Summer 2009

Thyroid and obesity: An unlikely relationship

Screening for postural concerns in the obese youth

Stevia: A new spin on sweet

Maintaining structure during summer vacation

Parents can lead the way to good health 

Thyroid and obesity: An unlikely relationship

Pam Swenerton, MSN, RN, CPNP, Children's Hospital of Wisconsin

 In children, obesity is defined as a body mass index greater than 95th percentile. Morbid obesity is greater than the 99th percentile. More than 60 percent of obese children go on to become obese adults. Obesity in adults is associated with an increased risk of hypertension, diabetes, hyperlipidemia, sleep apnea, coronary heart disease and stroke.

Historically, obesity has been thought of as criteria to establish a diagnosis of hypothyroidism.  However, hypothyroidism rarely is linked with obesity or dramatic weight gain. Screening for hypothyroidism in obese patients is a valid part of the work up, and results rarely are abnormal.

Recent studies in children and adults found that mildly elevated TSH levels (subclinical hypothyroidism) can appear in as high as 11 percent of the obese population, sometimes with elevated total or free T3. We know that caloric overfeeding can increase T3 concentration. In a majority of these children, thyroid levels returned to normal with weight loss and increased exercise. Among children, the elevation of free T3 and TSH seems to be a consequence of obesity rather than a cause.

When severe hypothyroidism is found (defined as elevated thyrotropin level and below normal thyroxin, usually with positive antibodies), the weight loss after treatment usually is less than 10 percent of body weight.

Here's what you need to know when screening, referring or treating patients for hypothyroidism. 

Screening patients

Screening for hypothyroidism includes a free T4 and TSH.

• If TSH is elevated, thyroid antibodies should be obtained.
• Following linear height is a good clinical indicator for the possibility of hypothyroidism.
• If a child is growing normally, it is unlikely he or she has hypothyroidism.
• Elevation of one or both thyroid antibodies with normal hormone levels should be followed. Antibodies can remain positive for years with normal thyroxin levels.

Referring patients

Please refer patients to Children's Hospital of Wisconsin's Endocrine Clinic  if:

• A goiter is found during a physical exam.
• There is a lower-than-normal thyroxin level, with or without an elevated TSH.
• There is a TSH greater than 10.
• There is a suppressed TSH, with or without an elevated thyroxin.

Treating patients

• To initiate treatment, health care providers usually use an arbitrary TSH cutoff of 10-12 uIU/mL (0.5-4.5), over which we treat with Thyroxin supplement. 
• For the children (not including the newborn population) in which the TSH is more than about 50 uIU/mL, we treat for the first week or two with lower doses, increasing gradually. 
• Laboratory follow up includes monitoring Free T4 and TSH every one to two months until Thyroxin and Thyrotropin levels are normal.

For more information about hypothyroidism, call Children's Hospital's Endocrine Clinic  at (414) 266-6750.

Bhowmick SK, Dasari G: The Prevalence of Elevated Serum Thyroid-stimulating Hormone in Childhood/Adolescent Obesity and of Autoimmune Thyroid Diseases in a Subgroup. Journal of the National Medical Association. 2007 Jul: 99(7):773-776.

Lomenick JP, Sayyid M, Smity WJ: Effects of Levo-thyroxine Treatment on Weight and Body Mass Index in Children with Acquired Hypothyroidism. Journal of Pediatrics. 2008 Jan: 152 (1): 96-100. 

Rinchr T, Isa A, de Sousa G: Thyroid Hormones and Their Relation to Weight Status. Hormone Research. 2008: 70(1): 51-7.

Screening for postural concerns in the obese youth

Stacy Stolzman, MPT, Children's Hospital of Wisconsin

Our posture impacts how we function. Many patients with obesity have postural abnormalities due to lack of physical activity and increased sedentary activity, which  create muscle tightness and weakness. Postural analysis is necessary during exams to identify patients' excessive fat-accumulation pattern, their static postural faults and their abnormal movement patterns.

Identifying an abnormal posture can help you address joint and muscle pain. It also assists in referring to orthopedics and physical therapy for further evaluation.

To screen a patient's posture, ask the patient to stand as they normally would and look at him or her from the anterior, posterior and lateral perspectives. Start at the foot and work up to the head in all planes. It is important to note that excess adipose tissue can make postural assessment challenging. Sometimes, imaging may be required to determine true skeletal alignment.

Common postural concerns include:

• Pes planus: Collapse of the medial arch with or without calcaneal valgus.
• Excessive lumbar lordosis: Excessive inward curve of the lower spine.
• Excessive thoracic kyphosis: Excessive outward curve of the middle spine.
• Coxa varus/valgus: Angling of the hip medially or laterally.
• Genu varus/valgus: Angling of the knee medially or laterally.
• Forward head: Anterior positioning of the upper spine.
• Protracted shoulder girdle: Shoulders pulled forward.

Muscular tightness in the pectorals, erector spinae, hamstrings, hip flexors and gastroc or soleus complex may contribute to postural concerns. Muscular weakness in the oblique and rectus abdominals, hip complex, shoulder complex and rhomboids also may contribute to postural concerns.

Muscular tightness and weakness can be resolved through stretching, strengthening exercises and guidance from a physical therapist.

Get additional postural definitions, images and related exercises to correct postural concerns here.

Stevia: A new spin on sweet

Tricia Vogt, dietetic intern, Mount Mary College; Michelle Smith-Beckley, RD, CD, Children's Hospital of Wisconsin

Life is getting sweeter for people looking for an alternative to sugar.

In 2008, the Food and Drug Administration approved one form of stevia, called rebiana. Because rebiana is plant-based, it is not an artificial sweetener, like Splenda®, Equal® or Sweet 'n Low®. Instead, it is an alternative, natural sugar substitute. It has very few calories and is 250 times sweeter than sugar.

Rebiana is thought to be safe. Recent studies have shown that it has no negative side effects on people. Research found that 1,000 mg (or 29 packets) of rebiana a day had no negative effects on general health, blood pressure or blood sugar control in people with type 2 diabetes. But, because it is a new food product, there has not been enough time for a long-term health study.

Many food companies are having a hard time making products with rebiana that taste good. As a plant-based product, it has a bitter taste. Coca-Cola® has found that rebiana works well in citrus-flavored soft drinks and soon will be selling Sprite Green. One cup of this soda will have 50 calories.

If you want to add Stevia to food items, look for the brand name, Truvia^TM, in grocery stores. You also may find it in health food stores as Stevia.

Brusick, D. A Critical Review of the Genetic Toxicity of Steviol and Steviol Glycosides. Food and Chemical Toxicology. 2008 Jul: 46 (7), p.S83-S91.

Carakostas, M. Overview: The History, Technical Function and Safety of Rebaudioside A, a Naturally Occurring Steviol Glycoside, for Use in Food and Beverages. Food and Chemical Toxicology. 2008 Jul: 46 (7), p.S1-S10.

Maki, K. The Hemodynamic Effects of Rebaudioside A in Healthy Adults with Normal and Low-normal Blood Pressure. Food and Chemical Toxicology. 2008 Jul: 46 (7), p.S40-S46.

McKay, B. FDA Clears Use of Herb As Sweetener. The Wall Street Journal. 2008 Dec. 18.

Prakash, I. Development of Rebiana, a Natural, Non-caloric Sweetener. Food and Chemical Toxicology. 2008 Jul: 46 (7), p.S75-S82.

Voiland, A. The Zero-Calorie Sweetener Stevia Arrives. U.S.News & World Report. 2008: Jul 28.

Maintaining structrue during summer vacation

Brian Fidlin, PsyD, director, NEW Kids Program

Summer vacation is here. Without the pressures of school, many kids spend their days riding bikes, eating ice cream and going swimming with friends. One of the best things about summer vacation is having a break from the structure and order of school.

At the same time, structure and order help put parameters around our lives. It helps us know when to get up in the morning, when to go to bed at night, when to eat and how to spend our time.

During the summer, health care professionals in the NEW (Nutrition, Exercise and Weight Management) Kids^TM Program often see patients who become more active. Other patients spend their days conquering new videogames, spraining their thumbs while texting and updating their social networking sites. Some kids wander in and out of the kitchen finding new things to eat. Others get so busy they forget to eat meals. This lack of structure can create an environment where kids can find themselves in a world of weight loss trouble.

During summer vacation, parents should be prepared to set their children up for success. Instruct the parents you work with to set a bedtime, wake-up time, schedule of daily activities and a menu. This structure will help children make significant strides in managing their weight, even while enjoying summer vacation.   

Parents can lead the way to good health

Erin Ruenger, YMCA of Metropolitan Milwaukee

For most families, it can be difficult to change daily routines and lifestyle habits to be healthier. NEW Kids at the Y can teach parents how to stick with lifestyle changes and improve the health of all family members. Whatever the family's goal, starting and sticking with a program long enough to affect change is much more likely when you get quality information and motivational support.

The program is a great way for parents and children to take the steps to make positive changes in their lives. A few of the ways the program empowers families to become healthier is by teaching them how to:

• Become smart grocery shoppers.
• Adjust serving sizes.
• Choose healthier snacks and beverages.
• Increase activity and play time.

Not only does the program teach children the benefits of eating healthier and being more active, but parents learn the information needed to continue lifestyle changes, for their entire family, after the program ends.

Kids look to their parents to be role models in all aspects of life. When parents make good decisions and take steps to improve their health, it is a great example for their children.

For more information about enrolling in the NEW Kids at the Y Program, contact one of the following YMCA's for specific information about program start dates.

West Suburban YMCA
(414) 302-9622 

Southwest YMCA
(414) 546-9622

Rite-Hite Family YMCA
(414) 354-9622 

Northside YMCA
(414) 265-9622