Presentation Transcript

1. Mal-Nutrition: Our National Pandemic

   Mark B. Stephens, MD MS FAAFP Associate Professor of Family Medicine
2. FOUR PRIMARY RISK FACTORS* Formula feeding during infancy Consumption of sugar-sweetened drinks Excessive television/video viewing Low physical activity Whitaker (2003)
3. THEMES Life on a J-shaped curve Applying Newton’s Laws of Thermodynamics Common Sense vs Evidence
4. Is BMI the best measure of obesity? Yes No
5. What do you think the best measure of obesity is? BMI Waist Circumference Skinfold thickness Bioelectrical Impedance CT Underwater Weighing
6. Are you comfortable helping patients lose weight? Yes No
7. Which do you find most helpful in assisting patients with weight loss? Diet Exercise Medication Surgery Motivational Counseling Combination of factors
8. Since entering Medical or Professional school, has your weight: Increased Decreased Stayed the same
9. When in your life was it easiest to exercise? Preschool Elementary School High School Graduate/prof school Residency Fellowship Staff life
10. What is the worst handicap for a child? Obesity Cleft lip Cystic Fibrosis Muscular Dystorphy Asthma ADHD Cerebral Palsy Diabetes
11. Now for the Data!
12. Is it OK to use the term “obese” to describe heavy children? Yes No
13. How many US children are overweight or obese? 1 in 2 1 in 3 1 in 4 1 in 5 1 in 6
14. How many Adults are overweight or at-risk? 2 of 3 1 of 2 1 of 3 1 of 4 1 of 5
15. OBJECTIVES Define terms Describe epidemiology Discuss risk factors and implications Decide what to do about it Take home messages Central role for Family Physicians
16. 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/
17. WHY BMI? Can be used from childhood into adolescence and adulthood Correlates with laboratory measures of fat Best we have for now
18. DIAGNOSIS Based on CDC BMI-for-Age curves Children (and adults) should be screened for obesity (SORT C) CSBM VS
19. So What? OVERWEIGHT CHILDREN BECOME OVERWEIGHT ADULTS Guo, 2002
20. So What, Part 2 OVERWEIGHT ADULTS HAVE MUCH HIGHER RISK* *For just about everything!!!!
21. 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
22. COLLATERAL DAMAGE Trifiletti, 2006
23. 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
24. 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
25. How many servings of fruits or vegetables are recommended per day? 1 2 3 4 5 or more
26. How many glasses of milk should adolescents consume per day? 1 2 3 or more No data
27. 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
28. How many HS students meet recommended activity levels? 1 in 2 1 in 3 1 in 4 1 in 5 1 in 10

29. SO WHAT?

    Jot down diseases you think obesity increases risk for
30. 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
31. Psychosocial Effects of Obesity Decreased self-esteem Bullying Stigmatization Sadness Loneliness Isolation Increased SI/SA
32. 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
33. STIGMATIZATION Overweight adolescent women Lower education Decreased earning potential The ‘worst’ handicap for young adolescents?* *PARENTS OVERLOOK!!
34. ‘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)
35. 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)
36. 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’
37. DIET, EXERCISE and the MODERN ENVIRONMENT
38. MAL-NUTRITION FOOD IS: Increasingly available Calorie-rich Nutrient-poor CHEAP
39. 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!
40. CALORIES Increased ‘availability’ (3300 to 3800 kcal/d from ’70 to ’98) Increased “density”
41. CARBS Added sugars 20% of adolescent Kcal Avg of 20 tsp/day Glycemic Index has increased.
42. CALCIUM Inverse relationship between calcium intake and adipose levels 85% of adolescents do not meet RDI for calcium
43. 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
44. 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
45. 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
46. 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
47. 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
48. 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
49. I’d rather Die than Exercise 6 of 10 British adults would rather die than exercise or eat properly UK Guardian September 23, 2007
50. 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
51. MOTORIZED TRANSPORTATION Walking/cycling decreased 40% from 1977 to 1999 in ages 5 to 15 Most families take an average of 4 trips per day The average ‘trip’ is 0.8 miles
52. Enough data! I understand that there is a problem!!
53. Have you read the NHLBI Guidelines?? Yes No
54. Do you feel bariatric surgery is effective? Yes No
55. In your career how many patients have you referred for bariatric surgery? 0 1 2-3 4-6 7-10 More than 10
56. In your career, how often have you prescribed meds for wt loss? 0 1 2-3 4-6 7-10 11-20 More than 20
57. Are you comfortable with motivational interviewing? Yes No
58. WHAT IS A PHYSICIAN TO DO? Multifactorial interventions delivered to the FAMILY were more effective at reducing BMI than interventions delivered to children alone Clin Ev Handbook, 2007 Do what you do best!!
59. Family Physicians: The Key to Success! Prenatal Care Infant Care Child Care Adolescent Care Adult Care Geriatric Care
60. Life on a J-shaped Curve Mortality Clinical Endpoint: Birthweight
61. BMI AND MORTALITY Mortality Clinical Endpoint: BMI
62. PRENATAL SGA at high risk for adult CV mortality! Barker Hypothesis = “The Fetal Jones” Fetal Programming Intrauterine deprivation Premature Infants LGA infants (fetal over-nutrition)
63. WHAT’S A FAMILY PHYSICIAN TO DO? “Optimize” BMI prior to conception Promote tobacco cessation Promote and sustain regular physical activity Promote and sustain healthy dietary choices Identify and treat gestational diabetes
64. Family Physicians: The Key to Success! Prenatal Care Infant Care Child Care Adolescent Care Adult Care Geriatric Care
65. INFANTS Breastfeed first 6 (preferably 12) months of life (SOR: A) Restrict sugar sweetened beverage use (SOR: C) Intake of sugar sweetened fruit drinks (other than 100% fruit juice) is associated with excess weight gain and obesity (SOR: B)
66. INFANTS If parents choose to introduce fruit juice, do so after 6 months (SOR: C) If parents choose to introduce fruit juice, they should provide only 100% fruit juice in a cup. Limit intake to 4-6 oz/day (SOR: C) Do not use fruit juice as a substitute for whole fruits. (SOR: C)
67. Family Physicians: The Key to Success! Prenatal Care Infant Care Child Care Adolescent Care Adult Care Geriatric Care
68. LIFE ON THE J-SHAPED CURVE Morbidity Clinical Endpoint: Adiposity Rebound
69. CHILD AVOID ADIPOSITY REBOUND In children with low birth weight, rapid gain in BMI after age 2 is associated with highest increase in adult mortality from heart disease (Cameron, 2002)
70. CHILD Visceral obesity predicts cardiovascular outcomes independent of BMI (Fox, 2007) Modern children have higher ‘visceral’ (intra-abominal) fat than prior generations Higher BMI in childhood associated with increased CHD risk as adult (Baker, 2007)
71. CHILD Mild caloric restriction Grow into weight Regular activity (together?!) Eat meals together! Limit TV/Videos
72. Family Physicians: The Key to Success! Prenatal Care Infant Care Child Care Adolescent/Adult
73. LIFE ON THE J-CURVE Mortality Clinical Endpoint(s): BP; Chol; BMI ...
74. ADOLESCENCE If current rates stay stable, adolescent overweight will increase the prevalence of obese 35-year-olds to 35% in men and 42% in women by 2020 (Bibbins-Domingo, 2007)
75. ADOLESCENT CARE Variety of foods School cafeteria choices School vending machines Daily physical activity Reduce television/video/computer ‘mindless’ time
76. DIET Mild caloric restriction Do not severely restrict calories No evidence for/against low-carb diets Reduce/eliminate pre-sweetened drinks Ensure adequate calcium intake Ensure adequate fiber intake Ensure adequate fruit and vegetable intake SHOP THE OUTER AISLE
77. ACTIVITY Imprint activity as a way of life early Emphasize health benefits of physical activity rather than competition
78. BEHAVIOR MODIFICATION Involve the family Meals Activities Emphasize the positive Important to patient? Confident they can change? Adjunct professionals
79. Medications Neurotransmitter Digestion Neuroendocrine Peripheral metabolism Sibutramine S/NE reuptake inhibitor Orlistat Lipase inhibition/fat absorption
80. MEDICATION Always a second line Metformin (+MVI) Orlistat Sibutramine All positive studies incorporate diet, exercise and behavioral modification. Obes Res Jan 2007
81. SURGERY Only for carefully selected patients at carefully selected centers www.obesitylapbandsurgery.com
82. TRICARE CRITERIA 100 pounds over ideal weight with: Diabetes, hypertension, cholecystitis, narcolepsy, Pickwickian syndrome, hypothalamic disorders or severe arthritis 200% or more over ideal weight Prior bypass for obesity with complications requiring another surgery **Nonsurgical treatment, gastric wraping, bubble, balloon or biliopancreatic bypass not covered
83. KP says BMI > 50 BMI > 40 and TWO or more of: OSA uncontrolled with CPAP DM uncontrolled with meds DJD of wt bearing joints HTN uncontrolled with meds CHF Other life-threatening/severe conditions directly related to obesity
84. SUMMARY J-shaped curve Theromodynamics Common sense
85. SUMMARY J-shaped curve Theromodynamics Energy Entropy Inertia Common sense
86. SUMMARY J-shaped curve Theromodynamics Common sense Do what you do best!! CSBM VS
87. “Unless effective population-level interventions to reduce obesity are developed, the steady rise in life expectancy observed in the modern era may soon come to an end and the youth of today may, on average, live less healthy and possibly even shorter lives than their parents.” Olshansky et al. NEJM 352:1138-1145, 2005
88. This lecture was practical 0 (not at all) 1 2 3 4 5 (very)
89. This lecture was informative 0 (not at all) 1 2 3 4 5 (very)
90. I will change my practice based on this lecture Yes No
91. VERBS RULE! Counsel the “ING”