Παρουσίαση καθ. Παιδιατρικής Γ. Χρούσου
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Transcript of Παρουσίαση καθ. Παιδιατρικής Γ. Χρούσου
Secular Growth Trends in Greece: Childhood Obesity,
a Social Phenomenon
George P. Chrousos
Athens University Medical School
Secular Growth Trends
Secular Trends in Obesity
Mascie-Taylor and Goto, 2007
90th Centile Abdominal Circumference in cm
Brambilla IJO 2007
Obesity Epidemic in Childhood and Adolescence,
the First Reports, USA
• >100% increase in the number of children diagnosed as overweight (OW) and obese (OB) during the past 30 years
• 1983: 18.6% preschoolers OW, 8.5% OB 2000: 22.6% OW, 10.3% OB Rocchini, NEJM, 2002
• NHANES 1999-2002: 31% and 16% of 6-19 years old in the USA are overweight and obese
Hannon, Pediatrics, 2005
Global Prevalence of Overweight and Obesity
Country, Year
Criteria of Definition
Age
group
Prevalence of OW and OB %
Increase of OW and OB % (time interval)
Australia, 1995
IOTF 4-6
7-11
12.8, 3.6
14.4, 5
(1985-1995)
OW:38%, OB:190%
Brazil, 1997
IOTF 6-9
10-18
17.4
12.6
(1974-1997)
OW: 250%
China, 1997
IOTF 6-9
10-18
11.3
6.2
(1991-1997)
OW: 7.6%, 38%
UK,
1994
IOTF 4-11 11.2, 2.1 (1984-1994)
OW: 44.5%
Germany,
1997
IOTF 5-6 12, 2.8 (1982-1997)
OW: 44%
Japan,
1996
120% of standard weight
6
12
4.5
9.5
(1970-1996)
OW: 185%, 188%
USA,
2000
CDC 2-19 27, 13.7 (1971-2000)
OB: (6-11) 283%,
(12-19):154%
Prevalence of BMI≥85th and ≥ 95th Percentile of 15 y of Age: Consensus Statement, 2004
Speiser, 2005
Secular Trends in Height and Weight, Males, Greece, 1978-2001
Height, Boys Weight, Boys
Chiotis, Ann Clin Ped Univ Ath 2003
Secular Trends in Height and Weight, Females, Greece, 1978-2001
Chiotis, Ann Clin Ped Univ Ath 2003
Weight, GirlsHeight, Girls
Secular Growth Trends in Greece,1978-2001, Conclusions
• Same methodology and research center
• Same area and origins
3th percentile
50th percentile
97th percentile
Height +2 cm +1 cm +3 cm
Weight +4 kg +6 kg +15 kgDifferences in males, 1978-2001,aged 18
Differences in females, 1978-2001aged 18
3th percentile
50th percentile
97th percentile
Height - - +1 cm
Weight - - +7 kg
Secular Growth Trends in Greece,2001 in Relation to USA, 2000
3th percentile
50th percentile
97th percentile
Height +3 cm +1 cm +1.5cm
Weight +6 kg +7 kg +6 kg
3th percentile
50th percentile
97th percentile
Height +3 cm +1 cm +1 cm
Weight +2 kg +2 kg -4 kg
Differences in males, aged 18
Differences in females, aged 18
BMI curves, 2001
Boys Girls
BMI Curves in Relation to BMI 25 or 30
Boys Girls
Evidence from Greece, Males, 2001:
BMI and prevalence of obesity in 10.925 subjects (5.537 males) of Hellenic origin aged 0-18 years, living in the
Athens area
Chiotis, Ann Clin Ped Univ Ath, 2004
Age years Normal% OW% OB%
0-1 87.05 2.88 10.07
1-6 79.95% 10.88 9.17
7-12 72.10 18.48 9.42
13-18 67.5 20.63 11.80
Total 72.11 17.48% 10.40%
OW: 25<BMI≤30, extrapolatedOB: BMI>30, extrapolated
Evidence from Greece, Females, 2001:
BMI and prevalence of obesity in 10.925 subjects (5.388 females) of Hellenic origin aged 0-18 years, living in the
Athens area
Chiotis, Ann Clin Ped Un Ath, 2004
Age years Normal% OW% OB%
0-1 81.68 9.16 9.16
1-6 88.68 8.00 3.31
7-12 81.82 14.49 3.69
13-18 81.87 14.48 3.65
Total 83.22 13.05% 3.73%
OW: 25<BMI≤30, extrapolatedOB: BMI>30, extrapolated
Other Reports from Greece
• Thessaloniki, 2001: aged 6-17 years• N=2.458
Age Normal% OW% OB%
6-10 69.1 25.3 5.6
11-17 78.4 19 2.6
Total 73.7 22.2 4.1
Krassas, 2001
• Crete, 1982-2002: aged 12.1 ± 0.1 y,
• N=528, N=620
Other Reports from Greece
Manios, 2005
Associated Nosology
Metabolic Syndrome Χ, 1988
Reaven and colleagues: clustering of: obesity insulin resistance arterial hypertension dyslipidemia glucose intolerance
Increased cardiovascular risk
NCEP Definition(National Cholesterol Education Panel)
• ≥3 criteria
• Central obesity (Waist Circumference M>102 cm, F> 88 cm)• Impaired fasting glucose (>110mg/dl)• Low HDL (Α<40 mg/dl, Γ<50 mg/dl)• High Triglycerides (>150 mg/dl)• Arterial Hypertension >130/85 mmHg
JAMA 2001
IDF Definition(International Diabetes Federation)
ΝCEP + Waist Circumference:
• Fixed component: M>94 cm, F>80 cm Alberti K et al. , Lancet 2005
WHO Definition(World Health Organization)
• Impaired glucose tolerance, diabetes, insulin resistance
+ ≥2 Arterial Hypertension ≥ 140/90 mmHg ΗDL: M<40 mg/dl, F<50mg/dl ΤG ≥ 150mg/dl Central Obesity –waist circumference or ΒΜΙ>30 Μicroalbuminuria Alberti K et al Diabet Med, 1998
NHANES III (1988-1994)
Metabolic Syndrome
0
5
10
15
20
25
30
35
40
20's 30's 40's 50's 60's 70's 80's
Age (years)
Pre
vale
nce
Park et al., 2003
Total: 4.2%
OB: 28.7%OW: 6.1%NW: 0.1%
Επίπτωση
Risk FactorsArterial Hypertension, Obesity, Insulin Resistance,
Dyslipidemia, Chronic stress (real or perceived)
Metabolic Markers Cholesterol, LDL, HDL, Tg, Lp(a), Apo-A1, Apo-B, Glucose, HbA1c, Insulin, Albumin
Adiponectin, hsCRP
Metabolic Syndrome
Diabetes Type II
Cardio-VascularDisease
BackgroundAge, Gender, Developmental History (SGA, LGA), Diet, Physical Activity,Genes
GENET IC BACKGROUND, RACE
SOCIAL &DEVELOPMENTAL
FACTORS
SOCIAL ENVIRONMENT & CULTURE
PERINATAL & DEVELOPMENTAL
PARAMETERS
UNFAVORABLE CLINICAL CHARACTERISTICS:
+Body fat, -- Lean mass, + Visceral fat
OBESITY RELATED DIABETES OF THE
YOUNG
CARDIOVASCULARDISEASE
METABOLIC SYNDROME
(PREDISEASE)
3 of: IR, IFG, IGT Hypertension Obesity Dyslipidaemia
SECONDARY METABOLIC
ABNORMALITIES: Hypoadiponectinaemia Urine microalbuminuria
Liver disease
BEHAVIOR PSYCHOLOGYChronic stress
Eating disordersDepression
CLINICALPHENOTYPE(OBESITY)
DIETARYBEHAVIOR
PHYSICALACTIVITY
Published pediatric papers concerning the metabolic
syndrome
15 published reports from 1999 to 2006• No of criteria: 3, or 4
• Adiposity: BMI or waist circumference • Cut-off points: 75th, 85th, or 95th
centile
• Glucose metabolism: IFG, IGT, HOMA,
Fasting Insulin
Methods: Children & Adolescents
≥3
-BMI > 95th percentile -ΤG > 95th percentile, -HDL < 5th percentile , -Systolic or Diastolic Blood Pressure >95th percentile -Impaired glucose tolerance: • impaired fasting glucose >105 mg/dl or >140 mg/dl but < 200 mg/dl, 2 hours after the OGTT Weiss R, NEJM 2004 Sharma AM, Acta Diabet 2005
Data from a Childhood-Adolescence Obesity Clinic
• 420 Greek children (198 girls, 222 boys)• White race• Mean age 10.2 years (3-16)• 75.8% prepubertal boys and • 54.2% prepubertal girls
Data from a Childhood-Adolescence Obesity Clinic
Defined as having the MS when ≥3 were positive:
BMI > 95th percentile ΤG > 95th percentile, HDL < 5th percentile , Systolic or Diastolic Blood Pressure >95th percentile Impaired glucose tolerance: impaired fasting glucose >105 mg/dl or >140 mg/dl but < 200 mg/dl, 2 hours after the OGTT Weiss R, NEJM 2004
• Additional 29% of boys and 30% of girls had partial MS (2 criteria)
• 44% of the entire population had at least one metabolic abnormality
• 15% of boys and 16% of girls had the full MS
Data from a Childhood-Adolescence Obesity Clinic
• Low HDL was the most common abnormality associated with obesity
Pervanidou, ECOG 2007
100
% M
etab
olic
Syn
drom
e
00
90
80
70
60
50
40
30
20
10p< 0.001
N=31 N=36 N=36 N=35
Metabolic s. Prevalence across BMI z-score Quartiles among Males
% M
etab
olic
S
yndr
ome
100
00
90
80
70
60
50
40
30
20
10
Metabolic s. Prevalence across BMI z-Score Quartiles among Females
p< 0.001
N=55 N=56 N=55 N=56
100
% M
etab
olic
Syn
drom
e
00
90
80
70
60
50
40
30
20
10
Metabolic s. Prevalence across Insulin Quartiles (μU/ml) among Males
N=25 N=24 N=27 N=25
P=0.018
100
00
% M
etab
olic
Syn
drom
e
90
80
70
60
50
40
30
20
10
Metabolic s. Prevalence across Insulin Quartiles (μU/ml) among Females
p< 0.001
N=48 N=50 N=50 N=50
Prevalence of the Metabolic Syndrome and Metabolic Abnormalities in 420 Greek Children and Adolescents Assessed for Simple Obesity: preliminary results
Depression & Obesity: age 14-19
Shape up America, NHANES IIIMartin & Moore, 2002
30%
20%
Obesity and Depression
CDI, depressive symptomatology
• 22% of the entire population (N=73, aged 8-14) had depressive symptoms
Obesity and Life Events
2/3 presented with one or more stressful lifeevents during the last year
24 H SAMPLING OVERNIGHTDEXAMETHASONE TEST
A.
B.
PL
AS
MA
CO
RT
ISO
L
8 am 8 pm 8 am
TARGET TISSUE SENSITIVITY
TA
RG
ET
TIS
SU
E R
ES
PO
NS
E
CORTISOL CONCENTRATION
HS N R THRESHOLDFOR HARMFULNESS
-D
-D
+D
+D
NS CS
NS CS
24 H
CO
RT
ISO
L
DARK
Influence of Circadian Clockon HPA Axis
SCNCircadian Center
PVN
CRH AVP
ACTH
F/B
TARGETTISSUES
StressOther Inputs
Cir
cula
tin
g F
/BT
arg
et T
iss
ue
Eff
ect
Time
Circadian fluctuation
-
-A circadian rhythm indirectly regulates the functions of all organs/tissues through modulation of glucocorticoid actions.
«Συμπάσχει η ψυχή τω σώματι νοσούντι και τεμνομένω, το δε σώμα τη ψυχή»
“The soul suffers when the body is diseased or traumatized, while the body suffers when the soul is ailing”
Aristotle
«Παχέες ταχυθάνατοι μάλλον των ισχνών»
“Obese people die earlier than thin ones”
Hippocrates
Conclusions
• Greece, like the US and other EU countries, has an increase of its OW and OB population in childhood and adolescence
• These changes resulted in increased prevalence of MS traits in childhood and forecast an increased morbidity and mortality in later life
Stress System and the Metabolic Syndrome
_________________________________
Cushing SyndromePseudocushing SyndromeMelancholic DepressionMetabolic Syndrome“Benign” Premature Adrenarche Linkage StudiesMonkey StudiesAIDS-related insulin resistance/lipodystrophy Seasonal Depression Atypical Depression
__________________________________________
PREGNANCY
FETUS
NutritionGestational diabetes
Nutrition /Stress
Insulin IGF-1
cortisol catecholamines insulin
LGASGA
Visceral AdiposityMetabolic Syndrome
Depression
visceral fat
cortisol
catecholamines
Melancholic Atypical
Metabolic Syndrome
visceral fat
lean body mass
bone mass
cortisol
catecholamines
insulin
70-75
Προσδόκιμο Ζωής (1998)
75-80
65-70 60-65 55-60
under 55
NA
Age adjusted death rates for CAD by country and sex, age 35-74 Age adjusted death rates for CAD by country and sex, age 35-74 (British Heart Foundation, Statistics Database 2003)(British Heart Foundation, Statistics Database 2003)
Greek Trends: Athens GMA
• C-Sections >70% <20%
• Breast Feeding <20% >90%
Real Expected