Obesity: Consequences &Costs Healthy Kids Collaborative Policy Summit March 28, 2012

1. Obesity: Consequences &CostsHealthy Kids Collaborative Policy SummitMarch 28, 2012 David N. Collier, MD, PhD, FAAP Associate Professor of Pediatrics, Family Medicine and Kinesiology Director, Pediatric Healthy Weight Research and Treatment Center

2. Objectives • Define obesity • Recognize common medical problems associated with obesity • Discuss costs to employers and society

3. How is Obesity Defined? Body Mass Index (BMI) • Calculated from height and weight • wt in kg/(ht in m)2 • 2005 US Preventive Services Task Force: • “Acceptable measure for identifying children and adolescents with excess weight.” • Feasible and reliable • Correlates with directly measured % body fat • Tracks with adult obesity measures

4. Definition of Obesity: Adults • Body mass index (BMI) • Weight (kg)/ [height (m)]2 • Adult criteria (WHO and NIH) • < 18.5 kg/m2 underweight • 18.5 < 25 normal weight • 25 < 30 overweight • > 30 obese • > 40 extreme obesity

5. Relative Risk of Death vs. BMI * * Calle EE et al NEJM 1999;341: 1097-1105 * * *

6. Body Mass Index and Age Adjusted Lifetime Relative Risk of Type 2 Diabetes (♀)Colditz et al. Am J Epidemiol 1990;132:501-513 Relative Risk 66% 32% 4.5%

8. Definition of Obesity: Children • Body mass index (BMI) • Weight (kg)/ [height (m)]2 • Age and gender specific norms (CDC) • Definitions: • BMI < 5th percentile: Underweight • BMI > 5th but < 85th ‘tile Healthy Weight • BMI > 85th but < 95th ‘tile Overweight • BMI > 95th Obese • BMI ≥ 99 Obese with increased risk

10. Prevalence of Obesity by Era/Age(data from various NHES and NHANES, BMI ≥ 95th tile)

11. Prevalence of Overweight, Obesity and Extreme Obesity (NHANES 2003-2004 vs. Eastern NC)

12. Tracking BMI-for-Age from Birth to 18 Years with Percent of Overweight Children who Are Obese at Age 25 Whitaker et al. NEJM:1997;337:869-873

13. Years of Life Lost as a Function of BMI at Age 20 (Fontaine KR JAMA 2003;289:187-93) Years Expected Life Lost

14. Risks related to childhood obesity Speiser PW et a.l J Clinical Endocrinology & Metabolism 2005;90:1871-87 • Endocrine • Cardiovascular • Respiratory • Visceral • Orthopedic • Renal • Dermatologic • Neurologic • Malignancies • Psycho-social

15. Endocrine risks • Type 2 Diabetes Mellitus • 30-50% of all new pediatric cases • Onset a early as 2 years of age • Impending epidemic in US? • 33% of boys born in 2000 • 39% of girls born in 2000 • Higher in certain populations • Hispanic, Native American, Asian American • 60-80 lifetime prevalence in certain populations • eNC = 66% - 78%??? • Poly Cystic Ovary Syndrome

16. Cardiovascular Risks related to childhood obesitySpeiser PW et a.l J Clinical Endocrinology & Metabolism 2005;90:1871-87 • Hypercholesterolemia • Obesity #1 cause childhood dyslipidemias • Bogalusa Heart Study • Plaque and fatty streak formation begins in childhood • Extent of plaque varies with: • BMI • blood pressure • lipid profile

17. Cardiovascular Risks related to childhood obesity (Speiser PW et a.l J Clinical Endocrinology & Metabolism 2005;90:1871-87) • Hypertension • Obesity #1 cause of childhood hypertension • Cardiomyopathy • Increased blood volume and pressure requires heart to work harder • Increased work induces fibrous hypertrophy • Left ventricle doesn’t fill or pump as well • Increased 02 requirement • Adipositas cordis • Trans-differentiation of cardiac myocytes into adipocytes

18. 45% of Obese Adolescents Already Have Impaired Vascular Reactivity (early CAD) Obese

19. Respiratory risks related to childhood obesity (Speiser PW et a.l J Clinical Endocrinology & Metabolism 2005;90:1871-87) • Asthma • Higher prevalence • More severe in obese children • Harder to ventilate/treat obese child • Obstructive sleep apnea • Obese child ≈ 6 x as likely to suffer • 90% prevalence in obese adolescents with habitual snoring • Intermittent airway collapse • Hypoxia and hypercapnea • Pulmonary artery hypertension • Right ventricular hypertrophy • Behavioral problems • Inattentiveness/hyperactivity • Irreversible cognitive defects • School failure • Secondary nocturnal enuresis Images from S. Boag @ www.path.gueensu.ca

20. Visceral risks related to childhood obesity (Speiser PW et a.l J Clin. Endo. & Metabolism 2005;90:1871-87) • Non-alcoholic fatty liver disease • Excessive caloric intake stored as fat in liver • 50% of obese children have radiographic evidence • 15% with elevated transaminases • 15% will progress to cirrhosis and liver failure • Obesity related NAFLD most common childhood liver disease • Gall bladder disease • Related to obesity but mechanism not clear • Can be precipitated by rapid weight loss

21. Orthopedic risks related to childhood obesity (Speiser PW et a.l J Clin Endo & Metabolism 2005;90:1871-87) • Slipped capital femoral epiphysis • Tibia vara (Blount’s disease) • Osteoarthritis • Scoliosis • Spondylolisthesis • Genu valgus • Pes planus

22. Walking-frontal plane (McMillan et al, Pediatr Phys Ther 2009; 21:187–193) HIP KNEE ANKLE

23. Risks related to childhood obesity Speiser PW et a.l J Clinical Endocrinology & Metabolism 2005;90:1871-87 • Endocrine • Cardiovascular • Respiratory • Visceral • Orthopedic • Renal • Dermatologic • Neurologic • Malignancies • Psycho-social

24. Obesity: the Most Expensive Risk Factor for North Carolina in 2006 “Tipping the Scales:” by Chenowith and Associates for Be Active North Carolina 2008 • $ 33 million youth medical costs • $ 2.8 billion adult medical costs • $960 million adult Rx drug costs • $ 11.8 billion lost productivity costs • $28,619 cost by mid career • $250,000 cost by retirement • 3.05% drop in OW/OB prevalence could: • Potentially save $ 3 billion (2007-2011) • Fund 68,000 full time jobs in North Carolina

25. Aggregate Costs Associated with Selected Risk Factors: North Carolina 2006“Tipping the Scales:” by Chenowith and Associates for Be Active North Carolina 2008

26. Aggregate medical spending attributable to overweight and obesity (Runge CF. Diabetes 2007;56:2668)

27. “Fast Food Comes to Africa”

28. Energy Balance:Energy intake = Energy expenditure Food and Beverage Intake Physical Activity Energy Intake Energy Expenditure

29. Culture/Society Media/Govt./Industry Community School/Peers Family/Home Child Physical Activity Food and Beverage Intake Energy Expenditure Energy Intake Ecological Systems Theory ModelDavison KK, Birch LL Obes Rev 2001;2:159-71

30. A Public Health Framework to Prevent and Control Overweight and Obesity • Food and BeverageIndustry • Agriculture • Education • Media • Government • Public Health Systems • Healthcare Industry • Business and Workers • Land Use and Transportation • Leisure and Recreation • Community- and Faith-based Organizations • Foundations and Other Funders Social Norms and Values • Home and Family • School • Community • Work Site • Healthcare Sectors of Influence Behavioral Settings • Genetics • Psychosocial • Other Personal Factors Individual Factors Food and Beverage Intake Physical Activity Energy Expenditure Energy Intake Energy Balance Note: Adapted from “Preventing Childhood Obesity.” Institute of Medicine, 2005. Prevention of Overweight and Obesity Among Children, Adolescents, and Adults

31. Contact Information • David N. Collier, MD, PhD, FAAP • ECU pediatric Healthy Weight Research and Treatment Center • Brody School of Medicine, Department of Pediatrics • collierd@ecu.edu • www.pedsweightcenter.ecu.edu • 252-744-3538 • Referrals: • Joy Aycock @ 252 744-3538