OBESITY THE NEW EPIDEMIC AN EPIDEMIC OF UNKNOWN
OBESITY – THE NEW EPIDEMIC AN EPIDEMIC OF UNKNOWN ORIGINS? Current Concepts in Pediatrics KM Morrison MD, FRCPC 16. October. 2009
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 OVERWEIGHT 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 OVERWEIGHT YOUTH IN HAMILTON 1 IN 2 WITH MULTIPLE CVRF 25% WITH PREDIABETES OTHER? Ebbeling CB, et al. Lancet. 2002; 360: 473 -482.
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 % 14 -FOLD RISK 19. 4% 1. 5% # risk factors* at age 6 -19 y/o Morrison et al. Pediatrics 2007 120: 340 * obesity blood pressure glucose triglycerides HDL-cholesterol
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
Appetite And Satiety Gale J Nutr 2004 134: 295
Understanding causation in youth Adult Fetal Infant Adolescent Child Morrison KM
FETAL ORIGINS OF OBESITY AND CVD Fetal • Diabetes in pregnancy • Maternal obesity • Smoking in pregnancy • Pre-eclampsia
Infant Nutrition Infant Breast feeding -Protective? Mary Cassatt, Louise Breastfeeding her Child, 1899
Nutritional problems Sugared drink consumption Child Large portion size Adolesce nt Fruit and vegetables
Physical Activity and obesity Child • Low physical activity associated with obesity • Less than 20% of Canadian youth met physical activity targets (60 min of activity 6+ days per week) Adolesce nt Janssen et al, 2005
Obesity, overweight & screen time: 6 – 11 y – CCHS, 2004 40 Prevalence of overweight or obesity * 30 11* Obese Overwt 20 5 10 13 0 <1 h /d 7 15 1 - 2 h/d 24* >2 h/d Screen time NOTE: 36% of children had > 2 h / d screen time
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 cm b) Body mass index > 25 kg / m 2 c) Body mass index > 90 th percentile for age and gender d)Body mass index > 95 th percentile for age and gender
Dissemination BMI (kg/m 2) Assessing Bodyweight in Children and Adolescents BMI= weight (kg)/height 2(m 2) 95 28 26 85 24 22 50 BMI= weight (lb)/ height 2(in 2)*703 20 18 16 Age: 5 yrs BMI = 20 kg/m 2 14 Age: 15 yrs BMI = 20 kg/m 2 12 2 4 6 8 10 12 14 16 18 20 Age (yrs)
Obesity classification in childhood - CDC 2000 BMI Obesity: > 95 th percentile for age and gender Overweight: >85 th percentile for age and gender OBESITY OVERWEIGHT
Approach to prevention Dissemination PREVENTION ALL YOUTH > 2 y Measure height, weight, BMI • Less than 2 hr TV / d <85% Plot on growth curve (CDC) ≥ 85 th Percentile for age and gender • Less than 1 c sugared drink per day • Daily activity – min 30 min
Dissemination MANAGEMENT OF OBESITY CANADIAN CLINICAL PRACTICE GUIDELINES ON THE MANAGEMENT AND PREVENTION OF OBESITY IN ADULTS AND CHILDREN Lau D et al, CMAJ 177 (11): 1391, 2007
Obesity treatment - 2008 Healthy Balanced Nutrition SURGERY Regular physical activity Family based behavioural therapy Pharmaco. TEAM – MUST BE RD therapy FAMILY FOCUSSED GOAL SETTING MOTIVATIONAL 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 Sugared drink consumption Child Large portion size Adolesce nt Fruit and vegetables
Implementing change? Adult Fetal Infant Adolescent Child Morrison KM RNAO BPG, 2005
THANK YOU! kmorrison@mcmaster. ca
Management: Pharmacotherapy Sibutramine (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 pressure Berkowitz 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.
- Slides: 31