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