Childhood Obesity, Problems and Solutions - University of Utah ...

The Obesity Epidemic:
Causes, Consequences and
Interventions
Paul Young
Department of Pediatrics
University of Utah School of Medicine
2010 School of Medicine Alumni Association Symposium: September 25, 2010

Objectives
• Describe the epidemic
• Overview of causes
• What clinicians can do
• Prevention
• Treatment

The Obesity “Epidemic”
• In 1985 about 10% of Americans were
obese
• Currently about 30% or 60,000,000
Americans are obese

Obesity Trends Among U.S. Adults
BRFSS, 1985
(*BMI ≥30, or ~ 30 lbs. overweight (175 lbs) for 5’ 4” person)
No Data

Obesity Trends* Among U.S. Adults
BRFSS, 1990
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data

Obesity Trends* Among U.S. Adults
BRFSS, 2000
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data

Obesity Trends Among U.S. Adults
BRFSS, 2007
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data

• BMI >30
Obesity in Adults
– for a 64 inch individual = a weight of about 175;
– for a 69 inch person, = a weight of 203
• BMI=Wt(KG)/Height 2 (m)
Wt (lbs)X703 /Ht 2 (inches)
• Obese weight=(Ht2X30)/703 • A BMI of >25 but < 30 = Overweight
• http://www.cdc.gov/healthyweight/index.html

Being Overweight
has become the “Norm”
Between 1980 and 2005 the proportion of
American adults with a BMI>25 increased
from 47% to 66%
Almost all of this increase resulted from an
increase in the number who are obese rather
than overweight.

Defining obesity in children

Why do we need to measure and plot BMI?
X
X

Childhood Obesity trends

1963
2010

Complications and Co-
– Dyslipidemia
– High BP
– Abnormal clotting
– Chronic Inflammation of
vessels
– Stroke
– Type 2 DM
– Polycystic ovary
syndrome
– (NASH) fatty liver
disease
morbidities
– Pseudotumor cerebri
– Sleep Apnea
– SCFE
– Osteoarthritis
– Pregnancy problems
– Depression
– Stigmatization and
prejudice
– Surgical Complications
– Premature Death

Consequences of the
Epidemic
• Increased mortality and morbidity
– Cardiovascular consequences related to
the Metabolic Syndrome
– The morbidity of nearly every chronic
disease is increased by the presence of
obesity/overweight
• Shortened life span
• Increased numbers with physical
disabilities

What’s Causing the Epidemic
• Is it “bad” or unhealthy behavior?
• Is it a genetic predisposition?
• Is it the social, physical and cultural
environment?
– The “obesogenic” environment

Causes of the epidemic
The “Obesogenic” Environment
IN
• Increasing availability of
inexpensive high calorie foods
– Fast foods
– Supersize portions
– High fat and sugar
• Heavy marketing and
advertising
– $6 billion per year
– McDonalds $1.7 billion
• Agricultural policy
• Changes in family life
OUT
• Decrease in physical activity
– Life and work that requires less
energy expenditure
– Less opportunities for
spontaneous play
– Less physical activity in school
• Increased television viewing
and screen time
• A built environment that
discourages walking or biking
as modes of transport

Why aren’t we all obese?
• Obesity results from an excess of fat storage
• Fat storage depends upon
– the genetic capacity to store excess energy intake as fat
– the availability of energy sources in excess of the amount
required (the obesogenic environment)
• The Thrifty Gene Hypothesis
– Neel JV (1962). "Diabetes mellitus: a "thrifty" genotype
rendered detrimental by "progress"?". Am. J. Hum. Genet.
14: 353–62

Possible genetic mechanisms to explain
why we aren’t all obese
• Thrifty genotype or “epigenotype”
• Variations in response to environmental
stimuli
• Variations in how activity affects us
• Variations in the energy costs of activity
• Variations in the type of fat that we store
– Brown fat vs White fat
• And many more
• Will “personalized medicine” be the answer?

Rationale for Trying to Prevent
Obesity
• The number of children, adolescents, and
adults who are overweight or obese has
increased dramatically in the past 30 years
• The severity of obesity has also increased
substantially
• The prevalence of obesity related conditions
and illnesses has increased markedly
• Treatment of obesity has not been very
successful

Prevention
• Primary
– Message or intervention goes to everyone
• Secondary
– Identify a high risk group
– Give them a specific message or
intervention
• Tertiary
– Prevent complications from the condition

Prevention Strategies
Expert committee from 15 national organizations
(Pediatrics 2007;120 supplement)
Convincing or moderate evidence
1. Limit consumption of sugar sweetened beverages
2. 5 servings of fruits and vegetables daily
3. Limit Screen time to

Prevention Strategies
Expert committee from 15 national organizations
(Pediatrics 2007;120 supplement)
Suggested on basis of limited data
1. A diet rich in calcium
2. A diet high in fiber
3. A diet with balanced amounts of fat, cho, protein
4. Exclusive breast feeding for 6 months with
maintenance after starting solids for 12 months
5. Moderate to vigorous physical activity for at least
60 minutes daily
6. Limit consumption of energy dense foods

Prevention Strategies
The “5-2-1-0” message
5 servings of fruits and vegetables each
day
A “serving” is about fist size
Less than 2 hours of screen time
TV, video games, computer
More than 1 hour of exercise
“moderate to vigorous”
Zero sweetened beverages
“no” soda or juice

Prevention for infants
• Start with the mother during pregnancy
– Social Learning Theory
– You are doing this for your baby
• Get mothers to practice the 5-2-1-0
approach for themselves and continue it
for the first two years
– A pilot project at the TMCP

Prevention for infants and toddlers
“Anticipatory guidance”
1. Breast feed for at least 6 months
– if you are bottle feeding, pretend you’re breast feeding
2. Don’t start solids until 6 months and start with
fruits/vegetables not cereal and continue breast
feeding
3. Don’t give your infant any sweetened beverages
(yes, this means no juice)
4. Continue to model your 5/2/1/0 activities
• Turn off the TV (2 hours max)
• No soda
• “Wear your baby” so she can be active with you

Wearing your baby

Prevention for children
• Continue the 5-2-1-0 message
– TV and videos as baby sitters are learned
behaviors
– Beverages should be low fat milk and water (no or
almost no juice)
– Make activity a part of every day
• Eat meals together
• Limit fast food meals
• A portion is about the size of the child’s fist
• Never force or reward a child for eating

Activity/exercise for prevention
• Exercise during childhood has a favorable
impact on body composition.
– promotes the development of lean body tissue
rather than adipose tissue
• Mechanical stimulation signals the
differentiation of stem cells into bone and
muscle and away from adipose tissue
Gutin B .Diet vs exercise for the prevention of pediatric obesity. International Journal of Obesity
(2010) 1–4

Secondary Prevention
• Family History
Who’s at risk?
– Overweight /obese, type 2 DM, CVD
• IDM
• Rapid early weight gain (more than doubling of birth
weight in first 4 months)
– IUGR/ SGA
• Early Adiposity Rebound
• BMI between 85th and 95th (at risk for obesity)

Between 2 and 6, children should become
skinnier
X
x

Secondary Prevention
“Prevention Plus”
1. “We don’t know why exactly, but we do know
that you will need to work harder than other
parents to prevent your child from becoming
overweight.”
2. “Your child’s BMI is between the 85th and 95th
percentile, we need to follow this more closely.
You need to think about portion size and
sweetened beverages but most important is
figuring out ways for him to be more active and
to set limits on his screen time.”

Tertiary Prevention
(Treatment)
• 2010 Change in USPTF
recommendation to an “A” (from an I)
regarding treatment effectiveness
• Screen all children for obesity using BMI
• Screen all >95% for co-morbidities
– Lipids, Type 2 DM, NASH

Treatment goals
• Maintain “stable weight” rather than
attempting to lose weight
• Improve fitness
• Chronic Care Model
– Registries and case management
– Self-management (regular weighing ?)
– Motivational Interviewing

Effect of Maintaining a stable weight
X
X x

The effect on BMI of maintaining a
stable weight
X
x

Summary
• We are in the midst of an epidemic of
childhood and adult obesity
• The consequences for the health of
individuals, the US population, and the
healthcare system are profound
• Prevention starting as early as possible with a
strong emphasis on physical activity is our
best hope for reversing the epidemic and its
consequences