Transcript Childhood Obesity - McMaster Faculty of Health Sciences

OBESITY – THE NEW EPIDEMIC
AN EPIDEMIC OF UNKNOWN ORIGINS?
Current Concepts in Pediatrics
KM Morrison MD, FRCPC
16.October.2009
OBJECTIVES
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Understand the elements which have contributed to
the rise in childhood and adolescent obesity
Discuss the health consequences related to
childhood obesity
Describe the current best practice approach to
intervention
Overweight and obesity in
Canadian children
Canadian children – 2 – 17 years Change
from 1979 to 2004
CCHS, Statistics Canada, 2005
HEALTH ISSUES IN OVERWEIGHT
YOUTH
Ebbeling CB, et al. Lancet. 2002;360:473-482.
QUESTION #1

What proportion of children presenting for weight
management have multiple metabolic complications
related to obesity?
a) 5 - 10%
b) 25 – 30%
c) 45 – 50%
d) 65 – 70%
HEALTH ISSUES IN OVERWEIGHT
YOUTH
IN HAMILTON
1 IN 2 WITH
MULTIPLE
CVRF
25% WITH
PREDIABETES
OTHER?
Ebbeling CB, et al. Lancet. 2002;360:473-482.
Children with CV risk factors are more likely to
have heart attacks and strokes as adults
Cardiovascular event rate by age 30-48
according to CV risk factors at age 6-19
20
15
%
14-FOLD
RISK
19.4%
10
5
1.5%
0
<3
at least 3
# risk factors* at age 6-19 y/o
Morrison et al. Pediatrics 2007 120:340
* obesity
blood pressure
 glucose
 triglycerides
HDL-cholesterol
TAKE HOME MESSAGE
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27% OF CHILDREN IN OUR REGION ARE
OVERWEIGHT OR OBESE
HEALTH CONSEQUENCES ARE COMMON
METABOLIC HEALTH CONSEQUENCES IN YOUTH
PREDICT HEAVY HEALTH BURDEN IN ADULTHOOD
A simple imbalance between input and output…
Storage
Appetite
And
Satiety
Gale J Nutr 2004 134:295
Understanding causation in youth
Adult
Fetal
Infant
Adolescent
Child
Morrison KM
FETAL ORIGINS OF OBESITY AND CVD
Fetal
•Diabetes in pregnancy
•Maternal obesity
•Smoking in pregnancy
•Pre-eclampsia
Infant Nutrition
Infant
Breast feeding
-Protective?
Mary Cassatt, Louise Breastfeeding her Child, 1899
Nutritional problems
Sugared drink consumption
Child
Large portion size
Adolescent
Fruit and vegetables
Physical Activity and obesity
Child
•Low physical activity associated with
obesity
•Less than 20% of Canadian youth met
physical activity targets
(60 min of activity 6+ days per week)
Adolescent
Janssen et al, 2005
Obesity, overweight & screen time:
6 – 11 y – CCHS, 2004
40
*
Prevalence of overweight
or obesity
30
11*
Obese
Overwt
20
5
10
13
0
<1 h /d
7
15
1 - 2 h/d
24*
>2h/d
Screen time
NOTE: 36% of children had > 2 h / d screen time
Prevention: Early Childhood Determinants
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Genetic
Maternal diabetes during pregnancy
Low birth weight?
Breast feeding may be protective
Family environment
Families and children that have these characteristics are in particular need of
ANTICIPATORY guidance
QUESTION # 2

According to the Canadian Clinical Practice
Guideline for the Prevention and Treatment of
obesity in children, obesity in adolescents is
classified by:
a) Waist circumference > 90 cm
b) Body mass index > 25 kg / m2
c) Body mass index > 90th percentile for age and gender
d)Body mass index > 95th percentile for age and gender
Dissemination
Assessing Bodyweight in Children
and Adolescents
BMI (kg/m2)
95
28
26
BMI=
weight (kg)/height2(m2)
85
24
22
50
BMI=
weight (lb)/ height2(in2)*703
20
18
16
Age: 5 yrs
BMI = 20 kg/m2
14
Age: 15 yrs BMI = 20 kg/m2
12
2
4
6
8 10 12 14 16 18 20
Age (yrs)
Obesity classification in childhood CDC 2000
BMI
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Obesity: > 95th
percentile for age
and gender
Overweight: >85th
percentile for age
and gender
OBESITY
OVERWEIGHT
Approach to prevention
Dissemination
PREVENTION
ALL YOUTH > 2 y
Measure height,
weight, BMI
•Less than 2 hr TV / d
<85%
Plot on growth curve
(CDC)
≥ 85th Percentile for
age and gender
•Less than 1 c sugared
drink per day
•Daily activity – min 30
min
Dissemination
MANAGEMENT OF OBESITY
CANADIAN CLINICAL PRACTICE GUIDELINES ON THE
MANAGEMENT AND PREVENTION OF OBESITY IN
ADULTS AND CHILDREN
Lau D et al, CMAJ 177 (11): 1391, 2007
Obesity treatment - 2008
Healthy Balanced
Nutrition
SURGERY
Regular physical
activity
Family based behavioural therapy
PharmacoTEAM – MUST BE RD
therapy
FAMILY FOCUSSED
GOAL SETTING
MOTIVATIONAL INTERVIEWING
Intervening in childhood obesity – metaanalyses
•64 RCTs
•5230 participants
•Meta-analysis results: reduction in
overweight at 6 and 12 months with:
- Lifestyle modification in children
- Lifestyle modification in
adolescents +/- meds
CONCLUSION: “combined behavioural lifestyle interventions compared to standard
care or self-help can produce a significant and clinically meaningful reduction in
overweight in children and adolescents”:
EG. Addressing nutritional
problems
Sugared drink consumption
Child
Large portion size
Adolescent
Fruit and vegetables
Implementing change?
Adult
Fetal
Infant
Adolescent
Child
Morrison KM
RNAO BPG, 2005
THANK YOU!
[email protected]
Management:
Pharmacotherapy
Sibutramine (Anorectic agent)
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Nonselective inhibitor of neuronal serotonin and norepinephrine
uptake
ONE RCT in adolescents – n=82
With behavioural therapy, lost 7.8 kg vs. 3.2 kg
44% of those on RX. had to decrease dose or discontinue due
to increased blood pressure
Berkowitz RI et al JAMA 2003;289:1805.
NOT READY FOR ROUTINE USE
Management:
Pharmacotherapy
Orlistat Inhibits lipase that breaks down triglyceride in gut prior

to absorption…thus inhibiting fat absorption
One RCT – Chanoine J et al 2005
 539
obese adolescents 12 – 16 yr x 52 WKS
 Orlistat – 120 mg tid vs placebo
•26.5% had 5% or more reduction
in BMI compared to 15.7% with
placebo
Chanoine, J.-P. et al. JAMA
2005;293:2873-2883.