Impact of Obesity on Adolescents With CKD: From Diagnosis Through Transplant

Impact of Obesity on Adolescents With CKD: From Diagnosis Through Transplant

Lauren Graf, MS, RDLauren Graf, MS, RDMontefiore Medical CenterMontefiore Medical Center

Lauren Graf, MS, RDLauren Graf, MS, RDMontefiore Medical CenterMontefiore Medical Center

Prevalence of Overweight Among U.S. Children

Prevalence of Overweight Among U.S. Children

17% of children and 17% of children and adolescents are obese adolescents are obese in the U.S. todayin the U.S. today

Over the past 20 years, Over the past 20 years, the proportion of the proportion of overweight children overweight children age 6-11years of age age 6-11years of age has nearly tripledhas nearly tripled

The rate of overweight The rate of overweight adolescents age 12-19 adolescents age 12-19 has more than tripled.has more than tripled.

17% of children and 17% of children and adolescents are obese adolescents are obese in the U.S. todayin the U.S. today

Over the past 20 years, Over the past 20 years, the proportion of the proportion of overweight children overweight children age 6-11years of age age 6-11years of age has nearly tripledhas nearly tripled

The rate of overweight The rate of overweight adolescents age 12-19 adolescents age 12-19 has more than tripled.has more than tripled.

0

5

10

15

20

1976-80

1988-94

1999-00

2001-02

2003-04

Dates

Prevalence of Overweight Among Children and Adolescents Ages 6-19 Years

Age 6-11Age 12-19

Per

cen

t

Information obtained from National Center for Health Statistics Available at: http://www.cdc.gov/nchs/products/pubs/pubd/hestats/overweight/overwght_child_03.htm

Adopted from National Center for Health Statistics Available at: http://www.cdc.gov/nchs/products/pubs/pubd/hestats/overweight/overwght_child_03.htm

Impact of Obesity on the Kidney

Fat cell KidneyMicroalbuminuria/proteinuriaGlomerulopathyFat secretes inflammatory cytokinesIncreased renal plasma flow (RPF)Enhances progression of otherrenal diseasesDiabetic nephropathyReduced renal survival aftertransplant

Rutkowski et al. J Ren Nutr. 2006;16:216-223

Incidence of Kidney Failure(per million population, 1990 by HSA unadjusted)

Incidence of Kidney Failure(per million population, 1990 by HSA unadjusted)

Adopted from NKDEP, available at: http://www.nkdep.nih.gov/resources/nkdep_ckd_presentation.ppt

Incidence of Kidney Failure (Per Million Population, 2000, per HSA unadjusted)

Incidence of Kidney Failure (Per Million Population, 2000, per HSA unadjusted)

Adopted from NKDEP, available at: http://www.nkdep.nih.gov/resources/nkdep_ckd_presentation.ppt

Obesity-Related Glomerulopathy(ORG)

Obesity-Related Glomerulopathy(ORG)

• ORG has distinct ORG has distinct findings on biopsy findings on biopsy including glomerular including glomerular hyperfiltration, hyperfiltration, increased accumulation increased accumulation of extracellular matrix of extracellular matrix and renal hypertrophyand renal hypertrophy

• May lead to ESRDMay lead to ESRD• Prevalence has Prevalence has

increased 10-fold over increased 10-fold over past 15 yearspast 15 years

• ORG has distinct ORG has distinct findings on biopsy findings on biopsy including glomerular including glomerular hyperfiltration, hyperfiltration, increased accumulation increased accumulation of extracellular matrix of extracellular matrix and renal hypertrophyand renal hypertrophy

• May lead to ESRDMay lead to ESRD• Prevalence has Prevalence has

increased 10-fold over increased 10-fold over past 15 yearspast 15 years

0

0.5

1

1.5

2

1986-1990 1991-1995 1996-2000

Dates

Increase In Obesity-Related Glomerulopathy Over a 15-Year Period

Pe

rce

nt

Wu et al. Endocrinology.2006;147:44-50, Kambham et al. Kidney Int. 2002;59:1498-1509, Chagnac et al. J Am Soc Nephrol;14:1480-1486

Weight Loss May Reverse ORG Weight Loss May Reverse ORG

• Weight loss may reverse or delay the Weight loss may reverse or delay the progression of renal insufficiency progression of renal insufficiency

• Studies have found that weight loss in Studies have found that weight loss in obese patients results in a significant obese patients results in a significant reduction in GFR, RPF and albuminuriareduction in GFR, RPF and albuminuria

• These improvements in renal These improvements in renal parameters are seen with significant parameters are seen with significant weight loss even if a normal BMI is not weight loss even if a normal BMI is not achieved achieved

• Weight loss may reverse or delay the Weight loss may reverse or delay the progression of renal insufficiency progression of renal insufficiency

• Studies have found that weight loss in Studies have found that weight loss in obese patients results in a significant obese patients results in a significant reduction in GFR, RPF and albuminuriareduction in GFR, RPF and albuminuria

• These improvements in renal These improvements in renal parameters are seen with significant parameters are seen with significant weight loss even if a normal BMI is not weight loss even if a normal BMI is not achieved achieved

Tran, Med J Aust.2006;184:367, Chagnac et al. J Am Soc Nephrol.2003;14:1480-1486

Risks of Obesity Throughout the Course of Kidney Disease

Risks of Obesity Throughout the Course of Kidney Disease

The number of patients starting dialysis The number of patients starting dialysis with a BMI greater than 35 has with a BMI greater than 35 has increased 64% over the past decadeincreased 64% over the past decade

If this continues, it is predicted that 20% If this continues, it is predicted that 20% of all patients will initiate dialysis in this of all patients will initiate dialysis in this already obese statealready obese state

Intervention and attempts to prevent Intervention and attempts to prevent obesity before ESRD is beneficialobesity before ESRD is beneficial

The number of patients starting dialysis The number of patients starting dialysis with a BMI greater than 35 has with a BMI greater than 35 has increased 64% over the past decadeincreased 64% over the past decade

If this continues, it is predicted that 20% If this continues, it is predicted that 20% of all patients will initiate dialysis in this of all patients will initiate dialysis in this already obese statealready obese state

Intervention and attempts to prevent Intervention and attempts to prevent obesity before ESRD is beneficialobesity before ESRD is beneficial

Kramer et al. Curr Opin Nephrol Hypertens.2007;16:237-41

Obesity and TransplantObesity and Transplant

Receiving a transplant with a BMI of Receiving a transplant with a BMI of greater than 35 is associated with a greater than 35 is associated with a significantly higher incidence of significantly higher incidence of • new onset transplant diabetes mellitus new onset transplant diabetes mellitus • wound complications post-transplant wound complications post-transplant • post-transplant weight gainpost-transplant weight gain

Receiving a transplant with a BMI of Receiving a transplant with a BMI of greater than 35 is associated with a greater than 35 is associated with a significantly higher incidence of significantly higher incidence of • new onset transplant diabetes mellitus new onset transplant diabetes mellitus • wound complications post-transplant wound complications post-transplant • post-transplant weight gainpost-transplant weight gain

Kent.. J Ren Nutr. 2007;17:107-113

Interventions to Help These Patients: Children

Interventions to Help These Patients: Children

For children under 12 years old, treatment For children under 12 years old, treatment should be family orientedshould be family oriented

Children under age 7 are cognitively able to Children under age 7 are cognitively able to grasp only simple nutrition concepts (e.g. grasp only simple nutrition concepts (e.g. food groups)food groups)

Bulk of the responsibility for making diet Bulk of the responsibility for making diet changes should be directed toward the changes should be directed toward the parents parents

The goal at this stage is developing good The goal at this stage is developing good nutrition habits and exposure to healthful nutrition habits and exposure to healthful foods.foods.

For children under 12 years old, treatment For children under 12 years old, treatment should be family orientedshould be family oriented

Children under age 7 are cognitively able to Children under age 7 are cognitively able to grasp only simple nutrition concepts (e.g. grasp only simple nutrition concepts (e.g. food groups)food groups)

Bulk of the responsibility for making diet Bulk of the responsibility for making diet changes should be directed toward the changes should be directed toward the parents parents

The goal at this stage is developing good The goal at this stage is developing good nutrition habits and exposure to healthful nutrition habits and exposure to healthful foods.foods.

Interventions to Help TeensInterventions to Help Teens

In teenagers, parents remain involved but In teenagers, parents remain involved but individual counseling is also criticalindividual counseling is also critical

Teens have much more autonomy and Teens have much more autonomy and often on their own after school or during often on their own after school or during dinnerdinner

The goal is to encourage teenagers to take The goal is to encourage teenagers to take responsibility for their health and food responsibility for their health and food choices, thus preparing them for adulthoodchoices, thus preparing them for adulthood

In teenagers, parents remain involved but In teenagers, parents remain involved but individual counseling is also criticalindividual counseling is also critical

Teens have much more autonomy and Teens have much more autonomy and often on their own after school or during often on their own after school or during dinnerdinner

The goal is to encourage teenagers to take The goal is to encourage teenagers to take responsibility for their health and food responsibility for their health and food choices, thus preparing them for adulthoodchoices, thus preparing them for adulthood

What Kind of Interventions are Available?

What Kind of Interventions are Available?

Nutrition counseling with an RD canNutrition counseling with an RD can• Provide diet educationProvide diet education• Help identify diet pitfalls and provide strategies or Help identify diet pitfalls and provide strategies or

suggestions for how to overcome themsuggestions for how to overcome them• Provide support and act as a coachProvide support and act as a coach

Social Work or Psychological CounselorSocial Work or Psychological Counselor• Help work through psychological issues related to Help work through psychological issues related to

overeatingovereating• Motivational Interviewing Motivational Interviewing

Nutrition counseling with an RD canNutrition counseling with an RD can• Provide diet educationProvide diet education• Help identify diet pitfalls and provide strategies or Help identify diet pitfalls and provide strategies or

suggestions for how to overcome themsuggestions for how to overcome them• Provide support and act as a coachProvide support and act as a coach

Social Work or Psychological CounselorSocial Work or Psychological Counselor• Help work through psychological issues related to Help work through psychological issues related to

overeatingovereating• Motivational Interviewing Motivational Interviewing

Doyle et al. Adv Chronic Kidney Dis. 2006;13:386-393

Programs Available in the Community

Programs Available in the Community

Dr. Iman Sharif, MD, MPH of Montefiore runs Dr. Iman Sharif, MD, MPH of Montefiore runs a program in the South Bronx targeted a program in the South Bronx targeted towards young children and parents. It towards young children and parents. It involves both nutrition classes and exerciseinvolves both nutrition classes and exercise

B’N Fit is an obesity program at Montefiore B’N Fit is an obesity program at Montefiore targeted for teenagers. Nutrition classes and targeted for teenagers. Nutrition classes and group sessions are run by an RD and MSWgroup sessions are run by an RD and MSW

Teens are taken to the gym several times per Teens are taken to the gym several times per week. week.

An 8-week summer day camp is also offered An 8-week summer day camp is also offered through B’N Fit. Days are filled with hiking, through B’N Fit. Days are filled with hiking, swimming and other physical activitiesswimming and other physical activities

Dr. Iman Sharif, MD, MPH of Montefiore runs Dr. Iman Sharif, MD, MPH of Montefiore runs a program in the South Bronx targeted a program in the South Bronx targeted towards young children and parents. It towards young children and parents. It involves both nutrition classes and exerciseinvolves both nutrition classes and exercise

B’N Fit is an obesity program at Montefiore B’N Fit is an obesity program at Montefiore targeted for teenagers. Nutrition classes and targeted for teenagers. Nutrition classes and group sessions are run by an RD and MSWgroup sessions are run by an RD and MSW

Teens are taken to the gym several times per Teens are taken to the gym several times per week. week.

An 8-week summer day camp is also offered An 8-week summer day camp is also offered through B’N Fit. Days are filled with hiking, through B’N Fit. Days are filled with hiking, swimming and other physical activitiesswimming and other physical activities

CKD Case Study for Patient C.S.

CKD Case Study for Patient C.S.

15 year old African American girl with morbid 15 year old African American girl with morbid obesity is an outpatient at Montefiore.obesity is an outpatient at Montefiore.

Weight: 139.8 kg, Height: 170.5 cm, BMI: 48Weight: 139.8 kg, Height: 170.5 cm, BMI: 48 C.S. was referred to the B’N Fit Program at C.S. was referred to the B’N Fit Program at

Montefiore by her PMD in the spring of 2006Montefiore by her PMD in the spring of 2006 During her physical she was found to have During her physical she was found to have

proteinuria, elevated creatinine and HTN. proteinuria, elevated creatinine and HTN.

15 year old African American girl with morbid 15 year old African American girl with morbid obesity is an outpatient at Montefiore.obesity is an outpatient at Montefiore.

Weight: 139.8 kg, Height: 170.5 cm, BMI: 48Weight: 139.8 kg, Height: 170.5 cm, BMI: 48 C.S. was referred to the B’N Fit Program at C.S. was referred to the B’N Fit Program at

Montefiore by her PMD in the spring of 2006Montefiore by her PMD in the spring of 2006 During her physical she was found to have During her physical she was found to have

proteinuria, elevated creatinine and HTN. proteinuria, elevated creatinine and HTN.

Case Study for Patient C.S. Continued

Case Study for Patient C.S. Continued

Referred to our renal clinic. A kidney biopsy Referred to our renal clinic. A kidney biopsy revealed obesity related FSGS. GFR = 70, revealed obesity related FSGS. GFR = 70, stage II CKDstage II CKD

She attended 4 sessions at the B’N Fit She attended 4 sessions at the B’N Fit Program and received individual nutrition Program and received individual nutrition counseling and follow-up with renal RD.counseling and follow-up with renal RD.

After 4 sessions, she abruptly stopped After 4 sessions, she abruptly stopped participating in B’N Fit and has failed to show participating in B’N Fit and has failed to show up for several appointments at the renal clinicup for several appointments at the renal clinic

One year later, she has regained all the One year later, she has regained all the weight she lost.weight she lost.

Referred to our renal clinic. A kidney biopsy Referred to our renal clinic. A kidney biopsy revealed obesity related FSGS. GFR = 70, revealed obesity related FSGS. GFR = 70, stage II CKDstage II CKD

She attended 4 sessions at the B’N Fit She attended 4 sessions at the B’N Fit Program and received individual nutrition Program and received individual nutrition counseling and follow-up with renal RD.counseling and follow-up with renal RD.

After 4 sessions, she abruptly stopped After 4 sessions, she abruptly stopped participating in B’N Fit and has failed to show participating in B’N Fit and has failed to show up for several appointments at the renal clinicup for several appointments at the renal clinic

One year later, she has regained all the One year later, she has regained all the weight she lost.weight she lost.

Growth Chart with BMIGrowth Chart with BMI

• Normal BMI ranges Normal BMI ranges differ in children and differ in children and adolescents based adolescents based

on age and sexon age and sex

• BMI is plotted BMI is plotted against age on the against age on the growth chartgrowth chart

• Normal BMI ranges Normal BMI ranges differ in children and differ in children and adolescents based adolescents based

on age and sexon age and sex

• BMI is plotted BMI is plotted against age on the against age on the growth chartgrowth chart

What has worked to help C.S. ?What has worked to help C.S. ?

Unsuccessful AttemptsUnsuccessful AttemptsIn May 2007, the renal RDIn May 2007, the renal RDand social worker attempted and social worker attempted to reach out to her through:to reach out to her through:• Follow up counseling visitsFollow up counseling visits• Email (food diary)Email (food diary)• Phone callsPhone callsThe above failed due to poor The above failed due to poor follow-upfollow-up

B’N Fit was not an option at B’N Fit was not an option at this time because of conflicts this time because of conflicts with schoolwith school

Unsuccessful AttemptsUnsuccessful AttemptsIn May 2007, the renal RDIn May 2007, the renal RDand social worker attempted and social worker attempted to reach out to her through:to reach out to her through:• Follow up counseling visitsFollow up counseling visits• Email (food diary)Email (food diary)• Phone callsPhone callsThe above failed due to poor The above failed due to poor follow-upfollow-up

B’N Fit was not an option at B’N Fit was not an option at this time because of conflicts this time because of conflicts with schoolwith school

Successful AttemptsSuccessful AttemptsC.S. has agreed to attendC.S. has agreed to attendthe B’N Fit Camp program the B’N Fit Camp program this summer for 8 weeks this summer for 8 weeks

Camp involves intenseCamp involves intensephysical activity each day physical activity each day with healthy meals with healthy meals providedprovided

Successful AttemptsSuccessful AttemptsC.S. has agreed to attendC.S. has agreed to attendthe B’N Fit Camp program the B’N Fit Camp program this summer for 8 weeks this summer for 8 weeks

Camp involves intenseCamp involves intensephysical activity each day physical activity each day with healthy meals with healthy meals providedprovided

Transplant Patient Case Study: Patient R.M.

Transplant Patient Case Study: Patient R.M.

13 year-old boy with ESRD secondary to 13 year-old boy with ESRD secondary to FSGS. He received a kidney transplant in FSGS. He received a kidney transplant in the spring of 2005the spring of 2005

Pre-transplant anthropometrics:Pre-transplant anthropometrics:Wt: 58.9 kg, ht: 154.6 cm BMI: 24.6Wt: 58.9 kg, ht: 154.6 cm BMI: 24.6

Two years later post-transplant at age 15: Two years later post-transplant at age 15: Wt: 106.5 kg, ht: 162 cm, BMI: 40.5Wt: 106.5 kg, ht: 162 cm, BMI: 40.5

13 year-old boy with ESRD secondary to 13 year-old boy with ESRD secondary to FSGS. He received a kidney transplant in FSGS. He received a kidney transplant in the spring of 2005the spring of 2005

Pre-transplant anthropometrics:Pre-transplant anthropometrics:Wt: 58.9 kg, ht: 154.6 cm BMI: 24.6Wt: 58.9 kg, ht: 154.6 cm BMI: 24.6

Two years later post-transplant at age 15: Two years later post-transplant at age 15: Wt: 106.5 kg, ht: 162 cm, BMI: 40.5Wt: 106.5 kg, ht: 162 cm, BMI: 40.5

Challenges With Patient R.M.Challenges With Patient R.M.

Weight steadily increases at each visit to Weight steadily increases at each visit to transplant clinictransplant clinic

Family history of obesity- R.M.’s mom is Family history of obesity- R.M.’s mom is morbidly obesemorbidly obese

Very low income family with poor access to Very low income family with poor access to food and safe places to exercise food and safe places to exercise

The family has not been receptive to The family has not been receptive to counseling from RD or social worker counseling from RD or social worker regarding weight loss.regarding weight loss.

Has refused referrals to weight loss/nutrition Has refused referrals to weight loss/nutrition programsprograms

Weight steadily increases at each visit to Weight steadily increases at each visit to transplant clinictransplant clinic

Family history of obesity- R.M.’s mom is Family history of obesity- R.M.’s mom is morbidly obesemorbidly obese

Very low income family with poor access to Very low income family with poor access to food and safe places to exercise food and safe places to exercise

The family has not been receptive to The family has not been receptive to counseling from RD or social worker counseling from RD or social worker regarding weight loss.regarding weight loss.

Has refused referrals to weight loss/nutrition Has refused referrals to weight loss/nutrition programsprograms

Adopted from www.lapietra.edu

The Childhood Obesity Cycle

Future DirectionsFuture Directions

Ways to Help Patients As CliniciansWays to Help Patients As Clinicians• Provide ongoing nutrition/psychological counseling for patients Provide ongoing nutrition/psychological counseling for patients

that need itthat need it• Be aware of programs/support groups in the area and make Be aware of programs/support groups in the area and make

appropriate referralsappropriate referrals

Public Health- efforts to help Public Health- efforts to help • Reaching out to change cultural beliefs- increase the perception Reaching out to change cultural beliefs- increase the perception

that overweight and obese pose significant health risks that overweight and obese pose significant health risks • Marketing campaigns to reach low income groups- ads, Marketing campaigns to reach low income groups- ads,

billboards, health fairs etc.billboards, health fairs etc.• More programs like B’N Fit for teens and childrenMore programs like B’N Fit for teens and children

Ways to Help Patients As CliniciansWays to Help Patients As Clinicians• Provide ongoing nutrition/psychological counseling for patients Provide ongoing nutrition/psychological counseling for patients

that need itthat need it• Be aware of programs/support groups in the area and make Be aware of programs/support groups in the area and make

appropriate referralsappropriate referrals

Public Health- efforts to help Public Health- efforts to help • Reaching out to change cultural beliefs- increase the perception Reaching out to change cultural beliefs- increase the perception

that overweight and obese pose significant health risks that overweight and obese pose significant health risks • Marketing campaigns to reach low income groups- ads, Marketing campaigns to reach low income groups- ads,

billboards, health fairs etc.billboards, health fairs etc.• More programs like B’N Fit for teens and childrenMore programs like B’N Fit for teens and children