school nurse and adolescent obesity: understanding the disease for effective prevention

School Nurse and Adolescent Obesity: Understanding the disease for effective

prevention

Manish Singh MD

Adjunct Assistant Professor of SurgeryUTHSC San Antonio . TexasMedical Director, Advanced Laparoscopic andBariatric SurgeryDoctors Hospital at RenaissanceBariatric and Metabolic Institute Edinburg .Texas

No disclosures

Objectives

1. Understanding obesity as disease.

2. Debunking various myths surrounding obesity

3. Differentiating between prevention and treatment of obesity

4. Understanding Various methods of management of obesity.

Myself

• Born and Medical School in India .

• Surgery Residency at St Agnes Hospital, Baltimore. ( 2004-2010)

• Fellowship in Advanced Laparoscopy and Bariatrics at Cleveland Clinic , Cleveland. (2011)

Obesity is a Disease.

Prevention

vs

Treatment

SURGICAL TREATMENTS FOR OBESITY I Dr. Manish Singh

Obesity is……a disease of excess fat storage with a number of

associated diseases, known as co-morbidities.

It is also…• multi-factorial (many different factors can cause

obesity)• life-long• progressive• potentially life-threatening• costly


Many factors influence obesity

OBESITY

BMI As a Vital Sign: A Guide to the Treatment of Morbid Obesity l

April 22, 2023 l 15

Weight Classification by BMI

BMI (kg/m2) WHO Classification

<18.5 Underweight

18.5-24.9 Normal Range

25-29.9 Preobese (overweight)

30-34.9 Obese class I (mild)

35-39.9 Obese class II (moderate)

≥40 Obese class III (morbid/severe)

Definition of Pediatric ObesityBMI % for Age and Gender

BMI z-score

At Risk for overweight 85th to 95th Percentile 1.04-1.64

Overweight 95 to 97th Percentile 1.65-1.88

Obese > 97th Percentile 1.89-1.99 Mild

2.0-2.49 Mod

>2.5 Severe

Prevalence of Overweight (>95th%ile)

Disparities of Risk

>85th %ile >95th %ile0

20

40

60

Boys 6-11

%

Non-Hispanic White Non-Hispanic Black Mexican-American

Disparities of Risk


10203040

Girls 6-11

%


Disparities of Risk

0

20

40

60


20

40

60

>85th %ile >95th %ile

Boys 12-19 Girls 12-19

% %


Disparities of Risk

• Epidemiological data suggest that minority children from lower socioeconomic strata have an almost 1 in 2 chance of being overweight or obese

(Mei et al., 1998; National Center for Health Statistics, 2001)

Why is Obesity in Children of Particular Concern?

• Linear relationship between degree of overweight and medical morbidity in children.

• Very high adolescent BMI has been associated with 30-40% higher adult mortality compared with medium BMI .

• Severely overweight children have a greater probability of becoming overweight adults than mildly or moderately obese children do.

Tracking BMI-for-Age from Birth to 18 Yearswith Percent of Overweight Children

Who Are Obese at Age 25

Birth 1 to 3 3 to 6 6 to 10 10 to 15 15 to 180

20

40

60

80

100

16 15 12 11 10 917 19

36

55

7567

26

52

69

8377

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

Age of child (years)

% o

bese

as

adul

ts

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

29

The Levels Of ObesityWhat does obesity look like? *based on female 5’4” tall

Normal Weight (BMI 19 to 24.9)

130#BMI 22

Overweight(BMI 25 to 29.9)

152#BMI 26

Obese (Class I)(BMI 30 to 34.9)

175#BMI 30

Obese (Class II)(BMI 35 to 39.9 )

205#BMI 35

Morbidly Obese(BMI 40 or more)

234#BMI 40

30

Obesity Is Rising At An Alarming Rate

Sturm R, Pub Health, 2007

Obesity Trends* Among U.S. AdultsBRFSS, 1985(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%


No Data <10% 10%–14%


No Data <10% 10%–14% 15%–19%


No Data <10% 10%–14% 15%–19% ≥20%


No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

Obesity Trends* Among U.S. AdultsBRFSS, 2002

No Data <10% 10%–14% 15%–19% 20%–24% ≥25%


No Data <10% 10%–14% 15%–19% 20%–24% ≥25%


No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Source: Behavioral Risk Factor Surveillance System, CDC.



No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

INTERESTING FACTS ABOUT OBESITY

• Child-safety seat manufacturers are starting to make bigger models after a recent study showed that over 250,000 U.S. children age 6 and under are too fat to use them.

• Airlines spent $275 million on 350 million additional gallons of fuel in 2000 to compensate for the additional weight of their passengers. Now we know why the peanuts are no longer free!

• Never forget your past: Aborigines and the Pima indians of Arizona developed obesity, type 2 diabetes, and hypertension after transitioning to a Western lifestyle.

• If the entire morbidly obese population of the U.S. lived in one state, it would be the 12th highest-populated state, with more people than Virginia

1994National Diabetes Surveillance SystemState-specific Estimates of Diagnosed Diabetes Among AdultsAge-Adjusted Prevalence of Diagnosed Diabetes per 100 Adult Population, by State, United States, 1994

71

Obesity & The Energy Balance Equation

“If we’re getting more obese as a society, it must be the case that our caloric intake exceeds our caloric expenditure.

• TRUE ?

ORFALSE?

• TRUE ?

FALSE

BMI As a Vital Sign: A Guide to the Treatment of Morbid Obesity l April 22, 2023 l 74

The Leptin Bathtub

80

The Leptin Bathtub

“In this analogy, the amount of water is the same as the amount of adipose tissue in your body. Your body is paying attention to the amount of adipose tissue you have. And that is the defended parameter; that is, when you try to push the amount of water, in this case the amount of body fat, in either direction, the brain is going to fight back by being able to alter how hungry you are and how rapidly you’re burning calories.”

Why diets don’t work ?

82

What is a Set Point ?

“The end result of all this regulatory activity on the part of the body is to defend a particular set point for energy storage, which turns out to effectively be body weight…On the left side is why diets don’t work. And this whole process is determined physiologically. ”

The Myth: Weight can be reliably controlled by voluntarily adjusting energy

balance through diet and exercise.

84

The Myth Of Weight Management

One of the durable misconceptions in the area of weight regulation and obesity is that it results from abnormal or inappropriate behavior…

85

The Myth Of Weight Management

“You have to either engage the body’s regulatory system to make it want to weigh less or you have to fight it. So, this myth comes from the fact that people believe that the best way to do it is to fight it.”

87

The Body’s Defense Of Set Point

“What weight you defend is not a static variable. It’s a variable that can change over time and over circumstance.

Bernstein, IL. Proc Soc Exp Biol Med; 1975 Nov; 150(2): 546-8

The data presented in the above graph is from a study conducted on laboratory rats

Two Questions1.If body weight regulation is so accurate, why is it that we are becoming more obese? In other words, why doesn't this system that makes it so difficult for us to lose weight also defend us from gaining weight in the first place?

2.Why do only some people become obese while others remain lean, even in our relatively obesogenic environment?

• "things in our environment are changing the biological signals that relate to what weight the body sees as appropriate."

The Body’s Defense Of Set Point

90

“Under different dietary conditions, the exact same signal of leptin provides a different response… The point here is things in our environment are changing the biological signals that relate to what weight the body sees as appropriate.”

The data presented in the above graph is from a study conducted on laboratory rats

• Why do only some people become obese while others remain lean, even in our relatively obesogenic environment?

GENETICS

92

Environmental Changes Driving Obesity

“Those four categories of changes in the environment are so profound that they create the perfect storm for re-regulating energy balance, re-regulating set point, and creating obesity.”

93

Evidence for Physiological Mechanisms

94

Surgery Changes Set Point

“What surgery is doing is it’s changing the nature of these physiological curves so that the control of appetite, or energy intake, is blunted in a way. So as you lose body fat you end up with less of a rise in energy intake. And as you lose body fat you see less of a conservation of energy expenditure.”

95

The Leptin Bathtub

96

RYGB vs Dieting

“All of these physiological changes are consistently in the opposite direction after surgery as compared with dieting, and so what that tells you once again is that dieting engenders a counter-regulatory response that pushes you back to your original set point. Surgery, by having the arrows go in the opposite direction, must be changing the physiology.”

The data in the chart above are from multiple studies, presented here in aggregate.

97

Metabolic Impact Of Surgery

Kaplan, LM et al. Bariatric Times. 2012;9(7):12–14.

ASMBS DIABETES OVERVIEW

Almost 21 million Americans or 7% of the population have diabetes – another 54 million have pre-diabetes. Studies show a higher body weight and longer duration of obesity significantly increase the risk of developing Type 2 diabetes .

BMI greater than 35 increases the risk for diabetes by 93-fold in women and 42-fold in men.

One out of every 10 health care dollars is spent on diabetes and its complications .

Natural History of Type 2 Diabetes

Risk Factors(Obesity)

Impaired glucose tolerance

Diagnosis

3 years ofDM 2

9 years of DM 2

UncontrolledHyperglicemia

Lifestyle

Monotherapy

Combined

Insulin

Decreased betacell function

50% 10%

HbA1c=<7,7% orFPG= 180mm/dl

HbA1c=8,5% orFPG=>240mm/dl

DiseaseProgression

100%

Impact of Diabetes Mellitus

Diabetes

The leading cause of new cases of end stage renal disease

A 2- to 4-fold increase in cardio-vascular mortality

The leading cause of new cases of blindness in working-aged adults

The leading cause of nontraumatic lower extremity amputations

www.hypertensiononline.org

http://www.hypertensiononline.org/

Treatment Options for Obesity

Obesity Treatment

The Practical Guide, Identification, Evaluation and Treatment of Overweight and Obesity in Adults. NIH Publication #00-4084, Oct, 2000

Surgery

Pharmacotherapy

Lifestyle Modification

Diet Physical Activity

BMI

Obesity Treatment Pyramid

NIH consensus of 1991 concluded:

“Diet alone cannot be considered a reasonable option for permanent weight loss.”

“Drug therapy for clinically severe obesity has been disappointing.”

Surgical intervention including Roux-en-Y Gastric Bypass is the most appropriate treatments for obesity as defined by: • BMI >40 or

• BMI >35 with co-morbidities

“Never ask a barber if you need a haircut”

Warren Buffet

Evaluation of Obesity Management

• Don’t confuse prevention with treatment

• Must measure effect of intervention

• Evidence based decisions


Adjustable gastric banding is one type of restrictive procedure

• Laparoscopic

• Second most frequently performedbariatric procedure

• Mean excess weight loss at 1 yearof 42%1

• Requires implanted medical device

• Lowest rate of complications

1. Buchwald, H. et al., JAMA. 2004; 292:1724-37.


Vertical sleeve gastrectomy is another restrictive option

1. ASMBS, Position Statement on Sleeve Gastrectomy as a Bariatric Procedure. June 17, 2007.

2. Lee CM, et al. Surg Endosc (2007) 21: 1810–1816

• Laparoscopic

• May be an option for carefullyselected patients, including high-risk or super-super-obese patients1.


• No implanted medical device


A combination approach is most common

1. Buchwald, H. et al., JAMA. 2004; 292:1724-37.2. Buchwald H. 2004 ASBS Consensus Conference Statement, Bariatric surgery for morbid obesity: Health implications for patients,

health professionals, and third party payers. SOARD 2005;(1):371-8.

Roux-en-Y Gastric Bypass• Laparoscopic

• Most frequently performedbariatric procedure


• No implanted medical device

• Low rate of complications2

Open Laparoscopic

Surgical Approach

Myths about Bariatric Surgery

1. Bariatric surgery is dangerous

2. Results are variable

3. Patients eventually regain their weight after surgery

4. Bariatric surgery is expensive

5. Patients may loose weight but it does not alter their life-span

6. Only surgeons endorse bariatric surgery

#1 Bariatric Surgery is Dangerous

Operative mortality ( 30 days) – Restrictive procedures 0.1%– Gastric bypass 0.5% – BPD/DS 1.1% – Avg. 0.28%

Buchwald et al. JAMA. 2004;292:1724-1737

Comparative Mortality

CraniotomyEsophagectom

yPancreatecto

myPedsHeart

Aortic Aneurysm CABG

Hip Replacement

10.7% 9.1% 8.3% 5.4% 3.9% 3.5% 0.3%

BARTIATRIC SURGERY

0.28%

*Adopted from Dimiek et al. JAMA 2004;292:847-851.

#2 Results are Variable

http://mbsaqip.org/

MBSAQIP Requirements

• Essential resources in place

• Adequate volume and experience

• Standardized procedures and care paths

• Long-term follow-up of 75% for five years

• Bariatric surgeons with proper coverage

• Reporting and sharing of outcomes according to templates

• Verified by site inspections

#3 Patients eventually regain their weight after surgery

SOS STUDY Sjostrom L et al. N Engl J Med 2004;351

#4 Bariatric Surgery is Expensive

Heath Economics of Obesity l April 22, 2023 l 124

Obesity Facts

Sources: National Center for Health Statistics, 2002; http://win.niddk.nih.gov/statistics/index.htm#econ

Obesity is the most common preventable cause of death second to smoking

6th leading cause of lost productivity

9.1% of total annual medical care expenditure are related to obesity

Total Cost to U.S. Employers due to Obesity ~ $14 billion/year

http://win.niddk.nih.gov/statistics/index.htm

#5 Patients may loose weight but surgery does not alter their life-span

Effect on Long-term Mortality Compared to Non-Operated Controls

Study Procedure F/U Mortality Reduction

MacDonald,1997 RYGB 9 yrs 88%

Flum, 2004 RYGB 4.4yrs 33%

Christou, 2004 RYGB 5 yrs 89%

Sjostrom, 2006 VBG/other 14 yrs 31%

Sowemimo, 2007 RYGB 4.4 yrs 50%

Adams, 2006 RYGB 8.4 yrs 53%

O’brien, 2006 LAGB 12 yrs 73%

#6 Only Surgeons Endorse Bariatric Surgery

#6 Only Surgeons Endorse Bariatric Surgery

NIH/NIDDK/NHLBICMS/MedicareInstitute for Clinical Systems ImprovementNorth American Association for the Study of Obesity, NASOAmerican Diabetes Association, ADAAmerican Medical Association, AMAInternational Association for the Study of Obesity, IASOUK National Institute for Health and Clinical Excellence, NICE

These organizations endorse bariatric surgery for the treatment for severe, chronic obesity:

Predictors of Diabetes Resolution

• Medical Therapy only- 12%• Medical Therapy + Bariatric surgery- 37-42%

Natural History of Type 2 Diabetes

Risk Factors(Obesity)

Impaired glucose tolerance

Diagnosis

3 years ofDM 2

9 years of DM 2

UncontrolledHyperglicemia

Lifestyle

Monotherapy

Combined

Insulin

Decreased betacell function

50% 10%

HbA1c=<7,7% orFPG= 180mm/dl

HbA1c=8,5% orFPG=>240mm/dl

DiseaseProgression

100%

Consider surgery•Poor control A1c > 7.5•Burden of treatment is high

Bariatric surgery is the only effective therapy for severe obesity

Metabolic Surgery

Not Just Bariatric Surgery...

Conclusions1. Obesity is a disease.

2. Difference between prevention and treatment of obesity

3. Debunking various myths surrounding obesity- body’s regulatory system has to modified to achieve weight loss.

4. Various methods of management of obesity- depends on the level of obesity

Case A

48 yo male Ht- 6’2’’BMI- 41No comorbidities

Question????

Question????

Case A

48 yo male Ht- 6’2’’BMI- 41No comorbidies

Case B

• 48 yo male• Ht- 6’2’’• BMI- 34• Comorbidities-

HtnDyslipidemiaGlucose intolerancesleep apnea.

Ronnie ColemanMr. OlympiaBMI 41.4

Case A

Case B

Thank You

school nurse and adolescent obesity: understanding the disease for effective prevention

Documents

treatment of obesity

overweight adults

adolescent obesity

probability of obesity

obese children

ile prevalence of overweight

degree of overweight

absence of overweight