obesity interventions that work the molten moment tracy flood md, phd director of the statewide...

Obesity Interventions That

WorkThe Molten Moment

Tracy Flood MD, PhDDirector of the Statewide Obesity Surveillance System

University of Wisconsin Madison

About Me

About Us

The Socio Ecological Model

Individual

Social, Organizational

Community, Public PolicyBuilt environment

Cellular

Question:How do we decrease obesity?

Clinic1 v 1 Populations

vs.

Why?UnhealthyWeight Gain

Obesity

“Toxic” Obesity =

Metabolic Syndrome(MetS)

Cardiovascular Dz(CVD)= Death

GoalProvide how-to-steps

on how to move the needle on obesity &

prevent premature death from cardiovascular disease.

OutlineWHY should we care? Metabolic Syndrome, CVD, etc!

Ok, we care. Let’s take action!

Let’s Design an intervention that works (review the lit reviews)

WHEN = Molten Moment WHERE = Clinic vs. Community WHAT WORKS?*

*Informed by Biology The Story of the Fat Cell

When do we act?

The Molten

Moment

Cold, Solid HOT, Malleable

The Molten Moment

The Molten Moment

Where do you strikeFor the biggest impact?

The Molten Moment

Where do you strikeFor the biggest impact?

birth 15 25+ 10 20

Age:

The Molten

Moment

Design anIntervention

?

Where do we act?

Pick an Obesity Intervention

Pick an Obesity InterventionIndividual

Organizational(ex. Schools, worksites)

Policy & Built environment

Will the Intervention work?1000+ Studies

35 Systematic Reviews & Meta-analyses & What Works for Health

= Evidence-based Interventions

Will the Intervention work?Define “What Works”

ChangeKey*Behaviors

Obesity

CVD

MetS

*Will define key behaviors for each case

The Molten

Moment

Design anIntervention

?

The Story of The Fat

Cell

What Works?

The Story of The Fat Cell

U.S. Prevalence of Overweight & Obesity

0-2 yrs 2-5 yrs 6-11 yrs 12-19 yrs 20-39 yrs 40-59 yrs 60+ yrs0

0.10.20.30.40.50.60.70.80.9

1

OverweightObesePediatric Definition Adult Definition

%

Little Cell, Big Problem

Data from NHANES 2011-12 Ogden, Carroll, Kit, Flegal 2014

Defining Obesity

ADULTSCHILDREN

Obese BMI ≥ 95th percentile

Overweight BMI 85th – 94th percentile

>

Obese

Over-weight

Normalweight

30

25

The Story of The Fat Cell

Glucose spike

Stem Cells can become Fat Cells(Arner Spalding 2010; Spalding, Arner 2008)

Fat Cell

OB

OW

NW

BMI

insulinGlucose Fat

Let’s Begin!

Pick an Obesity Intervention

Obese 15 yo girl who isotherwise healthy

Normal weight 35 yowith an obese preschooler

Obese 55 yo man with Metabolic Syndrome

Pick an Obesity Intervention

Obese 55 yo man with Metabolic Syndrome

Diet + Exercise

GoodAdvice

Rx

Results of Intervention

Advice Alone

Diet AloneExercise Alone

Diet+Exercise Orlistat

Sibutramine

Very Low Cal Diet

Average weight loss of subjects completing a minimum 1-year weight-management intervention; based on review of 80 studies (N=26,455; 18,199 completers [69%]). (Franz et al, 2007)

13 lbs

Note: Built environment & surgery not included

160 lb

weight5’6”

BMI

190 lb 30

25

OB

OW

NW

13 lbs

Results of Intervention

Meta-Analysis & Reviews

CVD improves, With minimal weight loss?

Multi-component Individualized programs

Worksite WellnessPrograms

Zoning for Active Living(Mixed use, good streetscape)

Behaviors:Physical Act/Active TransportBalanced Diet

Obesity

CVD

MetS

Weight(~4-8 lbs) prevent wt

Ref What Works for Health

The Story of The Fat Cell

Glucose spike

Stressed fat cells = Metabolic Syndrome(Arner Spalding 2010; Spalding, Arner 2008)

insulin

FATFAT FAT

The Story of The Fat Cell

Origins of Metabolic Syndrome(Arner Spalding 2010; Spalding, Arner 2008)

Fatty LiverTG

TG

HDLTG

TG (Fat)Used for fuel if active

FAFAFA

Result:Higher TG

Lower HDLHDL is the good cholesterolScavenges Xtra TG then is destroyed

FA

The Story of The Fat Cell

FAT

FAT

High TG, Low HDLHypertensionDiabetes=Metabolic Syndrome

Insulin Resistance

FAT

Insulin Resistance

= Metabolic Syndrome

Body Type& Risk

The Story of The Fat Cell

The Story of The Fat Cell

Metabolic HealthGood Poor

BMI

Obese

Normalweight

The Story of The Fat Cell

Obese 55 yo man with Metabolic Syndrome

The Story of The Fat Cell

Glucose spike

Relief with 7-10% Weight Loss(Arner Spalding 2010; Spalding, Arner 2008)

insulin

FATFAT FAT

The Story of The Fat Cell

Rebellion with >10% Weight Loss(Arner Spalding 2010; Spalding, Arner 2008)

5’6”

BMI

30

25

OB

OW

NW

I’m HUNGRY!!

I’m HUNGRY!!

FEED me!!

The Story of The Fat Cell

EAT MORE!BURN LESS!

I’m HUNGRY

!!

I’m HUNGRY

!!FEED me!!

Rebellion with >10% Weight Loss(Martins, Robertson, Morgan 2008)

lebeauleblog.wordpress.com

30 min of moderate exercise x 5 days a week to maintain

60-90 min of moderate exercise x 7 d/wk to maintain weight loss

I’m HUNGRY

!!

I’m HUNGRY

!!FEED me!!

(Martins, Robertson, Morgan 2008)

The Molten Moment

Behavior Change

Modest Weight

CVD Risk Decreases

The Molten Moment

Behavior Change Possible

CVD Risk Decreases

birth 15 25+ 10 20

Age:

Pick an Obesity Intervention

Obese 15 yo girl who isotherwise healthy

Normal weight 35 yowith an obese preschooler

Obese 55 yo man with Metabolic Syndrome

Pick an Obesity Intervention

Obese 15 yo girl who isotherwise healthy

Schoolbased

BehavTherapy

Neighbor-hood

Results of InterventionAdult Obesity

Meta-Analysis & Reviews

What Works For HealthN=13 meta-analysis &Systematic reviews

Individualized Behav programs

Multi-Component School-based

Access to Places for PA(Mixed use, streetscape, Rec Facilities)

Behaviors:Physical ActSedentary Behav (SB)Sugar-Sweetened Beverage

Obesity

CVD

MetS

Weight gain

Clinic-based counseling (SB)

Enhance/Expand Physical Ed

Safe Routes to School & Walking Schoolbus

Physically Active Classrooms & Structured Recess

Competitive Pricing in Schools

TV Monitoring Devices (SB)

But will she remain obese

for life?

The Story of The Fat Cell

The Story of The Fat Cell

CVD Risk: Sun et al., 2008Trajectory: Ventura, Loken, & Birch, 2009

Very High Risk of Future CVD

Finished w/ Linear Growth

Increased BMI = Increased Risk of CVD

Note: Subjects with BMI 25th to 75th percentile (CDC charts) were the referent group. Adapted from Bjorge, Engeland, Tverdal, & Smith (2008).

Figure. Mortality in adulthood (<55 y/o) of OW/OB adolescents (males and females) compared to normal weight peers.

Mortality risk in adulthood for OW/OB adolescents

If OW/OB teen Normal Weight by adulthoodRisk Factors & Atherosclerosis associated with adiposity

DECREASE (Oren et al., 2003; Weiss et al., 2009)

But our patient has a 92% chanceof remaining obese at the age of 40.

(Nader, 2008)

The Story of The Fat Cell

The Immortal Cell… sort of(Arner Spalding 2010; Spalding, Arner 2008)

The Molten Moment

birth 15 25+ 10 20

Age:

Behavior Change Possible

Decrease CVD Risk

Behavior Change Possible

Altered growth trajectory

Pick an Obesity Intervention

Obese 15 yo girl who isotherwise healthy

Normal weight 35 yowith an obese preschooler

Obese 55 yo man with Metabolic Syndrome

Pick an Obesity Intervention

Normal weight 35 yowith an obese preschooler

Early childcare

based

BehavTherapy

Neighbor-hood

Results of Intervention

Meta-Analysis & Reviews

What Works For HealthN=13 meta-analysis &Systematic reviews

Nutrition & PA Interventions in Preschool & Early Childcare

Access to Places for PA(Mixed use, streetscape, Rec Facilities)

Behaviors:Sugar-Sweetened Beverage

Obesity

CVD

MetSAllow me to

Explain

Sedentary BehaviorSleep

Provision of Health Food &Removal of Unhealthy Food

Intervention to reduce SB

The Story of The Fat Cell

The Story of The Fat CellI’m

Learning about the

world!

Sugar-sweetened beverages

Skipping Meals

Sedentary Behavior

Fat Cell of a PreschoolerSleep

Behavioral PlasticityPreschoolers mimic parents’:

Fruit & Vegetable consumptionPortion sizesSnacking frequencyTVPhysical activityGrocery shopping

“When mothers improve their diets in order to control their weight, their child (1-3 y/o) improves their diet as well, even if that was not the original intent” (Klohe-Lehman, et al., 2007)

Synthesis of Evidence

Synthesis: Behavior

Preschooler Teenager0

1

2

3

4

5

Hours Less of Weekly Sedentary Behavior After Intervention

(Wahi, et al., 2011) Meta-Analysis. RCT to reduce SB. 13 studies in review

Synthesis: BMI Change

6-12 yo

OB

OW

NW

OB

OW

NW

OB

OW

NW

0-5 yrs 6-12 yrs 13-18 yrs

-0.3

-0.25

-0.2

-0.15

-0.1

-0.05

0

Cochrane Meta-AnalysisBMI Change After Community-based Intervention by

Age (in kg/m2)

ns

(Waters, et al., 2011)Cochrane review of 55 studies. Meta-analysis on 37 studies, 27,946 children.

Synthesis: Success

20% 16%

90%

Danielsson et al., 2012 (0.5 SD BMI) Kraschnewski et al., 2010

Intervention Success Rates defined as enough BMI change to reduce CVD risk

BMI Percentile Chart

Beha

vior

BMI C

hang

eSu

cces

s

High RiskBorderline

RiskThinnest Weight

Successful Community Interventions

Moldable Habits

The Molten Moment

birth 15 25+ 10 20

Age:

Behavior Change Possible

Decrease CVD Risk

Behavior Change Possible

Alter growth trajectory

Behavior Change Possible

Obesity

MOLTEN MOMENTPrevention of Obesity

New GoalProvide how-to-steps

on how to move the needle on obesity &

prevent premature death from cardiovascular disease.

behavior &

Summary• Obesity is associated with MetS, CVD, & Death

• Small changes at any time = CVD• Small changes at the Molten Moment = Obesity• The 1v1 AND Population Interventions work We must all work together, doing what we can

FOR MORE INFORMATION: What Works for Health County Health Rankings.org

Thank You!

Questions/Comments?tflood@wisc.edu