Prof Louis Baur - Obesity Epidemic in a pandemic era.pdf

July 2022, 5th Nutrimet Update, Indonesia
Louise A Baur AM, FAHMS
Chair of Child & Adolescent Health, University of Sydney
National Health & Medical Research Council Leadership Fellow
Consultant Paediatrician, Weight Management Services, Sydney
Children’s Hospitals Network
President, World Obesity Federation
Email: louise.baur@health.nsw.gov.au
Obesity: Epidemic in a pandemic era

The University of Sydney
Child and adolescent obesity: prevalent globally -
and in Indonesia

Global prevalence of overweight & obesity: boys 5-19y
World Obesity Federation Global Obesity Observatory
https://data.worldobesity.org/maps/?group=B&year=2020
Data from the World Obesity Federation, working
with the NCD Risk Factor Collaboration

Available at: https://www.worldobesity.org/nlsegmentation/global-atlas-on-childhood-obesity
Year 2020 2025 2030
World 158m 206m 254m
And where do
they live?
Numbers of children & adolescents aged 5-19y globally
with obesity: Predicted numbers to 2030
Estimated 160%
increase in 10 years

Countries predicted to have >1 million school-age
children and youth living with obesity in 2030
Of these “top”
42 countries, 35
are low or
middle income
countries.
Indonesia is #4
Available at:
https://www.worldobesity.org
/nlsegmentation/global-
atlas-on-childhood-obesity

Under 5s,
globally
*Di Cesare M et al. BMC 2019; 17:212; Institute
of Health Metrics & Evaluation analyses
The prevalence of
obesity in under
5s has increased
Obesity prevalence (IOTF
definition) for boys aged
2-4 y, 1980 vs 2015*
1980
2015

Trends in prevalence of overweight in Indonesian children
aged 2.0 - 4.9 years – increasing, while measures of
undernutrition are decreasing
Rachmi CN, et al. PLoSOne
2016; 11(5): e0154756.
10.3 (8.5-12.5) 10.6 (8.8-12.8)
11.7 (9.8-13.9)
16.5 (14.6-18.6)
P for trends <0.05
Overweight/obesity: BMI for age Z-score >+2
“At risk”: BMIz +1 to +2
Data from the Indonesian Family Life Survey

COVID and obesity in children and adolescents

Obesity is associated with more severe COVID illness –
in children and adolescents, not just in adults
➢ Severe COVID - hospitalisation, ICU admissions, death -
occurred more commonly in adults with obesity, but also in
children and adolescents with more severe obesity
➢Data now from multiple countries

Data from >800 US hospitals & >43,000 patients aged ≤18y with
COVID-19 who had an Emergency Dept/inpatient encounter, Mar
2020-Jan 2021 - Hospitalisation risk*
Adjusted risk
ratio 3.07
*Kompaniyets L et al. JAMA Netw Open 2021 June 1; 4(6):e2111182
Adjusted risk ratios shown; reference group for each underlying condition was absence of that condition
Adjusted for age, sex, group, race, payer type, hospital urbanicity & US Census region, admission month, underlying conditions

* ICU admission, admission to stepdown unit, invasive
mechanical ventilation, death
Severe illness when hospitalised*
Adjusted risk
ratio 1.42
*Kompaniyets L et al. JAMA Netw Open 2021 June 1; 4(6):e2111182
Adjusted risk ratios shown; reference group for each underlying condition was absence of that condition
Adjusted for age, sex, group, race, payer type, hospital urbanicity & US Census region, admission month, underlying conditions

COVID-associated restrictions associated with an
increased prevalence of overweight & obesity in
children and adolescents in several countries

COVID restrictions associated with increased
obesity prevalence
• Documented in many countries e.g. US, China, Europe
• Why? The COVID-19 pandemic & its associated restrictions have:
oIncreased the frequency of food insecurity - food supply
chain workforce disproportionately impacted
oIncreased rates of physical inactivity
oPrompted a shift to ultra-processed foods
oIncreased levels of individual & family stress & mental
health problems
oHighlighted inequitable access to health care
oBeen felt especially by the unemployed/ those with poor
working conditions and experiencing many other inequities
* Pryor S, Dietz W. Current Obesity Reports 2022

Lessons for now and the future
– COVID vaccination: Prioritise those with
obesity
– Address structural inequalities,
recognising that severe COVID outcomes,
obesity & chronic diseases, food insecurity and
other inequalities are linked
– Invest in children & young people, who
bear a disproportionate burden of COVID
restrictions

Recognising overweight & obesity in the first place

Firstly – do routine growth assessments in order to
recognise overweight or obesity
Girl aged 6 years
Weight 33 kg
Height 120 cm
BMI 22.9 kg/m2
Above 95th centile for age
range
Patient’s BMI is in the
obesity range (“well above
the healthy weight”)
x
http://www.cdc.gov/GROWTHCHARTS/

Same child 6 months later
after family-focused lifestyle
intervention
Weight unchanged
Height  3 cm
→ Weight maintenance may
have an important impact on
BMI in growing children
http://www.cdc.gov/GROWTHCHARTS/

Waist:height ratio
• Easy to calculate
• Values >0.5 (for people >6 y) associated with
increased cardio-metabolic risk
McCarthy HD. Int J Obes 2006; 30: 988–992; Garnett SP et al. Int J Obes 2008; 32, 1028–1030

• Easy to calculate
• Values >0.5 (for people >6 y) associated with
increased cardio-metabolic risk
• “Keep your waist to less than half your height”
McCarthy HD. Int J Obes 2006; 30: 988–992; Garnett SP et al. Int J Obes 2008; 32, 1028–1030
Waist:height ratio

Secondly, raise the issue in a supportive, non-
stigmatising way

Raising the issue
• You are seeing a child for an apparently unrelated reason
(e.g. asthma, otitis media) and think the child may have a
weight issue….. How do you raise the issue?
• Clinical practice guidelines recommend ….
– Routinely measuring height & weight, calculating BMI, and plotting
on growth chart
– Discussing growth chart sensitively with parent/young person
2013 Australian NHMRC Clinical Practice Guidelines for the Management of Overweight & Obesity
Barlow SE and the Expert Committee of the AAP. Pediatr 2007; 120:S164-S192

• “I’ve plotted weight adjusted for
height here on the growth chart….
You can see that it’s above the healthy
range for age…. Does that surprise
you? …. Would you like to discuss it?”
• Then recommend a further
consultation to start addressing the
weight issue
• Could the primary reason for the
consultation be related to weight?
(e.g. asthma, enuresis, fracture, lower limb
pain, sleep disturbance …)
• If so, then highlight its importance
• Are there existing
problems associated
with excess weight?
• Start to explore or
investigate these
x

What treatment approaches should clinicians offer
children and adolescents with obesity?

Standard weight management
- Family engagement - Developmentally appropriate
- Long-term behaviour change - Change in diet & eating habits
- Increased physical activity - Decreased sedentary behaviours
- Improved sleep patterns
Additional therapies
- More intensive diets - Drug therapies
- Bariatric surgery
Elements of obesity management in children &
adolescents
Management of obesity-associated complications
Long-term weight maintenance strategies
AAP Clinical Algorithm, 2015; Barlow S & Expert Committee. Pediatrics 2007;120:S164–92; Baur LA et al. Nature Rev
Gastroenterol Hepatol 2011;8:635–45; NICE Obesity Guideline, 2014; NHMRC Clinical Practice Guidelines, 2013;
SIGN Guidelines, 2010; Steinbeck KS et al. Nature Rev Endocrinol 2018;14:331–44.

Interventions for treating children & adolescents with
obesity: an overview of Cochrane reviews*
o 6 separate reviews:
o Small reductions in body weight status for most behaviour change
interventions. Multicomponent behaviour change interventions may be
beneficial
<6y: 7 trials Mean BMIz reduction -0.3
6-11y: 70 trials Mean BMIz reduction -0.06; BMI reduction -0.53kg/m2
12-17y: 44 trials Mean BMI reduction -1.18kg/m2
Parent only interventions in
5-11y: 20 trials
Similar effects to parent-child interventions
Surgery: 1 trial
Drugs: 21 trials
Modest to moderate outcomes for behavioural interventions dependent
upon age groups
*Ells L et al. Int J Obesity 2018; 42:1823-1833

Multicomponent interventions vs control; ≤6 y; change in BMI z score
At end interv’n
(6-12 mo.)
6-8 mo. post
interv’n
Colquitt JL et al. Cochrane, 2016

Some practical examples of behavioural change

Available for free in 14 community languages
See this and other resources at:
pro.healthykids.nsw.gov.au
Available in English and in Arabic,
Burmese, Chinese (simplified and
traditional), Farsi, French, Hindi,
Karen, Korean, Nepali, Swahili,
Thai and Vietnamese
8 Healthy Habits: Core
messages for
anticipatory guidance
developed for clinicians
in New South Wales,
Australia

Changes in food intake
–Follow national nutrition guidelines
–Meal patterns:
–Regular meals; eat together as a family; decreased portion sizes; eat
breakfast
–Dietary intake:
–Nutrient-rich foods that are lower in energy and GI; vegetables;
healthier snacks; sugary drinks; drink water
–Whole-of-family lifestyle change:
–Includes engagement of the person who buys and cooks the food; role
modelling of parents vital
–Involvement of a dietitian, especially re prescribed menu
plans and diet
Barlow SE and the Expert Committee of the AAP. Pediatr 2007; 120:S164-S192; Dietz WH & Robinson TN. NEJM 2005;
352:2100-2109; Whitaker RC. Arch Pediatr Adoles Med 2003; 157:725-727.

Physical activity & sedentary behaviours
–Increased physical activity
–Aim for increase in incidental or unplanned activity eg walking or cycling to/from
school, household chores, playing with friends /family…
–Organised exercise programs and sports
–Choose activities that are fun & sustainable
–Explore access to recreation equipment or spaces
–Addressing screen time
–Aim to limit TV and other recreational small screens (in various forms) to <2
hours per day
–TV/screens out of the bedroom
–Parental involvement & role modelling crucial
–Involvement of an exercise professional (exercise scientist or
physiotherapist) where available
Barlow SE and the Expert Committee of the AAP. Pediatr 2007; 120:S164-S192; Dietz WH & Robinson TN. NEJM 2005;
352:2100-2109; Whitaker RC. Arch Pediatr Adoles Med 2003; 157:725-727.

Sleep behaviours
–Regular sleep routines
–Bedtime routines
–Sleep time and wake times
–Address screen behaviour
–TV/screens out of the bedroom
–Limit screen exposure prior to sleep time
–Parental involvement & role modelling crucial

Some key behavioural change strategies
–Goal setting
–Both behaviours and weight can be targeted; may require ++ session time to
plan and review
–Example: I will not buy any cookies or soda drinks during the weekly shopping. To make this easier,
I will leave the children at home and shop on my own. If the children ask for junk food, then I will
offer fruit instead.”
–Stimulus control
–Modifying or restricting environmental influences
–Example: not eating in front of the TV; not having TV in bedrooms; using smaller plates and
spoons; not storing unhealthy food choices in the house
–Self-monitoring
–Detailed recording of a specific behaviour
–Examples: Food diary, TV/screen use diary, daily pedometer measurement of physical activity,
weekly weighing
Baur LA et al Nature Rev Gastroenterol Hepatol 2011; Epstein LH et al Pediatrics 1998; 101:554-570; Dietz WH & Robinson
TN. NEJM 2005; 352:2100-2109; Saelens BE & McGrath AM. Child Health Care 2003; 32:137-152; Jebeile H Lancet Diab
Endocrinol 2022.

Available for free in 13 community languages
See this and other resources at:
Available in English and in Arabic,
Burmese, Chinese (simplified and
traditional), Farsi, French, Hindi,
Karen, Korean, Nepali, Swahili,
Thai and Vietnamese
8 Healthy Habits: Core
messages for
anticipatory guidance
developed for clinicians
in New South Wales,
Australia

What about treatment of those with moderate to severe
obesity?

Standard weight management
- Family engagement - Developmentally appropriate
- Long-term behaviour change - Change in diet & eating habits
- Increased physical activity - Decreased sedentary behaviours
- Improved sleep patterns
Additional therapies
- More intensive diets - Drug therapies
- Bariatric surgery
Management of obesity-associated complications
Long-term weight maintenance strategies
AAP Clinical Algorithm, 2015; Barlow S & Expert Committee. Pediatrics 2007;120:S164–92; Baur LA et al. Nature Rev
Gastroenterol Hepatol 2011;8:635–45; NICE Obesity Guideline, 2014; NHMRC Clinical Practice Guidelines, 2013;
SIGN Guidelines, 2010; Steinbeck KS et al. Nature Rev Endocrinol 2018;14:331–44.
Elements of obesity management in children &
adolescents

More intensive diets?
• Include:
o very low energy diets (VLEDs)
o specific macronutrient changes (e.g. low CHO, higher PRO
o intermittent energy restriction (various forms)
• Require specialist dietitians
• VLEDs: Potential for greater initial weight loss, used as pre-op
therapy in bariatric surgery, can lead to remission of T2DM in
adults
Steinbeck KS et al. Nature Rev Endocrinol 2018; 14:331-44.

• SHAKE IT study: adolescents with obesity and T2D (n=8)
• VLED for 8 weeks, then transition to a hypocaloric diet until 34
weeks
More intensive diets?
T2D, type 2 diabetes; VLED, very low-energy diet.
Gow M et al. Diabetologia 2017;60:406–15.
Gow ML et al. Diabetes Metab Syndr Obes 2021; 14:215-225
Andela S et al. . Obesity Reviews 2019; 20: 871-882.
Individual participant
5.0
0
2.5
–7.5
–2.5
–12.5
–10.0
–15.0
– 5.0
8 Weeks
34 Weeks
Percentage weight loss in adherent
participants
4 of the 5 adherers had remission of T2D at 34
weeks
Weight
loss
(%)
–15.0
5.0
0
2.5
–7.5
–2.5
–12.5
–10.0
– 5.0
Individual participant
Percentage weight loss in
non-adherent participants
Is there a role for VLEDs in
your management of
adolescents with moderate
to severe obesity?

95% remission in type 2 diabetes at 3y
• Teen-Longitudinal Assessment of Bariatric Surgery (Teen LABS)
• Prospective enrolment of 242 adolescents undergoing bariatric surgery in 5
US centres
• Largely Roux-en-Y gastric bypass or sleeve gastrectomy
Bariatric surgery improves weight and cardio-metabolic outcomes
in adolescents with severe obesity
Inge TH et al. New Engl J Med 2016;374:113–23.
–40
0
5
–10
–5
–20
–15
–30
–25
–35
3.0
2.0
1.0
0.5
0
Change
from
baseline
(%)
Years of follow up
Weight change from baseline
Sleeve
Bypass Bypass
Participants
(%)
3.0
2.0
1.0
0.5
0
Years of follow up
60
40
30
10
50
90
100
70
80
20
0
Prevalence of dyslipidaemia
Sleeve
Needs youth-
friendly,
bariatric
surgery
teams & long-
term follow-
up

Obesity pharmacotherapy
• A small, although growing, number of anti-obesity
medications approved for use in adults
• Few approved for use with youth – more in the US
than other jurisdictions
• Most use in adolecents is off-label
• FDA-approved for use in adolescents: orlistat,
phentermine, liraglutide
• *Not FDA-approved but off-label use “commonly
prescribed by trained providers”: metformin,
topiramate, exenatide, lisdexamfetamine
• GLP-1 receptor agonists likely to change adolescent
obesity management practice over the next few years
*Srivastava G et al. Obesity 2019; 27:190-204
Jebeile H etal. Lancet Diab Obesity 2022

There are barriers to delivering evidence-based care in
real-life settings

Barrier Potential intervention strategy
Poverty Focus on low-cost food alternatives
Provision of low cost physical activity alternatives
Culturally & linguistically diverse
patients
Culturally sensitive weight management advice
Learning disabilities &
developmental disorders
Greater family involvement
Intensive practical interventions
Involvement of specialist support services
Low literacy Minimise/eliminate written material
Simple key messages
Frequent phone support
Family in crisis Crisis intervention
Case management until the situation stabilises
Additional support services
Psychiatric disorders Mental health treatment & support services
Case management until the situation stabilises
Minshall GA, Davies F, Baur LA. Behavioral management of pediatric obesity. In: Ferry RJ Jr (Ed). Management of Pediatric
Obesity and Diabetes. New York: Humana Press; 2011
Barriers to providing behavioural treatment in real-life
clinical settings

PLUS weight stigmatisation*
• Widely experienced
• Delivered by family members, teachers, peers, health
professionals/ health system, general public …
• Results in barriers to seeking & receiving treatment, and
worsens treatment outcomes
• Health system: Highlights the importance of:
– clinician role modelling
– using appropriate language
– ensuring a safe and welcoming environment
*Pont SJ et al. Pediatrics 2017; 40:e20173034 Rubino F et al. Nature Med 2020; 26:485-497.

Jackson-Leach R et al. Clinical Obesity 2020;10:e12357.
PLUS, in many regions/ countries
–Services are often poorly resourced
–Services may not be publicly funded
–Services may be poorly coordinated across primary, secondary
& tertiary care
–Health professionals may be inadequately trained
Other barriers to providing evidence-based treatments in
real-life clinical settings

Summary
• Measure height & weight routinely and plot on BMI for age
charts
• Use a developmentally appropriate approach
• Support for behaviour change is key
• For moderate to severe obesity in adolescents: There is a
role for drug therapy and for bariatric surgery
• Research is underway investigating the optimal, targeted
use of more intensive dietary interventions
• Current services are vastly under-resourced in most
countries
• Tackle weight stigma!

Acknowledgements
–The Children’s Hospital at Westmead:
Weight Management Services, Institute of
Endocrinology, Obesity Research Group
–Shirley Alexander, Ian Caterson, Chris
Cowell, Sarah Garnett, Alicia Grunseit,
Jo Henderson, Hiba Jebeile, Natalie
Lister, Gerri Minshall, Kate Steinbeck…
–NSW Ministry of Health staff
• WHO ECHO Commission Working Group
• World Obesity Federation colleagues
• University of Sydney: Prevention
Research Collaboration, Boden Centre,
Charles Perkins Centre
Thank you!
Healthy Kids for
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Prof Louis Baur - Obesity Epidemic in a pandemic era.pdf

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