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Obesity and Related Diseases in Childhood

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  • The demographics of the United States have undergone dramatic changes that started >10,000 to 12,000 BC with the population of the continent by Native Americans. With the arrival of the Spanish and other Europeans, these demographics experienced the first rapid shift in the 1500s due to the influx of whites and to the demise of Native Americans as a result of disease and massacre by invaders. Slavery introduced various African ethnic groups during the 1600s, who continued to arrive in the United States through most of the 1800s. In addition, there was an influx of Asian populations in the west associated with the population boom and building of the railroads. However, the majority of Americans receiving health care by Western standards were predominantly white immigrants from Europe. This group rapidly established standards of health care that were predominantly based on European standards, with English being the predominant language spoken.
  • The expert committees’ recommendations are to classify BMI-for-age at or above the 95th percentile as overweight and between the 85th and 95th percentile as at risk of overweight. The 85th percentile is included on the BMI-for-age and the weight-for-stature charts to identify those at risk of overweight. The cutoff for underweight of less than the 5th percentile is based on recommendations by the World Health Organization Expert Committee on Physical Status. 1 1 The World Health Organization Expert Committee on Physical Status. The Use and Interpretation of Anthropometry. Physical Status: Report of a WHO Expert Committee: WHO Technical Report Series 854 , WHO, Geneva, 1996.
  • This slide depicts data from several NHANES surveys using the panel’s definition of overweight as a BMI of 25 to 29.9 kg/m 2 and of obesity as a BMI of greater than or equal to 30 kg/m 2 . From 1960 to 1994, the prevalence of overweight increased slightly from 37.8 to 39.4 percent in men and from 23.6 to 24.7 percent in women. In men and women together, overweight increased from 30.5 to 32.0 percent. During the same time period, however, the prevalence of obesity increased from 10.4 to 19.9 percent in men and from 15.1 to 24.9 percent in women. In men and women together, obesity increased from 12.8 to 22.5 percent. Most of the increase in obesity occurred in the past decade.
  • This slide shows that with increasing BMI levels, the prevalence of low HDL increases in both men and women. Low HDL was defined here as < 35 mg/dL in men and < 45 mg/dL in women. The prevalence of low HDL is more prevalent in women than in men at each level of BMI. However, the actual levels of HDL were higher in women than in men at all BMI levels.
  • Obesity now affects 1 in 5 children in the US.
  • The tracking of BMI that occurs from childhood to adulthood is clearly shown in data from a study by Robert Whitaker (Children’s Hospital Medical Center in Cincinnati) and colleagues. They examined the probability of obesity in young adults in relation to the presence or absence of overweight at various times during childhood. For example, in children 10 to 15 years old, 10% of those with BMI-for-age < 85th percentile were obese at age 25 whereas 75% of those with a BMI-for-age > 85th percentile were obese as adults and 80% of those with a BMI-for-age > 95th percentile were obese at age 25. (The sample size for the study was 854.) This study clearly shows that an overweight child is more likely than a child of normal weight to be obese as an adult. Other studies have shown this same trend of tracking occurring from childhood to adulthood.
  • Showing that prevalence rates vary by ethnicity. Reference: Strauss RS, Pollack HA. Epidemic increase in childhood overweight, 1986-1998. JAMA 286:2845-2848, 2001.
  • Children aged 6-19 Reference: Hedley AA, Ogden CL, Johnson CL, Carroll MD, Curtin LR, Flegal KM. Overweight and obesity amongh US children, adolescents, and adults, 1999-2002. JAMA 291:2847-2850, 2004.
  • Reference: Ogden CL, Flegal KM, Carroll MD, Johnson CL. Prevalence and trends in overwieght among US children and adolescents, 1999-2000. JAMA 288:1728-1732, 2002. 2002 data available at: Hedley AA, Ogden CL, Johnson CL, Carroll MD, Curtin LR, Flegal KM. Overweight and obesity amongh US children, adolescents, and adults, 1999-2002. JAMA 291:2847-2850, 2004.
  • BMI changes substantially with age. After about 1 year of age, BMI-for-age begins to decline and it continues falling during the preschool years until it reaches a minimum around 4 to 6 years of age. Here you see BMI-for-age tracking on the 95 th percentile.
  • Measurements must be obtained and recorded accurately if they are to be used as an effective screening tool. Stature and weight should be measured following recommended protocols. To illustrate the importance of accurate data, we used the case of a 5.5-year-old boy, weighing 41.5 lb with a height of 43 inches. His calculated BMI-for-age is 15.8. When plotted on the BMI-for-age chart for boys, his BMI is on the 50th percentile. If his height were measured or recorded inaccurately at 42.25 (3/4-inch below his actual height of 43 inches), his BMI-for-age would be 16.3 and would fall on the 75th percentile (orange dot). A measurement error of 3/4-inch in height resulted in a change of 25 percentiles. In this example, the measurement error did not cause a change in classification because growth remained within the normal range but you see what could happen.
  • In the next three slides, we want you to do a self-test to see how well you can screen for risk of overweight in children by looking. We want you to try to identify children with a BMI-for-age equal to or greater than the 85th percentile and less than the 95th percentile. It has been said that “few medical conditions can be diagnosed as confidently by untrained individuals as gross obesity.” Yet it is very difficult to distinguish children who are at risk of overweight from normal children. In childhood, the distinction is made more difficult by age-related physiological variations. So, see how you do with the three photos. This first one is a boy who is 3 years old. Does he appear at risk of overweight?
  • This boy’s height is 39.7 inches and his weight is 41 pounds. Using his height and weight, his calculated BMI is 18.3. Plotted on the BMI-for-age chart for boys, his BMI-for-age falls above the 95th percentile. Likewise, when plotted on the weight-for stature grid, it falls above the 95th percentile.
  • This is another 4-year-old girl. Does she appear at risk of overweight?
  • This girl’s height is 39.2 inches and her weight is 38.6 pounds. Using her height and weight we calculated BMI to be 17.8. Plotted on the BMI-for-age chart for girls, her BMI-for-age falls between the 90 th and 95 th percentiles. She is classified as at risk of overweight. The point of this exercise is to demonstrate the difficulty of making a consistently accurate visual assessment of at risk of overweight. BMI-for-age needs to be obtained and plotted on the appropriate growth chart to determine risk of overweight.
  • Measurements must be obtained and recorded accurately if they are to be used as an effective screening tool. Stature and weight should be measured following recommended protocols. To illustrate the importance of accurate data, we used the case of a 5.5-year-old boy, weighing 41.5 lb with a height of 43 inches. His calculated BMI-for-age is 15.8. When plotted on the BMI-for-age chart for boys, his BMI is on the 50th percentile. If his height were measured or recorded inaccurately at 42.25 (3/4-inch below his actual height of 43 inches), his BMI-for-age would be 16.3 and would fall on the 75th percentile (orange dot). A measurement error of 3/4-inch in height resulted in a change of 25 percentiles. In this example, the measurement error did not cause a change in classification because growth remained within the normal range but you see what could happen.
  • Dyslipidemia Evidence from adult studies Evidence in Children & Adolescents PDAY In vivo studies documenting decreased compliance of arteries and increased IMT in adolescents with dyslipidemia
  • PDAY- Pathologic Determinants of Atherosclerosis in Youth > 3000 Autopsy Study of Males > 15-34 years of age Progression of atherosclerosis from fatty streaks to raised lesions Risk factors include: High non-HDL cholesterol; Low HDL cholesterol, Smoking, Hypertension; HbA1C > 8%; Obesity (BMI > 30 kg/m 2 ) Intermediate lesions or Raised streaks in 15-19 year olds 10-20% depending on cororary artery or aorta
  • The NHANES III data on high blood cholesterol also show that as BMI increases above 25, the prevalence of high blood cholesterol increases up to a BMI of 30 where it appears to decrease somewhat in both men and women. High blood cholesterol is defined as a cholesterol level of  240 mg/dl. At each BMI level, the prevalence of high blood cholesterol is greater in women than in men.
  • This slide shows that with increasing BMI levels, the prevalence of low HDL increases in both men and women. Low HDL was defined here as < 35 mg/dL in men and < 45 mg/dL in women. The prevalence of low HDL is more prevalent in women than in men at each level of BMI. However, the actual levels of HDL were higher in women than in men at all BMI levels.
  • Study of children with isolated systolic hypertenion: prevalence was 50 % in obese individuals and 30% in non obese.
  • Obese children are at a 3 fold higher risk for hypertension than non obese Bogalusa Heart study: Overweight children were 2.4 to 4.5 time as likely to have elevated SBP and DBP respectively The risk of hypertension increases with increasing BMI There is no threshold effect
  • Data from NHANES III show that the age-adjusted prevalence of high blood pressure increases progressively with higher levels of BMI in men and women. The prevalence of high blood pressure in adults with BMI > 30 is 38.4 percent for men and 32.2 percent for women, respectively, compared with 18.2 percent for men and 16.5 percent for women with BMI  25 (a relative risk of 2.1 and 1.9 for men and women, respectively). Other studies, such as the large international Intersalt study, carried out in more than 10,000 men and women also reported a 10 kg (22 lb) higher body weight to be associated with a 3 mm Hg systolic and 2.3 mm Hg diastolic change in blood pressure. These differences in blood pressure translate into a 12 percent increased risk for CHD and 24 percent increased risk for stroke.
  • Children with high normal blood pressure are at very high risk to become hypertensive adults. Classifying as Hypertensive and Normotensive is artificial
  • Children 5-17 years of age Overweight Children 2 ½ more likely to have elevated cholesterol Central Adiposity is associated with greater increase in risk for abnormal lipid profile Definition Total cholesterol (TC) >200 LDL > 130 HDL<35
  • Switch to low or non fat milk at over 2 years of age.
  • Inflammatory Factors & Obesity Increase in atherogenic inflammatory factors in obese youth C-reactive protein, TNF-, PAI-1 CRP Increases with BMI with largest increase with BMI over 85% Fitness level inversely correlates with CRP
  • Obese with av bmi 29 Non obese with av bmi 20
  • >1 in 5 us adolescents smoke cigarettes ona daily basis by the time he/she is a senior
  • The panel chose to define overweight and obesity using the measure of the body mass index or BMI. BMI is a practical indicator of the severity of obesity, and it can also be determined from existing tables. Overweight is defined by the panel as a body mass index (BMI) of 25 to 29.9 kg/m 2 . Obesity is defined as an excess of total body fat that is documented by a BMI of > 30 kg/m 2 . BMI describes relative weight for height and is calculated as follows: BMI = weight (kg)/height squared (m 2 ). BMI is a direct calculation based on height and weight, regardless of gender.
  • This slide depicts data from several NHANES surveys using the panel’s definition of overweight as a BMI of 25 to 29.9 kg/m 2 and of obesity as a BMI of greater than or equal to 30 kg/m 2 . From 1960 to 1994, the prevalence of overweight increased slightly from 37.8 to 39.4 percent in men and from 23.6 to 24.7 percent in women. In men and women together, overweight increased from 30.5 to 32.0 percent. During the same time period, however, the prevalence of obesity increased from 10.4 to 19.9 percent in men and from 15.1 to 24.9 percent in women. In men and women together, obesity increased from 12.8 to 22.5 percent. Most of the increase in obesity occurred in the past decade.
  • Data from NHANES III show that the age-adjusted prevalence of high blood pressure increases progressively with higher levels of BMI in men and women. The prevalence of high blood pressure in adults with BMI > 30 is 38.4 percent for men and 32.2 percent for women, respectively, compared with 18.2 percent for men and 16.5 percent for women with BMI  25 (a relative risk of 2.1 and 1.9 for men and women, respectively). Other studies, such as the large international Intersalt study, carried out in more than 10,000 men and women also reported a 10 kg (22 lb) higher body weight to be associated with a 3 mm Hg systolic and 2.3 mm Hg diastolic change in blood pressure. These differences in blood pressure translate into a 12 percent increased risk for CHD and 24 percent increased risk for stroke.
  • The NHANES III data on high blood cholesterol also show that as BMI increases above 25, the prevalence of high blood cholesterol increases up to a BMI of 30 where it appears to decrease somewhat in both men and women. High blood cholesterol is defined as a cholesterol level of  240 mg/dl. At each BMI level, the prevalence of high blood cholesterol is greater in women than in men.
  • This slide shows that with increasing BMI levels, the prevalence of low HDL increases in both men and women. Low HDL was defined here as < 35 mg/dL in men and < 45 mg/dL in women. The prevalence of low HDL is more prevalent in women than in men at each level of BMI. However, the actual levels of HDL were higher in women than in men at all BMI levels.
  • As determined by the expert panel, caring for the overweight or obese patient is a two-step process that includes assessment and management: Assessment requires determining the degree of obesity and a patient’s absolute risk status based on other risk factors. Management includes both weight control or reducing excess body weight and maintaining that weight loss as well as instituting other measures to control associated risk factors. Obesity is a chronic disease, and both the patient and the practitioner need to understand that successful treatment requires a lifelong effort.
  • BMI is the measure of choice as a practical indicator of the severity of obesity. It can be calculated in a variety of ways: Weight in kilograms (kg) divided by height in meters squared (m 2 ). Using pounds and inches: weight (pounds)/height (inches) 2  703, (1 lb = 0.4536 kg), (1 in. = 2.54 cm = 0.0254 m). (A patient should be weighed with shoes off and clad only in a light robe or undergarments.) From existing tables. BMI is a direct measure based on height and weight, regardless of gender. The limitations of BMI are that BMI overestimates body fat in persons who are very muscular and can underestimate body fat in persons who have lost muscle mass (e.g., the elderly). Also, since the presence of excess fat in the abdomen is an independent predictor of risk factors and morbidity, waist circumference should also be measured. A high waist circumference is associated with an increased risk for type 2 diabetes, dyslipidemia, hypertension, and CVD in patients with a BMI in a range between 25 and 34.9 kg/m 2 . High-risk waist circumference in men is defined as >102 cm (>40 in.) and in women, it is >88 cm (>35 in.).
  • The primary classification of overweight and obesity is based on the measurement of BMI. This classification is designed to relate BMI to risk of disease. However, since BMI and disease risk vary among individuals and among different populations, the classification must be viewed as a broad generalization. Individuals who are very muscular may have a BMI placing them in an overweight category when they are not overly fat. Very short persons (under 5 feet) may have high BMIs that may not reflect overweight or fatness. Older persons often have lost muscle mass and have more fat for a given BMI than younger persons, women may have more fat for a given BMI than men, and persons with clinical edema may have less fat for a given BMI . Since disease risk increases with increasing BMI, there are three classes to define obesity. However, susceptibility to risk factors at a given weight varies among individuals. Some individuals may have multiple risk factors and mild obesity, whereas others may have fewer risk factors with more severe obesity.
  • In addition to measuring the patient’s BMI and waist circumference, one needs to assess the presence of concomitant CVD risk factors or comorbidities. Some obesity-associated diseases (e.g., CHD, type 2 diabetes) and risk factors (e.g., hypertension, high blood cholesterol) place patients in a very high-risk category for subsequent mortality. These diseases require aggressive modification of risk factors in addition to their own clinical management. Other obesity-associated diseases are less lethal, but still require appropriate clinical therapy. Overweight and obesity also aggravate several cardiovascular risk factors (e.g., triglycerides, physical inactivity). Identifying these risk factors is required as a guide to the intensity of the clinical intervention used to treat the weight problem.
  • The recommendation to treat overweight and obesity is based not only on the evidence that shows overweight is associated with increased morbidity and mortality, but also on RCT evidence that weight loss reduces risk factors for disease. Thus, weight loss may help control diseases worsened by overweight and obesity and may also decrease the likelihood of developing these diseases. Some benefits associated with weight loss include the following: Decreased cardiovascular risk. Decreased glucose and insulin levels. Decreased blood pressure. Decreased LDL-cholesterol and triglycerides and increased HDL-cholesterol. Decreased severity of sleep apnea. Reduced symptoms of degenerative joint disease. Improved gynecological conditions.
  • When physicians encounter patients in the clinical setting, the opportunity exists for: Identifying overweight and obesity and accompanying risk factors. Initiating treatment for both the weight and the risk factors, as well as chronic diseases such as CVD and type 2 diabetes. Consider the patient’s weight, waist circumference, and the presence of disease conditions or risk factors when assessing a patient for treatment of overweight and obesity. The strategy for the evaluation and treatment of overweight patients is presented in these slides of the Treatment Algorithm. This algorithm applies only to the assessment for overweight and obesity and subsequent decisions based on that assessment. It does not reflect any initial overall assessment for cardiovascular risk factors or diseases that are indicated. In overweight patients, control of cardiovascular risk factors deserves the same emphasis as weight loss therapy. Reduction of risk factors will reduce the risk for CVD whether or not efforts at weight loss are successful.
  • The key features of the algorithm are as follows: Patient assessment should include measures of weight and height to determine BMI and waist circumference (Box 4). If BMI is  25 or waist circumference is high (Box 5), then the presence of risk factors (Box 6) should be assessed. Patients with BMI  30, or BMI 25 to 29.9 or a high waist circumference AND two or more risk factors, need to work with their physicians to determine treatment goals and strategies.
  • If the patient is overweight but does not have two other risk factors, weight loss is not necessarily advised. For these patients, it is important to assess their desire to lose weight (Box 12). Weight loss in the clinical setting requires a major investment of time and effort by the health care team as well as expense to the patient. For these reasons, motivation for weight loss should be relatively high before initiating clinical therapy. For patients who do not want to lose weight, emphasis should be given to maintaining current weight or not gaining any more weight. However, if the patient has other risk factors, they need to be addressed (Box 13). For patients advised to lose weight, their progress needs to be assessed periodically (Box 9). If a patient achieves a 10 percent reduction in body weight in 6 months to 1 year, this can be considered good progress and the patient can enter the weight maintenance phase of counseling (Box 11). If the patient does not lose sufficient weight, assess the reasons for the failure to lose the weight (Box 10). Use these reasons to develop new goals and treatment strategies.
  • Patients who do not have a high BMI or high waist circumference need to be advised of the importance of staying in this category and should be given reinforcements to help them maintain their current weight and address other risk factors if present (Boxes 13 and 15). Such patients should be screened for weight gain every 2 years (Box 16).
  • The general goals of weight loss and management are At a minimum, to prevent further weight gain. To reduce body weight if prescribed. To maintain a lower body weight over the long term. Specific targets for each of these goals can be considered.
  • Target weight goals should be realistic. The idea of “healthier weights” rather than ideal weights should be emphasized. Also, weight loss should be considered as a slow, incremental process to achieving the goal; short, interim, and long-term goals should be set. 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.
  • The initial target goal of weight loss therapy is to decrease body weight by 10 percent. Once this target is achieved, further weight loss can be attempted if indicated. The rationale for this initial goal of moderate weight loss, i.e., 10 percent of initial body weight, is that It can decrease the severity of obesity-associated risk factors. It can set the stage for further weight loss, if indicated. It is realistic and can be achieved and maintained over time. A reasonable timeline for a 10 percent reduction in body weight is 6 months of therapy. For overweight patients with BMIs in the typical range of 27 to 35, caloric deficits of 300 to 500 kcal/day will result in weight losses of ½ to 1 lb/week and a 10 percent weight loss in 6 months. For more severely obese patients with BMIs > 35, deficits of up to 500 to 1,000 kcal/day will lead to weight losses of 1 to 2 lb/week and a 10 percent weight loss in 6 months. Theoretically, this caloric deficit should result in a loss of 26 to 52 pounds in a year. However, the average amount of weight lost usually is in the range of 20 to 25 pounds.
  • Once weight loss goals have been achieved, maintaining a lower body weight becomes a major challenge. Weight maintenance efforts should begin after 6 months of weight loss, since at this point it is difficult for most patients to continue to lose weight owing to changes in resting metabolic rates and difficulty in adhering to treatment strategies. To achieve additional weight loss, the patient must further decrease calories and/or increase physical activity since energy requirements decrease as weight is decreased. For weight maintenance, the combined modalities of therapy (dietary therapy, physical activity, and behavior therapy) must be continued indefinitely; otherwise, excess weight likely will be regained. Observation, monitoring, and encouragement of patients who have successfully lost weight should be continued on a long-term basis in order to help prevent weight regain.
  • In the guidelines, six strategies for weight loss and maintenance are discussed: dietary therapy, physical activity, behavior therapy, combined therapy, pharmacotherapy, and weight loss surgery. Each of these strategies will be featured in turn.
  • To achieve the greatest likelihood of success from weight loss therapy, therapy should include a combination of: Low-calorie, low-fat diets Increased physical activity Behavior modification Clinical trials have demonstrated that combining low-calorie diets, increased physical activity, and behavior therapy provides better outcomes for long-term weight reduction than programs that use only one or two of the modalities.
  • Eighty-six RCTs evaluated the effectiveness of different diets on weight loss; 34 of the RCTs examined the impact of a low-calorie diet (LCD) consisting of approximately 1,000 to 1,200 kcal/day. All of the studies, regardless of the length of the intervention, showed that LCDs result in weight loss; from the 25 RCTs with a duration of > 6 months, LCDs brought about a mean loss of approximately 8 percent of body weight over a period of 6 months to 1 year. The panel provides two recommendations supported by strong A-level evidence: A decrease in calorie intake is the most important dietary component of weight loss and maintenance. Reducing fat as a means of reducing calories is an important way to help reduce calories.
  • In the majority of overweight and obese patients, adjustment of the diet to reduce calorie intake will be required. Dietary therapy consists, in large part, of instructing patients on how to modify their diets to achieve a decrease in calorie intake. Key to the recommendation is the use of a moderate reduction in calorie intake to achieve a slow but progressive weight loss. The centerpiece of dietary therapy for weight loss in overweight patients is a low-calorie diet (LCD) (800 to 1,500 kcal/day); the evidence behind this statement is strong A-level evidence. LCDs have been shown to reduce total body weight by an average of 8 percent over a period of 6 months, accompanied by significant reductions in waist circumference. Since this represents an average that includes individuals who did not lose weight, an individual average goal of 10 percent is feasible. A patient may choose a diet of 1,000 to 1,200 calories for women and 1,200 to 1,500 calories for men.
  • Nine RCTs tested the effects of diets that varied in fat and caloric content on weight loss. Lower fat ranged from 20 to 30 percent of calories from fat. Three RCTs promoted lower fat diets with ad libitum calorie intake. All three studies showed that the lower fat diets resulted in a reduction in calories and produced greater weight loss compared with the higher fat diets. Three other RCTs showed that weight loss is greater in the lower fat diet with calorie reduction than with the lower fat diet alone. Taken together these studies provide strong evidence that lower fat diets can contribute to lower calorie intake even when calorie reduction is not the focus of the intervention. However, when LCDs also restrict fat, better weight loss is achieved.
  • Four RCTS compared VLCDs with LCDs: VLCDs provided 400 to 500 kilocalories/day whereas LCDs provided 1,000 to 1,500 kcal/day. VLCDs promoted weight loss of approximately 13 to 23 kg during the active phase of the trial, compared with 9 to 13 kg with LCDs. After 1 year, there was no long-term advantage of VLCD over LCD. Thus, there is strong evidence to support the statement that very low-calorie diets produce greater initial weight loss than low-calorie diets. However, long-term weight loss is not different from that achieved through a low-calorie diet.
  • Very low-calorie diets (VLCD), less than 800 cal/day, are not recommended for weight loss therapy because The deficits are too great, and nutritional inadequacies will occur unless supplementation with vitamins and minerals is provided. Although more weight is lost initially with the VLCD, more is usually regained. Rapid weight reduction does not allow for gradual acquisition of changes in eating behavior, which is key for successful long-term weight maintenance. Patients on VLCDs are at an increased risk of developing gallstones.
  • The LCD recommended in the guidelines for weight loss has a nutrient composition that also will help decrease other risk factors, notably high serum cholesterol and hypertension. The Step I diet recommended by the National Cholesterol Education Program provides the appropriate nutrient composition in terms of fats. A reduction in calories of 500 to 1,000 kcal/day will help achieve a weight loss of 1 to 2 lbs/week. Total fat should be no more than 30 percent of total calories; saturated fat should provide 8 to 10 percent of total calories, and dietary cholesterol should be <300 mg/day. Fat-modified foods may provide a helpful strategy for lowering total fat intake, but they are effective only if they are low in calories and there is no compensation of calories from other foods. Patients with high blood cholesterol levels may need to use the Step II diet to achieve further reductions in LDL-cholesterol level. In the Step II diet, saturated fat should be reduced to less than 7 percent of total calories and cholesterol levels to less than 200 mg/day. All other nutrients should be the same as in Step I.
  • Protein should be no more than 15 percent of total calories and should be derived from plant sources and lean sources of animal protein. Dietary carbohydrate should be approximately 55 percent or more of total calories and should be rich in complex carbohydrates from different vegetables, fruits, and whole grains—all good sources of vitamins, minerals, and fiber. Sodium chloride should be no more than 100 mmol/day (~ 2.4 g of sodium or ~ 6 g of sodium chloride). During weight loss, attention should be given to maintaining an adequate intake of vitamins and minerals , particularly calcium. Maintenance of the recommended calcium intake of 1,000 to 1,500 mg/day is especially important for women who may be at risk of osteoporosis. Some authorities recommend 20 to 30 grams/day of dietary fiber , with an upper limit of 35 grams. A diet rich in soluble fiber, including oat bran, legumes, barley, and most fruits and vegetables, may be effective in reducing blood cholesterol levels. A diet high in all types of fiber may also aid in weight management by promoting satiety at lower calorie and fat levels.
  • Transcript

    • 1. Stanley Bassin Ed.D Center For The Study Of Health Effects Of Exercise In Children University Children’s Hospital, UCI College of Medicine, Orange, CA. Obesity, and its Related Diseases: Prevention Begins in Childhood
    • 2. Obesity A Weighty Problem
    • 3.  
    • 4. The Anthropology of Physical Activity
    • 5.  
    • 6.  
    • 7. The Agricultural Period
    • 8. The Industrial Period
    • 9. The Electronics Age
    • 10.  
    • 11. Obesity
      • 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
    • 12.  
    • 13.  
    • 14.  
    • 15.  
    • 16. The “Top 10” alternative reasons for obesity:
      • Inadequate sleep. (Average sleep amounts have fallen, and many studies tie sleep deprivation to weight gain.)
    • 17. The “Top 10” alternative reasons for obesity:
      • 2. Endocrine disruptors, which are substances in some foods that might alter fats in the body.
    • 18. The “Top 10” alternative reasons for obesity:
      • 3. Nice temperatures. (Air conditioning and heating limit calories burned from sweating and shivering.)
    • 19. The “Top 10” alternative reasons for obesity:
      • 4. Fewer people smoking. (Less appetite suppression.)
    • 20. The “Top 10” alternative reasons for obesity:
      • 5. Medicines that cause weight gains
    • 21. The “Top 10” alternative reasons for obesity:
      • 6. Population changes. (More middle-agers and Hispanics, who have higher obesity rates.)
    • 22. The “Top 10” alternative reasons for obesity:
      • 7. Older birth moms. (That correlates with heavier children.)
    • 23. The “Top 10” alternative reasons for obesity:
      • 8. Genetic influences during pregnancy
    • 24. The “Top 10” alternative reasons for obesity:
      • 9. Darwinian natural selection. (Fat people out survive skinny ones).
    • 25. 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.
    • 26. Obesity Related Morbidity
      • The estimated number of deaths attributable to obesity among US adults is approximately 280,000.
    • 27. Obesity Related Morbidity
      • The estimated number of deaths attributable to obesity for nonsmokers is approximately 325,000
    • 28. The Theories of Obesity Fall Into Three Categories
    • 29. Genetic Influence of Human Variation in Body Fat
    • 30. Defining 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
    • 31. > 95 th percentile Overweight 85 th to < 95 th Risk of overweight percentile < 5 th percentile Underweight BMI-for-Age Cutoffs
    • 32. Disease Risk Associated with Overweight 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.
    • 33. Prevalence 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.
    • 34. Increasing Prevalence of Overweight and 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.
    • 35. Percentage of Overweight and 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.
    • 36. Source: http://www.cnn.com/SPECIALS/2007/fit.nation/obesity.map/
    • 37. Source: http://www.cnn.com/SPECIALS/2007/fit.nation/obesity.map/
    • 38. Source: http://www.cnn.com/SPECIALS/2007/fit.nation/obesity.map/
    • 39. Source: http://www.cnn.com/SPECIALS/2007/fit.nation/obesity.map/
    • 40. Source: http://www.cnn.com/SPECIALS/2007/fit.nation/obesity.map/
    • 41. Source: http://www.cnn.com/SPECIALS/2007/fit.nation/obesity.map/
    • 42. Source: http://www.cnn.com/SPECIALS/2007/fit.nation/obesity.map/
    • 43. Age-Adjusted Standardized Prevalence of Overweight (BMI 25–29.9) and Obesity (BMI > 30) BMI > 30 BMI 25–29.9 CDC/NCHS, United States, 1960-94, ages 20-74 years Percent
    • 44. NHANES III Age-Adjusted Prevalence of Low HDL-Cholesterol* According to BMI *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). Percent
    • 45. Carbo-Lipo-Terrorism in the U.S. A Report To: Orange County On: 2/18/04
    • 46.  
    • 47. Percent Overweight Children U.S. & Orange County Percent Overweight (>95% weight/height) Year Data from the CDC & Prevention, NCHS, NHANES, HHNES, NHES, Report on the Conditions of Children in Orange County, 2002
    • 48. Tracking BMI-for-Age from Birth to 18 Years with % of Overweight Children who Are Obese at Age 25 Whitaker et al. NEJM : 1997;337:869-873
    • 49. National Longitudinal Survey of Youth Prospective Cohort Study of 8270 Children (4-12 years old) - 1999
      • Risk of Overweight Overweight
      • > 85 th %ile BMI > 95 th %ile BMI
      • African American 38.4% 21.5%
      • Hispanics 37.9% 21.8%
      • Caucasian 25.8% 12.3%
    • 50. Secular Increases in Relative Weight and Adiposity in Children (5-14 years old) - Bogalusa Heart Study - * Change adjusted for height, age, race, and sex Source: Pediatrics 99:420-426, 1997 Change* 1992-1994 1973-1974 Study years +1.5 +1.6 +3.4 19.5 142 41.0 17.6 140 35.9 BMI (kg/m 2 ) Height (cm) Weight (kg)
    • 51. Prevalence of Overweight and Obesity Among US Children (6-19 years old) 1999-2002 Source: Hedley et al., JAMA 291:2847-2850, 2004 15.0% 29.9% 1999-2000 16.5% 31.5% 2001-2002  95 th percentile BMI  85 th percentile BMI
    • 52. Overweight in Children* (> 95 th percentile BMI) * 4722 children from NHANES; overweight > 95 th adjusted for age ** > 23% of African American and Mexican American adolescents Source: Ogden et al., JAMA 288:1728-1732, 2002 12-19 years 6-11 years 2-5 years 15.5** 10.5 6.1 15.3 11.3 4.0 10.4 7.2 5.0 1999-2002 1988-1994 1971-1974
    • 53. 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
    • 54. Example: 95th Percentile Tracking Age BMI 2 yrs 19.3 4 yrs 17.8 9 yrs 21.0 13 yrs 25.1 For Children, BMI Changes with Age Boys: 2 to 20 years BMI BMI BMI BMI
    • 55. 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
    • 56. Can you see risk?
      • This boy is 3 years, 3 weeks old.
      • Is his BMI-for-age
      • - > 85 th to <95 th percentile: at risk for overweight?
      Photo from UC Berkeley Longitudinal Study, 1973
    • 57. 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= >95 th percentile overweight Plotted BMI-for-Age Boys: 2 to 20 years BMI BMI BMI BMI
    • 58. Can you see risk?
      • This girl is 4 years old.
      • Is her BMI-for-age
      • - > 85 th to <95 th percentile: at risk for overweight?
      Photo from UC Berkeley Longitudinal Study, 1973
    • 59. 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 90 th –95 th percentile At risk for overweight Plotted BMI-for-Age Girls: 2 to 20 years BMI BMI BMI BMI
    • 60. 5 1/2 year old boy Weight: 41.5 lb Height: 43 in BMI= 15.8 BMI-for-age=50 th %tile Inaccurate height measurement: 42.25 BMI=16.3 BMI-for-age=75 th %tile Accurate Measurements are Critical Boys: 2 to 20 years BMI BMI BMI BMI
    • 61. 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
    • 62. Percent of the Population by Race/Ethnicity 1990, 2000, 2025 and 2050 Source: U.S. Bureau of the Census, decennial census and population projections Percent
    • 63. Source: Johnson, California’s Demographic Future, Public Policy Institute of California, 2003 California’s Population by Race 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.
    • 64. Overweight Prevalence by Race/Ethnicity for Adolescent Boys and Girls
    • 65.  
    • 66.  
    • 67.  
    • 68.  
    • 69.  
    • 70.  
    • 71.  
    • 72.  
    • 73.  
    • 74.  
    • 75.  
    • 76.  
    • 77.  
    • 78.  
    • 79. Cardiovascular Complications of Obesity Jody Kranz M.D. Div. Endocrinology & Diabetes CHOC Stan Bassin Ed.D Div. Cardiology UCI The Identification, Management and Treatment of the Obese Child
    • 80. 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
    • 81. Atherosclerosis Risk Factors
        • Increasing Blood Pressure
        • Dyslipidemia
        • Inflammatory factors
        • Homocysteine
        • Diabetes
        • Tobacco exposure
        • Family History
        • Male gender
        • Obesity
        • Sedentary Lifestyle
    • 82. Atherosclerosis Begins in Childhood
      • PDAY - P athologic D eterminants of At herosclerosis in Y outh
      • 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 cholesterol
        • Smoking Hypertension
        • HbA1C > 8% Obesity (BMI > 30 kg/m 2 )
    • 83. 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
    • 84. NHANES III Age-Adjusted Prevalence of High Blood Cholesterol* According to BMI *Defined as > 240 mg/dL. Brown C et al. Body Mass Index and the Prevalence of Risk Factors for Cardiovascular Disease (in preparation). Percent
    • 85. NHANES III Age-Adjusted Prevalence of Low HDL-Cholesterol* According to BMI *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). Percent
    • 86. Obesity & Hypertension
    • 87. 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
    • 88. Obesity 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.
    • 89. Prevalence of Hypertension in Children vs Distribution of BMI (%) BMI centile Percent with Hypertension (%)
    • 90. NHANES III Age-Adjusted Prevalence of Hypertension* According to BMI *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). Percent
    • 91. 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
    • 92. 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
    • 93. Obesity & Dyslipidemia
    • 94. Increased Risk of Abnormal Lipid Levels in Overweight vs. Normal Weight Teens
    • 95. Obesity 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.
    • 96. Weight Related Risks for CHD and Stroke
    • 97. Obesity and Dyslipidemia
      • Obesity is associated with higher LDL-C and triglycerides, and lower HDL-C.
    • 98. Obesity and Dyslipidemia
      • Weight loss reduces triglycerides, increases HDL-C, and lowers LDL-C
    • 99. Obesity 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
    • 100. Atherosclerosis & Dyslipidemia
      • Evidence from adult studies
      • Evidence in Children & Adolescents
        • PDAY
        • In vivo studies
          • decreased compliance of arteries
          • increased IMT in adolescents with dyslipidemia
    • 101. 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
    • 102. Obesity & Inflammatory Factors
    • 103. Prevalence of Elevated CRP (>0.22mg/dL) by BMI centile
    • 104. TNF-alpha Levels in Obese & Non-obese Adolescents Moon et al. NASO, Oct. 2003
    • 105. 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: 1 st & 2 nd Hand
    • 106. 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
    • 107. Francine Ratner Kaufman, MD Distinguished Professor of Pediatrics The Keck School of Medicine of USC Head, Center for Diabetes and Endocrinology Childrens Hospital Los Angeles Preventing Type 2 Diabetes?
    • 108. GLOBAL PROJECTIONS FOR THE DIABETES EPIDEMIC: 2003-2025 (millions) World 2003 = 194 million 2025 = 333 million Increase 72%
    • 109. Obesity (> 120%tile ideal body weight) in U.S. Adults 1992 Diabetes in U.S Adults 1992 No Data <4% 4%-6% 6%-8% 8%-10% >10%
    • 110. Obesity 1994 Diabetes 1994 No Data <4% 4%-6% 6%-8% 8%-10% >10%
    • 111. Obesity 1996 Diabetes 1996 No Data <4% 4%-6% 6%-8% 8%-10% >10%
    • 112. Obesity 1998 Diabetes 1998 No Data <4% 4%-6% 6%-8% 8%-10% >10%
    • 113. Obesity 1999 Diabetes 1999 No Data <4% 4%-6% 6%-8% 8%-10% >10%
    • 114. Obesity 2000 Diabetes 2000 No Data <4% 4%-6% 6%-8% 8%-10% >10%
    • 115. Insulin Resistance Age Puberty Type 2 Diabetes Prediabetes Beta Cell Defect Obesity BP, Lipids Gender – Girls Polycystic ovary syndrome Genetics Ethnicity Sedentary Lifestyle Beta Cell Defect
    • 116. Insulin Resistance Autoimmunity Type 2 Diabetes Prediabetes Beta Cell Defect Genetic Defect Intrauterine IUGR, DM Glucose toxicity Beta Cell Defect Fat cell toxicity
    • 117. Natural History of Type 2 Diabetes Genetic susceptibility Environmental factors Atherosclerosis Hyperglycemia Hypertension Retinopathy Nephropathy Neuropathy Blindness Renal failure CHD Amputation Onset of diabetes Complications Disability Death Ongoing hyperglycemia PRE Obesity Insulin resistance Risk for Disease Metabolic Syndrome 20.8 million 40 million 224,100
        • 0.5% of adolescents have diabetes
        • 71% type 1 and 29% type 2
        • 39,005 US teens with T2D
      Cost $132 Billion/2002
    • 118. Obesity 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.
    • 119. Obesity and Diabetes
      • Obesity worsens insulin sensitivity, eventually exhausting pancreatic production of insulin, causing hyperglycemia and diabetes.
    • 120.  
    • 121.  
    • 122.  
    • 123.  
    • 124.  
    • 125. Impaired Glucose Tolerance & Diabetes 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 Symptoms of diabetes & casual plasma glucose concentration 200 mg/dl 2-h PG > 200 mg/dl 2-h PG=140- 199mg/dl (IGT) 2-h PG <140 mg/dl FPG > 126 mg/dl FPG= 100 - 125 mg/dl (IFG) FPG <100 mg/dl Diabetes IFG or IGT Normal
    • 126. 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 1 st or 2 nd 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
    • 127. Absolute Fat and Lean Changes per Decade as a Function of Age in Men
    • 128. Absolute Fat and Lean Changes per Decade as a Function of Age in Women
    • 129. Definitions
      • Body Mass Index (BMI) describes relative
      • weight for height: weight (kg)/height (m 2 )
        • Overweight = 25–29.9 BMI
        • Obesity = > 30 BMI
    • 130. Age-Adjusted Standardized Prevalence of Overweight (BMI 25–29.9) and Obesity (BMI > 30) BMI > 30 BMI 25–29.9 CDC/NCHS, United States, 1960-94, ages 20-74 years Percent
    • 131. NHANES III Age-Adjusted Prevalence of Hypertension* According to BMI *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). Percent
    • 132. NHANES III Age-Adjusted Prevalence of High Blood Cholesterol* According to BMI *Defined as > 240 mg/dL. Brown C et al. Body Mass Index and the Prevalence of Risk Factors for Cardiovascular Disease (in preparation). Percent
    • 133. NHANES III Age-Adjusted Prevalence of Low HDL-Cholesterol* According to BMI *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). Percent
    • 134.
      • Requires two steps:
      • Assessment
      • Management
      Care of Overweight/Obese Patients
    • 135. Assessment of Overweight and Obesity
      • Body Mass Index
        • Weight (kg)/height (m 2 )
        • Weight (lb)/height (in 2 ) x 703
        • Table
      • Waist Circumference
        • High risk:
          • Men >102 cm (40 in.)
          • Women >88 cm (35 in.)
    • 136. Classification of Overweight and Obesity by BMI
    • 137. Determine Absolute Risk Status
      • Evaluate:
      • 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)
    • 138. The A, B, C Intervention
      • A ctivity
        • Minimum of 60 min/day of minimum intensity of a brisk walk.
        • Limit screen time (not associated with school work) < 1 hour
      • B everages
        • No regular soda or sugar/corn syrup sports drinks/punch
        • < 6 ounces juice/day
        • Increase water & non-or low fat milk (or other calcium containing food) consumption
      • C hange=Goal
        • Family changes eating & activity habits
        • Reasonable, achievable, step wise goals
        • Minimum nursing visits every 3-4 months: check progress & reinforce goals. Phone follow-up
    • 139.  
    • 140. Do You Know How Food Portions Have Changed in 20 Years? National Heart, Lung, and Blood Institute Obesity Education Initiative
    • 141. BAGEL 20 Years Ago Today 140 calories 3-inch diameter How many calories are in this bagel?
    • 142. BAGEL 140 calories 3-inch diameter Calorie Difference: 210 calories 350 calories 6-inch diameter 20 Years Ago Today
    • 143. 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 Act Calories In = Calories Out
    • 144. If you rake the leaves for 50 minutes you will burn the extra 210 calories.* *Based on 130-pound person Calories In = Calories Out
    • 145. CHEESEBURGER 20 Years Ago Today 333 calories How many calories are in today’s cheeseburger?
    • 146. Calorie Difference: 257 calories 590 calories CHEESEBURGER 20 Years Ago Today 333 calories
    • 147. Maintaining a Healthy Weight is a Balancing Act Calories In = Calories Out How long will you have to lift weights in order to burn the extra 257 calories?* *Based on 130-pound person
    • 148. 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
    • 149. SPAGHETTI AND MEATBALLS 20 Years Ago Today 500 calories 1 cup spaghetti with sauce and 3 small meatballs How many calories do you think are in today's portion of spaghetti and meatballs?
    • 150. Calorie Difference: 525 calories 1,025 calories 2 cups of pasta with sauce and 3 large meatballs 20 Years Ago Today 500 calories 1 cup spaghetti with sauce and 3 small meatballs SPAGHETTI AND MEATBALLS
    • 151. 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 Act Calories In = Calories Out
    • 152. *Based on 130-pound person If you houseclean for 2 hours and 35 minutes , you will burn approximately 525 calories.* Calories In = Calories Out
    • 153. FRENCH FRIES 20 Years Ago Today 210 Calories 2.4 ounces How many calories are in today’s portion of fries?
    • 154. 610 Calories 6.9 ounces Calorie Difference: 400 Calories FRENCH FRIES 20 Years Ago Today 210 Calories 2.4 ounces
    • 155. 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 Act Calories In = Calories Out
    • 156. *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
    • 157. 85 Calories 6.5 ounces How many calories are in today’s portion? SODA 20 Years Ago Today
    • 158. Calorie Difference: 165 Calories 250 Calories 20 ounces 85 Calories 6.5 ounces SODA 20 Years Ago Today
    • 159. 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 Act Calories In = Calories Out
    • 160. If you work in the garden for 35 minutes, you will burn approximately 165 calories.* *Based on 160-pound person Calories In = Calories Out
    • 161. Thank you for participating in Portion Distortion ! For more information about Maintaining a Healthy Weight visit www.nhlbi.nih.gov
    • 162. 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??
    • 163. Do You Know How Food Portions Have Changed in 20 Years? National Heart, Lung, and Blood Institute Obesity Education Initiative
    • 164. 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 calories 16 ounces Calorie Difference: 305 calories
    • 165. 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 Act Calories In = Calories Out
    • 166. If you walk 1 hour and 20 minutes, you will burn approximately 305 calories. * *Based on 130-pound person Calories In = Calories Out
    • 167. MUFFIN 20 Years Ago Today 210 calories 1.5 ounces How many calories are in today’s muffin?
    • 168. 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 Act Calories In = Calories Out
    • 169. If you vacuum for 1 hour and 30 minutes you will burn approximately 290 calories.* *Based on 130-pound person Calories In = Calories Out
    • 170. 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
    • 171. 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
    • 172. CHOCOLATE CHIP COOKIE 20 Years Ago Today 55 calories 1.5 inch diameter How many calories are in today’s large cookie?
    • 173. CHOCOLATE CHIP COOKIE 20 Years Ago Today 55 calories 1.5 inch diameter 275 calories 3.5 inch diameter Calorie Difference: 220 calories
    • 174. 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 Act Calories In = Calories Out
    • 175. *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
    • 176. CHICKEN STIR FRY 20 Years Ago Today 435 calories 2 cups How many calories are in today’s chicken stir fry?
    • 177. CHICKEN STIR FRY 20 Years Ago Today 435 calories 2 cups 865 calories 4 ½ cups Calorie Difference: 430 calories
    • 178. 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 Act Calories In = Calories Out
    • 179. *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
    • 180. 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.
                                                                     
    • 181. FAST FOOD MAKEOVERS
      • Del Taco Combo Burrito Meal = 1090 kcals.
      • 2 Del taco soft chicken tacos = 320 kcals.
    • 182. 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.
    • 183. 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.
    • 184. Adolescent and Adult Interventions
      • Decrease Television viewing
      • Decrease consumption of high fat foods
      • Increase fruit and vegetable intake
      • Increase moderate and vigorous physical activity
    • 185. Weight 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.
    • 186. Weight 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.
    • 187. Fat 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.
    • 188. Hypocaloric 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.
    • 189. 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
    • 190. Treatment Algorithm Patient 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 strategy for weight loss and risk 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 10 16 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} BMI measured in past 2 years?
    • 191. 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 No Yes 1 2 3 4 6 5 7 Yes No BMI measured in past 2 years? BMI  25 OR waist > 88 cm (F) > 102 cm (M)  Yes  Examination Treatment
    • 192. Devise goals and treatment strategy for weight loss and risk factor control Assess reasons for failure to lose weight Maintenance counseling 12 11 10 8 9 No Yes Yes No Desire to lose 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 weight check • Advise to maintain weight • Address other risk factors 13 16 Treatment Algorithm (Part 2 of 3)
    • 193. • Brief reinforcement • Educate on weight management Periodic weight check • Advise to maintain weight • Address other risk factors 14 15 13 16 5 Yes 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.
    • 194. Goals of Weight Management/Treatment
      • Prevent further weight gain (minimum goal).
      • Reduce body weight.
      • Maintain a lower body weight over long term.
    • 195. 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.
    • 196. Weight Loss Goals
      • Goal: Decrease body weight by 10 percent from
      • baseline.
      • 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
    • 197. 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.
    • 198. Strategies for Weight Loss and Maintenance
      • Dietary therapy
      • Physical activity
      • Behavior therapy
      • “ Combined” therapy
      • Pharmacotherapy
      • Weight loss surgery
    • 199. Weight Loss Therapy
      • Whenever possible, weight loss therapy should employ the combination of
      • Low-calorie/low-fat diets
      • Increased physical activity
      • Behavior modification
    • 200. 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 practical way to reduce calories. Evidence Category A.
    • 201. 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.
    • 202. Dietary Therapy (3 of 5) Although lower fat diets without targeted calorie reduction help promote weight loss by producing a reduced calorie intake, lower fat diets coupled with total calorie reduction produce greater weight loss than lower fat diets alone. Evidence Category A.
    • 203. Dietary Therapy (4 of 5) Very low-calorie diets produce greater initial weight loss than low-calorie diets. However, long-term (>1 year) weight loss is not different from an LCD. Evidence Category A.
    • 204. 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
    • 205. Low-Calorie Step I Diet
      • Nutrient 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
    • 206. 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
    • 207. Physical Activity Prescription
    • 208. Adults
    • 209. Physical Fitness Continuum
    • 210. Physical Activity, Exercise, and Physical Fitness
      • Physical activity: Any bodily movement produced by skeletal muscles that results in energy expenditure.
      • Exercise: A subset of physical activity That is planed, structured, and repetitive and is done to improve or maintain physical fitness.
      • Physical fitness: A set of attributes that are either health or skill related Health- endurance, strength, flexibility, Skill- balance, agility, power, reaction time, speed and coordination
    • 211. How Active Are You?
      • Your intensity ___ × Your duration ___ × Your frequency ___ = Your activity index.
    • 212. Intensity: How Hard Do You Exercise?
      • If your exercise results in: Your intensity score is:
      • No change in pulse from resting level 0
      • Little change in pulse from resting level – 1
      • as in slow walking, bowling, yoga
      • Slight increase in pulse and breathing – 2
      • As in table tennis, active golf
      • Moderate increase in pulse and breathing – 3
      • As leisurely bicycling, easy swimming, rapid working
      • Intermittent heavy breathing and sweating – 4
      • As in tennis singles, basketball, squash
      • Sustained heavy breathing and sweating – 5
      • As in jogging, cross country skiing, rope skipping
    • 213. Duration: How Long Do You Exercise?
      • If each session continues for: Your duration score is:
      • Less than 5 minutes 0
      • 5-14 minutes 1
      • 15-29 minutes 2
      • 30-44 minutes 3
      • 45-59 minutes 4
      • 60 minutes 5
    • 214. Frequency: How Often Do You Exercise?
      • If you exercise: Your frequency score is:
      • Less than 1 time a week 0
      • 1 time a week 1
      • 2 times a week 2
      • 3 times a week 3
      • 4 times a week 4
      • 5 times a week 5
    • 215. Here’s How You Can Translate Your Activity Index Into Your Estimated Level of Activity:
      • If your activity index is: Your estimated level of activity is:
      • Less than 15 sedentary
      • 15-24 low active
      • 25-60 moderate active
      • 41-60 active
      • Over 60 high active
    • 216. Components of Physical Fitness
      • Physical fitness component: Definition:
      • Cardiorespiratory Ability to do moderately strenuous
      • endurance activity over an extended period of time.
      • Body composition Percentage of the body that is fat.
      • Muscular strength Ability to exert maximum force in a single
      • exertion.
      • Muscular Ability to repeat movements over and over
      • endurance or to hold a particular position for a prolonged period.
      • Flexibility Ability to move a joint easily through its full range of motion.
    • 217. The Activity Pyramid
    • 218. Physical Activity Prescription
    • 219. Comparison Between Exercise Therapy and Drug Therapy
    • 220. Guidelines For Training
      • Train the way you want your body to change.
      • Train regularly.
      • Get in shape gradually.
      • Warm up before exercising, and cool down afterward.
      • Listen to your body.
      • Try training with a partner.
      • Train your mind.
      • Keep your exercise program in perspective.
    • 221. 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.
    • 222. 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
    • 223. Four Challenges
      • Enhancing Public Participation in Clinical Research
      • Developing Information Systems
      • An Adequately Trained Diverse Workforce
      • Funding
    • 224.
      • What is the benefit of increasing representation of women and minorities in the clinical research workforce?
      • Will increased diversity improve translation of the results of clinical research in minority communities?
      • What are the needs of the private and public sector?
      • 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
    • 225.
      • Where is demand exceeding supply?
      • What training programs and career tracks appear to foster the development and retention of women and minorities in the clinical research workforce?
      • What research related to evaluation of existing training efforts needs to be funded?
      • 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
    • 226.  
    • 227. Determining a Healthy Body Weight
      • Assess your body composition.
      • Choose a target value for BMI or percent body fat that is realistic for you and will ensure good health.
      • Consult a physician if you have any known risk factors for disease.
      • Determine the recommended body weight based on your BMI or percent body fat goal.
      • Examine the body weight that the formulas generate for you and allow for individual genetic, cultural, and lifestyle factors.
    • 228. Key Messages
      • Adolescents and young adults, both male and female, benefit from physical activity.
      • Physical activity need not be strenuous to be beneficial.
      • Moderate amounts of daily physical activity are recommended for people of all ages. This amount can be obtained in longer sessions of moderately intense activities, such as brisk walking for 30 minutes, or in shorter sessions of more intense activities, such as jogging or playing basketball for 15-20 minutes.
      • Greater amounts of physical activity are even more beneficial, up to a point. Excessive amounts of physical activity can lead to injuries, menstrual abnormalities, and bone weakening.
    • 229.  
    • 230. Eating Well and Feeling Good
      • Be active
      • Have fun!
      • Feel good about yourself
    • 231. “ All parts of the body which have a function, used in moderation and exercised in labours in which each is accustomed, become thereby healthy, well-developed and age more slowly, but if unused and left idle, they become liable to disease, defective in growth and age quickly.” - Hippocrates
    • 232.  

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