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ObesityObesityA Weighty ProblemA Weighty Problem
The “Top 10”
The Associated Press
The “Top 10” alternative reasons for obesity:
1. Inadequate sleep. (Average sleep amounts have fallen, and many studies tie sleep deprivation to weight gain.)
The “Top 10” alternative reasons for obesity:
2. Endocrine disruptors, which are substances in some foods that might alter fats in the body.
The “Top 10” alternative reasons for obesity:
3. Nice temperatures. (Air conditioning and heating limit calories burned from sweating and shivering.)
The “Top 10” alternative reasons for obesity:
4. Fewer people smoking. (Less appetite suppression.)
The “Top 10” alternative reasons for obesity:
5. Medicines that cause weight gains
The “Top 10” alternative reasons for obesity:
6. Population changes. (More middle-agers and Hispanics, who have higher obesity rates.)
The “Top 10” alternative reasons for obesity:
7. Older birth moms. (That correlates with heavier children.)
The “Top 10” alternative reasons for obesity:
8. Genetic influences during pregnancy
The “Top 10” alternative reasons for obesity:
9. Darwinian natural selection. (Fat people out survive skinny ones).
The “Top 10” alternative reasons for obesity
10. Assortative mating, or like mating with like,” Allison puts it. Translation: fat people procreating with others of the same body type, gradually skewing the population toward the heavy end.
Obesity Related MorbidityObesity Related Morbidity
• The estimated number of deaths attributable to obesity among US adults is approximately 280,000.
Obesity Related MorbidityObesity Related Morbidity
• The estimated number of deaths attributable to obesity for nonsmokers is approximately 325,000
ObesityObesity• AHA and NIH have recognized obesity as a major modifiable risk
factor for CHD
• Obesity is a risk factor for development of hypertension, diabetes, and dyslipidemia
• Obesity also linked to insulin resistance, particular intraabdominal fat estimated by waist circumference
The Theories of Obesity Fall Into The Theories of Obesity Fall Into Three CategoriesThree Categories
Genetic Influence of Human Variation Genetic Influence of Human Variation in Body Fatin Body Fat
Defining ObesityDefining Obesity
• Body Mass Index (BMI)= Weight divided by Height squared (kg/m 2).
• Normal Weight: 18.5 to 24.9
• Overweight: 25.0 to 29.9
• Obese I: 30.0 to 34.9
• Obese II: 35.0 to 39.9
• Obese III: > 40
Relationship Between Cardiovascular Disease Relationship Between Cardiovascular Disease and Their Risk Factorsand Their Risk Factors
Disease Risk Associated with Disease Risk Associated with Overweight and ObesityOverweight and Obesity
• “Disease risk in early life is associated with respiratory conditions and several risk factors for coronary heart disease and is predictive of hypertension, diabetes, coronary heart disease and all-cause mortality.”
• Other risk factors include certain types of cancers, high blood cholesterol level, gall bladder disease, and osteoarthritis.
Prevalence and Risk of ObesityPrevalence and Risk of Obesity
• NHANES III shows approximately 60% of men and 50% of women are obese or overweight, with 20% of men and 25% of women having a BMI of 30 or greater
• BMI 27-29 associated with a RR of total mortality of 1.6, BMI 29-32 RR 2.1, and BMI >=32 RR 2.2 vs. BMI <19 from Nurses’ Health Study.
Increasing Prevalence of Overweight Increasing Prevalence of Overweight and Obesityand Obesity
• Obesity has increased in every state, in both sexes, across all age groups, educational levels, and smoking statuses.
• Over the last 3 decades there has been a 25% increase in the number of people who qualify as overweight.
Percentage of Overweight and Percentage of Overweight and Obesity in the United States Obesity in the United States
• For adults 25 years and older the percentage of people who qualify as overweight is 63% for men and 55% for women.
• Specifically, 42% of men and 28% of women are overweight. While 21% of men and 27% of women are obese.
Prevalence of Obesity among US Adults Prevalence of Obesity among US Adults From Years 1991, 1993, 1995, and 1998From Years 1991, 1993, 1995, and 1998
Prevalence of Obesity among US Adults Prevalence of Obesity among US Adults From Years 1991, 1993, 1995, and 1998From Years 1991, 1993, 1995, and 1998
Increasing Prevalence of Overweight in Increasing Prevalence of Overweight in U.S. Adults and U.S. Adults and
of Obesityof Obesity
Age-Adjusted Standardized Prevalence of Overweight(BMI 25–29.9) and Obesity (BMI >30)
37.8
23.6
10.415.1
41.1
23.6
11.816.1
39.1
24.3
12.216.3
24.9
39.4
24.719.9
0
10
20
30
40
50
Men Women Men Women
NHES I NHANES I NHANES II NHANES III
BMI > 30BMI 25–29.9
CDC/NCHS, United States, 1960-94, ages 20-74 years
Per
cen
t
NHANES III Age-Adjusted Prevalence of Hypertension* According to BMI
16.518.221.922.5 24.025.2
32.2
38.4
0
10
20
30
40
50
Men Women
BMI <25 BMI 25-26 BMI 27-29 BMI >30
*Defined as mean systolic blood pressure 140 mm Hg, as mean diastolic 90 mm Hg, or currently taking antihypertensive medication .
Brown C et al. Body Mass Index and the prevalence of Risk Factors for Cardiovascular Disease (in preparation).
Per
cen
t
NHANES III Age-Adjusted Prevalence of High Blood Cholesterol* According to BMI
15.714.7
27.9
17.5
28.2
20.424.7
20.2
0
10
20
30
40
50
Men Women
BMI <25 BMI 25-26 BMI 27-29 BMI >30
*Defined as > 240 mg/dL.
Brown C et al. Body Mass Index and the Prevalence of Risk Factors for Cardiovascular Disease (in preparation).
Per
cen
t
NHANES III Age-Adjusted Prevalence of Low HDL-Cholesterol* According to BMI
16.5
9.1
27.0
17.2
27.223.1
41.5
31.4
0
10
20
30
40
50
60
Men Women
BMI <25 BMI 25-26 BMI 27-29 BMI >30
*Defined as <35 mg/dL in men and <45 mg/dL in women.
Brown C et al. Body Mass Index and the Prevalence of Risk Factors for Cardiovascular Disease (in preparation).
Per
cen
t
Carbo-Lipo-Terrorism in the U.S.
A Report To: Orange County
On: 2/18/04
Percent Overweight Children U.S. & Orange County
0
2
4
6
8
10
12
14
16
1963-70 1971-74 1976-80 1988-94 1999-2000
U.S. 6-11 yo
U.S.12-19 yo
Orange County2-12 yo
Per
cen
t O
verw
eig
ht
(>95
% w
eig
ht/
hei
gh
t)
YearData from the CDC & Prevention, NCHS, NHANES, HHNES, NHES, Report on the Conditions of Children in Orange County, 2002
No Data <4% 4%-6% 6%-8% 8%-10% >10%
Obesity (> 120%tile ideal body weight) in U.S. Adults
1992
Diabetes in U.S Adults
1992
Obesity 1994
No Data <4% 4%-6% 6%-8% 8%-10% >10%
Diabetes 1994
Obesity 1996
No Data <4% 4%-6% 6%-8% 8%-10% >10%
Diabetes 1996
Obesity 1998
No Data <4% 4%-6% 6%-8% 8%-10% >10%
Diabetes1998
Obesity 1999
No Data <4% 4%-6% 6%-8% 8%-10% >10%
Diabetes 1999
Obesity 2000
No Data <4% 4%-6% 6%-8% 8%-10% >10%
Diabetes 2000
Tracking BMI-for-Age from Birth to 18 Years with % of Overweight Children who Are Obese at Age 25
16 15 12 11 10 917 19
55
7567
26
52
69
8377
36
0
20
40
60
80
100
Birth 1 to 3 3 to 6 6 to 10 10 to 15 15 to 18Age of child (years)
% obese as adults
BMI < 85th BMI >=85th BMI >=95th
Whitaker et al. NEJM: 1997;337:869-873
> 95th percentile Overweight
85th to < 95th Risk of overweight percentile
< 5th percentile Underweight
BMI-for-Age Cutoffs
National Longitudinal Survey of Youth Prospective Cohort Study of
8270 Children (4-12 years old) - 1999
Risk of Overweight Overweight
> 85th %ile BMI > 95th %ile BMI
African American 38.4% 21.5%
Hispanics 37.9% 21.8%
Caucasian 25.8% 12.3%
Secular Increases in Relative Weight and Adiposity in Children (5-14 years old)
- Bogalusa Heart Study -
Study years Weight (kg)Height (cm)
BMI (kg/m2)
1973-1974 35.9 140 17.6
1992-1994 41.0 142 19.5
Change* +3.4 +1.6 +1.5* Change adjusted for height, age, race, and sexSource: Pediatrics 99:420-426, 1997
Prevalence of Overweight and Obesity Among US Children (6-19 years old)
1999-2002
1999-2000 2001-2002
85th percentile BMI 29.9% 31.5%
95th percentile BMI 15.0% 16.5%
Source: Hedley et al., JAMA 291:2847-2850, 2004
Overweight in Children*(> 95th percentile BMI)
1971-1974 1988-1994 1999-2002
2-5 years 5.0 7.2 10.4
6-11 years 4.0 11.3 15.3
12-19 years 6.1 10.5 15.5**
* 4722 children from NHANES; overweight > 95th adjusted for age** > 23% of African American and Mexican American adolescentsSource: Ogden et al., JAMA 288:1728-1732, 2002
Correlations of Weight and BMI at 7.7 and 23.6 Years
Source: Minneapolis Children’s BP Study, Circulation 99:1471, 1999
r=0.605
r=0.612
Example: 95th Percentile Tracking Age BMI
2 yrs 19.3 4 yrs 17.8 9 yrs 21.013 yrs 25.1
For Children, BMI Changes with Age
Boys: 2 to 20 years
BMI BMI
BMI BMI
BMI = 18
Age 4 years: >95th
BMI Changes with age
Boys: 2 to 20 years
BMI BMI
BMI BMI
Age 8 years: 85th
Age 13 years: <50th
Can you see risk?
• This boy is 3 years, 3 weeks old.
• Is his BMI-for-age
- >85th to <95th percentile: at risk for overweight?
Photo from UC Berkeley Longitudinal Study, 1973
Measurements:
Age=3 y 3 wks
Height=
100.8 cm (39.7 in)
Weight=
18.6 kg (41 lb)
BMI = 18.3
BMI-for-age= >95th percentile overweight
Plotted BMI-for-Age
Boys: 2 to 20 years
BMI BMI
BMI BMI
Can you see risk?
• This girl is 4 years old.• Is her BMI-for-age
- >85th to <95th percentile: at risk for overweight?
Photo from UC Berkeley Longitudinal Study, 1973
Measurements: Age=4 y
Height=
99.2 cm (39.2 in)
Weight=
17.55 kg (38.6 lb)
BMI=17.8
BMI-for-age= between 90th –95th percentile
At risk for overweight
Plotted BMI-for-Age
Girls: 2 to 20 years
BMI
BMIBMI
BMI
5 1/2 year old boy
Weight: 41.5 lb
Height: 43 in
BMI= 15.8
BMI-for-age=50th %tile
Inaccurate height measurement: 42.25
BMI=16.3
BMI-for-age=75th %tile
Accurate Measurements are Critical
Boys: 2 to 20 years
BMI BMI
BMI BMI
Childhood Overweight 2003 BMI (Body Mass Index) is Now Defining Tool
• BMI Calculated as Weight / Height Squared
• Used to judge appropriateness of weight for height
• Replaces weight for height charts and % ideal body wt
• For a child, BMI > 95% is obese BMI 85-95% is “at risk”
• BMI data from retrospective analysis: 1. Reflect increasing fatness 2. Predict adult risk
Prevalence of Overweight, U.S. Adults, 1988 to 1991Prevalence of Overweight, U.S. Adults, 1988 to 1991
Overweight Adults 20-74 Years of Overweight Adults 20-74 Years of Age, 1988-1994Age, 1988-1994
Overweight Prevalence by Overweight Prevalence by Race/Ethnicity for Adolescent Boys Race/Ethnicity for Adolescent Boys
and Girlsand Girls
Targeted History & Physical for the Obese Child
The Identification, Management & Treatment of the Obese Child
History
• Birth– Weight: LGA & SGA
• Risk factor for Diabetes Mellitus
– Decreased tone, poor feeding• Concern regarding Prader Willi
• Family History (below are RF for DM & dysmetabolic syndrome)
– Diabetes (1 vs 2, gestational)– Obesity (calculate parents BMI)– Hypertension– Dyslipidemia– Premature cardiovascular disease
Male < 55 yo Female < 65 yo
Medical history/Review of Systems
Possible Underlying Endogenous Cause of Obesity
• Decreased growth velocity or abnormal height
• Abnormal pubertal development
• Abnormal Developmental history– Prader Willi, Bardet Biedl, Sotos
• Dysmorphic Features• Hypothyroidism: cold, fatigue, dry skin, hair loss, constipation
Medical History/Review of Systems for the Obese Child
• Sleep– snoring, stops breathing, daytime sleepiness
• Menstrual History– Amenorrhea, Irregular Menses
• Leg pain– Hip, knee, tibial (SCFE, Blounts)
• Blood pressure• Lipid Levels• Recurrent yeast infections• Polyuria, Polydipsia
Directed Exam for Obese Youth
•Ht____cm Wt_____Kg BMI (kg/m2)____ (>85%Dietician) (BMI>40 or > 95%Endo)•BP_____ (HTN: Y/N) •Dyspnea at rest vs exertion•Tanner stage____•Normal Pubertal development: Y/N•Skin: Acanthosis: Y/N Hirsutism: Y/N•Ext: Hip, knee, valgus or varus deformity
The A, B, C Intervention
• AActivity1. Minimum of 60 min/day of minimum intensity of a brisk walk. 2. Limit screen time (not associated with school work) < 1 hour
• BBeverages1. No regular soda or sugar/corn syrup sports drinks/punch2. < 6 ounces juice/day3. Increase water & non-or low fat milk (or other calcium containing food)
consumption
• CChange=Goal1. Family changes eating & activity habits2. Reasonable, achievable, step wise goals3. Minimum nursing visits every 3-4 months: check progress & reinforce goals.
Phone follow-up
Who to Test for IGT & Diabetes
• Obese: BMI>85%
• Age: Earliest of the following, > 10 years of age or onset of puberty
• And 2 of the following:– Family history of T2DM in 1st or 2nd degree relative
– Ethnicity: Native American; African-American; Latino; Asian; Pacific Islander
– Conditions assoc. with or signs of insulin resistance: acanthosis nigricans; hypertension, dyslipidemia, PCOs
Based on ADA Recs: Diabetes Care 2003
Impaired Glucose Tolerance & Diabetes
Normal IFG or IGT DiabetesFPG <100 mg/dl FPG= 100 - 125 mg/dl
(IFG)FPG > 126 mg/dl
2-h PG <140 mg/dl 2-h PG=140- 199mg/dl (IGT)
2-h PG > 200 mg/dl
Symptoms of diabetes & casual plasma glucose concentration 200 mg/dl
Based on ADA Recs: Diabetes Care 2004
In the absence of unequivocal hyperglycemia, a diagnosis of diabetes must be confirmed, on a subsequent day, by measurement of FPG, 2-h PG, or random plasma glucose (if symptoms are present). The FPG test is greatly preferred because of ease of administration, convenience, acceptability to patients, and lower cost. Fasting is defined as no caloric intake for at least 8 h.
This test requires the use of a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water. 2-h PG, 2-h postload glucose
Do You Know How Food Portions Have Changed in 20 Years?
National Heart, Lung, and Blood InstituteObesity Education Initiative
BAGEL 20 Years Ago Today
140 calories 3-inch diameter
How many calories are in this bagel?
140 calories 3-inch diameter
Calorie Difference: 210 calories
350 calories 6-inch diameter
BAGEL 20 Years Ago Today
How long will you have to rake leaves in order to
burn the extra 210 calories?*
*Based on 130-pound person
Maintaining a Healthy Weight is a Balancing ActCalories In = Calories Out
If you rake the leaves for 50 minutes you will burn the extra 210 calories.*
*Based on 130-pound person
Calories In = Calories Out
CHEESEBURGER
20 Years Ago Today
333 calories How many calories are in today’s cheeseburger?
Calorie Difference: 257 calories
590 calories
CHEESEBURGER
20 Years Ago Today
333 calories
Maintaining a Healthy Weight is a Balancing ActCalories In = Calories Out
How long will you have to lift weights in order to burn the extra 257 calories?*
*Based on 130-pound person
If you lift weights for 1 hour and 30 minutes,you will burn approximately 257 calories.*
*Based on 130-pound person
Calories In = Calories Out
SPAGHETTI AND MEATBALLS20 Years Ago Today
500 calories1 cup spaghetti with sauce and 3 small meatballs
How many calories do you think are in today's portion of spaghetti and meatballs?
Calorie Difference: 525 calories
1,025 calories 2 cups of pasta with sauce and 3 large meatballs
20 Years Ago Today
500 calories1 cup spaghetti with sauce and 3 small meatballs
SPAGHETTI AND MEATBALLS
How long will you have to houseclean in order to burn the extra 525 calories?*
*Based on 130-pound person
Maintaining a Healthy Weight is a Balancing ActCalories In = Calories Out
*Based on 130-pound person
If you houseclean for 2 hours and 35 minutes, you will burn approximately 525 calories.*
Calories In = Calories Out
FRENCH FRIES 20 Years Ago Today
210 Calories
2.4 ounces How many calories are intoday’s portion of fries?
610 Calories6.9 ounces
Calorie Difference: 400 Calories
FRENCH FRIES 20 Years Ago Today
210 Calories
2.4 ounces
How long will you have to walk leisurely in order to burn those extra 400 calories?*
*Based on 160-pound person
Maintaining a Healthy Weight is a Balancing ActCalories In = Calories Out
*Based on 160-pound person
If you walk leisurely for 1 hour and 10 minutes you will burn approximately 400 calories.*
Calories In = Calories Out
85 Calories 6.5 ounces
How many calories are in today’s portion?
SODA20 Years Ago Today
Calorie Difference: 165 Calories
250 Calories 20 ounces
85 Calories 6.5 ounces
SODA20 Years Ago Today
How long will you have to work in the garden to burn those extra calories?*
*Based on 160-pound person
Maintaining a Healthy Weight is a Balancing ActCalories In = Calories Out
If you work in the garden for 35 minutes, you will burn approximately 165 calories.*
*Based on 160-pound person
Calories In = Calories Out
320 calories How many calories are in today’s turkey sandwich?
TURKEY SANDWICH20 Years Ago Today
Calorie Difference: 500 calories
820 calories 320 calories
TURKEY SANDWICH20 Years Ago Today
How long will you have to ride a bike in order to
burn those extra calories?*
*Based on 160-pound person
Maintaining a Healthy Weight is a Balancing ActCalories In = Calories Out
*Based on 160-pound person
If you ride a bike for 1 hour and 25 minutes,you will burn approximately 500 calories.*
Calories In = Calories Out
Thank you for participating in Portion Distortion!
For more information about Maintaining a Healthy Weightvisit www.nhlbi.nih.gov
TOO MUCH SODA Coke glass bottle (8 fl. oz.) =
100 kcals. Coke can (12 fl. oz) = 150 kcals. Coke plastic bottle (20 fl. oz. ) =
250 kcals. Super Big Gulp (44 fl. oz.) = 550
kcals. ***1 big gulp a day = 57
pounds /year!!!! What does the future hold??
Do You Know How Food Portions Have Changed in 20 Years?
National Heart, Lung, and Blood InstituteObesity Education Initiative
COFFEE 20 Years Ago
Coffee(with whole milk and sugar)
Today
Mocha Coffee(with steamed whole milk and
mocha syrup)
45 calories 8 ounces
350 calories16 ounces
Calorie Difference: 305 calories
How long will you have to walk in order
to burn those extra 305 calories?*
*Based on 130-pound person
Maintaining a Healthy Weight is a Balancing ActCalories In = Calories Out
If you walk 1 hour and 20 minutes, you
will burn approximately 305 calories.*
*Based on 130-pound person
Calories In = Calories Out
MUFFIN
20 Years Ago Today
210 calories 1.5 ounces
How many calories are in today’s muffin?
How long will you have to vacuum in order to burn those extra 290 calories?*
*Based on 130-pound person
Maintaining a Healthy Weight is a Balancing ActCalories In = Calories Out
If you vacuum for 1 hour and 30 minutes you
will burn approximately 290 calories.*
*Based on 130-pound person
Calories In = Calories Out
PEPPERONI PIZZA
20 Years Ago Today
500 caloriesHow many calories are in two large slices of today’s pizza?
How long will you have to play golf (while walking and carrying your clubs) in order to burn those extra 350 calories?*
*Based on 160-pound person
Maintaining a Healthy Weight is a Balancing ActCalories In = Calories Out
If you play golf (while walking and carrying your clubs) for 1 hour you will burn approximately 350
calories.*
*Based on 160-pound person
Calories In = Calories Out
CHICKEN CAESAR SALAD
20 Years Ago Today
390 calories 1 ½ cups
How many calories are in today’s chicken Caesar
salad?
How long will you have to walk the dog in
order to burn those extra 400 calories?*
*Based on 160-pound person
Maintaining a Healthy Weight is a Balancing ActCalories In = Calories Out
If you walk the dog for 1 hour and 20 minutes, you will burn approximately 400 calories.*
*Based on 160-pound person
Calories In = Calories Out
20 Years Ago Today
270 calories 5 cups
POPCORN
How many calories are in today’s large popcorn?
20 Years Ago Today
270 calories 5 cups
POPCORN
630 calories11 cups
Calorie Difference: 360 calories
How long will you have to do water aerobics in order to burn the extra 360 calories?*
*Based on 160-pound person
Maintaining a Healthy Weight is a Balancing ActCalories In = Calories Out
*Based on 160-pound person
If you do water aerobics for 1 hour and 15 minutes you will burn approximately 360 calories.*
Calories In = Calories Out
CHEESECAKE
20 Years Ago Today
260 calories
3 ounces 640 calories7 ounces
Calorie Difference: 380 calories
How long will you have to play tennis in order to burn those extra 380 calories?*
*Based on 130-pound person
Maintaining a Healthy Weight is a Balancing ActCalories In = Calories Out
*Based on 130-pound person
If you play tennis for 55 minutes you will burn approximately 380 calories.*
Calories In = Calories Out
CHOCOLATE CHIP COOKIE
20 Years Ago Today
55 calories1.5 inch diameter
How many calories are in today’s large cookie?
CHOCOLATE CHIP COOKIE
20 Years Ago Today
55 calories 1.5 inch diameter
275 calories3.5 inch diameter
Calorie Difference: 220 calories
How long will you have to wash the car to burn those extra 220 calories?*
*Based on 130-pound person
Maintaining a Healthy Weight is a Balancing ActCalories In = Calories Out
*Based on 130-pound person
If you wash the car for 1 hour and 15 minutes
you will burn approximately 220 calories.*
Calories In = Calories Out
CHICKEN STIR FRY
20 Years Ago Today
435 calories 2 cups
How many calories are in today’s chicken stir fry?
CHICKEN STIR FRY
20 Years Ago Today
435 calories 2 cups
865 calories4 ½ cups
Calorie Difference: 430 calories
How long will you have to do aerobic dance to burn those extra 430 calories?*
*Based on 130-pound person
Maintaining a Healthy Weight is a Balancing ActCalories In = Calories Out
*Based on 130-pound person
If you do aerobic dance for 1 hour and 5 minutes you will burn approximately 430 calories.*
Calories In = Calories Out
Thank you for participating in Portion Distortion II!
For more information about Maintaining a Healthy Weightvisit www.nhlbi.nih.gov
KID FRIENDLY SNACKS? Super Pretzel and
16 fl. oz. Snapple Fruit Punch = 630 kcals.
24 fl. oz. Banana Berry Jamba Juice = 470 kcals.
Venti Vanilla Creme Frappacchino = 870 kcals.
WHAT ABOUT SCHOOL?
PRACTICAL SUGGESTIONS
Encourage parents to limit contribution of calories from beverages (only milk required).
Encourage 5 a day program.
Suggest Stoplight Diet (Epstein)
Stress Family Commitment- entire family needs to follow new eating habits.
FAST FOOD MAKEOVERS
Big Mac Value Meal = 1250 kcals.
If you super size….. Add 360 kcals!
Hamburger Happy Meal with regular coke = 640 kcals.
If you switch to diet or water subtract 150 kcals.
FAST FOOD MAKEOVERS
Del Taco Combo Burrito Meal = 1090 kcals.
2 Del taco soft chicken tacos = 320 kcals.
SERVING SIZES
GRAIN = 1 slice of bread, ½ cup cooked rice or pasta.
FRUIT = 1 piece of fruit, ¾ cup juice.
VEGETABLE = ½ cup cooked or 1 cup raw.
MILK = 1 cup milk
MEAT = 2-3 oz. cooked lean meat or fish.
FATS and SWEETS: use sparingly.
Cardiovascular Complications of Cardiovascular Complications of ObesityObesity
Jody Kranz M.D.Div. Endocrinology & Diabetes
CHOCStan Bassin Ed.DDiv. Cardiology
UCI
The Identification, Management and Treatment of the Obese Child
Cardiovascular Complications of Obesity
• Cardiovascular Disease (CVD)– Atherosclerosis– Obesity– Hypertension– Lipids
• Inflammatory Factors• Homocysteine & Other Risk Factors• Guidance for Practitioners
– Guidelines/Schedule for cardiovascular health– Proper blood pressure measurement– Charts for determining hypertension
Cardiovascular Disease
• Leading cause of death in the United States– Half a million deaths year
• Atherosclerosis: disease of large & medium sized vessels that leads to decrease blood flow to the myocardium, brain and extremities.
• Atherosclerosis begins in childhood– Same risk factors as in adults
Atherosclerosis Begins in Childhood
PDAY-Pathologic Determinants of Atherosclerosis in Youth
Autopsy Evaluations of CVD Risk Factors Progression of atherosclerosis from fatty streaks to raised
lesions in persons > 15 years of age 10-20% of 15-19 year olds have intermediate lesions Risk factors:
High non-HDL cholesterol Low HDL cholesterolSmoking HypertensionHbA1C > 8% Obesity (BMI > 30 kg/m2)
Atherosclerosis Risk Factors
– Increasing Blood Pressure
– Dyslipidemia
– Inflammatory factors
– Homocysteine
– Diabetes
– Tobacco exposure
– Family History
– Male gender
– Obesity
– Sedentary Lifestyle
Obesity & Hypertension
Clinical Presentation of Hypertension• High blood pressure = BP > 90th percentile for age gender and
height.• Hypertension= BP > 95th percentile for age, gender and height. • Primary Hypertension
– most common cause of Hypertension in Children over 6 years of age<6 years of age
• Secondary Hypertension– Renal disease– Aortic Coarctation
• Primary isolated systolic– Isolated systolic hypertension is an independent risk factor for
cardiovascular disease– 50% prevalence in obese
Prevalence of Hypertension in Children vs Distribution of BMI (%)
6 5 611 12
23
34
0
10
20
30
40
50
< 5 10 25 50 75 90 >95
BMI centile
Per
cen
t w
ith
Hyp
erte
nsi
on
(%
)
Blood Pressure & CVD• Blood pressure is positively correlated with cardiovascular
risk across the entire BP range– Evidence from autopsy studies
– Increase in carotid intima media thickness in adolescents with hypertension
• Increase in Left Ventricular Mass/ Mass index indicating hypertrophy
• There is a synergistic effect on CVD with lipids
• Increases the risk for renal disease which in turn increases the risk for CVD
Treatment of Hypertension
• Weight loss– Demonstrated in observational & interventional
studies– Decrease of 8/7 to16/9 mmHg for children with
3.9kg weight loss vs 10% weight loss respectively
• Exercise– May have additive effect– Decrease of 10mm Hg with regular exercise
• Medication
Obesity & Dyslipidemia
Increased Risk of Abnormal Lipid Levels in Overweight vs.
Normal Weight Teens
0
2
4
6
8
10
12
7 to 8 9 to 10 11 to 12 13 to 14 15 to 17
Age (years)
Increased Risk
TC>200TG>130LDL>130HDL<35
Atherosclerosis & Dyslipidemia
• Evidence from adult studies
• Evidence in Children & Adolescents– PDAY– In vivo studies
• decreased compliance of arteries
• increased IMT in adolescents with dyslipidemia
Treatment of Dyslipidemia
• Weight loss• Exercise• Nutrition
– Saturated fat <10% of calories– Total fat < 20-30% of calories– < 300mg cholesterol/day– Increase fiber intake
• Medication
Obesity & Inflammatory Factors
Prevalence of Elevated CRP (>0.22mg/dL) by BMI centile
0
5
10
15
20
25
<25% 25-50% 50-75% 75-85% >85%
BMI centiles
Elevated CRP (%)
BoysGirls
TNF-alpha Levels in Obese & Non-obese Adolescents
5.88
18.15
0
5
10
15
20
Obese Non-Obese
Level of TNF-alpha (ng/mL)
Moon et al. NASO, Oct. 2003
Homocysteine & other CVD Risk Factors in Youth
• Homocysteine – An independent risk factor for CVD– > 10-12 umol/L increases CVD risk 2-4 fold– Not increased with obesity– Treatment: Folate 0.4 mg/day; B12 400-1000
ug/day; Vit. B6 400 mg/day
• Tobacco exposure: 1st & 2nd Hand
Preventing Cardiovascular Disease
• Regular exercise (4-5 times/week)– Decreases weight gain– Increases HDL– Decreases blood pressure– Decreases inflammatory factors
• Healthy eating patterns– Minimize saturated fat
• Cigarette Smoking Prevention
Adolescent ObesityAdolescent Obesityand its Effects into Adulthoodand its Effects into Adulthood
Obesity and CVD RiskObesity and CVD Risk
• In Nurses’ Health Study, 14-year CHD risk increased about 3.5-fold for BMI >29 vs. <21, weight gain of >20 kg associated with 2.5-fold increased risk.
• NHANES I follow-up showed a 1.5-fold greater risk of CVD in those women with a BMI >29 vs. <21.
• A waist circumference of >35 inches in women, and >40 inches in men is also associated with greater CHD risk.
Weight Related Risks for CHD and Weight Related Risks for CHD and StrokeStroke
Obesity and HypertensionObesity and Hypertension
• For every 1 kg/m2 increase in BMI, increased risk of hypertension in Nurses’ Health Study was 12%
• Those with a BMI >31 RR=6.3 for developing HTN compared with BMI <19.
• Study showed each 10 kg weight to be associated with an increase of 3mmHg SBP and 2.2mHg DBP.
• Increased insulin levels may explain relation of obesity with HTN, as compensatory increases in insulin are required to maintain glucose homeostasis, and insulin may elevate BP by affecting renal sodium retention, raising peripheral resistance.
Obesity and DiabetesObesity and Diabetes• Obesity worsens insulin sensitivity, eventually exhausting
pancreatic production of insulin, causing hyperglycemia and diabetes.
Obesity and DiabetesObesity and Diabetes
• In Pima Indians (approx 50% of adults diabetic), incidence (per 1000 person-years) was 0.8 if BMI <20, but 72 if BMI >40.
• In Nurses’ Health Study, BMI 23-23.9 showed a RR=3.6 for diabetes compared with BMI <22. Weight again was very important, with weight again of 20-35kg associated with an 11-fold greater risk of diabetes, >35kg 17-fold.
• In Health Professionals Study among men, BMI >35 associated with RR=42 for developing diabetes.
Obesity and DyslipidemiaObesity and Dyslipidemia
• Rates of cholesterol synthesis correlate with excess body mass
• Data suggest a 10kg/m2 increment in BMI is associated with a 3.2 mg/dl (women) to 10 mg/dl (men) lower HDL-C and about a 10 mg/dl greater LDL-C
Obesity and DyslipidemiaObesity and Dyslipidemia
• Obesity is associated with higher LDL-C and triglycerides, and lower HDL-C.
Obesity and DyslipidemiaObesity and Dyslipidemia
• Weight loss reduces triglycerides, increases HDL-C, and lowers LDL-C
Absolute Fat and Lean Changes per Absolute Fat and Lean Changes per Decade as a Function of Age in MenDecade as a Function of Age in Men
Absolute Fat and Lean Changes per Absolute Fat and Lean Changes per Decade as a Function of Age in WomenDecade as a Function of Age in Women
Definitions
Body Mass Index (BMI) describes relativeweight for height: weight (kg)/height (m2)
• Overweight = 25–29.9 BMI
• Obesity = > 30 BMI
Age-Adjusted Standardized Prevalence of Overweight(BMI 25–29.9) and Obesity (BMI >30)
37.8
23.6
10.415.1
41.1
23.6
11.816.1
39.1
24.3
12.216.3
24.9
39.4
24.719.9
0
10
20
30
40
50
Men Women Men Women
NHES I NHANES I NHANES II NHANES III
BMI > 30BMI 25–29.9
CDC/NCHS, United States, 1960-94, ages 20-74 years
Per
cen
t
NHANES III Age-Adjusted Prevalence of Hypertension* According to BMI
16.518.221.922.5 24.025.2
32.2
38.4
0
10
20
30
40
50
Men Women
BMI <25 BMI 25-26 BMI 27-29 BMI >30
*Defined as mean systolic blood pressure 140 mm Hg, as mean diastolic 90 mm Hg, or currently taking antihypertensive medication .
Brown C et al. Body Mass Index and the prevalence of Risk Factors for Cardiovascular Disease (in preparation).
Per
cen
t
NHANES III Age-Adjusted Prevalence of High Blood Cholesterol* According to BMI
15.714.7
27.9
17.5
28.2
20.424.7
20.2
0
10
20
30
40
50
Men Women
BMI <25 BMI 25-26 BMI 27-29 BMI >30
*Defined as > 240 mg/dL.
Brown C et al. Body Mass Index and the Prevalence of Risk Factors for Cardiovascular Disease (in preparation).
Per
cen
t
NHANES III Age-Adjusted Prevalence of Low HDL-Cholesterol* According to BMI
16.5
9.1
27.0
17.2
27.223.1
41.5
31.4
0
10
20
30
40
50
60
Men Women
BMI <25 BMI 25-26 BMI 27-29 BMI >30
*Defined as <35 mg/dL in men and <45 mg/dL in women.
Brown C et al. Body Mass Index and the Prevalence of Risk Factors for Cardiovascular Disease (in preparation).
Per
cen
t
Requires two steps:
• Assessment
• Management
Care of Overweight/Obese Patients
Assessment of Overweight and Obesity
• Body Mass Index–Weight (kg)/height (m2)–Weight (lb)/height (in2) x 703– Table
• Waist Circumference–High risk:• Men >102 cm (40 in.)• Women >88 cm (35 in.)
Obesity ClassBMI kg/m2Underweight<18.5Normal18.5–24.9Overweight25–29.9ObesityI30.0–34.9II35.0–39.9Extreme ObesityIII
≥
40.0
Classification of Overweight and Obesity by BMI
Determine Absolute Risk StatusEvaluate:
• Disease conditions (e.g., CHD, type 2 diabetes, sleep apnea)(+ = very high risk)
• Other obesity-associated diseases (e.g., gynecological abnormalities, osteoarthritis)
• Cardiovascular risk factors: smoking, hypertension, high LDL, low HDL, IGT, family hx (>3 = high risk)
• Other risk factors:
– Physical inactivity
– High serum triglycerides (>200 mg/dL)
Adolescent and Adult Adolescent and Adult InterventionsInterventions
• Decrease Television viewing• Decrease consumption of high fat foods• Increase fruit and vegetable intake• Increase moderate and vigorous physical activity
Weight Control and Risk ReductionWeight Control and Risk Reduction
• Weight loss improves BP, dyslipidemia, and diabetes.
• Clinical trials show normotensive overweight persons on a hypocaloric diet had a lowering of blood pressure and reduced incidence of hypertension. DASH diet high in vegetables and fruits showed significant lowering of SBP and DBP both in persons with and without HTN.
• Weight control also lessens hyperglycemia and has been shown to be related to reduced diabetes-related mortality and improvements in glucose and insulin levels.
• Among Indian coronary patients, those randomized to low saturated fat, high fruit and vegetable diet plus weight-loss advice, compared to usual care, showed a 50% reduction in cardiac events and 45% lower mortality in those who lost more than 5kg.
Weight Control and Risk ReductionWeight Control and Risk Reduction
• Meta-analysis of 70 randomized controlled trials shows correlation between fall in LDL-C and amount of weight loss (Dattilo et al., 1992)
• Combined programs of weight loss and exercise are associated with greater increases in HDL-C and more significant loss of weight and fat.
• Findings are less consistent in women, however, and often LDL-C/HDL-C ratio worsens. While HDL-C is inversely related to CHD risk in populations, low rates of CHD are seen in populations with low-fat diets who have lower levels of both LDL-C and HDL-C.
Fat vs. Caloric RestrictionFat vs. Caloric Restriction
• While fat from calories has been reduced from 40-42% to 34% over the past 30 years, recent data show we consume more calories
• Message of caloric restriction needs to be coupled with dietary fat reduction, with greater emphasis on fruit and vegetable consumption
• Greater availability of low-fat and fat-free foods allows for substitution away from traditional higher-fat alternatives. Fat and calorie restriction needs to be individualized to patient need and risk-factor profile.
Hypocaloric DietsHypocaloric Diets
• Such diets allow for 1000-1200 kcal/day, with very low-calorie diets providing only 400-500 kcal/day.
• Initial weight loss may be more rapid with the very low-calorie diet, but amount of weight loss over one year is similar with either plan and adherence better with the moderate diet.
• Combination of low calorie diet plus exercise is more successful than either strategy alone.
Health Benefits of Weight Loss
• Decreased cardiovascular risk
• Decreased glucose and insulin levels
• Decreased blood pressure
• Decreased LDL and triglycerides, increased HDL
• Decrease in severity of sleep apnea
• Reduced symptoms of degenerative joint disease
• Improved gynecological conditions
Treatment AlgorithmPatient Encounter
Hx of 25 BMI?
• Measure weight, height, and waist circumference
• Calculate BMI
Examination
Brief reinforcement/ educate on weight management
Periodic weight check
Advise to maintain weight/address other risk factors
Clinician and patient devise goals and treatment strategyfor weight loss andrisk factor control
Assess reasons for failure to lose weight
Maintenance counseling: Dietary therapy Behavior therapy Physical activity:
Treatment
Assess risk factors
No
Yes
1
2
14
15 13
12
11 1016
3
4 6
5 7
8
9
Yes
No
Yes
No
Hx BMI 25?
No
Yes
Yes
No
Does patient want to lose weight?
Yes
No
Progress being made/goal
achieved?
BMI 25 OR waist circumference
> 88 cm (F) > 102 cm (M)
BMI 30 OR
{[BMI 25 to 29.9 OR waist circumference
>88 cm (F) >102 cm (M)] AND 2 risk
factors}
BMImeasured in past
2 years?
No
BMI 30 OR
{[BMI 25 to 29.9 OR waist >88 cm (F)
>102 cm (M)] AND 2 risk
factors}
Treatment Algorithm (Part 1 of 3)Patient Encounter
Hx of 25 BMI?
• Measure weight, height, and waist circumference
• Calculate BMI
Assess risk factors
NoYes
1
2
3
46
5
7
Yes
No
BMI measured in
past 2 years?
BMI 25 ORwaist > 88 cm (F)
> 102 cm (M)
Yes
Examination
Treatment
Devise goals andtreatment strategy forweight loss and riskfactor control
Assess reasons forfailure to lose weight
Maintenance counseling
12
11 10
8
9
No
Yes
Yes
No Desire tolose weight?
Yes
No
Progress made?
BMI 30 OR
{[BMI 25 to 29.9 OR waist >88 cm (F)
>102 cm (M)]AND 2 risk
factors}
Examination
Treatment
7
Periodic weightcheck
• Advise to maintain weight
• Address other risk factors
13
16
Treatment Algorithm (Part 2 of 3)
• Brief reinforcement
• Educate on weightmanagement
Periodic weight check
• Advise to maintain weight
• Address other risk factors
14
15 13
16
5Yes
No
Yes
No
Hx BMI 25?
BMI 25 OR waist > 88 cm (F)
> 102 cm (M)
Examination
Treatment
Treatment
Algorithm (Part 3 of 3)
* This algorithm applies only to the assessment for overweight and obesity and subsequent decisions based on that assessment. It does not include any initial overall assessment for cardiovascular risk factors or diseases that are indicated.
Goals of Weight Management/Treatment
• Prevent further weight gain (minimum goal).
• Reduce body weight.• Maintain a lower body weight
over long term.
Target Weight: Realistic Goals• Substitute “healthier weight” for ideal or
landmark weight.
• Accept slow, incremental progress to goal.
— Short-term goal: 5 to 10 percent loss, 1 to 2 lb per week.
— Interim goal: Maintenance.
— Long-term goal: Additional weight loss, if desired, and long-term weight maintenance.
Weight Loss Goals
Goal: Decrease body weight by 10 percent frombaseline.• If goal is achieved, further weight loss can be
attempted if indicated.• Reasonable timeline: 6 months of therapy.
– Moderate caloric deficits– Weight loss 1 to 2 lb/week
Weight Loss Goals
• Start weight maintenance efforts after 6 months.
– May need to be continued indefinitely.
• If unable to lose weight, prevent further weight gain.
Strategies for Weight Loss and Maintenance
• Dietary therapy• Physical activity• Behavior therapy• “Combined” therapy• Pharmacotherapy• Weight loss surgery
Whenever possible, weight loss therapy should employ the combination of
• Low-calorie/low-fat diets
• Increased physical activity
• Behavior modification
Weight Loss Therapy
Dietary Therapy (1 of 5)
Low-calorie diets (LCD) are recommended for weight loss in overweight and obese persons.Evidence Category A.
Reducing fat as part of an LCD is a practicalway to reduce calories. Evidence Category A.
Dietary Therapy (2 of 5)
Low-calorie diets can reduce total body weight by an average of 8 percent and help reduce abdominal fat content over a period of 6 months. Evidence Category A.
Dietary Therapy (3 of 5)
Although lower fat diets without targeted caloriereduction help promote weight loss by producinga reduced calorie intake, lower fat diets coupledwith total calorie reduction produce greaterweight loss than lower fat diets alone. Evidence Category A.
Dietary Therapy (4 of 5)
Very low-calorie diets produce greater initialweight loss than low-calorie diets. However,long-term (>1 year) weight loss is not differentfrom an LCD. Evidence Category A.
Dietary Therapy (5 of 5)
Very Low-Calorie Diets (less than 800 kcal/day):
• Rapid weight loss• Deficits are too great• Nutritional inadequacies• Greater weight regain• No change in behavior• Greater risk of gallstones
Low-Calorie Step I DietNutrient Recommended Intake
Calories 500 to 1,000 kcal/day reduction
Total Fat 30 percent or less of total calories
SFA 8 to 10 percent of total calories
MUFA Up to 15 percent of total calories
PUFA Up to 10 percent of total calories
Cholesterol <300 mg/day
Low-Calorie Step I Diet (continued)
Nutrient Recommended Intake
Protein ~ 15 percent of total calories
Carbohydrate 55 percent or more of total calories
Sodium Chloride No more than 100 mmol/day (~ 2.4 g of sodium or ~ 6 g of sodium chloride)
Calcium 1,000 to 1,500 mg
Fiber 20 to 30 g
75.771.8
62.4
52.8
12.312.9
14.215.4
0.80.9 1 1.1 3
4.16.6
8.7 911.4
17.6
24.5
White, notHispanic
AfricanAmerican
NativeAmerican,Eskimo,
Aleut
Asian andPacific
Islander
HispanicOrigin (ofany race)
1990200020252050
75.771.8
62.4
52.8
12.312.9
14.215.4
0.80.9 1 1.1 3
4.16.6
8.7 911.4
17.6
24.5
White, notHispanic
AfricanAmerican
NativeAmerican,Eskimo,
Aleut
Asian andPacific
Islander
HispanicOrigin (ofany race)
1990200020252050
Source: U.S. Bureau of the Census, decennial census and population projections
Per
cent
Percent of the Population by Race/Ethnicity1990, 2000, 2025 and 2050
Source: Johnson, California’s Demographic Future, Public Policy Institute of California, 2003Source: Johnson, California’s Demographic Future, Public Policy Institute of California, 2003
California’s Population by California’s Population by Race and EthnicityRace and Ethnicity
• California leads the nation in diversity.
• The state is challenged with a substantial leadership
role in assuring a diverse workforce and designing and maintaining quality care for all populations.
Challenges for the Nation’s Workforce
• Insufficient numbers of staff;
• Unsatisfactory skill and proficiency levels;
• Inappropriate training to deal with a changed delivery environment;
• Racial and ethnic diversity;
• Racial and ethnic disparities in access to and quality of care.
Winds that are blowing...
• A national crisis is looming for health workforce but it has as much to do with lack of innovation, as it does with shortages of workers
Four Challenges
• Enhancing Public Participation in Clinical Research
• Developing Information Systems
• An Adequately Trained Diverse Workforce
• Funding
1. What is the benefit of increasing representation of women and minorities in the clinical research workforce?
2. Will increased diversity improve translation of the results of clinical research in minority communities?
3. What are the needs of the private and public sector?
4. Are the current approaches to training clinical investigators meeting the needs of academia, industry, and public health?
Source: IOM: Opportunities to Address Clinical Research Workforce Diversity Needs for 2010 , 2006
New paradigms in clinical research and research training
5. Where is demand exceeding supply?
6. What training programs and career tracks appear to foster the development and retention of women and minorities in the clinical research workforce?
7. What research related to evaluation of existing training efforts needs to be funded?
8. What are the key outcome measures?
Source: IOM: Opportunities to Address Clinical Research Workforce Diversity Needs for 2010 , 2006
New paradigms in clinical research and research training
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