obesity -- a weighty problem (dr. stanley bassin

ObesityObesityA Weighty ProblemA Weighty Problem

The “Top 10”

The Associated Press

The “Top 10” alternative reasons for obesity:

1. Inadequate sleep. (Average sleep amounts have fallen, and many studies tie sleep deprivation to weight gain.)


2. Endocrine disruptors, which are substances in some foods that might alter fats in the body.


3. Nice temperatures. (Air conditioning and heating limit calories burned from sweating and shivering.)


4. Fewer people smoking. (Less appetite suppression.)


5. Medicines that cause weight gains


6. Population changes. (More middle-agers and Hispanics, who have higher obesity rates.)


7. Older birth moms. (That correlates with heavier children.)


8. Genetic influences during pregnancy


9. Darwinian natural selection. (Fat people out survive skinny ones).

The “Top 10” alternative reasons for obesity

10. Assortative mating, or like mating with like,” Allison puts it. Translation: fat people procreating with others of the same body type, gradually skewing the population toward the heavy end.

Obesity Related MorbidityObesity Related Morbidity

• The estimated number of deaths attributable to obesity among US adults is approximately 280,000.

Obesity Related MorbidityObesity Related Morbidity

• The estimated number of deaths attributable to obesity for nonsmokers is approximately 325,000

ObesityObesity• AHA and NIH have recognized obesity as a major modifiable risk

factor for CHD

• Obesity is a risk factor for development of hypertension, diabetes, and dyslipidemia

• Obesity also linked to insulin resistance, particular intraabdominal fat estimated by waist circumference

The Theories of Obesity Fall Into The Theories of Obesity Fall Into Three CategoriesThree Categories

Genetic Influence of Human Variation Genetic Influence of Human Variation in Body Fatin Body Fat

Defining ObesityDefining Obesity

• Body Mass Index (BMI)= Weight divided by Height squared (kg/m 2).

• Normal Weight: 18.5 to 24.9

• Overweight: 25.0 to 29.9

• Obese I: 30.0 to 34.9

• Obese II: 35.0 to 39.9

• Obese III: > 40

Relationship Between Cardiovascular Disease Relationship Between Cardiovascular Disease and Their Risk Factorsand Their Risk Factors

Disease Risk Associated with Disease Risk Associated with Overweight and ObesityOverweight and Obesity

• “Disease risk in early life is associated with respiratory conditions and several risk factors for coronary heart disease and is predictive of hypertension, diabetes, coronary heart disease and all-cause mortality.”

• Other risk factors include certain types of cancers, high blood cholesterol level, gall bladder disease, and osteoarthritis.

Prevalence and Risk of ObesityPrevalence and Risk of Obesity

• NHANES III shows approximately 60% of men and 50% of women are obese or overweight, with 20% of men and 25% of women having a BMI of 30 or greater

• BMI 27-29 associated with a RR of total mortality of 1.6, BMI 29-32 RR 2.1, and BMI >=32 RR 2.2 vs. BMI <19 from Nurses’ Health Study.

Increasing Prevalence of Overweight Increasing Prevalence of Overweight and Obesityand Obesity

• Obesity has increased in every state, in both sexes, across all age groups, educational levels, and smoking statuses.

• Over the last 3 decades there has been a 25% increase in the number of people who qualify as overweight.

Percentage of Overweight and Percentage of Overweight and Obesity in the United States Obesity in the United States

• For adults 25 years and older the percentage of people who qualify as overweight is 63% for men and 55% for women.

• Specifically, 42% of men and 28% of women are overweight. While 21% of men and 27% of women are obese.

Prevalence of Obesity among US Adults Prevalence of Obesity among US Adults From Years 1991, 1993, 1995, and 1998From Years 1991, 1993, 1995, and 1998

Increasing Prevalence of Overweight in Increasing Prevalence of Overweight in U.S. Adults and U.S. Adults and

of Obesityof Obesity

Age-Adjusted Standardized Prevalence of Overweight(BMI 25–29.9) and Obesity (BMI >30)

37.8

23.6

10.415.1

41.1

23.6

11.816.1

39.1

24.3

12.216.3

24.9

39.4

24.719.9

0

10

20

30

40

50

Men Women Men Women

NHES I NHANES I NHANES II NHANES III

BMI > 30BMI 25–29.9

CDC/NCHS, United States, 1960-94, ages 20-74 years

Per

cen

t

NHANES III Age-Adjusted Prevalence of Hypertension* According to BMI

16.518.221.922.5 24.025.2

32.2

38.4

0

10

20

30

40

50

Men Women

BMI <25 BMI 25-26 BMI 27-29 BMI >30

*Defined as mean systolic blood pressure 140 mm Hg, as mean diastolic 90 mm Hg, or currently taking antihypertensive medication .

Brown C et al. Body Mass Index and the prevalence of Risk Factors for Cardiovascular Disease (in preparation).

Per

cen

t

NHANES III Age-Adjusted Prevalence of High Blood Cholesterol* According to BMI

15.714.7

27.9

17.5

28.2

20.424.7

20.2

0

10

20

30

40

50

Men Women

BMI <25 BMI 25-26 BMI 27-29 BMI >30

*Defined as > 240 mg/dL.

Brown C et al. Body Mass Index and the Prevalence of Risk Factors for Cardiovascular Disease (in preparation).

Per

cen

t

NHANES III Age-Adjusted Prevalence of Low HDL-Cholesterol* According to BMI

16.5

9.1

27.0

17.2

27.223.1

41.5

31.4

0

10

20

30

40

50

60

Men Women

BMI <25 BMI 25-26 BMI 27-29 BMI >30

*Defined as <35 mg/dL in men and <45 mg/dL in women.


Per

cen

t

Carbo-Lipo-Terrorism in the U.S.

A Report To: Orange County

On: 2/18/04

Percent Overweight Children U.S. & Orange County

0

2

4

6

8

10

12

14

16

1963-70 1971-74 1976-80 1988-94 1999-2000

U.S. 6-11 yo

U.S.12-19 yo

Orange County2-12 yo

Per

cen

t O

verw

eig

ht

(>95

% w

eig

ht/

hei

gh

t)

YearData from the CDC & Prevention, NCHS, NHANES, HHNES, NHES, Report on the Conditions of Children in Orange County, 2002

No Data <4% 4%-6% 6%-8% 8%-10% >10%

Obesity (> 120%tile ideal body weight) in U.S. Adults

1992

Diabetes in U.S Adults

1992

Obesity 1994

No Data <4% 4%-6% 6%-8% 8%-10% >10%

Diabetes 1994

Obesity 1996

No Data <4% 4%-6% 6%-8% 8%-10% >10%

Diabetes 1996

Obesity 1998

No Data <4% 4%-6% 6%-8% 8%-10% >10%

Diabetes1998

Obesity 1999

No Data <4% 4%-6% 6%-8% 8%-10% >10%

Diabetes 1999

Obesity 2000

No Data <4% 4%-6% 6%-8% 8%-10% >10%

Diabetes 2000

Tracking BMI-for-Age from Birth to 18 Years with % of Overweight Children who Are Obese at Age 25

16 15 12 11 10 917 19

55

7567

26

52

69

8377

36

0

20

40

60

80

100

Birth 1 to 3 3 to 6 6 to 10 10 to 15 15 to 18Age of child (years)

% obese as adults

BMI < 85th BMI >=85th BMI >=95th

Whitaker et al. NEJM: 1997;337:869-873

> 95th percentile Overweight

85th to < 95th Risk of overweight percentile

< 5th percentile Underweight

BMI-for-Age Cutoffs

National Longitudinal Survey of Youth Prospective Cohort Study of

8270 Children (4-12 years old) - 1999

Risk of Overweight Overweight

> 85th %ile BMI > 95th %ile BMI

African American 38.4% 21.5%

Hispanics 37.9% 21.8%

Caucasian 25.8% 12.3%

Secular Increases in Relative Weight and Adiposity in Children (5-14 years old)

- Bogalusa Heart Study -

Study years Weight (kg)Height (cm)

BMI (kg/m2)

1973-1974 35.9 140 17.6

1992-1994 41.0 142 19.5

Change* +3.4 +1.6 +1.5* Change adjusted for height, age, race, and sexSource: Pediatrics 99:420-426, 1997

Prevalence of Overweight and Obesity Among US Children (6-19 years old)

1999-2002

1999-2000 2001-2002

85th percentile BMI 29.9% 31.5%

95th percentile BMI 15.0% 16.5%

Source: Hedley et al., JAMA 291:2847-2850, 2004

Overweight in Children*(> 95th percentile BMI)

1971-1974 1988-1994 1999-2002

2-5 years 5.0 7.2 10.4

6-11 years 4.0 11.3 15.3

12-19 years 6.1 10.5 15.5**

* 4722 children from NHANES; overweight > 95th adjusted for age** > 23% of African American and Mexican American adolescentsSource: Ogden et al., JAMA 288:1728-1732, 2002

Correlations of Weight and BMI at 7.7 and 23.6 Years

Source: Minneapolis Children’s BP Study, Circulation 99:1471, 1999

r=0.605

r=0.612

Example: 95th Percentile Tracking Age BMI

2 yrs 19.3 4 yrs 17.8 9 yrs 21.013 yrs 25.1

For Children, BMI Changes with Age

Boys: 2 to 20 years

BMI BMI

BMI BMI

BMI = 18

Age 4 years: >95th

BMI Changes with age

Boys: 2 to 20 years

BMI BMI

BMI BMI

Age 8 years: 85th

Age 13 years: <50th

Can you see risk?

• This boy is 3 years, 3 weeks old.

• Is his BMI-for-age

- >85th to <95th percentile: at risk for overweight?

Photo from UC Berkeley Longitudinal Study, 1973

Measurements:

Age=3 y 3 wks

Height=

100.8 cm (39.7 in)

Weight=

18.6 kg (41 lb)

BMI = 18.3

BMI-for-age= >95th percentile overweight

Plotted BMI-for-Age

Boys: 2 to 20 years

BMI BMI

BMI BMI

Can you see risk?

• This girl is 4 years old.• Is her BMI-for-age

- >85th to <95th percentile: at risk for overweight?

Photo from UC Berkeley Longitudinal Study, 1973

Measurements: Age=4 y

Height=

99.2 cm (39.2 in)

Weight=

17.55 kg (38.6 lb)

BMI=17.8

BMI-for-age= between 90th –95th percentile

At risk for overweight

Plotted BMI-for-Age

Girls: 2 to 20 years

BMI

BMIBMI

BMI

5 1/2 year old boy

Weight: 41.5 lb

Height: 43 in

BMI= 15.8

BMI-for-age=50th %tile

Inaccurate height measurement: 42.25

BMI=16.3

BMI-for-age=75th %tile

Accurate Measurements are Critical

Boys: 2 to 20 years

BMI BMI

BMI BMI

Childhood Overweight 2003 BMI (Body Mass Index) is Now Defining Tool

• BMI Calculated as Weight / Height Squared

• Used to judge appropriateness of weight for height

• Replaces weight for height charts and % ideal body wt

• For a child, BMI > 95% is obese BMI 85-95% is “at risk”

• BMI data from retrospective analysis: 1. Reflect increasing fatness 2. Predict adult risk

Prevalence of Overweight, U.S. Adults, 1988 to 1991Prevalence of Overweight, U.S. Adults, 1988 to 1991

Overweight Adults 20-74 Years of Overweight Adults 20-74 Years of Age, 1988-1994Age, 1988-1994

Overweight Prevalence by Overweight Prevalence by Race/Ethnicity for Adolescent Boys Race/Ethnicity for Adolescent Boys

and Girlsand Girls

Targeted History & Physical for the Obese Child

The Identification, Management & Treatment of the Obese Child

History

• Birth– Weight: LGA & SGA

• Risk factor for Diabetes Mellitus

– Decreased tone, poor feeding• Concern regarding Prader Willi

• Family History (below are RF for DM & dysmetabolic syndrome)

– Diabetes (1 vs 2, gestational)– Obesity (calculate parents BMI)– Hypertension– Dyslipidemia– Premature cardiovascular disease

Male < 55 yo Female < 65 yo

Medical history/Review of Systems

Possible Underlying Endogenous Cause of Obesity

• Decreased growth velocity or abnormal height

• Abnormal pubertal development

• Abnormal Developmental history– Prader Willi, Bardet Biedl, Sotos

• Dysmorphic Features• Hypothyroidism: cold, fatigue, dry skin, hair loss, constipation

Medical History/Review of Systems for the Obese Child

• Sleep– snoring, stops breathing, daytime sleepiness

• Menstrual History– Amenorrhea, Irregular Menses

• Leg pain– Hip, knee, tibial (SCFE, Blounts)

• Blood pressure• Lipid Levels• Recurrent yeast infections• Polyuria, Polydipsia

Directed Exam for Obese Youth

•Ht____cm Wt_____Kg BMI (kg/m2)____ (>85%Dietician) (BMI>40 or > 95%Endo)•BP_____ (HTN: Y/N) •Dyspnea at rest vs exertion•Tanner stage____•Normal Pubertal development: Y/N•Skin: Acanthosis: Y/N Hirsutism: Y/N•Ext: Hip, knee, valgus or varus deformity

The A, B, C Intervention

• AActivity1. Minimum of 60 min/day of minimum intensity of a brisk walk. 2. Limit screen time (not associated with school work) < 1 hour

• BBeverages1. No regular soda or sugar/corn syrup sports drinks/punch2. < 6 ounces juice/day3. Increase water & non-or low fat milk (or other calcium containing food)

consumption

• CChange=Goal1. Family changes eating & activity habits2. Reasonable, achievable, step wise goals3. Minimum nursing visits every 3-4 months: check progress & reinforce goals.

Phone follow-up

Who to Test for IGT & Diabetes

• Obese: BMI>85%

• Age: Earliest of the following, > 10 years of age or onset of puberty

• And 2 of the following:– Family history of T2DM in 1st or 2nd degree relative

– Ethnicity: Native American; African-American; Latino; Asian; Pacific Islander

– Conditions assoc. with or signs of insulin resistance: acanthosis nigricans; hypertension, dyslipidemia, PCOs

Based on ADA Recs: Diabetes Care 2003

Impaired Glucose Tolerance & Diabetes

Normal IFG or IGT DiabetesFPG <100 mg/dl FPG= 100 - 125 mg/dl

(IFG)FPG > 126 mg/dl

2-h PG <140 mg/dl 2-h PG=140- 199mg/dl (IGT)

2-h PG > 200 mg/dl

Symptoms of diabetes & casual plasma glucose concentration 200 mg/dl

Based on ADA Recs: Diabetes Care 2004

In the absence of unequivocal hyperglycemia, a diagnosis of diabetes must be confirmed, on a subsequent day, by measurement of FPG, 2-h PG, or random plasma glucose (if symptoms are present). The FPG test is greatly preferred because of ease of administration, convenience, acceptability to patients, and lower cost. Fasting is defined as no caloric intake for at least 8 h.

This test requires the use of a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water. 2-h PG, 2-h postload glucose

Do You Know How Food Portions Have Changed in 20 Years?

National Heart, Lung, and Blood InstituteObesity Education Initiative

BAGEL 20 Years Ago Today

140 calories 3-inch diameter

How many calories are in this bagel?


Calorie Difference: 210 calories


BAGEL 20 Years Ago Today

How long will you have to rake leaves in order to

burn the extra 210 calories?*

*Based on 130-pound person

Maintaining a Healthy Weight is a Balancing ActCalories In = Calories Out

If you rake the leaves for 50 minutes you will burn the extra 210 calories.*


Calories In = Calories Out

CHEESEBURGER

20 Years Ago Today

333 calories How many calories are in today’s cheeseburger?


590 calories

CHEESEBURGER

20 Years Ago Today

333 calories


How long will you have to lift weights in order to burn the extra 257 calories?*


If you lift weights for 1 hour and 30 minutes,you will burn approximately 257 calories.*



SPAGHETTI AND MEATBALLS20 Years Ago Today

500 calories1 cup spaghetti with sauce and 3 small meatballs

How many calories do you think are in today's portion of spaghetti and meatballs?


1,025 calories 2 cups of pasta with sauce and 3 large meatballs

20 Years Ago Today

500 calories1 cup spaghetti with sauce and 3 small meatballs

SPAGHETTI AND MEATBALLS

How long will you have to houseclean in order to burn the extra 525 calories?*




If you houseclean for 2 hours and 35 minutes, you will burn approximately 525 calories.*


FRENCH FRIES 20 Years Ago Today

210 Calories

2.4 ounces How many calories are intoday’s portion of fries?

610 Calories6.9 ounces

Calorie Difference: 400 Calories

FRENCH FRIES 20 Years Ago Today

210 Calories

2.4 ounces

How long will you have to walk leisurely in order to burn those extra 400 calories?*




If you walk leisurely for 1 hour and 10 minutes you will burn approximately 400 calories.*


85 Calories 6.5 ounces

How many calories are in today’s portion?

SODA20 Years Ago Today

Calorie Difference: 165 Calories

250 Calories 20 ounces

85 Calories 6.5 ounces

SODA20 Years Ago Today

How long will you have to work in the garden to burn those extra calories?*



If you work in the garden for 35 minutes, you will burn approximately 165 calories.*



320 calories How many calories are in today’s turkey sandwich?

TURKEY SANDWICH20 Years Ago Today


820 calories 320 calories

TURKEY SANDWICH20 Years Ago Today

How long will you have to ride a bike in order to

burn those extra calories?*




If you ride a bike for 1 hour and 25 minutes,you will burn approximately 500 calories.*


Thank you for participating in Portion Distortion!

For more information about Maintaining a Healthy Weightvisit www.nhlbi.nih.gov

TOO MUCH SODA Coke glass bottle (8 fl. oz.) =

100 kcals. Coke can (12 fl. oz) = 150 kcals. Coke plastic bottle (20 fl. oz. ) =

250 kcals. Super Big Gulp (44 fl. oz.) = 550

kcals. ***1 big gulp a day = 57

pounds /year!!!! What does the future hold??

http://images.google.com/imgres?imgurl=www.sodashop.com/coke/392903.jpg&imgrefurl=http://www.sodashop.com/ccmain.shtml&h=183&w=265&sz=13&tbnid=5WKjNFTp7jIJ:&tbnh=74&tbnw=107&prev=/images%3Fq%3Dglass%2Bcoke%2Bbottle%26start%3D20%26svnum%3D10%26hl%3Den%26lr%3D%26ie%3DUTF-8%26oe%3DUTF-8%26sa%3DN

http://moon.ouhsc.edu/dthompso/namics/gifiles/coke_can.gif

http://images.google.com/imgres?imgurl=www.minghung.com/news19.jpg&imgrefurl=http://www.minghung.com/cnews1998r.htm&h=410&w=134&sz=16&tbnid=eVSD8ghl_SQJ:&tbnh=119&tbnw=39&prev=/images%3Fq%3Dcoca%2Bcola%2Bbottle%2Bplastic%26svnum%3D10%26hl%3Den%26lr%3D%26ie%3DUTF-8%26oe%3DUTF-8

http://images.google.com/imgres?imgurl=thecabin.net/images/promotions/coke.gif&imgrefurl=http://thecabin.net/subscribe.html&h=150&w=56&sz=4&tbnid=uMipsEW0W5QJ:&tbnh=88&tbnw=33&prev=/images%3Fq%3D2%2BLiter%2Bcoke%26start%3D20%26svnum%3D10%26hl%3Den%26lr%3D%26ie%3DUTF-8%26oe%3DUTF-8%26sa%3DN

Do You Know How Food Portions Have Changed in 20 Years?

National Heart, Lung, and Blood InstituteObesity Education Initiative

COFFEE 20 Years Ago

Coffee(with whole milk and sugar)

Today

Mocha Coffee(with steamed whole milk and

mocha syrup)

45 calories 8 ounces

350 calories16 ounces


How long will you have to walk in order

to burn those extra 305 calories?*



If you walk 1 hour and 20 minutes, you

will burn approximately 305 calories.*



MUFFIN

20 Years Ago Today

210 calories 1.5 ounces

How many calories are in today’s muffin?

How long will you have to vacuum in order to burn those extra 290 calories?*



If you vacuum for 1 hour and 30 minutes you

will burn approximately 290 calories.*



PEPPERONI PIZZA

20 Years Ago Today

500 caloriesHow many calories are in two large slices of today’s pizza?

How long will you have to play golf (while walking and carrying your clubs) in order to burn those extra 350 calories?*



If you play golf (while walking and carrying your clubs) for 1 hour you will burn approximately 350

calories.*



CHICKEN CAESAR SALAD

20 Years Ago Today

390 calories 1 ½ cups

How many calories are in today’s chicken Caesar

salad?

How long will you have to walk the dog in

order to burn those extra 400 calories?*



If you walk the dog for 1 hour and 20 minutes, you will burn approximately 400 calories.*



20 Years Ago Today

270 calories 5 cups

POPCORN

How many calories are in today’s large popcorn?

20 Years Ago Today

270 calories 5 cups

POPCORN

630 calories11 cups


How long will you have to do water aerobics in order to burn the extra 360 calories?*




If you do water aerobics for 1 hour and 15 minutes you will burn approximately 360 calories.*


CHEESECAKE

20 Years Ago Today

260 calories

3 ounces 640 calories7 ounces


How long will you have to play tennis in order to burn those extra 380 calories?*




If you play tennis for 55 minutes you will burn approximately 380 calories.*


CHOCOLATE CHIP COOKIE

20 Years Ago Today

55 calories1.5 inch diameter

How many calories are in today’s large cookie?

CHOCOLATE CHIP COOKIE

20 Years Ago Today

55 calories 1.5 inch diameter

275 calories3.5 inch diameter


How long will you have to wash the car to burn those extra 220 calories?*




If you wash the car for 1 hour and 15 minutes

you will burn approximately 220 calories.*


CHICKEN STIR FRY

20 Years Ago Today

435 calories 2 cups

How many calories are in today’s chicken stir fry?

CHICKEN STIR FRY

20 Years Ago Today

435 calories 2 cups

865 calories4 ½ cups


How long will you have to do aerobic dance to burn those extra 430 calories?*




If you do aerobic dance for 1 hour and 5 minutes you will burn approximately 430 calories.*


Thank you for participating in Portion Distortion II!

For more information about Maintaining a Healthy Weightvisit www.nhlbi.nih.gov

KID FRIENDLY SNACKS? Super Pretzel and

16 fl. oz. Snapple Fruit Punch = 630 kcals.

24 fl. oz. Banana Berry Jamba Juice = 470 kcals.

Venti Vanilla Creme Frappacchino = 870 kcals.

WHAT ABOUT SCHOOL?

PRACTICAL SUGGESTIONS

Encourage parents to limit contribution of calories from beverages (only milk required).

Encourage 5 a day program.

Suggest Stoplight Diet (Epstein)

Stress Family Commitment- entire family needs to follow new eating habits.

FAST FOOD MAKEOVERS

Big Mac Value Meal = 1250 kcals.

If you super size….. Add 360 kcals!

Hamburger Happy Meal with regular coke = 640 kcals.

If you switch to diet or water subtract 150 kcals.

FAST FOOD MAKEOVERS

Del Taco Combo Burrito Meal = 1090 kcals.

2 Del taco soft chicken tacos = 320 kcals.

SERVING SIZES

GRAIN = 1 slice of bread, ½ cup cooked rice or pasta.

FRUIT = 1 piece of fruit, ¾ cup juice.

VEGETABLE = ½ cup cooked or 1 cup raw.

MILK = 1 cup milk

MEAT = 2-3 oz. cooked lean meat or fish.

FATS and SWEETS: use sparingly.

Cardiovascular Complications of Cardiovascular Complications of ObesityObesity

Jody Kranz M.D.Div. Endocrinology & Diabetes

CHOCStan Bassin Ed.DDiv. Cardiology

UCI

The Identification, Management and Treatment of the Obese Child

Cardiovascular Complications of Obesity

• Cardiovascular Disease (CVD)– Atherosclerosis– Obesity– Hypertension– Lipids

• Inflammatory Factors• Homocysteine & Other Risk Factors• Guidance for Practitioners

– Guidelines/Schedule for cardiovascular health– Proper blood pressure measurement– Charts for determining hypertension

Cardiovascular Disease

• Leading cause of death in the United States– Half a million deaths year

• Atherosclerosis: disease of large & medium sized vessels that leads to decrease blood flow to the myocardium, brain and extremities.

• Atherosclerosis begins in childhood– Same risk factors as in adults

Atherosclerosis Begins in Childhood

PDAY-Pathologic Determinants of Atherosclerosis in Youth

Autopsy Evaluations of CVD Risk Factors Progression of atherosclerosis from fatty streaks to raised

lesions in persons > 15 years of age 10-20% of 15-19 year olds have intermediate lesions Risk factors:

High non-HDL cholesterol Low HDL cholesterolSmoking HypertensionHbA1C > 8% Obesity (BMI > 30 kg/m2)

Atherosclerosis Risk Factors

– Increasing Blood Pressure

– Dyslipidemia

– Inflammatory factors

– Homocysteine

– Diabetes

– Tobacco exposure

– Family History

– Male gender

– Obesity

– Sedentary Lifestyle

Obesity & Hypertension

Clinical Presentation of Hypertension• High blood pressure = BP > 90th percentile for age gender and

height.• Hypertension= BP > 95th percentile for age, gender and height. • Primary Hypertension

– most common cause of Hypertension in Children over 6 years of age<6 years of age

• Secondary Hypertension– Renal disease– Aortic Coarctation

• Primary isolated systolic– Isolated systolic hypertension is an independent risk factor for

cardiovascular disease– 50% prevalence in obese

Prevalence of Hypertension in Children vs Distribution of BMI (%)

6 5 611 12

23

34

0

10

20

30

40

50

< 5 10 25 50 75 90 >95

BMI centile

Per

cen

t w

ith

Hyp

erte

nsi

on

(%

)

Blood Pressure & CVD• Blood pressure is positively correlated with cardiovascular

risk across the entire BP range– Evidence from autopsy studies

– Increase in carotid intima media thickness in adolescents with hypertension

• Increase in Left Ventricular Mass/ Mass index indicating hypertrophy

• There is a synergistic effect on CVD with lipids

• Increases the risk for renal disease which in turn increases the risk for CVD

Treatment of Hypertension

• Weight loss– Demonstrated in observational & interventional

studies– Decrease of 8/7 to16/9 mmHg for children with

3.9kg weight loss vs 10% weight loss respectively

• Exercise– May have additive effect– Decrease of 10mm Hg with regular exercise

• Medication

Obesity & Dyslipidemia

Increased Risk of Abnormal Lipid Levels in Overweight vs.

Normal Weight Teens

0

2

4

6

8

10

12

7 to 8 9 to 10 11 to 12 13 to 14 15 to 17

Age (years)

Increased Risk

TC>200TG>130LDL>130HDL<35

Atherosclerosis & Dyslipidemia

• Evidence from adult studies

• Evidence in Children & Adolescents– PDAY– In vivo studies

• decreased compliance of arteries

• increased IMT in adolescents with dyslipidemia

Treatment of Dyslipidemia

• Weight loss• Exercise• Nutrition

– Saturated fat <10% of calories– Total fat < 20-30% of calories– < 300mg cholesterol/day– Increase fiber intake

• Medication

Obesity & Inflammatory Factors

Prevalence of Elevated CRP (>0.22mg/dL) by BMI centile

0

5

10

15

20

25

<25% 25-50% 50-75% 75-85% >85%

BMI centiles

Elevated CRP (%)

BoysGirls

TNF-alpha Levels in Obese & Non-obese Adolescents

5.88

18.15

0

5

10

15

20

Obese Non-Obese

Level of TNF-alpha (ng/mL)

Moon et al. NASO, Oct. 2003

Homocysteine & other CVD Risk Factors in Youth

• Homocysteine – An independent risk factor for CVD– > 10-12 umol/L increases CVD risk 2-4 fold– Not increased with obesity– Treatment: Folate 0.4 mg/day; B12 400-1000

ug/day; Vit. B6 400 mg/day

• Tobacco exposure: 1st & 2nd Hand

Preventing Cardiovascular Disease

• Regular exercise (4-5 times/week)– Decreases weight gain– Increases HDL– Decreases blood pressure– Decreases inflammatory factors

• Healthy eating patterns– Minimize saturated fat

• Cigarette Smoking Prevention

Adolescent ObesityAdolescent Obesityand its Effects into Adulthoodand its Effects into Adulthood

Obesity and CVD RiskObesity and CVD Risk

• In Nurses’ Health Study, 14-year CHD risk increased about 3.5-fold for BMI >29 vs. <21, weight gain of >20 kg associated with 2.5-fold increased risk.

• NHANES I follow-up showed a 1.5-fold greater risk of CVD in those women with a BMI >29 vs. <21.

• A waist circumference of >35 inches in women, and >40 inches in men is also associated with greater CHD risk.

Weight Related Risks for CHD and Weight Related Risks for CHD and StrokeStroke

Obesity and HypertensionObesity and Hypertension

• For every 1 kg/m2 increase in BMI, increased risk of hypertension in Nurses’ Health Study was 12%

• Those with a BMI >31 RR=6.3 for developing HTN compared with BMI <19.

• Study showed each 10 kg weight to be associated with an increase of 3mmHg SBP and 2.2mHg DBP.

• Increased insulin levels may explain relation of obesity with HTN, as compensatory increases in insulin are required to maintain glucose homeostasis, and insulin may elevate BP by affecting renal sodium retention, raising peripheral resistance.

Obesity and DiabetesObesity and Diabetes• Obesity worsens insulin sensitivity, eventually exhausting

pancreatic production of insulin, causing hyperglycemia and diabetes.

Obesity and DiabetesObesity and Diabetes

• In Pima Indians (approx 50% of adults diabetic), incidence (per 1000 person-years) was 0.8 if BMI <20, but 72 if BMI >40.

• In Nurses’ Health Study, BMI 23-23.9 showed a RR=3.6 for diabetes compared with BMI <22. Weight again was very important, with weight again of 20-35kg associated with an 11-fold greater risk of diabetes, >35kg 17-fold.

• In Health Professionals Study among men, BMI >35 associated with RR=42 for developing diabetes.

Obesity and DyslipidemiaObesity and Dyslipidemia

• Rates of cholesterol synthesis correlate with excess body mass

• Data suggest a 10kg/m2 increment in BMI is associated with a 3.2 mg/dl (women) to 10 mg/dl (men) lower HDL-C and about a 10 mg/dl greater LDL-C


• Obesity is associated with higher LDL-C and triglycerides, and lower HDL-C.


• Weight loss reduces triglycerides, increases HDL-C, and lowers LDL-C

Absolute Fat and Lean Changes per Absolute Fat and Lean Changes per Decade as a Function of Age in MenDecade as a Function of Age in Men

Absolute Fat and Lean Changes per Absolute Fat and Lean Changes per Decade as a Function of Age in WomenDecade as a Function of Age in Women

Definitions

Body Mass Index (BMI) describes relativeweight for height: weight (kg)/height (m2)

• Overweight = 25–29.9 BMI

• Obesity = > 30 BMI

Age-Adjusted Standardized Prevalence of Overweight(BMI 25–29.9) and Obesity (BMI >30)

37.8

23.6

10.415.1

41.1

23.6

11.816.1

39.1

24.3

12.216.3

24.9

39.4

24.719.9

0

10

20

30

40

50

Men Women Men Women

NHES I NHANES I NHANES II NHANES III

BMI > 30BMI 25–29.9

CDC/NCHS, United States, 1960-94, ages 20-74 years

Per

cen

t

NHANES III Age-Adjusted Prevalence of Hypertension* According to BMI

16.518.221.922.5 24.025.2

32.2

38.4

0

10

20

30

40

50

Men Women

BMI <25 BMI 25-26 BMI 27-29 BMI >30

*Defined as mean systolic blood pressure 140 mm Hg, as mean diastolic 90 mm Hg, or currently taking antihypertensive medication .

Brown C et al. Body Mass Index and the prevalence of Risk Factors for Cardiovascular Disease (in preparation).

Per

cen

t

NHANES III Age-Adjusted Prevalence of High Blood Cholesterol* According to BMI

15.714.7

27.9

17.5

28.2

20.424.7

20.2

0

10

20

30

40

50

Men Women

BMI <25 BMI 25-26 BMI 27-29 BMI >30

*Defined as > 240 mg/dL.


Per

cen

t

NHANES III Age-Adjusted Prevalence of Low HDL-Cholesterol* According to BMI

16.5

9.1

27.0

17.2

27.223.1

41.5

31.4

0

10

20

30

40

50

60

Men Women

BMI <25 BMI 25-26 BMI 27-29 BMI >30

*Defined as <35 mg/dL in men and <45 mg/dL in women.


Per

cen

t

Requires two steps:

• Assessment

• Management

Care of Overweight/Obese Patients

Assessment of Overweight and Obesity

• Body Mass Index–Weight (kg)/height (m2)–Weight (lb)/height (in2) x 703– Table

• Waist Circumference–High risk:• Men >102 cm (40 in.)• Women >88 cm (35 in.)

Obesity ClassBMI kg/m2Underweight<18.5Normal18.5–24.9Overweight25–29.9ObesityI30.0–34.9II35.0–39.9Extreme ObesityIII

≥

40.0

Classification of Overweight and Obesity by BMI

Determine Absolute Risk StatusEvaluate:

• Disease conditions (e.g., CHD, type 2 diabetes, sleep apnea)(+ = very high risk)

• Other obesity-associated diseases (e.g., gynecological abnormalities, osteoarthritis)

• Cardiovascular risk factors: smoking, hypertension, high LDL, low HDL, IGT, family hx (>3 = high risk)

• Other risk factors:

– Physical inactivity

– High serum triglycerides (>200 mg/dL)

Adolescent and Adult Adolescent and Adult InterventionsInterventions

• Decrease Television viewing• Decrease consumption of high fat foods• Increase fruit and vegetable intake• Increase moderate and vigorous physical activity

Weight Control and Risk ReductionWeight Control and Risk Reduction

• Weight loss improves BP, dyslipidemia, and diabetes.

• Clinical trials show normotensive overweight persons on a hypocaloric diet had a lowering of blood pressure and reduced incidence of hypertension. DASH diet high in vegetables and fruits showed significant lowering of SBP and DBP both in persons with and without HTN.

• Weight control also lessens hyperglycemia and has been shown to be related to reduced diabetes-related mortality and improvements in glucose and insulin levels.

• Among Indian coronary patients, those randomized to low saturated fat, high fruit and vegetable diet plus weight-loss advice, compared to usual care, showed a 50% reduction in cardiac events and 45% lower mortality in those who lost more than 5kg.

Weight Control and Risk ReductionWeight Control and Risk Reduction

• Meta-analysis of 70 randomized controlled trials shows correlation between fall in LDL-C and amount of weight loss (Dattilo et al., 1992)

• Combined programs of weight loss and exercise are associated with greater increases in HDL-C and more significant loss of weight and fat.

• Findings are less consistent in women, however, and often LDL-C/HDL-C ratio worsens. While HDL-C is inversely related to CHD risk in populations, low rates of CHD are seen in populations with low-fat diets who have lower levels of both LDL-C and HDL-C.

Fat vs. Caloric RestrictionFat vs. Caloric Restriction

• While fat from calories has been reduced from 40-42% to 34% over the past 30 years, recent data show we consume more calories

• Message of caloric restriction needs to be coupled with dietary fat reduction, with greater emphasis on fruit and vegetable consumption

• Greater availability of low-fat and fat-free foods allows for substitution away from traditional higher-fat alternatives. Fat and calorie restriction needs to be individualized to patient need and risk-factor profile.

Hypocaloric DietsHypocaloric Diets

• Such diets allow for 1000-1200 kcal/day, with very low-calorie diets providing only 400-500 kcal/day.

• Initial weight loss may be more rapid with the very low-calorie diet, but amount of weight loss over one year is similar with either plan and adherence better with the moderate diet.

• Combination of low calorie diet plus exercise is more successful than either strategy alone.

Health Benefits of Weight Loss

• Decreased cardiovascular risk

• Decreased glucose and insulin levels

• Decreased blood pressure

• Decreased LDL and triglycerides, increased HDL

• Decrease in severity of sleep apnea

• Reduced symptoms of degenerative joint disease

• Improved gynecological conditions

Treatment AlgorithmPatient Encounter

Hx of 25 BMI?

• Measure weight, height, and waist circumference

• Calculate BMI

Examination

Brief reinforcement/ educate on weight management

Periodic weight check

Advise to maintain weight/address other risk factors

Clinician and patient devise goals and treatment strategyfor weight loss andrisk factor control

Assess reasons for failure to lose weight

Maintenance counseling: Dietary therapy Behavior therapy Physical activity:

Treatment

Assess risk factors

No

Yes

1

2

14

15 13

12

11 1016

3

4 6

5 7

8

9

Yes

No

Yes

No

Hx BMI 25?

No

Yes

Yes

No

Does patient want to lose weight?

Yes

No

Progress being made/goal

achieved?

BMI 25 OR waist circumference

> 88 cm (F) > 102 cm (M)

BMI 30 OR

{[BMI 25 to 29.9 OR waist circumference

>88 cm (F) >102 cm (M)] AND 2 risk

factors}

BMImeasured in past

2 years?

No

BMI 30 OR

{[BMI 25 to 29.9 OR waist >88 cm (F)

>102 cm (M)] AND 2 risk

factors}

Treatment Algorithm (Part 1 of 3)Patient Encounter

Hx of 25 BMI?

• Measure weight, height, and waist circumference

• Calculate BMI

Assess risk factors

NoYes

1

2

3

46

5

7

Yes

No

BMI measured in

past 2 years?

BMI 25 ORwaist > 88 cm (F)

> 102 cm (M)

Yes

Examination

Treatment

Devise goals andtreatment strategy forweight loss and riskfactor control

Assess reasons forfailure to lose weight

Maintenance counseling

12

11 10

8

9

No

Yes

Yes

No Desire tolose weight?

Yes

No

Progress made?

BMI 30 OR

{[BMI 25 to 29.9 OR waist >88 cm (F)

>102 cm (M)]AND 2 risk

factors}

Examination

Treatment

7

Periodic weightcheck

• Advise to maintain weight

• Address other risk factors

13

16

Treatment Algorithm (Part 2 of 3)

• Brief reinforcement

• Educate on weightmanagement

Periodic weight check

• Advise to maintain weight

• Address other risk factors

14

15 13

16

5Yes

No

Yes

No

Hx BMI 25?

BMI 25 OR waist > 88 cm (F)

> 102 cm (M)

Examination

Treatment

Treatment

Algorithm (Part 3 of 3)

* This algorithm applies only to the assessment for overweight and obesity and subsequent decisions based on that assessment. It does not include any initial overall assessment for cardiovascular risk factors or diseases that are indicated.

Goals of Weight Management/Treatment

• Prevent further weight gain (minimum goal).

• Reduce body weight.• Maintain a lower body weight

over long term.

Target Weight: Realistic Goals• Substitute “healthier weight” for ideal or

landmark weight.

• Accept slow, incremental progress to goal.

— Short-term goal: 5 to 10 percent loss, 1 to 2 lb per week.

— Interim goal: Maintenance.

— Long-term goal: Additional weight loss, if desired, and long-term weight maintenance.

Weight Loss Goals

Goal: Decrease body weight by 10 percent frombaseline.• If goal is achieved, further weight loss can be

attempted if indicated.• Reasonable timeline: 6 months of therapy.

– Moderate caloric deficits– Weight loss 1 to 2 lb/week

Weight Loss Goals

• Start weight maintenance efforts after 6 months.

– May need to be continued indefinitely.

• If unable to lose weight, prevent further weight gain.

Strategies for Weight Loss and Maintenance

• Dietary therapy• Physical activity• Behavior therapy• “Combined” therapy• Pharmacotherapy• Weight loss surgery

Whenever possible, weight loss therapy should employ the combination of

• Low-calorie/low-fat diets

• Increased physical activity

• Behavior modification

Weight Loss Therapy

Dietary Therapy (1 of 5)

Low-calorie diets (LCD) are recommended for weight loss in overweight and obese persons.Evidence Category A.

Reducing fat as part of an LCD is a practicalway to reduce calories. Evidence Category A.


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.


Although lower fat diets without targeted caloriereduction help promote weight loss by producinga reduced calorie intake, lower fat diets coupledwith total calorie reduction produce greaterweight loss than lower fat diets alone. Evidence Category A.


Very low-calorie diets produce greater initialweight loss than low-calorie diets. However,long-term (>1 year) weight loss is not differentfrom an LCD. Evidence Category A.


Very Low-Calorie Diets (less than 800 kcal/day):

• Rapid weight loss• Deficits are too great• Nutritional inadequacies• Greater weight regain• No change in behavior• Greater risk of gallstones

Low-Calorie Step I DietNutrient Recommended Intake

Calories 500 to 1,000 kcal/day reduction

Total Fat 30 percent or less of total calories

SFA 8 to 10 percent of total calories

MUFA Up to 15 percent of total calories

PUFA Up to 10 percent of total calories

Cholesterol <300 mg/day

Low-Calorie Step I Diet (continued)

Nutrient Recommended Intake

Protein ~ 15 percent of total calories

Carbohydrate 55 percent or more of total calories

Sodium Chloride No more than 100 mmol/day (~ 2.4 g of sodium or ~ 6 g of sodium chloride)

Calcium 1,000 to 1,500 mg

Fiber 20 to 30 g

75.771.8

62.4

52.8

12.312.9

14.215.4

0.80.9 1 1.1 3

4.16.6

8.7 911.4

17.6

24.5

White, notHispanic

AfricanAmerican

NativeAmerican,Eskimo,

Aleut

Asian andPacific

Islander

HispanicOrigin (ofany race)

1990200020252050

75.771.8

62.4

52.8

12.312.9

14.215.4

0.80.9 1 1.1 3

4.16.6

8.7 911.4

17.6

24.5

White, notHispanic

AfricanAmerican

NativeAmerican,Eskimo,

Aleut

Asian andPacific

Islander

HispanicOrigin (ofany race)

1990200020252050

Source: U.S. Bureau of the Census, decennial census and population projections

Per

cent

Percent of the Population by Race/Ethnicity1990, 2000, 2025 and 2050

Source: Johnson, California’s Demographic Future, Public Policy Institute of California, 2003Source: Johnson, California’s Demographic Future, Public Policy Institute of California, 2003

California’s Population by California’s Population by Race and EthnicityRace and Ethnicity

• California leads the nation in diversity.

• The state is challenged with a substantial leadership

role in assuring a diverse workforce and designing and maintaining quality care for all populations.

Challenges for the Nation’s Workforce

• Insufficient numbers of staff;

• Unsatisfactory skill and proficiency levels;

• Inappropriate training to deal with a changed delivery environment;

• Racial and ethnic diversity;

• Racial and ethnic disparities in access to and quality of care.

Winds that are blowing...

• A national crisis is looming for health workforce but it has as much to do with lack of innovation, as it does with shortages of workers

Four Challenges

• Enhancing Public Participation in Clinical Research

• Developing Information Systems

• An Adequately Trained Diverse Workforce

• Funding

1. What is the benefit of increasing representation of women and minorities in the clinical research workforce?

2. Will increased diversity improve translation of the results of clinical research in minority communities?

3. What are the needs of the private and public sector?

4. Are the current approaches to training clinical investigators meeting the needs of academia, industry, and public health?

Source: IOM: Opportunities to Address Clinical Research Workforce Diversity Needs for 2010 , 2006

New paradigms in clinical research and research training

5. Where is demand exceeding supply?

6. What training programs and career tracks appear to foster the development and retention of women and minorities in the clinical research workforce?

7. What research related to evaluation of existing training efforts needs to be funded?

8. What are the key outcome measures?

Source: IOM: Opportunities to Address Clinical Research Workforce Diversity Needs for 2010 , 2006

New paradigms in clinical research and research training

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obesity -- a weighty problem (dr. stanley bassin

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