SlideShare a Scribd company logo
1 of 106
Download to read offline
28th Annual
Update in Medicine
Conference
Francisco J Cervantes MD FAAP
Diabetes: It is a matter of Fat
October 26, 2012
Laredo TX
WWW.LaredoPediatrics.com
America is facing an epidemic!!
The U.S. is the fattest nation in the world.
64.5% of Americans are overweight or obese.
Source: JAMA. 2002;288:1723-1727
Obesity is the second largest preventable
cause of death in the U.S.! (Smoking is #1.)
Source: JAMA 1996; 276: 1907-1950.
Obesity Goes Global
(Time Magazine August 25,2003)
diabetesisamatteroffat
PROGRESSION OF WEIGHT
PROJECTION OF WEIGHT
diabetesisamatteroffat
diabetesisamatteroffat
diabetesisamatteroffat
Future Family Pictures
diabetesisamatteroffat
diabetesisamatteroffat
diabetesisamatteroffat
BMI History
• The body mass index is a brainchild of a
Belgian statistician and mathematician named
Adolphe Quatelet who created the BMI
sometime from1830 to 1850
Article Source:
http://EzineArticles.com/125508
BMI History
• his project was intended to describe the
standard proportions of the human build.
• The equation was largely ignored by the
medical community even though insurance
companies began using somewhat vague
comparisons of height and weight among
policyholders beginning in the early twentieth
century
BMI History
• Medical researchers searched for an accurate,
uniform way to measure fatness for decades
when in 1972, physiology professor and obesity
researcher Ancel Keys published his “Indices of
Relative Weight and Obesity,” a landmark study of
more than 7,400 men in five countries. Keys
considered the various height-weight formulas in
existence and found Quetelet’s equation to be
the best marker of body-fat percentage. He
renamed this number the body mass index or
BMI.
BMI as Standard
• BMI became an international standard for
obesity measurement in the 1980s. The public
learned about BMI the late 1990s, when the
government launched an initiative to
encourage healthy eating and exercise.
DEFINITION OF OBESITY
• By 1985, the National Institutes of Health
began defining obesity according to body
mass index. (27.8 for men and 27.3 for
women)
• Then in 1998, the NIH consolidated the
threshold for men and women and added the
category of overweight.
BMI and healthy weight
• In 1998, the NIH lowered the overweight
threshold for BMI 27.8 to 25 to match
international guidelines.
• The move added 30 million Americans who were
previously in the "healthy weight" category to the
"overweight" category.
• Today, the NIH advises doctors and their patients
to include BMI in a complete assessment of a
person's body size and overall health.
Is BMI an Accurate Measure of
Obesity?
It's important to note that although BMI
is accurate most of the time, it may
overestimate or underestimate body
fat. For example, BMI doesn't
distinguish between body fat and
muscle mass, which weighs more than
fat.
diabetesisamatteroffat
Waist and Hip Ratio
waist-to-hip ratios are a much more
accurate way of determining the
kinds of body fat that might actually
pose health risks.
BodyMass Index (2-20 yrs)
Underweight
Normal weight
At risk of overweight
Overweight
Obese
BMI < 5th %tile
BMI 5th to < 84th %tile
BMI 85th to < 94th %tile
BMI ≥ 95th %tile
BMI > 99th %tile
Weight and Height Assessment
• Before 1980, doctors generally used weight-
for-height tables -- one for men and one for
women -- that included ranges of body
weights for each inch of height. These tables
were limited because they were based on
weight alone.
diabetesisamatteroffat
BMI scale for Adult Population
Body Mass Index
 2003: AAP recommended
that pediatricians calculate
and plot the BMI of all
children and adolescents
yearly
 Yet, only a minority of
pediatricians routinely use
BMI
 Adoption of BMI use is less
than optimal
 Many prefer to rely on “visual
impression” to diagnose
overweight
Advantages of BMI-for-Age
 BMI-for-age relates to health risk
 Correlates with clinical risk factors for
cardiovascular disease including hyperlipidemia,
elevated insulin, and high blood pressure
 BMI-for-age during pubescence is related to lipid
levels and high blood pressure in middle age
Height Measurement
Caution with Plotting BMI
BMI in Children: the tricks
BMI CHART WITH 97 PERCENTILES
diabetesisamatteroffat
BMI screening shortcomings
• Why is there insufficient evidence of its
effectiveness?
• Screening ALONE is insufficient to improve clinical
outcomes
• Screening needs to trigger other actions
– Treatment algorithms
– Reviewing family history
– Identifying high risk behaviors related to diet and physical
activity
– Screening for comorbidities
BMI AND OBESITY
The National Institutes of Health (NIH)
recommends that doctors assess whether their
patients are overweight based on three factors:
• BMI
• Waist circumference measures of abdominal fat
• Risk factors for diseases associated with obesity,
such as high blood pressure, high LDL ("bad”
cholesterol), low HDL ("good" cholesterol), high
blood sugar, and smoking
A Rational Approach
August 2002: Modified Diet, basically: lower
sugar intake, more protein and vegetables,
diet drinks or water. Blood work and diet
recommended at school to Overweight kids
and close f/u
September 2003: Results of First 1000 classified
patients
April 2004: Update to 3000 patients
Distribution of children by BMI
August, 2005
Local Experience
•2116 patients, about equally divided,
boys (1041, 49.2%) and girls (1075, 50.8%)
•First generation American-born children of
Hispanic descend.
•Patients were followed because of changes in
BMI then the discovery of the fatty liver and
subsequently Gallbladder disease.
• All patients have at least one metabolic screen.
•BMI groups normal BMI 75, 85, 95,97 and ≥99
WWW.Laredopediatrics.com
Screening
• CMP, GGT, Lipid profile, Liver Function Test:
Alkaline phosphatase, ALT, AST, Bilirubin,
• HbA1c, Insulin, THS and T4
• Biometric information; Weight, Height, BMI,
Waist and hip circumference and Percentage of
body fat
• Blood pressure
• Ultrasound of the liver if altered liver enzymes, or
complaining of RUQ pain or discomfort
TOTAL TESTS DONE PER PATIENT
BOYS n Tests % Tests
NL 213 162 76.1
85 81 85 104.9
90 153 182 119.0
95 73 125 171.2
96 79 137 173.4
97 130 243 186.9
98 141 311 220.6
99 71 168 236.6
99+ 164 307 187.2
TOTAL 1105 1720 155.7
GIRLS n TESTS % Tests
NL 289 323 111.8
85 156 162 104.5
90 201 356 177.1
95 59 120 203.4
96 56 111 198.2
97 97 197 203.1
98 142 258 181.7
99 65 128 196.9
99+ 87 105 120.7
TOTAL 1152 1860 161.5
2012
0
50
100
150
200
250
300
NR Risk ≥ 95 ≥ 97 ≥ 99
Male # of
Patient
Female # of
Patient
Total number of patient distributed according to the BMI group and sex
Statistical Analysis of BMI Distribution
The large bones myth
diabetesisamatteroffat
diabetesisamatteroffat
Body Composition in Girls
diabetesisamatteroffat
Adipocytes as an endocrine organ
• Increasing adiposity leads to increasing levels
of “adipokines”
• Adipocyte-derived inflammatory markers that
act in pro- and anti-inflammatory pathways
• Macrophages found in adipose tissue likely
have a role in the obese-inflammatory state
and its related disease
Obesity is a state of chronic inflammation!!
Pediatric Clinics of North America
Pediatr Clin Am 53 (2006) 777-794
Changes in weight and its effects
Are they Taller?
BOYS GIRLS
Age N Percentile Age N Percentile
Normal 6.37 34 15 9.37 48 15
Risk OW 8.27 82 35 8.67 86 25
Obese 7.89 223 25 8.12 196 45
Morbid 9.17 57 65 7.44 47 65
TOTAL 396 377
Girls Growth Chart
FASTING GLUCOSE BY BMI
Insulin by Age in Normal BMI
2005
n= 86 n= 127
BMI vs. Insulin
Insulin by Age and NL BMI
diabetesisamatteroffat
Insulin in Normal BMI Children
Age in years
Correlation between Insulin & Glucose
Incidence of Type II Diabetes in
Laredo Pediatrics & Neonatology
(11 yr follow up)
diabetesisamatteroffat
Cholesterol Total and BMI
diabetesisamatteroffat
Cholesterol > 190/200
Triglycerides (TGL) vs. BMI
diabetesisamatteroffat
Cholesterol
Components
(TGL/5)
September 2012
diabetesisamatteroffat
Obvious Acanthosis
Subtle Neck Acanthosis
Acanthosis
diabetesisamatteroffat
Source: Pediatric Clinics of North America 2011; 58:1375-1392 (
Pathophysiology of Fatty Liver
women—especially pregnant, use of hormone replacement
therapy, or birth control pills (decrease gallbladder movement)
people over age 60 (As people age, the body tends to secrete more
cholesterol into bile)
American Indians (Pima Indians of Arizona, 70% of women have
gallstones by age 30)
Mexican Americans
overweight or obese ( Bile salts Cholesterol GB emptying
people who fast or lose a lot of weight quickly
people with a family history of gallstones (possible genetic link)
people with diabetes (high levels of fatty acids called triglycerides)
people who take cholesterol-lowering drugs
Who is at risk for gallstones?
The Classic 4 F’s still apply: Female, Fertile, Forty, Fat
Development of Cholecystitis
75 Percentile Factor
Abnormal values by
Percentile
Boys Girls
TGL 75% 85%
HDL 90% 85%
Glucose 50% 75%
Insulin 50% 75%
Genu Valgus
Adiposity: Gained and lost 20 lbs in a couple
of months
diabetesisamatteroffat
diabetesisamatteroffat
Is Practice, and practice, and practice, and practice, and practice……..
It is Possible!!
Slipped capital femoral epiphysis
(SCFE)
The ball at the upper end of the femur (thigh bone) slips off in a
backward direction. Due to weakness of the growth plate. Most
often, it develops during periods of accelerated growth, shortly
after the onset of puberty is an unusual disorder of the adolescent
hip It is not rare.
TYPES:
• Stable SCFE. This is referred to as a "mild slip," which causes some
stiffness or pain in the knee or groin area, and possibly a limp
• Unstable SCFE. This is a more severe usually much more painful,
unable to bear weight on the affected side, ROM severely limited,
leg turns outward, is more serious because it can restrict blood
flow to the hip joint, leading necrosis
Slipped capital femoral epiphysis
(SCFE)
Risk Factors:
• The cause of SCFE is unknown. It occurs two to three times more often in
males than females. A large number of patients are overweight.
• In most cases, is a slow and gradual process. However, it may occur
suddenly and be associated with a minor fall or trauma.
• Symptomatic SCFE, treated early and well, allows for good long-term hip
function
Symptoms:
• Weeks or months of hip or knee pain and an intermittent limp
• walks with a limp. In certain severe cases, unable to bear any weight on
the affected leg
• affected leg is usually turned outward in comparison to the normal leg
• affected leg may appear to be shorter
Slipped Capital Femoral Epiphysis
(SCFE)
Normal anatomy
Types of SCFE
14 yr old with
SCFE
Is not only elasticity
diabetesisamatteroffat
diabetesisamatteroffat
Ecological Predictors of Childhood
Obesity
Source: Pediatric Clinics of North America 2011; 58:1333-1354 (DOI:10.006 )
Socio-environmental Model
Pediatric Clinics of North America
Volume 58, Issue 6 , Pages 1403-1424 , December 2011
Recommendations from the AAP
For providers to implement in primary care settings:
• Routinely document BMI and assess children for obesity.
• Deliver messages about healthy eating and activity
behaviors to all children and families, regardless of
children’s weight status.
• Establish practice procedures for addressing overweight
and obesity (e.g., determine, medical assessments to
review, and flag charts of overweight and obese children to
indicate need for intervention).
• Involve and train interdisciplinary teams.
• Audit charts to identify current practices and goals for
improvement, and assess improvement over time.
Recommendations from the AAP
For providers to discuss with families:
• Limit sugar-sweetened beverages.
• Increase vegetables and fruits (at least 9 servings per day).
• Limit television and other screen time (no television for
children younger than 2 years, less than 2 hours per day for
children older than 2 years), and remove televisions from
children’s sleeping areas.
• Eat breakfast every day.
• Limit meals eaten out at restaurants.
• Increase family meals (parents and children eat together).
• Limit portion sizes
But, I only eat like a bird!
Yes, but….
diabetesisamatteroffat
PEPPERONI PIZZA
20 Years Ago Today
500 calories
850 calories
Calorie Difference: 350 calories
playing golf while walking and carrying your
clubs for 1 hour you will burn approximately
350 calories. (based on a 160 lbs person)
diabetesisamatteroffat
diabetesisamatteroffat
diabetesisamatteroffat
Facts About Diabetes
 80% in our children has at least 1 close
relative with diabetes
10% has one of the parents with diabetes
1% has both parents with diabetes
Mexican American have poor tolerance to
carbohydrates
As the intake of carbohydrates increases so
are the levels of insulin, visceral fat and
acanthosis.
THE GOOD NEWS: IT IS REVERSIBLE!!
MAXIMUM DAILY TOLERANCE OF CARBOHYDRATES
IN MEXICAN AMERICAN CHILDREN
50 – 100 GRAMS OF CARBOHYDRATES
3 Fruits (10X 3 = 30 grams)
a banana accounts for 30 to 40 grams
1 cup plain cereal = 30 grams
2 to 3 glasses of 8 oz of regular milk = 30 grams
( Regular = 10; 2% 11; Skim 15 grams)
DIABETES
DON’T STARCH YOURSELF
Pasta, Rice, Beans, Cereal, Chips, Pizza,
Tortilla, Bread,
Of course Cake, Cookies, Doughnuts;
Don’t even mention sodas, sweetened
beverages and sport drinks
diabetesisamatteroffat
diabetesisamatteroffat
Hippocrates Master of Medicine:
460-377 B.C
“Thus Curiosity, Keenness of observation
and the value of scrupulous record
keeping became paramount priorities in
the new philosophy of Care”
Sherwin B Nuland describing Hippocrates Influence on Medicine

More Related Content

What's hot

Global Epidemiology Of Obesity
Global Epidemiology Of ObesityGlobal Epidemiology Of Obesity
Global Epidemiology Of ObesityDr Sumeet Shah
 
Cardiovascular effects of obesity
Cardiovascular effects of obesityCardiovascular effects of obesity
Cardiovascular effects of obesityAtul Dixit
 
Obesity And Female CANCER, Dr. Sharda Jain & Lifecare team
Obesity  And  Female CANCER, Dr. Sharda Jain & Lifecare team Obesity  And  Female CANCER, Dr. Sharda Jain & Lifecare team
Obesity And Female CANCER, Dr. Sharda Jain & Lifecare team Lifecare Centre
 
Introduction to the active life 2016.ppja (1) (1)
Introduction to the active life 2016.ppja (1) (1)Introduction to the active life 2016.ppja (1) (1)
Introduction to the active life 2016.ppja (1) (1)Jackie Arcana
 
Epidemiology of obesity
Epidemiology of obesityEpidemiology of obesity
Epidemiology of obesityArun Kokane
 
The role of exercise in medicine
The role of exercise in medicineThe role of exercise in medicine
The role of exercise in medicineNursing Hi Nursing
 
Metabolic syndrome and erectile dysfunction
Metabolic syndrome and erectile dysfunctionMetabolic syndrome and erectile dysfunction
Metabolic syndrome and erectile dysfunctionTarek Anis
 
Japan and the "Metabo Law"
Japan and the "Metabo Law"Japan and the "Metabo Law"
Japan and the "Metabo Law"markppt
 
Metabolism
MetabolismMetabolism
Metabolismcallr
 
Does waist circumference predict disease risk beyond metabolic risk factors a...
Does waist circumference predict disease risk beyond metabolic risk factors a...Does waist circumference predict disease risk beyond metabolic risk factors a...
Does waist circumference predict disease risk beyond metabolic risk factors a...PeterJaniszewski
 
Metabolic syndrome in Community Medicine
Metabolic syndrome in Community Medicine Metabolic syndrome in Community Medicine
Metabolic syndrome in Community Medicine Dr. Anees Alyafei
 
Health Risks of Being Overweight
Health Risks of Being OverweightHealth Risks of Being Overweight
Health Risks of Being OverweightMarketingTeamBiz
 
Metabolic Syndrome - June 2014
Metabolic Syndrome - June 2014Metabolic Syndrome - June 2014
Metabolic Syndrome - June 2014Geoffrey Douglas
 
Obesity and cancer(final)
Obesity and cancer(final)Obesity and cancer(final)
Obesity and cancer(final)TomPeter13
 
Metabolic Syndrome, Diabetes, and Cardiovascular Disease ... Metabolic Synd...
Metabolic Syndrome, Diabetes, and Cardiovascular Disease ... 	 Metabolic Synd...Metabolic Syndrome, Diabetes, and Cardiovascular Disease ... 	 Metabolic Synd...
Metabolic Syndrome, Diabetes, and Cardiovascular Disease ... Metabolic Synd...MedicineAndFamily
 

What's hot (20)

Obesity
ObesityObesity
Obesity
 
Global Epidemiology Of Obesity
Global Epidemiology Of ObesityGlobal Epidemiology Of Obesity
Global Epidemiology Of Obesity
 
Cardiovascular effects of obesity
Cardiovascular effects of obesityCardiovascular effects of obesity
Cardiovascular effects of obesity
 
Obesity And Female CANCER, Dr. Sharda Jain & Lifecare team
Obesity  And  Female CANCER, Dr. Sharda Jain & Lifecare team Obesity  And  Female CANCER, Dr. Sharda Jain & Lifecare team
Obesity And Female CANCER, Dr. Sharda Jain & Lifecare team
 
Introduction to the active life 2016.ppja (1) (1)
Introduction to the active life 2016.ppja (1) (1)Introduction to the active life 2016.ppja (1) (1)
Introduction to the active life 2016.ppja (1) (1)
 
Epidemiology of obesity
Epidemiology of obesityEpidemiology of obesity
Epidemiology of obesity
 
The role of exercise in medicine
The role of exercise in medicineThe role of exercise in medicine
The role of exercise in medicine
 
Metabolic syndrome and erectile dysfunction
Metabolic syndrome and erectile dysfunctionMetabolic syndrome and erectile dysfunction
Metabolic syndrome and erectile dysfunction
 
Obesity....
 Obesity.... Obesity....
Obesity....
 
Obesity epid624
Obesity epid624Obesity epid624
Obesity epid624
 
metabolic syndrome review
metabolic syndrome reviewmetabolic syndrome review
metabolic syndrome review
 
Japan and the "Metabo Law"
Japan and the "Metabo Law"Japan and the "Metabo Law"
Japan and the "Metabo Law"
 
Metabolism
MetabolismMetabolism
Metabolism
 
Does waist circumference predict disease risk beyond metabolic risk factors a...
Does waist circumference predict disease risk beyond metabolic risk factors a...Does waist circumference predict disease risk beyond metabolic risk factors a...
Does waist circumference predict disease risk beyond metabolic risk factors a...
 
Metabolic syndrome in Community Medicine
Metabolic syndrome in Community Medicine Metabolic syndrome in Community Medicine
Metabolic syndrome in Community Medicine
 
Health Risks of Being Overweight
Health Risks of Being OverweightHealth Risks of Being Overweight
Health Risks of Being Overweight
 
Metabolic Syndrome - June 2014
Metabolic Syndrome - June 2014Metabolic Syndrome - June 2014
Metabolic Syndrome - June 2014
 
Obesity and cancer(final)
Obesity and cancer(final)Obesity and cancer(final)
Obesity and cancer(final)
 
Metabolic Syndrome, Diabetes, and Cardiovascular Disease ... Metabolic Synd...
Metabolic Syndrome, Diabetes, and Cardiovascular Disease ... 	 Metabolic Synd...Metabolic Syndrome, Diabetes, and Cardiovascular Disease ... 	 Metabolic Synd...
Metabolic Syndrome, Diabetes, and Cardiovascular Disease ... Metabolic Synd...
 
The Weight of the Nation: Obesity - The Disease that Started it All
The Weight of the Nation: Obesity - The Disease that Started it AllThe Weight of the Nation: Obesity - The Disease that Started it All
The Weight of the Nation: Obesity - The Disease that Started it All
 

Viewers also liked

Flavocytochrome p450 bm3 mutant a264 e undergoes substrate dependent formatio...
Flavocytochrome p450 bm3 mutant a264 e undergoes substrate dependent formatio...Flavocytochrome p450 bm3 mutant a264 e undergoes substrate dependent formatio...
Flavocytochrome p450 bm3 mutant a264 e undergoes substrate dependent formatio...John Clarkson
 
Raman microscopy and x ray diffraction a combined study of fibrillin-rich mic...
Raman microscopy and x ray diffraction a combined study of fibrillin-rich mic...Raman microscopy and x ray diffraction a combined study of fibrillin-rich mic...
Raman microscopy and x ray diffraction a combined study of fibrillin-rich mic...John Clarkson
 
Temperature fields during the development of combustion in a rapid compressio...
Temperature fields during the development of combustion in a rapid compressio...Temperature fields during the development of combustion in a rapid compressio...
Temperature fields during the development of combustion in a rapid compressio...John Clarkson
 
Vibrational analysis of the phenylazonaphthol pigment ca4b
Vibrational analysis of the phenylazonaphthol pigment ca4bVibrational analysis of the phenylazonaphthol pigment ca4b
Vibrational analysis of the phenylazonaphthol pigment ca4bJohn Clarkson
 
SELECTION OF IMAGES TAKEN FOR FIRM MAGAZINE
SELECTION OF IMAGES TAKEN FOR FIRM MAGAZINESELECTION OF IMAGES TAKEN FOR FIRM MAGAZINE
SELECTION OF IMAGES TAKEN FOR FIRM MAGAZINEjxshbrown
 
Secret of happiness_e_book_sec.83833e2f-1ce5-40b2-bce1-6bb954129a58
Secret of happiness_e_book_sec.83833e2f-1ce5-40b2-bce1-6bb954129a58Secret of happiness_e_book_sec.83833e2f-1ce5-40b2-bce1-6bb954129a58
Secret of happiness_e_book_sec.83833e2f-1ce5-40b2-bce1-6bb954129a58Shahid Mojib
 
Probing the chemistries of flavin ring systems of p hydroxybenzoate hydroxyla...
Probing the chemistries of flavin ring systems of p hydroxybenzoate hydroxyla...Probing the chemistries of flavin ring systems of p hydroxybenzoate hydroxyla...
Probing the chemistries of flavin ring systems of p hydroxybenzoate hydroxyla...John Clarkson
 
UV resonance raman study of streptavidin binding of biotin and 2 iminobiotin ...
UV resonance raman study of streptavidin binding of biotin and 2 iminobiotin ...UV resonance raman study of streptavidin binding of biotin and 2 iminobiotin ...
UV resonance raman study of streptavidin binding of biotin and 2 iminobiotin ...John Clarkson
 
Volunteers in urban Forestry: Treasure or Trouble
Volunteers in urban Forestry: Treasure or TroubleVolunteers in urban Forestry: Treasure or Trouble
Volunteers in urban Forestry: Treasure or TroubleLee Mueller
 
Recruitingblogs50recruitingstatseverytalentacquisitionproneedstoknowppt3 10-1...
Recruitingblogs50recruitingstatseverytalentacquisitionproneedstoknowppt3 10-1...Recruitingblogs50recruitingstatseverytalentacquisitionproneedstoknowppt3 10-1...
Recruitingblogs50recruitingstatseverytalentacquisitionproneedstoknowppt3 10-1...Shahid Mojib
 
Ultraviolet resonance raman study of the avidin biotin complex
Ultraviolet resonance raman study of the avidin biotin complexUltraviolet resonance raman study of the avidin biotin complex
Ultraviolet resonance raman study of the avidin biotin complexJohn Clarkson
 
Vibrational analysis of trans azobenzene
Vibrational analysis of trans azobenzeneVibrational analysis of trans azobenzene
Vibrational analysis of trans azobenzeneJohn Clarkson
 
A theoretical study of the structure and vibrations of 2,4,6 trinitrotoluene
A theoretical study of the structure and vibrations of 2,4,6 trinitrotolueneA theoretical study of the structure and vibrations of 2,4,6 trinitrotoluene
A theoretical study of the structure and vibrations of 2,4,6 trinitrotolueneJohn Clarkson
 
A theoretical study of the structure and vibrations of 2,4,6-trinitrotoluene
A theoretical study of the structure and vibrations of 2,4,6-trinitrotolueneA theoretical study of the structure and vibrations of 2,4,6-trinitrotoluene
A theoretical study of the structure and vibrations of 2,4,6-trinitrotolueneJohn Clarkson
 
UV raman evidence of a tyrosine in apo human serum transferrin with a low p k...
UV raman evidence of a tyrosine in apo human serum transferrin with a low p k...UV raman evidence of a tyrosine in apo human serum transferrin with a low p k...
UV raman evidence of a tyrosine in apo human serum transferrin with a low p k...John Clarkson
 
impotance of technology in education
impotance of technology in educationimpotance of technology in education
impotance of technology in educationRitchel Bihag
 

Viewers also liked (20)

Flavocytochrome p450 bm3 mutant a264 e undergoes substrate dependent formatio...
Flavocytochrome p450 bm3 mutant a264 e undergoes substrate dependent formatio...Flavocytochrome p450 bm3 mutant a264 e undergoes substrate dependent formatio...
Flavocytochrome p450 bm3 mutant a264 e undergoes substrate dependent formatio...
 
Raman microscopy and x ray diffraction a combined study of fibrillin-rich mic...
Raman microscopy and x ray diffraction a combined study of fibrillin-rich mic...Raman microscopy and x ray diffraction a combined study of fibrillin-rich mic...
Raman microscopy and x ray diffraction a combined study of fibrillin-rich mic...
 
Temperature fields during the development of combustion in a rapid compressio...
Temperature fields during the development of combustion in a rapid compressio...Temperature fields during the development of combustion in a rapid compressio...
Temperature fields during the development of combustion in a rapid compressio...
 
Vibrational analysis of the phenylazonaphthol pigment ca4b
Vibrational analysis of the phenylazonaphthol pigment ca4bVibrational analysis of the phenylazonaphthol pigment ca4b
Vibrational analysis of the phenylazonaphthol pigment ca4b
 
SELECTION OF IMAGES TAKEN FOR FIRM MAGAZINE
SELECTION OF IMAGES TAKEN FOR FIRM MAGAZINESELECTION OF IMAGES TAKEN FOR FIRM MAGAZINE
SELECTION OF IMAGES TAKEN FOR FIRM MAGAZINE
 
Secret of happiness_e_book_sec.83833e2f-1ce5-40b2-bce1-6bb954129a58
Secret of happiness_e_book_sec.83833e2f-1ce5-40b2-bce1-6bb954129a58Secret of happiness_e_book_sec.83833e2f-1ce5-40b2-bce1-6bb954129a58
Secret of happiness_e_book_sec.83833e2f-1ce5-40b2-bce1-6bb954129a58
 
Probing the chemistries of flavin ring systems of p hydroxybenzoate hydroxyla...
Probing the chemistries of flavin ring systems of p hydroxybenzoate hydroxyla...Probing the chemistries of flavin ring systems of p hydroxybenzoate hydroxyla...
Probing the chemistries of flavin ring systems of p hydroxybenzoate hydroxyla...
 
UV resonance raman study of streptavidin binding of biotin and 2 iminobiotin ...
UV resonance raman study of streptavidin binding of biotin and 2 iminobiotin ...UV resonance raman study of streptavidin binding of biotin and 2 iminobiotin ...
UV resonance raman study of streptavidin binding of biotin and 2 iminobiotin ...
 
Volunteers in urban Forestry: Treasure or Trouble
Volunteers in urban Forestry: Treasure or TroubleVolunteers in urban Forestry: Treasure or Trouble
Volunteers in urban Forestry: Treasure or Trouble
 
Yousef Taha c.v
Yousef Taha c.vYousef Taha c.v
Yousef Taha c.v
 
Recruitingblogs50recruitingstatseverytalentacquisitionproneedstoknowppt3 10-1...
Recruitingblogs50recruitingstatseverytalentacquisitionproneedstoknowppt3 10-1...Recruitingblogs50recruitingstatseverytalentacquisitionproneedstoknowppt3 10-1...
Recruitingblogs50recruitingstatseverytalentacquisitionproneedstoknowppt3 10-1...
 
Ultraviolet resonance raman study of the avidin biotin complex
Ultraviolet resonance raman study of the avidin biotin complexUltraviolet resonance raman study of the avidin biotin complex
Ultraviolet resonance raman study of the avidin biotin complex
 
Vibrational analysis of trans azobenzene
Vibrational analysis of trans azobenzeneVibrational analysis of trans azobenzene
Vibrational analysis of trans azobenzene
 
Apparels in delhi ppt
Apparels  in delhi pptApparels  in delhi ppt
Apparels in delhi ppt
 
A theoretical study of the structure and vibrations of 2,4,6 trinitrotoluene
A theoretical study of the structure and vibrations of 2,4,6 trinitrotolueneA theoretical study of the structure and vibrations of 2,4,6 trinitrotoluene
A theoretical study of the structure and vibrations of 2,4,6 trinitrotoluene
 
A theoretical study of the structure and vibrations of 2,4,6-trinitrotoluene
A theoretical study of the structure and vibrations of 2,4,6-trinitrotolueneA theoretical study of the structure and vibrations of 2,4,6-trinitrotoluene
A theoretical study of the structure and vibrations of 2,4,6-trinitrotoluene
 
Ed.tech2D
Ed.tech2DEd.tech2D
Ed.tech2D
 
UV raman evidence of a tyrosine in apo human serum transferrin with a low p k...
UV raman evidence of a tyrosine in apo human serum transferrin with a low p k...UV raman evidence of a tyrosine in apo human serum transferrin with a low p k...
UV raman evidence of a tyrosine in apo human serum transferrin with a low p k...
 
New Kids in Town 10-2013 EDITED
New Kids in Town 10-2013 EDITEDNew Kids in Town 10-2013 EDITED
New Kids in Town 10-2013 EDITED
 
impotance of technology in education
impotance of technology in educationimpotance of technology in education
impotance of technology in education
 

Similar to diabetesisamatteroffat

Obesity in European Children
Obesity in European ChildrenObesity in European Children
Obesity in European ChildrenQuinn Collor
 
Obesity & Metabolic syndrome
Obesity & Metabolic syndromeObesity & Metabolic syndrome
Obesity & Metabolic syndromeDr. Animesh Gupta
 
Life style choices presentation 2014
Life style choices presentation 2014Life style choices presentation 2014
Life style choices presentation 2014Kerry Harrison
 
Obesity by bijay [autosaved]
Obesity by bijay [autosaved]Obesity by bijay [autosaved]
Obesity by bijay [autosaved]BijayKumarMahato1
 
Obesity ,complication,metabolic syndrome by dr.Tasnim
Obesity ,complication,metabolic syndrome by dr.TasnimObesity ,complication,metabolic syndrome by dr.Tasnim
Obesity ,complication,metabolic syndrome by dr.Tasnimdr Tasnim
 
P488 obesity
P488 obesityP488 obesity
P488 obesitymjpol
 
Body_Composition
Body_CompositionBody_Composition
Body_Compositionmgsonline
 
Foreyt day1 pl3
Foreyt day1 pl3Foreyt day1 pl3
Foreyt day1 pl3chip2012
 
Obesity.ppt
Obesity.pptObesity.ppt
Obesity.pptShama
 
Effective treatment for obesity in Mindheal Homeopathy clinic ,Chembur, Mum...
Effective treatment for obesity   in Mindheal Homeopathy clinic ,Chembur, Mum...Effective treatment for obesity   in Mindheal Homeopathy clinic ,Chembur, Mum...
Effective treatment for obesity in Mindheal Homeopathy clinic ,Chembur, Mum...Shewta shetty
 
Nih causes of weight gain and obesity and strategies and help losing weight
Nih causes of weight gain and obesity and strategies and help losing weightNih causes of weight gain and obesity and strategies and help losing weight
Nih causes of weight gain and obesity and strategies and help losing weightPrab Tumpati
 

Similar to diabetesisamatteroffat (20)

Obesidad 2017
Obesidad 2017Obesidad 2017
Obesidad 2017
 
Obesity
Obesity Obesity
Obesity
 
Obesity in European Children
Obesity in European ChildrenObesity in European Children
Obesity in European Children
 
Obesity & Metabolic syndrome
Obesity & Metabolic syndromeObesity & Metabolic syndrome
Obesity & Metabolic syndrome
 
Life style choices presentation 2014
Life style choices presentation 2014Life style choices presentation 2014
Life style choices presentation 2014
 
Obesity by bijay [autosaved]
Obesity by bijay [autosaved]Obesity by bijay [autosaved]
Obesity by bijay [autosaved]
 
Obesity ,complication,metabolic syndrome by dr.Tasnim
Obesity ,complication,metabolic syndrome by dr.TasnimObesity ,complication,metabolic syndrome by dr.Tasnim
Obesity ,complication,metabolic syndrome by dr.Tasnim
 
Obesity
ObesityObesity
Obesity
 
Obesity surgery
Obesity surgeryObesity surgery
Obesity surgery
 
Ppt 1
Ppt 1Ppt 1
Ppt 1
 
P488 obesity
P488 obesityP488 obesity
P488 obesity
 
Obesity(2003)
Obesity(2003)Obesity(2003)
Obesity(2003)
 
Body_Composition
Body_CompositionBody_Composition
Body_Composition
 
Intro & etiology of obesity
Intro & etiology of obesityIntro & etiology of obesity
Intro & etiology of obesity
 
Foreyt day1 pl3
Foreyt day1 pl3Foreyt day1 pl3
Foreyt day1 pl3
 
Obesity.ppt
Obesity.pptObesity.ppt
Obesity.ppt
 
Effective treatment for obesity in Mindheal Homeopathy clinic ,Chembur, Mum...
Effective treatment for obesity   in Mindheal Homeopathy clinic ,Chembur, Mum...Effective treatment for obesity   in Mindheal Homeopathy clinic ,Chembur, Mum...
Effective treatment for obesity in Mindheal Homeopathy clinic ,Chembur, Mum...
 
Obesity
ObesityObesity
Obesity
 
Ross 5-7-15
Ross 5-7-15Ross 5-7-15
Ross 5-7-15
 
Nih causes of weight gain and obesity and strategies and help losing weight
Nih causes of weight gain and obesity and strategies and help losing weightNih causes of weight gain and obesity and strategies and help losing weight
Nih causes of weight gain and obesity and strategies and help losing weight
 

diabetesisamatteroffat

  • 1. 28th Annual Update in Medicine Conference Francisco J Cervantes MD FAAP Diabetes: It is a matter of Fat October 26, 2012 Laredo TX WWW.LaredoPediatrics.com
  • 2. America is facing an epidemic!! The U.S. is the fattest nation in the world. 64.5% of Americans are overweight or obese. Source: JAMA. 2002;288:1723-1727 Obesity is the second largest preventable cause of death in the U.S.! (Smoking is #1.) Source: JAMA 1996; 276: 1907-1950.
  • 3. Obesity Goes Global (Time Magazine August 25,2003)
  • 14. BMI History • The body mass index is a brainchild of a Belgian statistician and mathematician named Adolphe Quatelet who created the BMI sometime from1830 to 1850 Article Source: http://EzineArticles.com/125508
  • 15. BMI History • his project was intended to describe the standard proportions of the human build. • The equation was largely ignored by the medical community even though insurance companies began using somewhat vague comparisons of height and weight among policyholders beginning in the early twentieth century
  • 16. BMI History • Medical researchers searched for an accurate, uniform way to measure fatness for decades when in 1972, physiology professor and obesity researcher Ancel Keys published his “Indices of Relative Weight and Obesity,” a landmark study of more than 7,400 men in five countries. Keys considered the various height-weight formulas in existence and found Quetelet’s equation to be the best marker of body-fat percentage. He renamed this number the body mass index or BMI.
  • 17. BMI as Standard • BMI became an international standard for obesity measurement in the 1980s. The public learned about BMI the late 1990s, when the government launched an initiative to encourage healthy eating and exercise.
  • 18. DEFINITION OF OBESITY • By 1985, the National Institutes of Health began defining obesity according to body mass index. (27.8 for men and 27.3 for women) • Then in 1998, the NIH consolidated the threshold for men and women and added the category of overweight.
  • 19. BMI and healthy weight • In 1998, the NIH lowered the overweight threshold for BMI 27.8 to 25 to match international guidelines. • The move added 30 million Americans who were previously in the "healthy weight" category to the "overweight" category. • Today, the NIH advises doctors and their patients to include BMI in a complete assessment of a person's body size and overall health.
  • 20. Is BMI an Accurate Measure of Obesity? It's important to note that although BMI is accurate most of the time, it may overestimate or underestimate body fat. For example, BMI doesn't distinguish between body fat and muscle mass, which weighs more than fat.
  • 22. Waist and Hip Ratio waist-to-hip ratios are a much more accurate way of determining the kinds of body fat that might actually pose health risks.
  • 23. BodyMass Index (2-20 yrs) Underweight Normal weight At risk of overweight Overweight Obese BMI < 5th %tile BMI 5th to < 84th %tile BMI 85th to < 94th %tile BMI ≥ 95th %tile BMI > 99th %tile
  • 24. Weight and Height Assessment • Before 1980, doctors generally used weight- for-height tables -- one for men and one for women -- that included ranges of body weights for each inch of height. These tables were limited because they were based on weight alone.
  • 26. BMI scale for Adult Population
  • 27. Body Mass Index  2003: AAP recommended that pediatricians calculate and plot the BMI of all children and adolescents yearly  Yet, only a minority of pediatricians routinely use BMI  Adoption of BMI use is less than optimal  Many prefer to rely on “visual impression” to diagnose overweight
  • 28. Advantages of BMI-for-Age  BMI-for-age relates to health risk  Correlates with clinical risk factors for cardiovascular disease including hyperlipidemia, elevated insulin, and high blood pressure  BMI-for-age during pubescence is related to lipid levels and high blood pressure in middle age
  • 31. BMI in Children: the tricks
  • 32. BMI CHART WITH 97 PERCENTILES
  • 34. BMI screening shortcomings • Why is there insufficient evidence of its effectiveness? • Screening ALONE is insufficient to improve clinical outcomes • Screening needs to trigger other actions – Treatment algorithms – Reviewing family history – Identifying high risk behaviors related to diet and physical activity – Screening for comorbidities
  • 35. BMI AND OBESITY The National Institutes of Health (NIH) recommends that doctors assess whether their patients are overweight based on three factors: • BMI • Waist circumference measures of abdominal fat • Risk factors for diseases associated with obesity, such as high blood pressure, high LDL ("bad” cholesterol), low HDL ("good" cholesterol), high blood sugar, and smoking
  • 36. A Rational Approach August 2002: Modified Diet, basically: lower sugar intake, more protein and vegetables, diet drinks or water. Blood work and diet recommended at school to Overweight kids and close f/u September 2003: Results of First 1000 classified patients April 2004: Update to 3000 patients
  • 39. Local Experience •2116 patients, about equally divided, boys (1041, 49.2%) and girls (1075, 50.8%) •First generation American-born children of Hispanic descend. •Patients were followed because of changes in BMI then the discovery of the fatty liver and subsequently Gallbladder disease. • All patients have at least one metabolic screen. •BMI groups normal BMI 75, 85, 95,97 and ≥99 WWW.Laredopediatrics.com
  • 40. Screening • CMP, GGT, Lipid profile, Liver Function Test: Alkaline phosphatase, ALT, AST, Bilirubin, • HbA1c, Insulin, THS and T4 • Biometric information; Weight, Height, BMI, Waist and hip circumference and Percentage of body fat • Blood pressure • Ultrasound of the liver if altered liver enzymes, or complaining of RUQ pain or discomfort
  • 41. TOTAL TESTS DONE PER PATIENT BOYS n Tests % Tests NL 213 162 76.1 85 81 85 104.9 90 153 182 119.0 95 73 125 171.2 96 79 137 173.4 97 130 243 186.9 98 141 311 220.6 99 71 168 236.6 99+ 164 307 187.2 TOTAL 1105 1720 155.7 GIRLS n TESTS % Tests NL 289 323 111.8 85 156 162 104.5 90 201 356 177.1 95 59 120 203.4 96 56 111 198.2 97 97 197 203.1 98 142 258 181.7 99 65 128 196.9 99+ 87 105 120.7 TOTAL 1152 1860 161.5 2012
  • 42. 0 50 100 150 200 250 300 NR Risk ≥ 95 ≥ 97 ≥ 99 Male # of Patient Female # of Patient Total number of patient distributed according to the BMI group and sex
  • 43. Statistical Analysis of BMI Distribution
  • 49. Adipocytes as an endocrine organ • Increasing adiposity leads to increasing levels of “adipokines” • Adipocyte-derived inflammatory markers that act in pro- and anti-inflammatory pathways • Macrophages found in adipose tissue likely have a role in the obese-inflammatory state and its related disease Obesity is a state of chronic inflammation!! Pediatric Clinics of North America Pediatr Clin Am 53 (2006) 777-794
  • 50. Changes in weight and its effects
  • 51. Are they Taller? BOYS GIRLS Age N Percentile Age N Percentile Normal 6.37 34 15 9.37 48 15 Risk OW 8.27 82 35 8.67 86 25 Obese 7.89 223 25 8.12 196 45 Morbid 9.17 57 65 7.44 47 65 TOTAL 396 377
  • 54. Insulin by Age in Normal BMI 2005 n= 86 n= 127
  • 56. Insulin by Age and NL BMI
  • 58. Insulin in Normal BMI Children Age in years
  • 60. Incidence of Type II Diabetes in Laredo Pediatrics & Neonatology (11 yr follow up)
  • 73. Source: Pediatric Clinics of North America 2011; 58:1375-1392 ( Pathophysiology of Fatty Liver
  • 74. women—especially pregnant, use of hormone replacement therapy, or birth control pills (decrease gallbladder movement) people over age 60 (As people age, the body tends to secrete more cholesterol into bile) American Indians (Pima Indians of Arizona, 70% of women have gallstones by age 30) Mexican Americans overweight or obese ( Bile salts Cholesterol GB emptying people who fast or lose a lot of weight quickly people with a family history of gallstones (possible genetic link) people with diabetes (high levels of fatty acids called triglycerides) people who take cholesterol-lowering drugs Who is at risk for gallstones? The Classic 4 F’s still apply: Female, Fertile, Forty, Fat
  • 75. Development of Cholecystitis 75 Percentile Factor Abnormal values by Percentile Boys Girls TGL 75% 85% HDL 90% 85% Glucose 50% 75% Insulin 50% 75%
  • 77. Adiposity: Gained and lost 20 lbs in a couple of months
  • 80. Is Practice, and practice, and practice, and practice, and practice……..
  • 82. Slipped capital femoral epiphysis (SCFE) The ball at the upper end of the femur (thigh bone) slips off in a backward direction. Due to weakness of the growth plate. Most often, it develops during periods of accelerated growth, shortly after the onset of puberty is an unusual disorder of the adolescent hip It is not rare. TYPES: • Stable SCFE. This is referred to as a "mild slip," which causes some stiffness or pain in the knee or groin area, and possibly a limp • Unstable SCFE. This is a more severe usually much more painful, unable to bear weight on the affected side, ROM severely limited, leg turns outward, is more serious because it can restrict blood flow to the hip joint, leading necrosis
  • 83. Slipped capital femoral epiphysis (SCFE) Risk Factors: • The cause of SCFE is unknown. It occurs two to three times more often in males than females. A large number of patients are overweight. • In most cases, is a slow and gradual process. However, it may occur suddenly and be associated with a minor fall or trauma. • Symptomatic SCFE, treated early and well, allows for good long-term hip function Symptoms: • Weeks or months of hip or knee pain and an intermittent limp • walks with a limp. In certain severe cases, unable to bear any weight on the affected leg • affected leg is usually turned outward in comparison to the normal leg • affected leg may appear to be shorter
  • 84. Slipped Capital Femoral Epiphysis (SCFE) Normal anatomy Types of SCFE
  • 85. 14 yr old with SCFE
  • 86. Is not only elasticity
  • 89. Ecological Predictors of Childhood Obesity Source: Pediatric Clinics of North America 2011; 58:1333-1354 (DOI:10.006 )
  • 90. Socio-environmental Model Pediatric Clinics of North America Volume 58, Issue 6 , Pages 1403-1424 , December 2011
  • 91. Recommendations from the AAP For providers to implement in primary care settings: • Routinely document BMI and assess children for obesity. • Deliver messages about healthy eating and activity behaviors to all children and families, regardless of children’s weight status. • Establish practice procedures for addressing overweight and obesity (e.g., determine, medical assessments to review, and flag charts of overweight and obese children to indicate need for intervention). • Involve and train interdisciplinary teams. • Audit charts to identify current practices and goals for improvement, and assess improvement over time.
  • 92. Recommendations from the AAP For providers to discuss with families: • Limit sugar-sweetened beverages. • Increase vegetables and fruits (at least 9 servings per day). • Limit television and other screen time (no television for children younger than 2 years, less than 2 hours per day for children older than 2 years), and remove televisions from children’s sleeping areas. • Eat breakfast every day. • Limit meals eaten out at restaurants. • Increase family meals (parents and children eat together). • Limit portion sizes
  • 93. But, I only eat like a bird!
  • 96. PEPPERONI PIZZA 20 Years Ago Today 500 calories 850 calories Calorie Difference: 350 calories playing golf while walking and carrying your clubs for 1 hour you will burn approximately 350 calories. (based on a 160 lbs person)
  • 100. Facts About Diabetes  80% in our children has at least 1 close relative with diabetes 10% has one of the parents with diabetes 1% has both parents with diabetes Mexican American have poor tolerance to carbohydrates As the intake of carbohydrates increases so are the levels of insulin, visceral fat and acanthosis. THE GOOD NEWS: IT IS REVERSIBLE!!
  • 101. MAXIMUM DAILY TOLERANCE OF CARBOHYDRATES IN MEXICAN AMERICAN CHILDREN 50 – 100 GRAMS OF CARBOHYDRATES 3 Fruits (10X 3 = 30 grams) a banana accounts for 30 to 40 grams 1 cup plain cereal = 30 grams 2 to 3 glasses of 8 oz of regular milk = 30 grams ( Regular = 10; 2% 11; Skim 15 grams)
  • 103. DON’T STARCH YOURSELF Pasta, Rice, Beans, Cereal, Chips, Pizza, Tortilla, Bread, Of course Cake, Cookies, Doughnuts; Don’t even mention sodas, sweetened beverages and sport drinks
  • 106. Hippocrates Master of Medicine: 460-377 B.C “Thus Curiosity, Keenness of observation and the value of scrupulous record keeping became paramount priorities in the new philosophy of Care” Sherwin B Nuland describing Hippocrates Influence on Medicine