Childhood Obesity: Now Childhood Obesity: Now What?What?

Ann M. Childers, M. D.Ann M. Childers, M. D.

American Society of Bariatric PhysiciansAmerican Society of Bariatric Physicians

The Nutrition and Metabolism SocietyThe Nutrition and Metabolism Society

Once upon a time,Once upon a time,

19401940

Fifth Grade Class, Fifth Grade Class, 19401940

Woodstock 1969

55thth Grade Class 1969 Grade Class 1969

Then Came the Dietary Then Came the Dietary Recommendations of Recommendations of 1980, and the 1980, and the Food Pyramid of 1992Food Pyramid of 1992

Modern ClassroomModern Classroom

One in Three Children One in Three Children Overweight or ObeseOverweight or Obese

NAFLD: Prevalence estimated at ~10%

Health in the Health in the United StatesUnited States

WORST in the world for WORST in the world for percentage of obese persons percentage of obese persons (30.6%)(30.6%)

WORSE than TOP20 industrialized WORSE than TOP20 industrialized nations for healthy life expectancy nations for healthy life expectancy (#22)(#22)

Burden of IllnessBurden of Illness

Metabolic syndrome is as high as 50% Metabolic syndrome is as high as 50% among severely obese children and among severely obese children and adolescentsadolescents

~44% of American adults have either ~44% of American adults have either metabolic syndrome or diabetemetabolic syndrome or diabete

No. 1 in the world in total health No. 1 in the world in total health expenditure per capita.expenditure per capita.

Re-balance: InsulinRe-balance: Insulin

Better story?Better story?

Chubby CheeksChubby Cheeks

Acanthosis NigricansAcanthosis Nigricans

Nutritional ImpactNutritional Impact

Low Iron Stores:Low Iron Stores: CognitionCognition Depression/ADHDDepression/ADHD RLSRLS Test: Ferritin (CBC Test: Ferritin (CBC

has low sensitivity)has low sensitivity)

Low Vitamin DLow Vitamin D Test: 25(OH)Vit DTest: 25(OH)Vit D

Body ImageBody Image

81% of 10 year olds polled say they 81% 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 teen Over ½ of teen girls and 1/3 of teen boys use unhealthy weight controlboys use unhealthy weight control– Including but not limited to: skipping Including but not limited to: skipping

meals, fasting, cigarettes, vomiting, meals, fasting, cigarettes, vomiting, laxativeslaxatives

History of History of Human NutritionHuman Nutrition

If all of human history was condensed If all of human history was condensed into one year, we only began farming into one year, we only began farming and eating grains yesterday, when and eating grains yesterday, when dental disease became common and dental disease became common and we became shorter/fatter.we became shorter/fatter.

We began consuming processed We began consuming processed vegetable oils & trans fats within the vegetable oils & trans fats within the past 10 minutes, when heart disease past 10 minutes, when heart disease became our No. 1 killer.became our No. 1 killer.

The (Un-) Natural The (Un-) Natural

History of ManHistory of Man

From This ------------------------------------------- This: 1.8M Yrs

From This -------- This: 35 Yrs

Vegetarian GorillaVegetarian Gorilla

Relative gut proportions for extant hominoids (percentage Relative gut proportions for extant hominoids (percentage of total gut volume)of total 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 primate foods: do the diets of our closest living relatives have lessons for us?have lessons for us?, pp. 488-498, pp. 488-498

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

Elia Psouni and colleagues analyzed Elia Psouni and colleagues analyzed 70 species of animal for how diets 70 species of animal for how diets are bornare born

Nature vs Nuture?Nature vs Nuture?

Figure 5. Time to weaning in humans is quantitatively predictable from a Figure 5. Time to weaning in humans is quantitatively predictable from a carnivorous diet.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.0032452http://www.plosone.org/article/info:doi/10.1371/journal.pone.0032452

Twice-told tale? ..the Twice-told tale? ..the fable of Lipid & fable of Lipid & CholesterolCholesterol

Keys won Keys won AmericaAmerica’’s s confidence confidence – Named Named ““Father of Father of

the Lipid the Lipid HypothesisHypothesis””

– Featured on the Featured on the cover of Time cover of Time (1961) (1961)

How Americans Got How Americans Got Obese: Obese:

the Lipid Hypothesis!the Lipid Hypothesis! The Lipid Hypothesis (LH): Dietary fat The Lipid Hypothesis (LH): Dietary fat

raises cholesterol and cholesterol raises cholesterol and cholesterol causes heart diseasecauses heart disease

Promoted by Ancel Keys in early Promoted by Ancel Keys in early 1950s, via his 7 Countries Study. 1950s, via his 7 Countries Study.

BIAS? Keys had data from 22 BIAS? Keys had data from 22 countries, but failed to report on 15 countries, but failed to report on 15 that didnthat didn’’t fit his Hypothesis.t fit his Hypothesis.

Left: Data Keys Published Right: Data Keys Had

MONICA Study… vs. MONICA Study… vs. Keys?Keys? 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 No correlation found between total

blood cholesterol values and death blood cholesterol values and death from heart diseasefrom heart disease

MONICA Data MONICA Data shows no causal effects!shows no causal effects!

MONICA data graph by Dr. Malcolm Kendrick

whatwhat’’s next?s next?

You mayYou may

Simple folk-story? Simple folk-story? USDA: Light on USDA: Light on Fats, and Carbohydrate Fats, and Carbohydrate HeavyHeavy

How to fatten hogs! 1921 Farmer’s Cyclopedia of Livestock, pg 545

Industry Creates Dietary Industry Creates Dietary Confusion:Confusion:Smart Choices ProgramSmart Choices Program Endorsed by top Endorsed by top

nutritionists at nutritionists at Tufts University Tufts University and Baylor and Baylor College of College of MedicineMedicine

Corporate Corporate sponsored: sponsored: KelloggKellogg’’s, PepsiCo, s, PepsiCo, ConAgra, ConAgra,

Kraft FoodsKraft Foods

Smart Choices Smart Choices Program (cont.)Program (cont.) 44% sugar44% sugar 96% refined 96% refined

carbohydratecarbohydrate Coal tar dyes: Red Coal tar dyes: Red

Dye #40, Yellow Dye #40, Yellow Dye #6 (child Dye #6 (child hyperactivity)hyperactivity)

Seed dye Annatto Seed dye Annatto (allergies)(allergies)

VitaminsVitamins Some fiberSome fiber

Same old-story? Same old-story? USDA: Light on USDA: Light on Fats, and Carbohydrate Fats, and Carbohydrate HeavyHeavy

How to fatten hogs! 1921 Farmer’s Cyclopedia of Livestock, pg 545

A Calorie is Not a A Calorie is Not a Calorie: Insulin is KeyCalorie: Insulin is Key

Better Science?Better Science?

Taubs, Gary. Scientific American, FOOD ISSUE Fall13

What we knew in What we knew in 19121912““Skim milk is one of the most valuable Skim milk is one of the most valuable adjuncts of the farm for fattening swine. adjuncts of the farm for fattening swine. Used with corn, kafir corn or any of the Used with corn, kafir corn or any of the common grain by-products, an almost common grain by-products, an almost ideal ration is formed. Hogs like it, and ideal ration is formed. Hogs like it, and relish rations mixed with it. As a result of relish rations mixed with it. As a result of five yearfive year’’s work in feeding skim milk at s work in feeding skim milk at the New York station at Cornell, it is the New York station at Cornell, it is concluded that the most economical concluded that the most economical returns are secured when the milk is fed returns are secured when the milk is fed with corn meal.with corn meal.””

FarmerFarmer’’s Cyclopedia of Livestock, pg 545s Cyclopedia of Livestock, pg 545

What My Farmer SaysWhat My Farmer Says

““I want my meat pigs to be pre-I want my meat pigs to be pre-diabetic”diabetic”

Her approach: Grains + Fat Free Her approach: Grains + Fat Free MilkMilk

Control Diet Control Diet vs. vs. Low Carb (20 g CHO per day), High Fat, Ad Low Carb (20 g CHO per day), High Fat, Ad Lib DietLib Diet

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 Mean 24 hr. plasma glucose

normalized.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.

Leptin & Hunger Leptin & Hunger controlcontrol

Better story!Better story!

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

Population StudiesPopulation Studies

3 year study, 12,829 Adolescents: 3 year study, 12,829 Adolescents: Skim and 1% milk, but not dairy fat, Skim and 1% milk, but not dairy fat, associated with weight gain associated with 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: In 9 yr study: 19,352 Swedish women: In middle age, one serving full fat milk middle age, one serving full fat milk per day --> 15% less weight gain; full per day --> 15% less weight gain; full fat cheese --> 30% less weight gain fat cheese --> 30% less weight gain

(Rosell, et. al. AJCN 2006) (Rosell, et. al. AJCN 2006)

Less Carbohydrates, Less Carbohydrates, More Natural Fats & More Natural Fats & High Quality Proteins High Quality Proteins

Brain is 60-70% fat & significant Brain 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 not Fats and proteins block hunger; do not

interfere with leptininterfere with leptin Fats promote absorption of vitamins Fats promote absorption of vitamins

and mineralsand minerals Fats slow release of sugar to the blood Fats slow release of sugar to the blood

streamstream

In the News:In the News:British Medical JournalBritish Medical Journal

Observations: Saturated fat is not the major issueTuesday, October 22, 2013“It is time to bust the myth of the role of saturated fat in heart disease,” argues a British cardiologist.

““ItIt’’s Time to End the s Time to End the Low Fat Myth Low Fat Myth””

Food Business News, 4/7/14:Food Business News, 4/7/14:

Staying power seen in Staying power seen in shift from shift from

carbohydratescarbohydrates““Health-conscious parents Health-conscious parents have have responded in some responded in some strange ways strange ways such as preparing unhealthy foods such as preparing unhealthy foods for their children in the morning, for their children in the morning, like bacon and sausages, like bacon and sausages, to make to make sure they are satiated sure they are satiated during the during the day”day”

Fats Promote Satiety.Fats Promote Satiety.Fats Do Not Fats Do Not

Promote Promote Insulin.Insulin.

High Carb, Low Fat High Carb, Low Fat Diets Diets Universally recommended for tx Universally recommended for tx

hyperlipidemia, prevention heart dzhyperlipidemia, prevention heart dz Lower HDLLower HDL Raise triglycerides Raise triglycerides Drive LDL toward Small, DenseDrive LDL toward Small, Dense

– NMR LipoprofileNMR Lipoprofile

Nutrient PoorNutrient Poor

High carbohydrate diets, and high High carbohydrate diets, and high grain diets in particular, are grain diets in particular, are nutrient poor.nutrient poor.

Striking a Balance:Striking a Balance:CHO & Fat CHO & Fat

DoesnDoesn’’t the Brain Need t the Brain Need Carbohydrates?Carbohydrates? Ask any Eskimo: The Ask any Eskimo: The

brain functions well brain functions well on ketones from on ketones from carnivorous dietcarnivorous diet– Ketogenic diet used in Ketogenic diet used in

epileptic childrenepileptic children Gluconeogenesis: Gluconeogenesis:

Proteins converted Proteins converted to carbohydrates as to carbohydrates as neededneeded

Brain functions well Brain functions well on less than 40% on less than 40% dietary dietary carbohydratescarbohydrates

Inuit child fishing with harpoons

Hunter Gatherer DietHunter Gatherer Diet

Worldwide, 73% of H-G societies derive >55-65% of energy from animal foods

Fake FoodFake Food

Real FoodReal Food

The ProblemThe Problem

Proposed MechanismProposed Mechanism

Insulin = storage hormoneInsulin = storage hormone– ““Bail out” strategy for body under Bail out” strategy for body under

sugar assaultsugar assault– Interferes with energy release from Interferes with energy release from

fat cellsfat cells– Interferes with leptin sensitivityInterferes with leptin sensitivity– Too much lowers satiety, increases Too much lowers satiety, increases

body fat, promotes MetS/DM IIbody fat, promotes MetS/DM II

What now?What now?

Revert dietary CHO load to 40% Revert dietary CHO load to 40% or less of diet calories (SAD or less of diet calories (SAD currently at 55%)currently at 55%)

Discourage the consumption of Discourage the consumption of fermentable carbohydratesfermentable carbohydrates

Discourage marketing of Discourage marketing of fermentable CHOs to childrenfermentable CHOs to children

Encourage adequate protein and Encourage adequate protein and increase dietary fatsincrease dietary fats

For more informationFor more information

Dr. ChildersDr. Childers’’ blog: blog:

annchilders.blogspot.comannchilders.blogspot.com

The Nutrition & Metabolism The Nutrition & Metabolism SocietySocietynmsociety.org