Maura D. Frank, M.D. Daniel Green, M.D.

1. Childhood Obesity:Epidemiology and TrendsMaura D. Frank, M.D.

2. HSS educational activities are carried out in a manner that serves the educational component of our Mission. As faculty we are committed to providing transparency in any/all external relationships prior to giving an academic presentation. Maura D. Frank, M.D. Weill Cornell Medical College Komansky Center for Children’s Health Disclosure: I DO NOThave a financial relationship with any commercial interest. :

3. Obesity: The Problem Overweight and obesity are a major public health concern in the United States. 33.8% prevalence of obesity in adults in 2007-2008.1,2

4. Trends: US Adults http://www.cdc.gov/obesity/data/trends.html

6. Tripled in 6 -11 year olds: 6.5 to 19.6%

7. More than tripled in 12 to 19 year olds: 5 to 18.1% 3,4

8. Classification in Children and Adolescents Overweight: 85th to 94th %ile of the gender-specific body mass index (BMI) growth charts for age and gender. Obesity: at or above the 95th percentile for age and gender. Obesity among adults is defined as a BMI of 30 or higher. 5 Extreme Obesity: at or above the 99th %ile BMI for age and gender

10. National data: Obesity and Overweight 2003-2006: 16.3% obese 15.6% overweight 31.9% overweight or obese 11.3% at or above the 97th %ile 2007-2008 16.9% obese 14.8% overweight 31.7% overweight or obese 11.9% at or above the 97th %ile3,4

11. New York City New York City 2009: 21% of public school children from kindergarten to eighth grade are obese, and another 18% overweight 6 NYPH/Komansky Center 2005: 27% of adolescent patients in the general clinical practice were obese and another 19.5% overweight.

13. Males by Race/Ethnicity

14. Racial/Ethnic disparities: Females 1988-1994: Female non-Hispanic black adolescent at 16.3% were more likely to be obese compared with non-Hispanic white adolescent girls at 8.9%. 2007-2008: Female non-Hispanic black adolescents were significantly more likely to be obese at 29.2% compared with non-Hispanic white adolescents at 14.5%. Between 1988-1994 and 2007-2008 the prevalence of obesity increased: From 8.9% to 14.5% among non-Hispanic white girls. From 16.3% to 29.2% among non-Hispanic black girls. From 13.4% to 17.4% among Mexican-American girls. 7

15. Female Race/Ethnicity

16. Infants and Toddlers 2008 obesity prevalence in low income preschoolers in Head Start Overall rate 14.6% (10.4% all pre-schoolers) American Indian or Alaskan native: 21.2%8 Only 2 states, Colorado and Hawaii, had obesity prevalences ≤ 10% for this population. 7 Elevated rates of weight for length in 0-2 year olds: 9.5% overall, but 14.9% for Hispanic males 3

17. Table 1. Prevalence of High Weight for Recumbent Length Among US Children From Birth to 2 Years of Age, 2007-2008a,b. Ogden, C. L. et al. JAMA 2010;303:242-249 Copyright restrictions may apply.

18. Co-morbidities of childhood obesity Significant co-morbidities in youth Tracking of obeisty and co-morbidities to adulthood Strong evidence that obese children and youth are likely to become obese adults.9-12 The Bogalusa Heart Study: 25% of obese adults were overweight as children, and that if onset of overweight is prior to 8yo, obesity in adulthood is likely to be moresevere.13

19. Co-Morbidities Cardiovascular Elevated blood pressure, at least 13% having increased systolic BP and 9% with elevated diastolic BP.14 Elevated LDL cholesterol, low HDL13 Effects of deconditioning

20. Co-Morbidities Endocrine/Metabolic Type II Diabetes15: Close to half of newly diagnosed cases of diabetes in children are Type II 16 Polycystic Ovarian Syndrome: women with POS are more likely to be obese17 Vitamin D Deficiency

21. Respiratory/ENT Asthma may occur more frequently and be exacerbated by obesity18 Obstructive Sleep Apnea: daytime sleepiness, poor attention, academic difficulties, RVH/pulmonary hypertension19-21 Worsening of asthma due to inactivity?

22. Co-morbidities Neurologic Pseudotumorcerebri22 Rare but can result in vision loss Obesity is one of several risk factors Psychiatric Quality of life23 Depression Sexual and physical abuse may increase risk

23. Co-morbidities GI NAFLD (steatosis, steatohepatitis, fibrosis, cirrhosis) 24-25 Cholelithiasis26 GERD and constipation exacerbated27,28 Musculoskeletal Blount Disease SCFE Osgood Schlatter’s Increased fractures and musculoskeletal discomfort Joint changes/osteoarthritis 29-32

24. Genetic Influences Family History: parental obesity and family history of Type2 DM 33,16 Twin studies34 Hormones that influence appetite, satiety, and fat distribution: leptin, ghrelin, adiponectin35 Genetic conditions causing obesity are rare: Primary Cushing syndrome (short, violaceousstriae) and Prader-Willi

25. Prenatal and early childhood effects Infants of Diabetic mothers: cycle of increased risk of obesity, later diabetes 36 Excessive maternal weight gain: Children of women whose weight gain during gestation exceeded IOM guidelines were 48% more likely to be overweight at age 7 than children whose weight gain was in the recommended range.37

26. Prenatal and early childhood effects: Nicotine exposure Strong relationship between maternal smoking and subsequent obesity, hypertension, and type 2 diabetes in offspring. May be mediated via nicotine’s direct effects on the hypothalamus, altering its regulation of body weight and energy balance May also be related to low birth weight, a well established outcome of maternal cigarette smoking, and a significant risk factor for the development of obesity, hypertension, and type 2 diabetes.38

27. Prenatal and early Childhood Effects Breastfeeding: Breastfeeding decreases the risk of obesity The longer the duration of breastfeeding, the better the protective effect. 39,40 Timing of introduction of solid foods: Introduction of solid foods in formula fed infants prior to 4 months is associated with a 6-fold increase in risk of obesity at age 3 years. 41 Sleep: Evidence accumulating for short sleep duration as a risk factor for childhood obesity42,43

28. How did we get here?The “Obesigenic” Environment Sugar Sweetened Beverages (SSBs) School breakfast and lunch: school lunch associated with rapid weight gain in low-income girls 44 Food availability and choice in low income neighborhoods45-47 Portion size

29. The “Obesigenic” Environment PA in schools Decline Emphasis on academics Outside play Associated with lower BMI Safety concerns Play and activity venues Screen time48

30. Tackling the Problem AAP/AMA Task Force 2007: promotion of a step-wise approach toward obesity, from prevention to intensive, multidisciplinary interventions 49 Intensive intervention programs combining both nutrition and physical activity show varying rates of success 50

31. NYPH-Komansky Health For Life Program (H4L) Multidisciplinary healthy lifestyle program for 8-18 year olds who are either overweight or obese (≥ 85th %ile BMI). Multidisciplinary team of physicians (general pediatrician and adolescent specialist, pediatric residents), dietitians, physical therapists, a social worker, a nurse, and medical student mentors Three month intensive program with one year follow-up includes individual visits and a 10-week core workshop and activity series

32. Health for Life Baseline Measurements BMI %ile Mean 97.2th %ile (Y), 97.5th %ile (O) Range 85th – 100th %ile Blood pressure: 36% systolic BP ≥ 120 7% systolic BP ≥ 130 HDL: 40% abnormal (<40 mg/dL) Vitamin D: 58.8% deficient (<20ng/mL) 38.2% insufficient (20-29 ng/mL)

33. Results: BMI z-scores (Groups 1-10) Younger cohort (8-11 yo) 66% of participants decreased BMI z-score Mean decreased from 2.12 to 2.05 Older cohort (12-18 yo) 48% of participants decreased BMI z-score Mean decreased from 2.26 to 2.16

35. USDA/School food changes

38. References 11. Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting obesity in young adulthood from childhood and parental obesity. N Engl J Med 1997; 37(13):869–873. SerdulaMK, Ivery D, Coates RJ, Freedman DS. Williamson DF. Byers T. Do obese children become obese adults? A review of the literature. Prev Med 1993;22:167–177. Freedman DS, Khan LK, Dietz WH, Srinivasan SR, Berenson GS. Relationship of childhood overweight to coronary heart disease risk factors in adulthood: The Bogalusa Heart Study. Pediatrics 2001;108:712–718. Freedman DS, Mei Z, Srinivasan SR, Berenson GS, Dietz WH. Cardiovascular risk factors and excess adiposity among overweight children and adolescents: the Bogalusa Heart Study. JPediatr. 2007 Jan;150(1):12–17.e2. Sinha R, Fisch G, Teague B, Tamborlane WV, Banyas B, Allen K, Savoye M, Reiger V, Taksali S, Barbetta G, Sherwin RS, Caprio, S. Prevalence of Impaired Glucose Tolerance among Children and Adolescents with Marked Obesity. The New England Journal of Medicine. 2002; 346(11): 802-810. Fagot-Campagna A, Pettitt DJ, Engelgau MM, et al. Type 2 diabetes among North American children and adolescents: an epidemiologic review and a public health perspective. J Pediatr. 2000;136:664 – 672. MichelmoreKF, Balen AH, Dunger DB, Vessey MP. Polycystic ovaries and associated clinical and biochemical features in young women. ClinEndocrinol (Oxf). 1999;51:779 –786. Ford ES. The epidemiology of obesity and asthma. J Allergy ClinImmunol. 2005;115:897–909. Wing YK, Hui SH, Pak WM, et al. A controlled study of sleep related disordered breathing in obese children. Arch Dis Child. 2003;88:1043–1047.

39. References Redline S, Tishler PV, Schluchter M, Aylor J, Clark K, Graham G. Risk factors for sleep-disordered breathing in children: associations with obesity, race, and respiratory problems. Am J RespirCrit Care Med. 1999;159:1527–1532. Kalra M, Inge T, Garcia V, et al. Obstructive sleep apnea in extremely overweight adolescents undergoing bariatric surgery. Obes Res. 2005;13:1175–1179. Scott IU, Siatkowski RM, Eneyni M, Brodsky MC, Lam BL. Idiopathic intracranial hypertension in children and adolescents. Am J Ophthalmol. 1997;124:253–255. SchwimmerJB, Burwinkle TM, Varni JW. Health-related quality of life of severely obese children and adolescents. JAMA. 2003;289:1813–1819 Ogden CL, Yanovski SZ, Carroll MD, Flegal KM. The Epidemiology of Obesity. Gastroenterology. 2007;132: 2087-2102. Schwimmer JB, Deutsch R, Kahen T, Lavine JE, Stanley C, Behling C. Prevalence of Fatty Liver in Children andAdolescents. Pediatrics. 2006; 118; 1388-1393 Kaechele V, Wabitsch M, Thiere D, et al. Prevalence of gall- bladder stone disease in obese children and adolescents: influenceof the degree of obesity, sex, and pubertal development. J PediatrGastroenterolNutr. 2006;42:66 –70. Fishman L, Lenders C, Fortunato C, Noonan C, Nurko S. Increased prevalence of constipation and fecal soiling in a population of obese children. J Pediatr. 2004;145:253–254.

40. References HampelH, Abraham NS, El-Serag HB. Meta-analysis: obesity and the risk for gastroesophagealreflux disease and its complications. Ann Intern Med. 2005;143:199 –211 Wearing SC, Hennig EM, Byrne NM, Steele JR, Hills AP. Musculoskeletal Disorders Associated with Obesity: a Biomechanical Perspective. Obesity Reviews.2006; 7(3): 239-250 Dietz WH Jr, Gross WL, Kirkpatrick JA Jr. Blount disease (tibia vara): another skeletal disorder associated with childhood obe- sity. J Pediatr. 1982;101:735–737 ManoffEM, Banffy MB, Winell JJ. Relationship between body mass index and slipped capital femoral epiphysis. J PediatrOrthop. 2005;25:744 –746 Taylor ED, Theim KR, Mirch MC, et al. Orthopedic complica- tions of overweight in children and adolescents. Pediatrics. 2006;117:2167–2174 Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting obesity in young adulthood from childhood and parental obesity. N Engl J Med. 1997;337:869 – 873 Maes HH, Neale MC, Eaves LJ. Genetic and environmental factors in relative body weight and human adiposity. Behav Genet. 1997;27:325–351 Gale SM, Castracane VD, Mantzoros CS. Energy homeostasis, obesity and eating disorders: recent advances in endocrinology. J Nutr. 2004;134:295–298systems for prevention in primary care: randomised trial. BMJ. 2004;328:388 Dabelea, D. The Predisposition to Obesity and Diabetes in Offspring of Diabetic Mothers. Diabetes Care. 2007; 30:Supplement 2.

41. References WrotniakBH, Shults J, Butts S, Stettler N, Gestational weight gain and risk of overweight in the offspring at age 7 y in a multicenter, multiethnic cohort study, American Journal of Clinical Nutrition, 2008, 87(6): 1818-24 Bruin JE, Gerstein HC, Holloway AC. Long-Term Consequences of Fetal and Neonatal Nicotine Exposure: A Critical Review. Toxicological Sciences 2010; 116(2):364-374 Division of Nutrition and Physical Activity: Research to Practice Series No. 4: Does breastfeeding reduce the risk of pediatric overweight? Atlanta: Centers for Disease Control and Prevention, 2007. http://www.cdc.gov/nccdphp/dnpa/nutrition/pdf/breastfeeding_r2p.pdf Owen CG, Martin RM, Whincup PH, Smith GD, Cook DG. Effect of infant feeding on the risk of obesity across the life course: a quantitative review of published evidence. Pediatrics. 2005;115(5):1367-1377. Huh SY, Rifas-Shiman SL, Taveras EM, Oken E, Gillman MW. Timing of Solid Food Introduction and Risk of Obesity in PreSchool Aged Children. Pediatrics doi:10.1542/peds.2010-0740. Chen X, Beydoun MA, Wang Y. Is sleep duration associated with childhood obesity? A systematic review and meta-analysis. Obesity (Silver Spring). 2008:16(2):265-274. 43. TaverasEM, Rifas-Shiman SL, Oken E, Gunderson EP, Gillman MW. Short Sleep Duration in Infancy and Risk of Childhood Overweight. Arch PediatrAdolesc Med. 2008 April; 162(4): 305-311. 44. HernancezDC, Francis La, Doyle EA. National School Lunch Participation and Sex Differences in Body Mass Index Trajectories of Children From Low-Income Families. Arch PediatrAdolesc Med. doi: 10.1001/archpediatricd.2010.253

42. References 45. MorlandK,Wing S, Diez Roux A, Poole C. Neighborhood Characteristics Associated with the Location of Food Stores and Food Service Places. American Journal of Preventive Medicine. 2002; 22(1): 23-29 46. MorlandK, Filomena S. Disparities in the Availability of Fruits and Vegetables between Racially Segregated Urban Neighborhoods. Public Health Nutrition. 2007; 10: 1481-9 47. Powell LP, Auld C, Chaloupka FJ, O’Malley PM, Johnson LD. Associations Between Access to Food Stores and Adolescent Body Mass Index. Am J Prev Med 2007;33(4S):S301-S307. 48. Dennison BA, Erb TA, Jenkins PL. Television viewing and television in bedroom associated with overweight risk among low-income pre-school children. Pediatrics 2002 June: 109(6); 1028-35. 49. Barlow SE, and the Expert Committee. Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report. Pediatrics. 2007; 120: S 164-192 50. Savoye M, Shaw M, Dziura J, Tamborlane MD, Rose P, Guandalini C, Goldberg-Cell R, Burgert T, Cali A, Weiss R, Caprio S. Effects of a Weight Management Program on Body Composition and Metabolic Parameters in Overweight Children. JAMA 2007;297:2697-2704.

43. 40 Orthopaedic Issues in theYoung Obese Athlete Daniel W. Green, MS, MD, FACS, FAAP Pediatric Orthopaedic Surgery Hospital for Special Surgery Associate Clinical Professor Cornell University Medical College

44. HSS educational activities are carried out in a manner that serves the educational component of our Mission. As faculty we are committed to providing transparency in any/all external relationships prior to giving an academic presentation. Daniel Green Disclosure: DO NOT have a financial relationship with any commercial interest.

45. What is “Orthopaedics” 42

46. 43 “Orthopaedics” Greek Language Orthos : straight Pais : child

47. www.orthoinfo.org Your Orthopaedic Connection – YOC: www.orthoinfo.org

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49. www.stopsportsinjuries.org 46

50. www.stopsportsinjuries.org

52. 49 PEDIATRIC OBESITY Orthopaedic Issues Orthopedic Slipped capital femoral epiphysis 60 to 80% are obese Blount’s disease (Tibia vara) (Bow Legs) 70% are obese Knock Knees Degenerative Arthritis Patella Instability/Patella Dislocations Unique Fracture Patterns

53. Slipped Capital Femoral Epiphysis (SCFE): The most common hip disorder of adolescents, in which the proximal femoral epiphysis is displaced posteriorly on the femoral neck.

54. 51 SCFE: Epidemiology Incidence is related to puberty, with boys at risk in ages 10-17, girls at risk in ages 8-15. Rare post-menarchal 60% are over 95th percentile for age-weight. 80% are over the 80th % percentile 5% had parents with SCFE.

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56. SCFE: History Most are NOT associated with a significant amount of trauma. Limp Pain in the groin, thigh or knee. The majority of patient with SCFE are be able to walk.

57. Location of Pain:SCFE 54

58. Fig. 1 Number of primary care visits before CHLA 55

59. Changes in Gait and Range of Motion in SCFE +/-Antalgic gait + Abductor lurch (Coxalgic gait) External Foot Progression angle Hip externally rotates when it is flexed Decreased internal rotation-especially in flexion. Pain with internal rotation of hip

60. Range of Motion Changes in SCFE

61. 58 Loder, Richards, Shapiro et al. 54 patients Tx for acute SCFE. Reduction occurred in 26 unstable, 2 stable. 14/30 (47%) unstable had satisfactory result. 24/25 (96%) stable have satisfactory result. 14/30 (47%) unstables went on to AVN. 0/30 stables went on to AVN.

62. “the first essential to treatment is early diagnosis”Philip D. Wilson, Sr., M.D. 1924 59

63. PHILIP D. WILSON THE TREATMENT OF SLIPPING OF THE UPPER FEMORAL EPIPHYSIS WITH MINIMAL DISPLACEMENT J Bone Joint Surg Am. 1938;20:379-399. 60

64. 61 J Bone Joint Surg Am. 1938;20:379-399. “ It-is trite to remark that the best time to treat a disease is from time beginning, but thus statement is so true of slipping of the upper femoral epiphysis that it needs to be emphasized. The earliest stages of slipping almost always give rise to symptoms which, if the physician is alert, can he recognized and will lead to time correct diagnosis.”

65. 62 J Bone Joint Surg Am. 1938;20:379-399. “Given a patient between the ages of ten and sixteen years, complaining of intermittent pain and stiffness in the knee or thigh with at times a noticeable limp, one should consider slipping of the epiphysis as one of the first possibilities. Nor should one be led astray by the frequent localization of pain at the inner side of the knee into making only a local examination of that part; a thorough examination of the entire extremity should be made.”

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68. Bow Legs: Genu Varum:Blounts DiseaseKnock Knees : Genu Valgum 65

69. Normal Alignment in Children Non-obese children at the age of 3-4 years old develop physiologic genuvalgum that naturally straightens out by the age of 8. 66

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74. Obesity and Lower Extremity Malalignment It is largely assumed that obesity places children at higher risk for slipped capital femoral epiphysis (SCFE), genuvalgum, and tibia vara.

75. The Effect of Pediatric Obesity on Lower Limb Alignment Daniel W. Green, M.D. Shevaun Doyle, M.D. Sarah Yagerman 72

76. 73 Compared with non-overweight children, those who are obesehave a greater prevalence of valgus and varus lower extremity malalignment as measured with a goniometer. Hypothesis

77. Physical Exam: Weight & height. TFA, IM distance. ROM angles of the hip, knees, ankles, and spine. Photograph of standing AP alignment of legs. Parent Reported Child Health Questionnaire (CHQ-PF28): Evaluation of children’s physical and psychosocial well-being. Pediatric/Adolescent Outcomes Questionnaire: Assessment of overall physical function Methods

78. 75 22 females, 18 males Demographics

79. 76 Data P<0.001

80. Intermalleolar distance the width between the ankles when the patella are forward and the knees are just touch in a patient with genu valgum Average IM distance in obese group (±SD): 8.1 ± 4.4cm Control group IM distance (±SD): 3.4 ± 2.1cm 77

81. Obese children, BMI >95th percentile, have greater genu valgum than non-overweight children. Summary

82. 79 Bow Legs: Tibia Vara (Blount’s Disease) Should be suspected if bowing persists past 2 years Abnormal growth at the medial aspect of the proximal tibial physis Associated with obesity; most common in African-Americans Continues to worsen unless diagnosis and appropriate treatment are accomplished

83. 80 Tibia Vara (Blount’s Disease) Three types: Infantile, juvenile, adolescent Infantile: birth to 3 years, most common form, usually seen in obese children who walked before 1 year, usually noticed when walking began and has persisted, may be bilateral or may resolve on one side and persist on the other Juvenile: onset at 4-10 years of age, obesity risk factor, more often unilateral, usually less severe Adolescent: older than 11 years of age, most common in obese African American males

84. Tibia Vara: Radiographic Evaluation AP radiograph both legs standing Metaphyseal beaking Metaphyseal-diaphyseal angle (Drennan) obtained by measuring the angle formed by a line parallel to the top of the proximal tibial metaphysis and a line perpendicular to the long axis of the tibial shaft 81

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97. 94 Implant Mediated Guided Growth Hemiepiphysiodesis: Excellent technique for obese children Utilizes growth to correct deformity Growth plates must be open Earlier detection of mal-alignment in obese children will provide better surgical outcomes Outpatient procedure

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99. Implant Mediated Guided Growth 8.28.08

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114. Thank You!Daniel W Green, MDgreendw@hss.edu 111

115. 112 References The Development of the Tibiofemoral Angle in Children PENTTI SALENIUS, M.D.*, AND ElLA VANKKA, M.D.*, J Bone Joint Surg Am. 1975;57:259-261. Correlation of Body Mass Index and Radiographic Deformities in Children with Blount Disease By Sanjeev Sabharwal, MD, Caixia Zhao, MD, and Emily McClemens, PA-CJ Bone Joint Surg Am. 2007;89:1275-1283

116. 113 Thank You