acids are also steatogenic
and seem to increase visceral adiposity.
Ferrola et al. World J Hepatol 2015 October 28; 7(24): 2522-2534

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Management of Childhood
Obesity

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Recommended Calorie Distribution

Carbohydrate Protein Fat

Infant ≤ 2 years 25-55% 10-20% 35-60%
> 2 years 55-60% 10-20% <30%

Hendricks, Duggan,
Walker. Manual of
Pediatric Nutrition 3rd

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Diet recommendations

• Avoid obesity and maintain normal weight and growth.

• Low carbohydrate (48% total energy).
• Fat intake (< 30% total energy), saturated fat (10%
total energy), cholesterol < 300 mg per day.
• Increase dietary fiber
• Sufficient salt content (5 g per day).
• Increase intake of iron, calcium and fluor
• Less sugar / SSB < 10% of total energy.

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USDA Recommendation for Elementary school

children

• Main food
– 350 kcal, salt 480 mg
• Snack
– 200 kcal, salt 200 mg
• Fat
– Total fat < 35%
– Sat fat < 10%
– Trans fat : 0
• Sugar
– < 35% total sugar in
food.

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Food that can be sold at school

• Plain water or sparkling water

• Low fat milk without flavor
• Non fat milk with or without flavor
• 100% fruit or vegetable juice without
sweetener or 100% fruit or vegetable juice
without sweetener diluted with water (or
soda).
• Elementary School è restriction for milk /
juice 240 ml / portion
• High school èrestriction for milk / juice 360
ml / portion
• No plain water restriction

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Food that can be sold at school

Senior High School :
§ Plain water / sparkling water with flavor, zero calorie.
§ Plain water / sparkling water with flavor, low calorie (< 5
kcal / 240 ml or < 10 kcal / 600 ml).
§ Drinking water in bottles of a maximum of 360 ml with a
calorie content of 40 kcal / 240 ml or 60 kcal / 360 ml.

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Physical activity and change

of lifestyle

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• MET : the ratio of work metabolic rate to a standard

resting metabolic rate of 1.0 (4.184 kJ) / kg/h
• 1 MET is considered a resting metabolic rate obtained
during quiet sitting.
• Activities are listed in the Compendium as multiples of
the resting MET level and range from 0.9 (sleeping) to
18 METs (running at 0.9 mph).
Med. Sci. Sports Exerc., Vol. 32, No. 9, Suppl.,
pp. S498–S516, 2000

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METs of sports

Athletics Track 5.0 Volleyball beach 8.0

Baseball 5.0 Volleyball rebound 6.0
Basketball 7.0 Volleyball outdoor 4.0
Soccer 10.0 Taichi 4.0
Cycling mountain bike. 8.5 Tennis outdoor 7.0
Cycling transport 6.0 Table tennis 4.0
Cycling recreation 4.0 Jogging 7.0
Swimming (laps) 8.0 Marathon 16.0
Dancing ballet 6.0 Walking-power 6.5
Dancing modern 6.0 Walking-transport 4.0
Domestic work 3.0 Walking-pleasure 3.5

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Sweeping 3.6
Vacuuming 3.9
Active video games full body
—action running 4.8 - 7.7
—baseball 3.7 - 6.6
—dance 2.3 - 5.0
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Changes of school lifestyle
§ Beri nasihat anak untuk minum
air putih sesering mungkin.
§ Biarkan anak membawa botol
minum air putih ke dalam kelas
§ Jangan berikan permen atau
kupon makanan sebagai hadiah.
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§ Minta orang tua untuk
membawakan bekal
makanan sehat.
§ Tidak memberikan
makanan pada acara
pertemuan / perayaan
§ Ajak anak untuk belajar di
luar kelas misal pada saat
pelajaran sains.
§ Ajak anak untuk menirukan
gerak.
§ Doronglah anak beraktivitas
saat jam istirahat.
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Changes of school lifestyle

Jangan memberikan
hukuman dalam bentuk
aktivitas fisik
§ Dorong anak untuk
berpartisipasi pada
kegiatan eks-kul olah
raga
§ Jadilah “role model”

Masukkan topik
makanan sehat dan
aktivitas fisik pada jam
olah raga

Identifikasi siswa yang

mempunyai gangguan
makan atau
mendapatkan “bullying”

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Take home messages

• An early rebound is a risk factor for later obesity in

childhood and adulthood.
• Familial predisposition to obesity and obesity-related
complications and its impact on obesity in children is an
important marker of the complex interplay between
genetic and environmental factors.
• A balanced diet with a low glycemic index and reduced
sugar is needed.
• Physical activity with lifestyle changes in school must be
taught from an early age.

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