obesity – the new epidemic an epidemic of unknown origins?

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OBESITY – THE NEW EPIDEMIC AN EPIDEMIC OF UNKNOWN ORIGINS? Current Concepts in Pediatrics 16.October.2009 KM Morrison MD, FRCPC

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Obesity – The NEW EPIDEMIC AN epidemic of unknown origins?. Current Concepts in Pediatrics16.October.2009 KM Morrison MD, FRCPC. OBJECTIVES. Understand the elements which have contributed to the rise in childhood and adolescent obesity - PowerPoint PPT Presentation

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Page 1: Obesity – The NEW EPIDEMIC AN epidemic of unknown origins?

OBESITY – THE NEW EPIDEMIC

AN EPIDEMIC OF UNKNOWN ORIGINS?

Current Concepts in Pediatrics16.October.2009KM Morrison MD, FRCPC

Page 2: Obesity – The NEW EPIDEMIC AN epidemic of unknown origins?

OBJECTIVES

Understand the elements which have contributed to the rise in childhood and adolescent obesity

Discuss the health consequences related to childhood obesity

Describe the current best practice approach to intervention

Page 3: Obesity – The NEW EPIDEMIC AN epidemic of unknown origins?

Overweight and obesity in Canadian children

Page 4: Obesity – The NEW EPIDEMIC AN epidemic of unknown origins?

Canadian children – 2 – 17 years Change from 1979 to 2004

CCHS, Statistics Canada, 2005

Page 5: Obesity – The NEW EPIDEMIC AN epidemic of unknown origins?

HEALTH ISSUES IN HEALTH ISSUES IN OVERWEIGHT YOUTHOVERWEIGHT YOUTH

Ebbeling CB, et al. Lancet. 2002;360:473-482.

Page 6: Obesity – The NEW EPIDEMIC AN epidemic of unknown origins?

QUESTION #1

What proportion of children presenting for weight management have multiple metabolic complications related to obesity?a) 5 - 10%b) 25 – 30%c) 45 – 50%d) 65 – 70%

Page 7: Obesity – The NEW EPIDEMIC AN epidemic of unknown origins?

HEALTH ISSUES IN HEALTH ISSUES IN OVERWEIGHT YOUTHOVERWEIGHT YOUTH

Ebbeling CB, et al. Lancet. 2002;360:473-482.

1 IN 2 WITH

MULTIPLE CVRF

25% WITH PRE-

DIABETES

IN HAMILTON

OTHER?

Page 8: Obesity – The NEW EPIDEMIC AN epidemic of unknown origins?

14-FOLD RISK

Children with CV risk factors are more likely to have heart attacks and strokes as adults

Cardiovascular event rate by age 30-48 according to CV risk factors at age 6-19

0

5

10

15

20

< 3 at least 3

1.5%

19.4%

%

# risk factors* at age 6-19 y/o

* obesity blood pressure glucose triglycerides HDL-cholesterol

Morrison et al. Pediatrics 2007 120:340

Page 9: Obesity – The NEW EPIDEMIC AN epidemic of unknown origins?

TAKE HOME MESSAGE

27% OF CHILDREN IN OUR REGION ARE OVERWEIGHT OR OBESE

HEALTH CONSEQUENCES ARE COMMON

METABOLIC HEALTH CONSEQUENCES IN YOUTH PREDICT HEAVY HEALTH BURDEN IN ADULTHOOD

Page 10: Obesity – The NEW EPIDEMIC AN epidemic of unknown origins?

A simple imbalance between input and output…

Storage

Page 11: Obesity – The NEW EPIDEMIC AN epidemic of unknown origins?

Gale J Nutr 2004 134:295

AppetiteAndSatiety

Page 12: Obesity – The NEW EPIDEMIC AN epidemic of unknown origins?
Page 13: Obesity – The NEW EPIDEMIC AN epidemic of unknown origins?

Understanding causation in youth

Fetal

Infant

ChildAdolescent

Adult

Morrison KM

Page 14: Obesity – The NEW EPIDEMIC AN epidemic of unknown origins?

FETAL ORIGINS OF OBESITY AND CVD

•Diabetes in pregnancy•Maternal obesity•Smoking in pregnancy•Pre-eclampsia

Fetal

Page 15: Obesity – The NEW EPIDEMIC AN epidemic of unknown origins?

Infant Nutrition

Breast feeding

-Protective?

Mary Cassatt, Louise Breastfeeding her Child, 1899

Infant

Page 16: Obesity – The NEW EPIDEMIC AN epidemic of unknown origins?

Nutritional problems

Fruit and vegetables

Sugared drink consumption

Large portion size

Child

Adolescent

Page 17: Obesity – The NEW EPIDEMIC AN epidemic of unknown origins?

Physical Activity and obesity

•Low physical activity associated with obesity

•Less than 20% of Canadian youth met physical activity targets

(60 min of activity 6+ days per week)

Janssen et al, 2005

Child

Adolescent

Page 18: Obesity – The NEW EPIDEMIC AN epidemic of unknown origins?

Obesity, overweight & screen time: 6 – 11 y – CCHS, 2004

NOTE: 36% of children had > 2 h / d screen time

0

10

20

30

40

<1 h /d 1 - 2 h/d > 2 h / d

Screen time

Pre

vale

nce o

f overw

eig

ht

or

ob

esit

y

Obese

Overwt

57

11*

1315

24*

*

Page 19: Obesity – The NEW EPIDEMIC AN epidemic of unknown origins?

Prevention: Early Childhood Determinants

Genetic Maternal diabetes during pregnancy Low birth weight? Breast feeding may be protective Family environment

Families and children that have these characteristics are in particular need of ANTICIPATORY guidance

Page 20: Obesity – The NEW EPIDEMIC AN epidemic of unknown origins?

QUESTION # 2

According to the Canadian Clinical Practice Guideline for the Prevention and Treatment of obesity in children, obesity in adolescents is classified by:a) Waist circumference > 90 cmb) Body mass index > 25 kg / m2c) Body mass index > 90th percentile for age

and genderd)Body mass index > 95th percentile for age

and gender

Page 21: Obesity – The NEW EPIDEMIC AN epidemic of unknown origins?

Age: 5 yrsAge: 5 yrs BMI = 20 kg/mBMI = 20 kg/m22

Age: 15 yrsAge: 15 yrs BMI = 20 kg/mBMI = 20 kg/m22

28

26

24

22

20

18

16

14

12

2 4 6 8 10 12 14 16 18 20Age (yrs)

BMI (kg/m2)

Assessing Bodyweight in Children

and Adolescents

BMI=weight (kg)/height2(m2)

50

85

95

BMI=weight (lb)/ height2(in2)*703

Dissemination

Page 22: Obesity – The NEW EPIDEMIC AN epidemic of unknown origins?

Obesity classification in childhood - CDC 2000

BMI Obesity: > 95th

percentile for age and gender

Overweight: >85th percentile for age and gender

OBESITY

OVERWEIGHT

Page 23: Obesity – The NEW EPIDEMIC AN epidemic of unknown origins?

Approach to prevention

ALL YOUTH > 2 y

Measure height, weight, BMI

Plot on growth curve (CDC)

<85%

PREVENTION

•Less than 2 hr TV / d

•Less than 1 c sugared drink per day

•Daily activity – min 30 min

≥ 85th Percentile for age and gender

Dissemination

Page 24: Obesity – The NEW EPIDEMIC AN epidemic of unknown origins?

CANADIAN CLINICAL PRACTICE GUIDELINES ON THE MANAGEMENT AND PREVENTION OF OBESITY IN ADULTS AND CHILDREN

MANAGEMENT OF OBESITY

Lau D et al, CMAJ 177 (11): 1391, 2007

Dissemination

Page 25: Obesity – The NEW EPIDEMIC AN epidemic of unknown origins?

Obesity treatment - 2008

Healthy Balanced Nutrition

Regular physical activity

Family based behavioural therapy Pharmaco-

therapy

SURGERY

TEAM – MUST BE RDFAMILY FOCUSSEDGOAL SETTINGMOTIVATIONAL INTERVIEWING

Page 26: Obesity – The NEW EPIDEMIC AN epidemic of unknown origins?

Intervening in childhood obesity – meta-analyses

•64 RCTs

•5230 participants

•Meta-analysis results: reduction in overweight at 6 and 12 months with:

- Lifestyle modification in children

- Lifestyle modification in adolescents +/- meds

CONCLUSION: “combined behavioural lifestyle interventions compared to standard care or self-help can produce a significant and clinically meaningful reduction in overweight in children and adolescents”:

Page 27: Obesity – The NEW EPIDEMIC AN epidemic of unknown origins?

EG. Addressing nutritional problems

Fruit and vegetables

Sugared drink consumption

Large portion size

Child

Adolescent

Page 28: Obesity – The NEW EPIDEMIC AN epidemic of unknown origins?

RNAO BPG, 2005

Implementing change?

Fetal

Infant

ChildAdolescen

t

Adult

Morrison KM

Page 29: Obesity – The NEW EPIDEMIC AN epidemic of unknown origins?

[email protected]

THANK YOU!

Page 30: Obesity – The NEW EPIDEMIC AN epidemic of unknown origins?

Management:PharmacotherapySibutramine (Anorectic agent) Nonselective inhibitor of neuronal serotonin and

norepinephrine uptake ONE RCT in adolescents – n=82 With behavioural therapy, lost 7.8 kg vs. 3.2 kg 44% of those on RX. had to decrease dose or

discontinue due to increased blood pressureBerkowitz RI et al JAMA

2003;289:1805.

NOT READY FOR ROUTINE USE

Page 31: Obesity – The NEW EPIDEMIC AN epidemic of unknown origins?

Management:Pharmacotherapy

Orlistat Inhibits lipase that breaks down triglyceride in gut prior to absorption…thus inhibiting fat absorption

One RCT – Chanoine J et al 2005 539 obese adolescents 12 – 16 yr x 52 WKS Orlistat – 120 mg tid vs placebo

•26.5% had 5% or more reduction in BMI compared to 15.7% with placebo

Chanoine, J.-P. et al. JAMA 2005;293:2873-2883.