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Obesity – The NEW EPIDEMIC AN epidemic of unknown origins?

Obesity – The NEW EPIDEMIC AN epidemic of unknown origins?. Current Concepts in Pediatrics 16.October.2009 KM Morrison MD, FRCPC. OBJECTIVES. Understand the elements which have contributed to the rise in childhood and adolescent obesity

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Obesity – The NEW EPIDEMIC AN epidemic of unknown origins?

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  1. Obesity – The NEW EPIDEMICAN epidemic of unknown origins? Current Concepts in Pediatrics 16.October.2009 KM Morrison MD, FRCPC

  2. 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

  3. Overweight and obesity in Canadian children

  4. Canadian children – 2 – 17 years Change from 1979 to 2004 CCHS, Statistics Canada, 2005

  5. HEALTH ISSUES IN OVERWEIGHT YOUTH Ebbeling CB, et al. Lancet. 2002;360:473-482.

  6. 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%

  7. HEALTH ISSUES IN OVERWEIGHT YOUTH IN HAMILTON 1 IN 2 WITH MULTIPLE CVRF 25% WITH PRE-DIABETES OTHER? Ebbeling CB, et al. Lancet. 2002;360:473-482.

  8. 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 * obesity blood pressure  glucose  triglycerides HDL-cholesterol 19.4% 14-FOLD RISK % 1.5% # risk factors* at age 6-19 y/o Morrison et al. Pediatrics 2007 120:340

  9. 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

  10. Storage A simple imbalance between input and output…

  11. Appetite And Satiety Gale J Nutr 2004 134:295

  12. Understanding causation in youth Adult Fetal Infant Adolescent Child Morrison KM

  13. FETAL ORIGINS OF OBESITY AND CVD Fetal • Diabetes in pregnancy • Maternal obesity • Smoking in pregnancy • Pre-eclampsia

  14. Infant Nutrition Breast feeding -Protective? Infant Mary Cassatt, Louise Breastfeeding her Child, 1899

  15. Fruit and vegetables Sugared drink consumption Nutritional problems Child Large portion size Adolescent

  16. 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) Adolescent Janssen et al, 2005

  17. 40 * 30 Obese Overwt 11* Prevalence of overweight or obesity 20 7 5 10 24* 15 13 0 <1 h /d 1 - 2 h/d > 2 h / d Screen time Obesity, overweight & screen time: 6 – 11 y – CCHS, 2004 NOTE: 36% of children had > 2 h / d screen time

  18. 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

  19. 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 / m2 c) Body mass index > 90th percentile for age and gender d)Body mass index > 95th percentile for age and gender

  20. CPOCPG Dissemination Assessing Bodyweight in Childrenand Adolescents BMI (kg/m2) BMI= weight (kg)/height2(m2) 95 28 26 24 22 20 18 16 14 12 85 BMI= weight (lb)/ height2(in2)*703 50 2 4 6 8 10 12 14 16 18 20 Age (yrs)

  21. OBESITY OVERWEIGHT Obesity classification in childhood - CDC 2000 BMI • Obesity: > 95th percentile for age and gender • Overweight: >85th percentile for age and gender

  22. CPOCPG Dissemination Approach to prevention • PREVENTION • Less than 2 hr TV / d • Less than 1 c sugared drink per day • Daily activity – min 30 min ALL YOUTH > 2 y Measure height, weight, BMI Plot on growth curve (CDC) <85% ≥ 85th Percentile for age and gender

  23. CPOCPG 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

  24. Obesity treatment - 2008 Healthy Balanced Nutrition Regular physical activity SURGERY Pharmaco- therapy Family based behavioural therapy TEAM – MUST BE RD FAMILY FOCUSSED GOAL SETTING MOTIVATIONAL INTERVIEWING

  25. 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”:

  26. Fruit and vegetables Sugared drink consumption EG. Addressing nutritional problems Child Large portion size Adolescent

  27. Implementing change? RNAO BPG, 2005 Adult Fetal Infant Adolescent Child Morrison KM

  28. THANK YOU! kmorrison@mcmaster.ca

  29. 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

  30. 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.

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