obesity – the new epidemic an epidemic of unknown origins? current concepts in...
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OBESITY – THE NEW EPIDEMIC
AN EPIDEMIC OF UNKNOWN ORIGINS?
Current Concepts in Pediatrics16.October.2009KM Morrison MD, FRCPC
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
Overweight and obesity in Canadian children
Canadian children – 2 – 17 years Change from 1979 to 2004
CCHS, Statistics Canada, 2005
HEALTH ISSUES IN HEALTH ISSUES IN OVERWEIGHT YOUTHOVERWEIGHT YOUTH
Ebbeling CB, et al. Lancet. 2002;360:473-482.
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%
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?
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
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
A simple imbalance between input and output…
Storage
Gale J Nutr 2004 134:295
AppetiteAndSatiety
Understanding causation in youth
Fetal
Infant
ChildAdolescent
Adult
Morrison KM
FETAL ORIGINS OF OBESITY AND CVD
•Diabetes in pregnancy•Maternal obesity•Smoking in pregnancy•Pre-eclampsia
Fetal
Infant Nutrition
Breast feeding
-Protective?
Mary Cassatt, Louise Breastfeeding her Child, 1899
Infant
Nutritional problems
Fruit and vegetables
Sugared drink consumption
Large portion size
Child
Adolescent
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
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*
*
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
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
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
Obesity classification in childhood - CDC 2000
BMI Obesity: > 95th
percentile for age and gender
Overweight: >85th percentile for age and gender
OBESITY
OVERWEIGHT
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
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
Obesity treatment - 2008
Healthy Balanced Nutrition
Regular physical activity
Family based behavioural therapy Pharmaco-
therapy
SURGERY
TEAM – MUST BE RDFAMILY FOCUSSEDGOAL SETTINGMOTIVATIONAL INTERVIEWING
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”:
EG. Addressing nutritional problems
Fruit and vegetables
Sugared drink consumption
Large portion size
Child
Adolescent
RNAO BPG, 2005
Implementing change?
Fetal
Infant
ChildAdolescen
t
Adult
Morrison KM
THANK YOU!
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
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.