MODERN EPIDEMICS OF CHILDHOOD
Educational Objectives
| The goals of this program are to improve management of overweight and obesity in children and to improve management
of autism. After hearing and assimilating this program, the clinician will be better able to:
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 | 1. Use appropriate screening tests for prediabetes and diabetes in overweight and obese children.
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| 2. Predict risk for mortality based on body mass index and blood pressure in overweight and obese children.
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| 3. Recommend a staged approach to help families reach fitness goals.
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| 4. Describe markers used to identify autism in children.
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| 5. Counsel parents of children with autism about screening and treatment.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning
committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest.
Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary
business or commercial interest. For this program, the faculty and planning committee reported nothing to disclose.
Acknowledgements
Dr. Larimore spoke in Estes Park, CO, at the 60th Anniversary and Annual Scientific Conference, presented July 18-
20, 2008, by the Colorado Academy of Family Physicians. Dr. Camarata was recorded in San Diego, CA, on June 28,
2008, at the San Diego Academy of Family Physicians’ 51st Annual Postgraduate Symposium, Family Medicine Update:
2008. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production
of this program.
| CHILDHOOD OBESITY: A PRACTICAL APPROACH FROM A BUSY CLINICIAN —Walter L. Larimore, MD,
Assistant Clinical Professor, Department of Family Medicine, University of Colorado Health Sciences Center, Denver,
and Visiting Faculty and Clinical Instructor in Family Medicine, In His Image Family Medicine Residency Program,
Tulsa, OK
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| Obesity epidemic: 1985—data available from <50% of states; no state reported >14% prevalence of obesity;
1991—rate of obesity in adults, 15% to 19%; epidemic began spreading in southern and midwestern states;
1997—rates reached ≥20% in 3 states; 2000—only one state (Colorado) had rate 10% to 14%; 2001—rate
reached 25% in Mississippi; 2006—rates reached 30% in some states; 1970 to 2000—obesity rates quadrupled;
rates of type 2 diabetes and hospital admissions increased
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| Metabolic syndrome in children: in United States, by age 12 to 14 yr, 51.2% of obese children have metabolic
syndrome; nearly 10% of obese children 8 to 11 yr of age have metabolic syndrome; child 8 yr of age with metabolic
syndrome likely to develop type 2 diabetes and/or heart disease within 10 yr
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| Screening for diabetes: American Diabetes Association (and Canadian equivalent) recommends screening for
dysglycemia (utilizing fasting blood glucose [FBG]) in obese children ≥10 yr of age; recent data show nearly 9% of
obese children screened for prediabetes have it when measured by FBG, nearly 25% when screened with 2-hr glucose
tolerance test; current recommendations likely to change
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| Hypertension: over last decade, rates in children increased 40%; body mass index (BMI) and waist circumference
associated with elevated blood pressure (BP); in children, waist circumference >1 cm above normal for age (based
on normal growth curves) increases likelihood of hypertension by 10%, and likelihood of prehypertension by 5%;
nearly 75% of cases of childhood prehypertension and hypertension undiagnosed; Bogalusa Heart Study found
children with BP ≥90th percentile had signs of early organ damage (eg, thickening of heart wall or increased urinary
albumin)
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| Mortality and morbidity: teenagers with BMI >30 or BMI >95th percentile have 30% to 40% higher adult mortality
than age-adjusted population with normal BMI; without intervention, lifespan of overweight or obese children
shortened by 8 to 20 yr; quality of life similar to that of children suffering from cancer; children 5 to 10 times
as likely to be depressed or anxious, and 50% to 100% more likely to bully or be bullied; 14% of deaths from cancer
in men (20% in women) due to overweight and obesity
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| Impact on society: in 2002, estimated that Social Security Administration pays $77 million/mo to citizens with obesity-related
disabilities; annual Medicare expenditures (≈$7205) doubled for those with BMI >30; for every 2 hr
young girl spends watching television, risk for obesity increases 23% (risk for diabetes by 14%); additional serving
of soda increases risk for obesity by 60%; physical education classes and recess time in schools—shown to improve
school performance and standardized testing scores; 40% of schools in United States reduced time spent in
physical education class and recess; perception that time spent in physical education and recess undermines academic
learning is main barrier to physical activity in schools; perceptions of parents—parents of overweight and
obese children tend to be overweight or obese and do not see their children as overweight or obese; parents who are
overweight or obese put children at greatest risk for obesity or overweight; only 30% of parents of obese teenagers
identify them as obese
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| Family fitness assessment tool: available at www.drwalt.com or www.supersizedkids.com; 10 questions about
nutritional habits; 10 questions about activities (including sleep and vacation); 5 questions about BMI; families
graded A through F in each category
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| Family fitness 8-wk plan: tested in 3 clinical trials; for any family member who scores <3 As; 6 different activities
chosen “as a family”
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| Week 1: journaling recommended; calculate BMI; measure BP of each family member; begin discussing activities
to do as family; meal times—choices include using answering machine during dinner at home, eliminating ≥1
visits/wk to fast food restaurants, and switching to smaller dinner plates; nutrition—eat ≥1 serving of fruit or
vegetables at each meal; talk to children about increasing intake of plant or other healthy proteins; rest—eliminate
caffeine, chocolate, cocoa, and soft drinks after 3:00 PM; media—eg, computer, video games, television; reduce
usage to <4 hr/day; consider removing screens from bedrooms
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| Week 2: meet as family to discuss what worked and what did not; learn how to read food labels; plan family exercise;
turn off television during meals; nutrition—reduce desserts to smaller portions; replace one dessert per
week with fresh fruit; children who fill their own plates equally satiated, and actually serve themselves less food
than when parents serve them; reduce red meats to ≤3 meals/wk; try new fish or vegetarian protein recipes;
rest—set and enforce bedtime and wake-up time; less sleep increases likelihood of obesity; media—try no television
1 day/week
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| Results: after 8 wk, waist circumference decreased in adults and children; weight loss; increased family Apgar
scores; increase in number of meals family shared together; in children 4 to 12 yr of age, rate of pre-high BP or
high BP (based on single reading) decreased from nearly 30% to ≈12% (56% reduction); population of children
with normal BP increased from 70% to nearly 87% (≈24% increase)
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| Recommendations: assess key dietary habits (eg, consumption of sweets and beverages), physical activity habits,
readiness of family to change lifestyle habits, and family history of obesity and obesity-related illnesses; laboratory
testing recommended, based on degree of obesity and associated illnesses; staged approach to treatment of childhood
obesity (eg, 8-wk plan); limit consumption of sweets, beverages, and fast food; limit screen time (eg, computer
usage, television, video games); engage in physical activity for ≥60 min/day; encourage family meals on most
or all days of week
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| BMI percentiles: for every child >2 yr of age, record BMI percentile at least once per year; if child’s BMI between
fifth and 50th percentile, congratulate family; if BMI in 50th to 74th percentile, child has normal BMI but at risk; if
BMI in 75th to 84th percentile, child at risk; if BMI in 85th to 94th percentile, label and diagnose child as overweight;
if BMI in ≥95th percentile, child obese (label that obesity and react)
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| BP percentiles: record diastolic and systolic BP percentile for every child at every visit; evaluate BP based on sex
of child and height percentile; if systolic and diastolic BP in <90th percentile, congratulate family; if BP in 90th to
94th percentile, child has pre-high BP (based on one measurement; based on 3 measurements, child has prehypertension);
if BP in ≥95th percentile, child has high BP or hypertension
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| Management recommendations: family fitness assessment tool; laboratory testing—for overweight children
(BMI in 84th-94th percentile) with no obesity-related illness, obtain fasting lipid profile; if child has obesity-related
illness (eg, prehypertension, hypertension), perform liver function testing and testing for dysglycemia; FBG
(consider 2-hr glucose tolerance testing); for obese children, serum urea nitrogen (BUN) and creatinine recommended;
first follow-up visit—recheck child’s BMI and BP percentiles; review results of assessment tool and laboratory
testing; if abnormalities found, recommend intervention; schedule follow-up visit; explain 8-wk plan;
second follow-up visit (after 8 wk)—recheck BMI and BP percentiles; if no improvement, recommend second 8-
wk plan (more intense with just as many choices for families); schedule follow-up visit; third follow-up visit (after
level 2, 8-wk plan)—recheck BMI and BP percentiles and do follow-up laboratory testing; if any findings abnormal,
refer to, eg, registered dietitian, school nurse, or pediatric endocrinologist; schedule follow-up
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| AUTISM: EARLY DIAGNOSIS AND TREATMENT —Stephen M. Camarata, PhD, Professor, Department of
Hearing and Speech Sciences, and Associate Professor of Special Education, Vanderbilt University, Nashville, TN
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| Introduction: important to be proactive in helping families navigate treatment; screening—universal screening for
autism by age 2 yr “not realistic goal at this time”; sensitivity and specificity of autism screening checklist “just not
there”
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| Identifying autism by age 2 yr: requires 2- to 3-hr diagnostic session completed by trained objective clinician;
studies show high false-positive rate; can be performed with higher validity in children 4 to 5 yr of age
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| What is autism? Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)—qualitative
impairment in social interaction and communication; restrictive and repetitive or stereotyped behavior; delays or abnormal
functioning with onset before age 3 yr in social interaction, language, and symbolic play; reduced or absence
of motivation in social interaction (key marker; in verbal and nonverbal interaction); overreliance on routines; toe walking
may be marker; disruptions in language development; classic autism—combination of disruptions in behavior, social
skills, and language; autism spectrum disorder (ASD)—weakness in any area (eg, behavior, social skills,
language); no standard definition; pervasive developmental disorders (PDD)—includes autism, Asperger’s syndrome,
Rett syndrome, and PDD not otherwise specified (PDD-NOS)
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| Incidence of autism: since definition of autism changing, difficult to determine whether incidence increasing; estimated
incidence, 1 in 150; some people with language disorder (particularly, receptive language disorder) diagnosed
with ASD (speaker’s position, “I don’t agree with that”); contributing factors—declining age of diagnosis;
expanding definition; improved health care and decrease in sudden infant death syndrome (“perhaps these children
that are living are now turning up as autistic”); highest increase in incidence of ASD (incidence of classic autism
increasing slightly but still fairly low [1 in 1000]); 90% of ASD not classic autism
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| Neurology of autism: implicated regions include hippocampus, amygdala, cerebellum, auditory cortex, frontal
lobe, prefrontal cortex, and corpus callosum; no consistent findings; difficult to pinpoint loci with imaging technology;
disruptions in autism multifaceted; no consistent neurologic markers
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| Genetics: duplications or deletions in chromosome 15 (common; “doesn’t account for what we see in autism”); concordance
of 40% to 50% in monozygotic twins, 8% to 15% in dizygotic twins; “genetically linked, but clearly not
genetically deterministic”; >70 genes may be associated; autism not condition of single or dual genes; no genetic
test for autism; genetic screening for fragile X syndrome recommended in children who display autism
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| Environmental factors: hypothesized links include deprivation, diet, allergies, mercury exposure, lead exposure,
and vaccinations; no specific factors or combination of factors linked to autism
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| Markers: head size; changes in cognitive ability; however, due to population overlap, some markers (eg, head size)
unreliable; late talking—most late talkers not autistic; best marker in children 2 yr of age; all children with autism
talk late; assess understanding (children with autism have poor comprehension); resistance of social interaction;
joint attention—following other person’s gaze; pointing; showing toys to others; eliciting attention; inconsistent
markers—lining up toys (children with autism become upset when toy lineup changed); lack of playing with other
children (most 2-yr-olds not social); tantrums
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| Management: speaker noticed age of children when parents inquire about autism decreasing (ie, from 4 yr of age to
12-24 mo of age); consider referral for evaluation; monitor health; be aware that parents likely to try alternative or
questionable treatment; refer to—developmental pediatricians; child psychiatrists; pediatric neurologists; psychologists;
speech pathologists; differential diagnosis—important (eg, 70%-80% of late-talking children 2 yr of age
normalize by age 4 yr); sleep disorders; digestive disruptions; tantrums can be sign of pain; self-injury; monitor
hearing status
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| Treatment: “there’s no cure”; children can be taught to function with behavioral management; >50% can be taught
to speak; most have cognitive impairment; children become interested in one area and practice it repeatedly; early
intervention treatment given through education system; some regional centers and private practices provide treatment;
receiving feedback for different treatments for different children recommended; questionable treatment—
chela-tion; gluten-free diets; megavitamins; hyperbaric therapy; sensory integration; auditory integration; no consistent
findings with drug therapy (eg, guanfacine [Tenex], methylphenidate [Ritalin])
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| Speaking to parents: reassure parents that they did not cause problem; stress that no miracle cures exist; management
of autism long incremental process; discuss referral; be proactive about advising parents about questionable or controversial
therapy; preschool or day care not mandatory; encourage parents to receive active support; make sure parents
maintain common sense; ask parents to report frequently; make parents comfortable about refusing questionable treatment;
stress positive effects of behavioral intervention; recent data show no link to measles, mumps, and rubella
(MMR) vaccine or thimerosal; mercury present in influenza vaccines; concordance in siblings ≈10% for ASD (lower
for PDD [autism]); facilitate support network in practice; understand fears of parents; help parents overcome guilt; do
not allow fear to diminish enjoyment of child’s toddler years
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| Questions and answers: screening tools—Modified Checklist for Autism in Toddlers (M-CHAT; false-positive
rates high); school classes—time spent with typical children beneficial; self-contained classrooms may be necessary;
placement in regular classes determined on case-by-case basis; savants—people with autism repeat activities
(eg, drawing, playing piano), resulting in spikes in abilities; children learn in focused way on narrow abilities; loss
of language in otherwise socially and neurologically normal child 2 yr of age—may be due to pathologic conditions
(eg, meningitis, measles, mumps); in childhood disintegrative disorder, children regress and lose language
ability (“not a good sign”); prism glasses—not effective for autism, learning disabilities, or dyslexia; music—
children with autism often respond to music; effectiveness of music therapy still undetermined
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Suggested Reading
Bao W et al: Essential hypertension predicted by tracking of elevated blood pressure from childhood to adulthood: the Bogalusa
Heart Study. Am J Hypertens 8:657, 1995; Bowler D: Autism: the international journal of research and practice. Editorial. Autism
12:331, 2008; Dehghan M et al: Childhood obesity, prevalence and prevention. Nutr J 4:24, 2005; Eichler EE et al:
A hot spot of genetic instability in autism. N Engl J Med 358:737, 2008; Eliakim A et al: Parental obesity and higher pre-intervention
BMI reduce the likelihood of a multidisciplinary childhood obesity program to succeed--a clinical observation. J Pediatr
Endocrinol Metab 17:1055, 2004; Epstein LH: Family-based behavioural intervention for obese children. Int J Obes Relat
Metab Disord 20 Suppl 1:S14, 1996; Fombonne E: Is autism getting commoner? Br J Psychiatry 193:59, 2008; Hollander
E: New developments in autism spectrum disorders. Interview by Dr. George Lundberg. Medscape J Med 10:152, 2008;
Koegel LK et al: Setting generalization of question-asking by children with autism. Am J Ment Retard 102:346, 1998; Koegel
RL et al: Increasing speech intelligibility in children with autism. J Autism Dev Disord 28:241, 1998; Larimore W et
al: SuperSized Kids: How to Rescue Your Child from the Obesity Threat. New York: Warner Books; 2005; Poling JS:
Vaccines and autism revisited. N Engl J Med 359:655; author reply 656, 2008; Summerbell CD et al: Interventions for preventing
obesity in children. Cochrane Database Syst Rev:CD001871, 2005; Tanas R et al: A family-based education program
for obesity: a three-year study. BMC Pediatr 7:33, 2007.
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