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Mal-Nutrition : Our N ational Pandemic. Mark B. Stephens, MD MS FAAFP Associate Professor of Family Medicine. FOUR PRIMARY RISK FACTORS*. Formula feeding during infancy Consumption of sugar-sweetened drinks Excessive television/video viewing Low physical activity. Whitaker (2003).
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Mal-Nutrition: Our National Pandemic Mark B. Stephens, MD MS FAAFP Associate Professor of Family Medicine
FOUR PRIMARY RISK FACTORS* • Formula feeding during infancy • Consumption of sugar-sweetened drinks • Excessive television/video viewing • Low physical activity Whitaker (2003)
THEMES • Life on a J-shaped curve • Applying Newton’s Laws of Thermodynamics • Common Sense vs Evidence
Is BMI the best measure of obesity? • Yes • No
What do you think the best measure of obesity is? • BMI • Waist Circumference • Skinfold thickness • Bioelectrical Impedance • CT • Underwater Weighing
Are you comfortable helping patients lose weight? • Yes • No
Which do you find most helpful in assisting patients with weight loss? • Diet • Exercise • Medication • Surgery • Motivational Counseling • Combination of factors
Since entering Medical or Professional school, has your weight: • Increased • Decreased • Stayed the same
When in your life was it easiest to exercise? • Preschool • Elementary School • High School • Graduate/prof school • Residency • Fellowship • Staff life
What is the worst handicap for a child? • Obesity • Cleft lip • Cystic Fibrosis • Muscular Dystorphy • Asthma • ADHD • Cerebral Palsy • Diabetes
Is it OK to use the term “obese” to describe heavy children? • Yes • No
How many US children are overweight or obese? • 1 in 2 • 1 in 3 • 1 in 4 • 1 in 5 • 1 in 6
How many Adults are overweight or at-risk? • 2 of 3 • 1 of 2 • 1 of 3 • 1 of 4 • 1 of 5
OBJECTIVES • Define terms • Describe epidemiology • Discuss risk factors and implications • Decide what to do about it • Take home messages • Central role for Family Physicians
DEFINITIONS • Underweight • BMI <5% for age • Normal • BMI 6%-84% for age • At risk for overweight • BMI 85%-95% for age • Overweight* • BMI >95% for age *Overwt = Obese (IOM, 2005) http://www.cdc.gov/growthcharts/
WHY BMI? • Can be used from childhood into adolescence and adulthood • Correlates with laboratory measures of fat Best we have for now
DIAGNOSIS • Based on CDC BMI-for-Age curves • Children (and adults) should be screened for obesity (SORT C) CSBM VS
So What? OVERWEIGHT CHILDREN BECOME OVERWEIGHT ADULTS Guo, 2002
So What, Part 2 OVERWEIGHT ADULTS HAVE MUCH HIGHER RISK* *For just about everything!!!!
Background Data* • Overweight has tripled in US kids since 1980 • 31% of 6-19 year-olds are overweight or at-risk-to-become overweight • 10% of 2-5 year-olds are overweight or at-risk-to-become overweight *www.cdc.gov
COLLATERAL DAMAGE Trifiletti, 2006
Country Boys > 85%ile Girls > 85%ile Austria 12% 11% Belgium 13% 15% France 10% 13% Ireland 19% 14% Portugal 14% 21% Sweden 12% 12% USA 28% 31% Not Just an “American” Problem
URBANIZATION AND GLOBALIZATION • “NUTRITION TRANSITION” • Agro-food systems (global corporations) • Cheap, calorie-dense foods, fats and oils • Reduction in local subsistence farming • Congregation in urban areas • Consumer culture • Less physical activity • More oils/fats/calories
How many servings of fruits or vegetables are recommended per day? • 1 • 2 • 3 • 4 • 5 or more
How many glasses of milk should adolescents consume per day? • 1 • 2 • 3 or more • No data
How many HS students watch more than 3 hours of TV/day? • 1 in 2 • 1 in 3 • 1 in 4 • 1 in 5 • 1 in 10
How many HS students meet recommended activity levels? • 1 in 2 • 1 in 3 • 1 in 4 • 1 in 5 • 1 in 10
SO WHAT? Jot down diseases you think obesity increases risk for
Hypertension Diabetes Hyperlipidemia Coronary Artery Disease Gallbladder disease Steatohepatitis Obstructive sleep apnea Pseutotumor cerebri Orthopedic complaints PCOS Metabolic Syndrome Depression All-cause mortality Childhood/Adolescent Overweight Increases Risk for
Psychosocial Effects of Obesity • Decreased self-esteem • Bullying • Stigmatization • Sadness • Loneliness • Isolation • Increased SI/SA
STIGMATIZATION • Children shown pictures of obese kids and kids with various disabilities said they would be least likely to befriend the obese child Latner, Obes Res 2003
STIGMATIZATION • Overweight adolescent women • Lower education • Decreased earning potential • The ‘worst’ handicap for young adolescents?* *PARENTS OVERLOOK!!
‘Causes’ of Obesity INTAKE OUTPUT • Energy is neither created nor destroyed • The disorder of an isolated system can never decrease (Entropy) • A body at rest tends to stay at rest (Inertia)
CAUSALITY? : GENETICS? *Genetics explains 30-50% of tendency to adiposity • Genetics* • Leptin • Melanocortin • Adiponectin • 1 parent obese (50%); 2 parents (80%) *At least 430 genes linked with obesity phenotypes at present (Spieser, 2005)
CAUSALITY? : GENETICS? • Secondary obesity • Prader-Willi • Bardet-Biedl • Beckwith-Wiedeman Secondary causes should particularly be considered when the child is obese AND short OR ‘dysmorphic’
MAL-NUTRITION FOOD IS: • Increasingly available • Calorie-rich • Nutrient-poor • CHEAP
FAT • 4% decrease in overall fat intake in US since 1970 • ADDED fat (butter, oil shortening) has doubled since 1909 (annual average of 64lb/person) *Recent WHI data!
CALORIES • Increased ‘availability’ (3300 to 3800 kcal/d from ’70 to ’98) • Increased “density”
CARBS • Added sugars 20% of adolescent Kcal • Avg of 20 tsp/day • Glycemic Index has increased.
CALCIUM • Inverse relationship between calcium intake and adipose levels • 85% of adolescents do not meet RDI for calcium
FRUITS AND VEGETABLES • Overall US intake has increased 24% since 1970 • 80% of children and adolescents do not meet USDA recommendations (5-a-day) Eat a Rainbow
FAST FOOD • On any given day, 20-30% of US households patronize a restaurant. • 25%-50%* of all meals are away-from-home (35% of overall energy intake) • Fast food = 10% of school food! *Washington Post, 2007
FAST FOOD Children and Adults who consume fast food: • More total energy • More total fat • More total carbohydrate • More added sugars • Less fiber • Less calcium • Fewer fruits and vegetables
SUGARED BEVERAGES Sugar-Sweetened Beverages (SSB) • Beverage of choice • Intake has doubled over past 20 years • Average 19 oz/day for boys; 11 oz/day for girls
PHYSICAL INACTIVITY • 25% of adolescents do not engage in ‘sufficient’ physical activity; 14% do not exercise at all. • Only 28% of 9th-12th graders have daily PE • Many in PE aren’t active! • Play is the traditional, spontaneous form of physical activity • Organized sports activities
PHYSICAL INACTIVITY • Free time is increasing • 2-3 hours/wk used for physical activity • 28 hours/wk used for television/videos • >40,000 targeted ads for candy, cereal and fast food
I’d rather Die than Exercise • 6 of 10 British adults would rather die than exercise or eat properly • UK Guardian September 23, 2007
TV/VIDEO… • 38% of children watch at least 3 hours of TV on most, if not all, school days. • 98% of households have 1 TV; 75% have 2+ • Hours of TV viewing correlate directly with BMI