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The <strong>Obesity</strong> Epidemic:<br />

Causes, Consequences <strong>and</strong><br />

Interventions<br />

Paul Young<br />

Department <strong>of</strong> Pediatrics<br />

<strong>University</strong> <strong>of</strong> <strong>Utah</strong> School <strong>of</strong> Medicine<br />

2010 School <strong>of</strong> Medicine Alumni Association Symposium: September 25, 2010


Objectives<br />

• Describe the epidemic<br />

• Overview <strong>of</strong> causes<br />

• What clinicians can do<br />

• Prevention<br />

• Treatment


The <strong>Obesity</strong> “Epidemic”<br />

• In 1985 about 10% <strong>of</strong> Americans were<br />

obese<br />

• Currently about 30% or 60,000,000<br />

Americans are obese


<strong>Obesity</strong> Trends Among U.S. Adults<br />

BRFSS, 1985<br />

(*BMI ≥30, or ~ 30 lbs. overweight (175 lbs) for 5’ 4” person)<br />

No Data


<strong>Obesity</strong> Trends* Among U.S. Adults<br />

BRFSS, 1990<br />

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)<br />

No Data


<strong>Obesity</strong> Trends* Among U.S. Adults<br />

BRFSS, 2000<br />

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)<br />

No Data


<strong>Obesity</strong> Trends Among U.S. Adults<br />

BRFSS, 2007<br />

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)<br />

No Data


• BMI >30<br />

<strong>Obesity</strong> in Adults<br />

– for a 64 inch individual = a weight <strong>of</strong> about 175;<br />

– for a 69 inch person, = a weight <strong>of</strong> 203<br />

• BMI=Wt(KG)/Height 2 (m)<br />

Wt (lbs)X703 /Ht 2 (inches)<br />

• Obese weight=(Ht2X30)/703 • A BMI <strong>of</strong> >25 but < 30 = Overweight<br />

• http://www.cdc.gov/healthyweight/index.html


Being Overweight<br />

has become the “Norm”<br />

Between 1980 <strong>and</strong> 2005 the proportion <strong>of</strong><br />

American adults with a BMI>25 increased<br />

from 47% to 66%<br />

Almost all <strong>of</strong> this increase resulted from an<br />

increase in the number who are obese rather<br />

than overweight.


Defining obesity in children


Why do we need to measure <strong>and</strong> plot BMI?<br />

X<br />

X


<strong>Childhood</strong> <strong>Obesity</strong> trends


1963<br />

2010


Complications <strong>and</strong> Co-<br />

– Dyslipidemia<br />

– High BP<br />

– Abnormal clotting<br />

– Chronic Inflammation <strong>of</strong><br />

vessels<br />

– Stroke<br />

– Type 2 DM<br />

– Polycystic ovary<br />

syndrome<br />

– (NASH) fatty liver<br />

disease<br />

morbidities<br />

– Pseudotumor cerebri<br />

– Sleep Apnea<br />

– SCFE<br />

– Osteoarthritis<br />

– Pregnancy problems<br />

– Depression<br />

– Stigmatization <strong>and</strong><br />

prejudice<br />

– Surgical Complications<br />

– Premature Death


Consequences <strong>of</strong> the<br />

Epidemic<br />

• Increased mortality <strong>and</strong> morbidity<br />

– Cardiovascular consequences related to<br />

the Metabolic Syndrome<br />

– The morbidity <strong>of</strong> nearly every chronic<br />

disease is increased by the presence <strong>of</strong><br />

obesity/overweight<br />

• Shortened life span<br />

• Increased numbers with physical<br />

disabilities


What’s Causing the Epidemic<br />

• Is it “bad” or unhealthy behavior?<br />

• Is it a genetic predisposition?<br />

• Is it the social, physical <strong>and</strong> cultural<br />

environment?<br />

– The “obesogenic” environment


Causes <strong>of</strong> the epidemic<br />

The “Obesogenic” Environment<br />

IN<br />

• Increasing availability <strong>of</strong><br />

inexpensive high calorie foods<br />

– Fast foods<br />

– Supersize portions<br />

– High fat <strong>and</strong> sugar<br />

• Heavy marketing <strong>and</strong><br />

advertising<br />

– $6 billion per year<br />

– McDonalds $1.7 billion<br />

• Agricultural policy<br />

• Changes in family life<br />

OUT<br />

• Decrease in physical activity<br />

– Life <strong>and</strong> work that requires less<br />

energy expenditure<br />

– Less opportunities for<br />

spontaneous play<br />

– Less physical activity in school<br />

• Increased television viewing<br />

<strong>and</strong> screen time<br />

• A built environment that<br />

discourages walking or biking<br />

as modes <strong>of</strong> transport


Why aren’t we all obese?<br />

• <strong>Obesity</strong> results from an excess <strong>of</strong> fat storage<br />

• Fat storage depends upon<br />

– the genetic capacity to store excess energy intake as fat<br />

– the availability <strong>of</strong> energy sources in excess <strong>of</strong> the amount<br />

required (the obesogenic environment)<br />

• The Thrifty Gene Hypothesis<br />

– Neel JV (1962). "Diabetes mellitus: a "thrifty" genotype<br />

rendered detrimental by "progress"?". Am. J. Hum. Genet.<br />

14: 353–62


Possible genetic mechanisms to explain<br />

why we aren’t all obese<br />

• Thrifty genotype or “epigenotype”<br />

• Variations in response to environmental<br />

stimuli<br />

• Variations in how activity affects us<br />

• Variations in the energy costs <strong>of</strong> activity<br />

• Variations in the type <strong>of</strong> fat that we store<br />

– Brown fat vs White fat<br />

• And many more<br />

• Will “personalized medicine” be the answer?


Rationale for Trying to Prevent<br />

<strong>Obesity</strong><br />

• The number <strong>of</strong> children, adolescents, <strong>and</strong><br />

adults who are overweight or obese has<br />

increased dramatically in the past 30 years<br />

• The severity <strong>of</strong> obesity has also increased<br />

substantially<br />

• The prevalence <strong>of</strong> obesity related conditions<br />

<strong>and</strong> illnesses has increased markedly<br />

• Treatment <strong>of</strong> obesity has not been very<br />

successful


Prevention<br />

• Primary<br />

– Message or intervention goes to everyone<br />

• Secondary<br />

– Identify a high risk group<br />

– Give them a specific message or<br />

intervention<br />

• Tertiary<br />

– Prevent complications from the condition


Prevention Strategies<br />

Expert committee from 15 national organizations<br />

(Pediatrics 2007;120 supplement)<br />

Convincing or moderate evidence<br />

1. Limit consumption <strong>of</strong> sugar sweetened beverages<br />

2. 5 servings <strong>of</strong> fruits <strong>and</strong> vegetables daily<br />

3. Limit Screen time to


Prevention Strategies<br />

Expert committee from 15 national organizations<br />

(Pediatrics 2007;120 supplement)<br />

Suggested on basis <strong>of</strong> limited data<br />

1. A diet rich in calcium<br />

2. A diet high in fiber<br />

3. A diet with balanced amounts <strong>of</strong> fat, cho, protein<br />

4. Exclusive breast feeding for 6 months with<br />

maintenance after starting solids for 12 months<br />

5. Moderate to vigorous physical activity for at least<br />

60 minutes daily<br />

6. Limit consumption <strong>of</strong> energy dense foods


Prevention Strategies<br />

The “5-2-1-0” message<br />

5 servings <strong>of</strong> fruits <strong>and</strong> vegetables each<br />

day<br />

A “serving” is about fist size<br />

Less than 2 hours <strong>of</strong> screen time<br />

TV, video games, computer<br />

More than 1 hour <strong>of</strong> exercise<br />

“moderate to vigorous”<br />

Zero sweetened beverages<br />

“no” soda or juice


Prevention for infants<br />

• Start with the mother during pregnancy<br />

– Social Learning Theory<br />

– You are doing this for your baby<br />

• Get mothers to practice the 5-2-1-0<br />

approach for themselves <strong>and</strong> continue it<br />

for the first two years<br />

– A pilot project at the TMCP


Prevention for infants <strong>and</strong> toddlers<br />

“Anticipatory guidance”<br />

1. Breast feed for at least 6 months<br />

– if you are bottle feeding, pretend you’re breast feeding<br />

2. Don’t start solids until 6 months <strong>and</strong> start with<br />

fruits/vegetables not cereal <strong>and</strong> continue breast<br />

feeding<br />

3. Don’t give your infant any sweetened beverages<br />

(yes, this means no juice)<br />

4. Continue to model your 5/2/1/0 activities<br />

• Turn <strong>of</strong>f the TV (2 hours max)<br />

• No soda<br />

• “Wear your baby” so she can be active with you


Wearing your baby


Prevention for children<br />

• Continue the 5-2-1-0 message<br />

– TV <strong>and</strong> videos as baby sitters are learned<br />

behaviors<br />

– Beverages should be low fat milk <strong>and</strong> water (no or<br />

almost no juice)<br />

– Make activity a part <strong>of</strong> every day<br />

• Eat meals together<br />

• Limit fast food meals<br />

• A portion is about the size <strong>of</strong> the child’s fist<br />

• Never force or reward a child for eating


Activity/exercise for prevention<br />

• Exercise during childhood has a favorable<br />

impact on body composition.<br />

– promotes the development <strong>of</strong> lean body tissue<br />

rather than adipose tissue<br />

• Mechanical stimulation signals the<br />

differentiation <strong>of</strong> stem cells into bone <strong>and</strong><br />

muscle <strong>and</strong> away from adipose tissue<br />

Gutin B .Diet vs exercise for the prevention <strong>of</strong> pediatric obesity. International Journal <strong>of</strong> <strong>Obesity</strong><br />

(2010) 1–4


Secondary Prevention<br />

• Family History<br />

Who’s at risk?<br />

– Overweight /obese, type 2 DM, CVD<br />

• IDM<br />

• Rapid early weight gain (more than doubling <strong>of</strong> birth<br />

weight in first 4 months)<br />

– IUGR/ SGA<br />

• Early Adiposity Rebound<br />

• BMI between 85th <strong>and</strong> 95th (at risk for obesity)


Between 2 <strong>and</strong> 6, children should become<br />

skinnier<br />

X<br />

x


Secondary Prevention<br />

“Prevention Plus”<br />

1. “We don’t know why exactly, but we do know<br />

that you will need to work harder than other<br />

parents to prevent your child from becoming<br />

overweight.”<br />

2. “Your child’s BMI is between the 85th <strong>and</strong> 95th<br />

percentile, we need to follow this more closely.<br />

You need to think about portion size <strong>and</strong><br />

sweetened beverages but most important is<br />

figuring out ways for him to be more active <strong>and</strong><br />

to set limits on his screen time.”


Tertiary Prevention<br />

(Treatment)<br />

• 2010 Change in USPTF<br />

recommendation to an “A” (from an I)<br />

regarding treatment effectiveness<br />

• Screen all children for obesity using BMI<br />

• Screen all >95% for co-morbidities<br />

– Lipids, Type 2 DM, NASH


Treatment goals<br />

• Maintain “stable weight” rather than<br />

attempting to lose weight<br />

• Improve fitness<br />

• Chronic Care Model<br />

– Registries <strong>and</strong> case management<br />

– Self-management (regular weighing ?)<br />

– Motivational Interviewing


Effect <strong>of</strong> Maintaining a stable weight<br />

X<br />

X x


The effect on BMI <strong>of</strong> maintaining a<br />

stable weight<br />

X<br />

x


Summary<br />

• We are in the midst <strong>of</strong> an epidemic <strong>of</strong><br />

childhood <strong>and</strong> adult obesity<br />

• The consequences for the health <strong>of</strong><br />

individuals, the US population, <strong>and</strong> the<br />

healthcare system are pr<strong>of</strong>ound<br />

• Prevention starting as early as possible with a<br />

strong emphasis on physical activity is our<br />

best hope for reversing the epidemic <strong>and</strong> its<br />

consequences

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