ueda2015 prevention of obesity dr.mohamed abuel-ghate

Prevention of Obesity

Prof. Dr. Mohamed AboulghateProfessor, Cairo University

Secretary General, Egyptian Medical Association for the Study of Obesity

Introduction Comorbidities Causes Prevention

What is Obesity

Obesity is the disease in which fat has accumulated to such an extent that health may be adversely affected

Obesity is a chronic relapsing disease (WHO 1997)


Diagnosing Obesity

Weight (kg)

Height (m) x Height (m) BMI =

Adult Under 5 5-19

Overweight 25-29.9 > 2 SD above the WHO growth standard median

> 1 SD above the WHO growth standard median

Obese ≥ 30 > 3 SD above the WHO growth standard median

> 2 SD above the WHO growth standard median


Prevalence of Obesity


“Obesity, the epidemic of the 21st century”World Health Organization


Obesity in Egypt

Overweight Obese

5-9 20.5 15.1

10-14 28.4 9.9

15-19 25.2 4.9

Men 58.8 (53.6-64.0) 22.4 (19.9-24.8)

Women 66.2 (59.9-72.5) 41.6 (35.5-47.7)


Complicationsof Obesity

Complications of obesity


Wolf et al 1998


Type 2 DM 61%

Hypertension 17%

Coronary Heart Disease 30%

Gallbladder disease 30%

Osteoathritis 24%

Brast cancer 11%

Endometrial cancer 34%

Colon cancer 11%

Proportion of disease prevalence attributable to obesity

Willett et al 1999


Chan et al 1994


Diabetes vs Waist Circumference & BMI

<25

25-30

>300

5

10

15

20

<8484-92

92-9999-107

>107

<25

25-30

>30

BMI

Waist circumference (cm)

Dia

bet

es p

revale

nce

)%(

Balkau et al. 2007


Health Benefits of Weight and Visceral Fat Reduction

• A 2.5 cm decrease in WC is associated with improvement in:

Glucose control

Blood pressure

Lipid levels

• Modest weight loss (2-3%) is associated with improvement in clinical

markers

Fasting plasma glucose: -3.8 mg/dl

Triglycerides: -29.2 mg/dl

SBP: -1.1 mmHg

DBP: -1.3 mmHg

Noria et al. 2004


Causes of Obesity

Causes of Obesity

Disturbed Energy Balance

•Energy Input (Diet)• Energy Output (Physical

activity)

Body Predisposition

•Genes•Prenatal Influences•Childhood influences


Balanced, Healthy, Eucaloric Diet

Fats: Unsaturated

Dairy: Skimmed

Protein: Lean

Carbohydrates: Complex

Choose minimally processed, whole foods—whole grains, vegetables, fruits, nuts, healthful sources of protein (fish, poultry, beans), and plant oils.

Limit sugared beverages, refined grains, potatoes, red and processed meats, and other highly processed foods, such as fast food.

Energy Balance - Diet

My Plate, USDA 2011


Energy Balance - Physical Activity

• Increases total energy expenditure

• Decreases fat around the waist and total body fat, slowing the development of abdominal obesity.

• Builds muscle mass, increasing BMR

• Reduces depression and anxiety, which may motivate people to stick with their exercise regimens over time.

U.S. Dept. of Health and Human Services 2008.


Causes of Obesity



activity)

Body Predisposition



• Single Gene Mutations : Rare forms of obesity eg. genes that code for the hormone leptin

• Multiple Genes Variations: Common Obesity

More than 30 candidate genes on 12 chromosomes have been associated with BMI

Genes

O’Rahilly 2009; Heid 2010


Causes of Obesity



activity)

Body Predisposition



• Maternal Smoking During Pregnancy:

50% higher risk of childhood obesity

• Gestational Weight Gain:

4 times the risk of being overweight

• Gestational Diabetes

Increased risk of obesity and overweight

Pre-natal Influences

Oken 2008; Oken 2007; Ludwig 2010; Hillier 2007


Causes of Obesity



activity)

Body Predisposition

•Genes•Prenatal Influences

•Childhood influences


• Rapid Weight Gain: higher risk of later obesity

• Breastfeeding: 13-22% reduced risk of obesity

• < 12 hours sleep double the odds of being overweight at age 3

Childhood Influences

• In 2008, a study conducted on 1,100 mother–child pairs: – Maternal smoking during pregnancy – gestational weight gain– duration of breastfeeding– infant sleep

All variables +ve All -ve

% obese at age 3 6% 29%

Baird 2005; Arenz 2004; Owen 2005; Taveras 2008


Causes of Obesity



activity)

Body Predisposition


The Obesogenic

Environment


The Obesogenic Environment• Families:

– Excess gestational weight gain– Increased smoking among women– Food choices (convenience, affordability, preferences and tradition)– Less breast feeding (women entering work-force)– Electronic leisure (TV, computers, internet, videogames)– Household applinces(washing machines, vacum cleaners, microwaves)

• Worksite: – Accessible unhealthy food– Automation– Office jobs (mental vs physical)– Work stress– Lunch break culture– On-site PA facilities


The Obesogenic Environment

• Schools: – Junk food and sweetened beverages– Peer-pressure– Few PE sessions– Unequipped PA facilities

• Neighborhood: – Greater access to stores and fast food outlets– Scarcity of safe, appealing walking paths, parks, PA

facilities– Inconvenience of public transportation

• Food marketing


Prevention of Obesity

Prevention1- Families

• Avoid excess gestational weight gain

• Smoking cessation

• Breast feeding

• Weight monitoring

• Healthy food at home (pre-meal snacks, air fryers)

• School meals

• Physical activity

• Role models


Prevention2- Nurseries and child care

• Age-appropriate healthy foods

• Active play, in fun, short bursts

• Keeping televisions turned off and away from areas where children sleep.

• Educating parents about healthy eating and activity habit


Prevention3- Schools

• PA sessions

• Healthy food choices

• Limiting availability and marketing of unhealthy foods

• Health education of students


Prevention4- Health Care Systems

1. Health Care Providers

a. Paediatricians

b. Obstetricians

c. Internists

2. Hospitals

3. Health Care Funders/Insurers

4. Health Care Training Institutions


The Role of Health Care Providers

Harvard School of Public Health:

Recommendations for Obesity Prevention by Health Care Providers


Paediatrics• Measure patients’ BMI percentile for age at every well-child visit for children ages 2 and older;

for younger children, measure weight-for-length percentile

• Counsel all patients and their families on healthy eating, physical activity, and healthy growth, regardless of current weight status

• Counsel all patients and their families to limit television time to no more than two hours per day and to remove televisions from children’s bedrooms

• Counsel all patients and their families to limit consumption of sugar-sweetened beverages and encourage other healthful eating behaviors:– Eating breakfast daily– Limiting restaurant eating, especially fast-food restaurants – Eating meals as a family – Limiting portion sizes

• Counsel all patients and their families to help children achieve 60 minutes of moderate to vigorous physical activity per day

• Establish procedures for follow-up assessment (including laboratory tests), counseling, and treatment plans for children who are overweight or obese

• Establish policies to avoid weight bias in pediatric clinics, such as by requiring all employees to be trained on weight-bias prevention


Obstetrics, Pre- and Post-natal care

• Counsel patients on the importance of being at a healthy weight before pregnancy and gaining weight at a healthy rate during pregnancy

• Recommend that mothers breastfeed and provide training and support for breastfeeding

• Counsel patients on the importance of avoiding smoking during pregnancy

• Screen pregnant women for gestational diabetes


Internal Medicine

• Routinely measure BMI in all adult patients

• Order appropriate follow-up laboratory tests for patients who are overweight and obese and prescribe a long-term treatment strategy, which may include:– Counseling/coaching/behavioral interventions on diet/lifestyle change– Weight loss medication for appropriate individuals who have been unable to

lose weight through conventional therapy and who have no contraindications

– Bariatric surgery for patients with severe obesity unable to lose weight through conventional therapy and who have no contraindications

• Design physician offices to avoid stigmatizing overweight or obese patients, such as by providing private weighing areas and using scales that can measure weights greater than 300 pounds


Weight gain with conventional T2D therapies

Kahn et al 2000

84

86

88

90

92

94

96

98

0 0.6 1.2 1.8 2.4 3 3.6 4.2 4.8

Roziglitazone

Metformin

Glibenclamide

0

1

2

3

4

5

6

7

8

9

0 1 2 3 4 5 6 7 8 9 10 11 12

Conventional (n=411)Glibenclamide (n=277)Metformin (n=342)Insulin (n=409)

Wei

gh

t (K

g)

Ch

ang

e in

wei

gh

t (K

g)

Years Years

1 2 3 4 5


Potential mechanisms behind insulin-induced weight gain

•Treatment induced reduction of renal glycosuria

•Changes in energy metabolism (5-10%)

•Defensive snacking

•Reduced satiety signaling in arcuate nucleus

•General anabolic effect of insulin

•Non-physiological pharmacokinetics


Liraglutide: A T2D-therapy, now approved for weight loss

0

10

20

30

40

50

60

Liraglutide3.0mg

Liraglutide1.8mg

Placebo

>5% weight loss

>10% weight loss

Davies et al 2014


Liraglutide

•Liraglutide 3.0 was superior to liraglutide 1.8 and placebo with respect

to mean and categorical weight loss

•Liraglutide 3.0 also provided significantly greater improvements in

HbA1c vs. placebo•More overweight/obese individuals with liraglutide 3.0 mg vs. liraglutide 1.8

mg and placebo reached HbA1c target of <6.5%

•Liraglutide was generally well tolerated•No differences between liraglutide 3.0 and 1.8 mg were noted in

safety/tolerability, except for gastro-intestinal adverse events

Davies et al 2014


Healthy Hospitals

• Encourage healthy eating

• Offer healthy food

• Promote breastfeeding


Health Insurance Providers

• Cover obesity-related conditions

• Incentivise healthy behaviors

• Fund obesity prevention efforts


Health Care Professional Training

• Provide training in obesity prevention and lifestyle counseling, such as– Interpreting BMI percentile for age– Counseling on nutrition and physical activity– Motivational interviewing skills

• Distribute position statements and other evidence-based information on obesity prevention

• Encourage members to be role models for healthy eating and activity


Prevention5- Worksites

• Onsite PA facilities and changing rooms

• Access to nutritionists and other counselors

• Worksite or company-wide policies that provide healthier food options

• Reimbursing exercise-related expenses


Prevention6- Local and national policy

• Agriculture policy: Planting and buying of fresh fruits and vegetables• Revenue policy: Taxing unhealthy foods and subsidizing healthy choices• Zoning regulations: Bringing supermarkets to low-income

neighborhoods and limiting fast-food restaurants • Mass-communication policy: Restricting advertising to youth about

unhealthy food• Food regulations: Standerdising food labelling to include calorie-per-

serving and recommended daily limits• Public health marketing: Developing social marketing campaigns to

promote healthy living• Community design: Planning to promote active transportation. Build,

maintain and increase access to walk/cycle paths, parks and recreation facilities

• Transportation: Improving infra-structure for public transportation


Thank you

Prof .Dr. Mohamed AboulghateProfessor, Cairo University

Secretary General, Egyptian Medical Association for the Study of Obesity

ueda2015 prevention of obesity dr.mohamed abuel-ghate

Documents

prevention of obesity

obesity obesity

obesity weight

prevention type

study of obesity

complicationsof obesity

growth standard median

gallbladder disease