miti, presunzioni ed evidenze in obesità...
TRANSCRIPT
Gestione multidisciplinare e integrata tra ospedale e territorio del paziente sovrappeso-obeso in età pediatrica
Trento, sabato 16 maggio 2015
Miti, presunzioni ed evidenze in obesità pediatrica
Claudio Maffeis
UOC Pediatria ad Indirizzo Diabetologico e Malattie del MetabolismoCentro Regionale Specializzato in Diabetologia Pediatrica
AOUI e Università di Verona
Prevalenza di sovrappeso ed obesità nei bambini di 8-9 anni in Italia
Okkioalla Salute 2014
Overweight
0,0%
5,0%
10,0%
15,0%
20,0%
25,0%
National reference I.O.T.F. C.D.C.
males
females
totale
Obesity
0,0%
2,0%
4,0%
6,0%
8,0%
10,0%
12,0%
14,0%
16,0%
18,0%
National reference I.O.T.F. C.D.C
males
females
totale
Prevalenza di sovrappeso e obesitàin Italia tra I 2 ed I 6 anni
Maffeis C et al. Obes Res, 2006
Il bambino obeso “brucia” meno calorie rispetto al bambino normopeso:
Ingrassa perché ha un difetto termogenetico!
total energy expenditure in normal weight
and obese prepubertal children
0
500
1000
1500
2000
2500
energy
expenditure
(kcal/day)
Nonobese Obese
Bandini & Dietz, Maffeis & Schutz, Butte NF, etc.
P<0,01
kcal/day
2,000
1,000
0
components of the total daily energyexpenditure of a 10-year-old boy
Thermogenesis
BMR
EEActivity
EEGrowth
60 %
10 %
30 %
< 2 %
energy
expenditure
adjusted for FFM
(kcal/day)
energy
expenditure
(kcal/day)
Maffeis C, et al. Int J Obes ‘92
1,000
1,300
1,000
1,300
basal energy expenditure of 9-year-old children
p = ns
p < 0.05
obese post-obese never-obese
obese
%
meal
energy
6
3
0
meal-induced thermogenesis
p = ns
Molnar D et al. Eur J Pediatr ‘85
Maffeis C et al. Eur J Clin Nutr ‘92
post-obese never-obese
Il bambino ha bisogno di tanta energia per crescere
Spesa energetica per l’accrescimento
Il bambino obeso non ha un vero problema di salute: ha solo qualche chilo di troppo!
ACCUMULO
ECTOPICO DI GRASSO
OBESITÀ
INFIAMMAZIONE
INSULIN RESISTANCE
INSULINORESISTENZA
SINDROMEMETABOLICA
a
*
** m
d
dd
dd
a
Franzese A, Vajro P, et al.
Dig Dis Sci 1997
Sbarbati M, Maffeis C, et al. Pediatrics 2006
Ipertensione
dislipidemia
IGT – T2D
Basta un po’ di volontà e il peso in piùsi perde facilmente!
primary care surveillance and intervention for overweight or obese 5-
10-year-old children: the LEAP 2 randomised controlled trial
INTERVENTION4 standard consultations over 12 weeks targeting change
in nutrition, physical activity, & sedentary behaviour, supported by purpose designed family materials
BMI(kg/m2)
15
20
25P = ns
intervention control
baseline
6 months
12 months
primary care screening followed by brief counselling is not effective In overweight or mildly obese children and it would be very costly if universally implemented
Wake M, et al BMJ 2009
Two-year Follow-up in 21,784 Overweight Childrenand Adolescents With Lifestyle Intervention
100
80
60
40
20
0
(%)
lost of
follow-up
SDS BMI
reduction
<0.5
SDS BMI
reduction
>0.5
Reinehr T, et al Obesity 2009
time (months)
6 12 24 6 12 24 6 12 24
100
80
60
40
20
0
(%)
lost of
follow-up
SDS BMI
reduction
<0.5
SDS BMI
reduction
>0.5
time (months)
6 12 24 6 12 24 6 12 24
129 treatment centers 5 centers with the highest success rate
Se un bambino nasce con basso peso bisogna alimentarlo con abbondanza per fargli recuperare presto il peso….. in difetto!
Fattori di rischio di obesità
Peso alla nascita
Peso a termine (kg)4.52.5
Odds ratio for childhood obesity by infant weight gain between 0 and 1 year adjusted for sex, age, a weight
Lakshman R, et al. Circulation 2012;126:1770-9.
Velocità di crescita primo anno
Lunghezza (cm)7545 6555
Peso (kg)
0
12
8
4
Se il latte della mamma scarseggia, diamo il latte di vacca che è buono e fa crescere bene!
FORMULA PROTEIN CONTENT AND WEIGHT GAIN
A RANDOMIZED CLINICAL TRIAL
Age(months)1 3 6 12 24
Weight/Lenght
(z score)
1.0
0.5
0
-0.5
-1.0
*
* High protein formula
Human Milk
Low protein formula
Socha P, et al. Am J Clin Nutr. 2011;94(6 Suppl):1776S-1784S
Se il bambino viene allattato al seno non diventerà mai obeso!
2013;368:446-54.
“…. Although existing data indicate that breast-feeding does nothave important antiobesity effects in children, it has otherimportant potential benefits for the infant and mother and shouldtherefore be encouraged. “
BREAST-FEEDING AND OBESITY
Se il piccolo ha tanta fame e cresce bene posso introdurre gli alimenti solidi anche presto, dopo i primissimi mesi di vita
Timing of Solid Food Introduction and Risk of Obesity in Preschool-Aged Children
Huh SY, et al. Pediatrics 2011;127:e544
Una caloria è una caloria: poco importa se è da proteine, grassi o carboidrati
nutrient requirements
Age (years)
0
350
0 186 12
g/day
250
150
50
carbohydrate
lipid
protein
50
25
0
fatmass(%)
10 30 50
lipid intake (% of energy intake)
Maffeis C et al. Int J Obes ‘96
r = 0.28 P< 0.01
Gazzaniga JM, et al.AJCN ‘93
Klesges RC et al. AJCN ‘94
fatty foodmore palatable
high energy density
less satiating
covert manipulation of dietary fat and energy density: effect on substrate flux and food intake in men eating ad libitum
0
- 5
0
5
10
15
1 2 3 4
fat balance
time (days)
Stubb RJ, et al. AJCN 1995; 62:316-29.
- 10
20
5 6 7 0
- 5
0
5
10
15
1 2 3 4
energy balance
time (days)
- 10
20
5 6 7
MJ MJ
high fat
medium fat
low fat
dietary pattern prospectively associated with increased adiposityduring childhood and adolescence
Ambrosini GL, et al. Int J Obes 2012;36:1299-1305
High RiskDietary Pattern
Energy-denseHigh-fatLow-fiber
high-fibre, low-fat diet predicts long-term weight loss and decreased type 2 diabetes risk: the Finnish Diabetes Prevention Study
Lindstrom J, et al. Diabetologia 2006
1
0
Hazard ratiofor Diabetes *
low-fat/high fibre
low-fat/low fibre
high-fat/high fibre
high-fat/low fibre
•Adjusted for: group assignment, age, sex, baseline BW, fat & fibre intake,baseline 2-h glucose, baseline and follow-up period physical activity, weight change
2
3
4
5
6
Joint classification of whole- and refined-grain intake on visceral adipose tissue (VAT) volume
McKeown N M et al. Am J Clin Nutr 2010;92:1165-1171
-30 60 120 180 2400
MIXED
MEAL
Time (min)
60
90
120
150
Blood glucose and triacylglycerol postprandial profile
Plasma
glucose &
TAG
(mg/dl)triacylglycerol
glucose
60
70
80
90
100
110
120
130
140
0' 60' 90' 120' 150' 180' 240' 300'
LF meal
HF meal
Time (min)
TAG(mg/dl)
p< 0.05
Postprandial triacylglycerol profile after two isocaloric, isoproteicmeals with different fat and carboidrate content in obese children
Maffeis C, et al. Obesity 2010
0 100 200 300
140
120
100
80
60
Fat/Carbohydrate
Fat/Carbohydrate
65
75
85
95
(U/l)P<0.05
P = ns
ox-LDL
Maffeis C, et al. Nutr Metab Cardiovasc Dis 2011
POSTPRANDIAL PRO-ATEROGENIC PROFILE: change of oxidized lipoprotein concentration in obese children after two isocaloric, isoproteic meals with a different fat and carbohydrate content
Fat/Carbohydrate
Fat/Carbohydrate
Time (h)0 5
Per calare si deve fare attivitàfisica ad elevata intensità!
Bravata DM, et al. JAMA 2007;298:2296-304.
Using pedometers to increase physical activity and improve health
Efficacy of a 12 Weeks Exercise Program withoutDiet in Reducing Obesity in Men
Ross R, et al. Ann Intern Med. 2OOO;133:92-1O3.
0 - 2 - 8- 4 - 6
Body weight (kg)
Waist circumference (cm)
Body fat (kg)
Subcutaneous abdominal fat (kg)
Visceral abdominal fat (kg)
- 10
Exercise: brisk walking/light jogging, 80% max HR, 700 kcal/day.
VO2max (L/min)
energy expenditure during walking and running in obese and nonobese prepubertal children
0 2 4 6 8 10
0
2.5
5
10
speed (km/h)
METs
7.5
Maffeis C, et al. J Pediatrics 1993
OBESE
NONOBESEP<0.05
the role of free-living daily walking in human weight gain and obesity
Levine JA et al. Diabetes 2008
Maffeis, C. et al. JCEM 2005;90:231-236
Nutrient oxidation measured during walking at speeds of 4, 5, and 6 km/h, respectively, in a group of obese prepubertal children
Lee D, et al. J Am Coll Cardiol 2014;64:472-81
Leisure-Time Running Reduces All-Cause and CardiovascularMortality Risk In a 15-year follow-up
Lee D, et al. J Am Coll Cardiol 2014;64:472-81
Leisure-Time Running Reduces All-Cause and CardiovascularMortality Risk In a 15-year follow-up
Running, even 5 to 10 min/day and atslow speeds <6 miles/h, is associatedwith markedly reduced risks of death
from all causes and cardiovasculardisease
Non preoccupiamoci: se la “dieta” fallisce ci sono farmaci e chirurgia
Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent
Overweight & Obesity: Summary Report
Barlow SE & the Expert Committee Pediatrics 2007 (suppl.) (modified)
Obiettivi comportamentali della terapia
Allattamento al seno
Colazione
Pasti consumati in famiglia (vs Fast Food)
Alimentazione bilanciata in nutrienti (RDA)
Frutta e vegetali, Fibra
Densità energetica dei cibi e dei pasti
Porzioni
Bevande zuccherate
(Calcio)
Video-esposizione
Attività fisica
Take home message
L’obesità è una malattia, che va prevenuta e
curata con attenzione.
Gli obiettivi per l’intervento sono chiari.
Gli strumenti: accanto all’alimentazione, l’attività
fisica svolge un ruolo di assoluto rilievo.
Il risultato potrà essere favorevole nel medio-lungo
termine solamente se famiglia, pediatra, scuola (e
società) collaboreranno attivamente e con
pazienza allo scopo.
VIII° CONGRESSO NAZIONALE:
NUTRIZIONE, METABOLISMO E DIABETE NEL BAMBINO E NELL’ADOLESCENTE
La pediatria dà i… “numeri”?
Hotel CTC Best Western
Verona, 25-26 settembre 2014
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