DR. SONIA S. KANITKAR

CONSULTANT NEONATOLOGIST, PEDIATRICIAN & ADOLESCENT SPECIALIST

MEMBER “ IAP TASK FORCE” FOR PREVENTION OF OBESITY

ADOLESCENT OBESITY- WHAT’S NEW?

DEFINING OBESITY

“ CHANGES IN DEFINITION”

Overweight is defined as a BMI at or above the 85th percentile and lower than the 95th percentile for adolescent of same age & sex.

Obesity is defined as a BMI at or above the 95th percentile for adolescents of same age & sex.

Severe Obesity -Although various definitions have been proposed to identify severe obesity in children and adolescents, BMI ≥99th percentile has been the most commonly used.

Cut off values of BMI for overweight & Obesity

Agency Tendency for State of overwt. (1994)

overweight (1994) NOW obesity( 2007) NOW State of overwt (2007)

WHO > 25 kg/m2 > 30 kg/m2

IOTF > 23 kg/m2 > 25 kg/m2

NCHS > 85thcentile > 95th centile

Source: National Health Statistics Reports * Number 25 * June 25, 2010

OBESITY STATS: What’s New?

FOR THE FIRST TIME

---Obesity & extreme obesity among US low income, preschool aged children went down. In 2003-2010, the prevalence of obesity reduced slightly from 15.21% to 14.94%.

--- Similarly prevalence of extreme obesity reduced from 2.22% to 2.07%

(Ref: Study from Pediaric nutrition Surveillance Sys-1998-2010)

Breaking News!!!!!

“GLOBESITY ” Is Rapidly Becoming A Major Public Health Problem

GLOBESITY- What it means?

1) Obesity Epidemic – conquering globally, even developing countries2) The rate of increase of obesity among adolescents has

slowed. 3) The overall prevalence has begun to plateau.4) The trend -- fastest- growing subcategory of obesity is

“SEVERE” pediatric & adolescent obesity—5) Severe obesity afflicts between 4% and 6% of all youth in

the United States.

Ref : American Heart Association ------ Circulation October 8, 2013 vol. 128 no. 151689-1712

Evidence Based Stats

Results of a study released online Sept. 16 in the journal Pediatrics. The study- More than 34,000 adolescents in grades 6 to 10 . The first group , studied from 2001-'02 -- 14.9 percent were overweight

and 10.3 percent were obese. The second from 2005-'06 - 17 percent and 12.7 percent, respectively -- The final group from 2009-'10 ----overweight dropped to 16.6 percent,

obesity leveled off at 12.7 percent.

SOURCES: Ronald Iannotti, Ph.D., chairman, department of exercise and health sciences, University of Massachusetts, Boston; Sharon Strohn, R.D., manager, clinical nutrition and diabetes education, Children's Hospital of Pittsburgh, Pennsylvania; Robert Gensure, M.D., pediatric endocrinologist, Children's Hospital at Montefiore, New York City; October 2013 Pediatrics

Changes in prevalence2001--2010

2001-20022005-2006

2009-2010

0%10%20%30%40%50%60%70%80%90%

100%

normalobesityoverweight

Indian Stats- “Overweight /Obesity on the rise”

School children in Chennai

> 22% HSE group 15% from MSE groups .

only 4.5% from LSE group urban well-off children : highest Risk

Ramachandran A, Snehalatha C, Vinitha R, Thayyil M, Sathish Kumar CK, Sheeba L, et al. Prevalence of overweight in urban Indian adolescent

school children. Diabetes Res Clin Pract 2002; 57: 185 -190.Courtesy: Dr. Swati Bhave

What’s New – In India

School childrenDelhi31% overweight;7.5% obesePune24% overweightChennai22% overweight.1

According to NFHS 3(2005)--

Overwt. & Obesity is most common in states of Punjab, Kerala & Delhi

1. Indian Pediatric 2002; 39: 449-452. 2. Indian Pediatric 2004; 41: 559-575.3. Diabetes Res Clin Pract 2002; 57: 185-190. Courtesy: Dr. Swati Bhave

In Short !!Adolescents of Urban India Upper Strata Urban slums

Are Obese!!!

Adolescents of Rural India Are Undernourished!!

Etiology- What’s New ?

1)“Urbanization & Media hype” leading to consumption of oversized meals at home & restaurants

Source: Children, Adolescents, Obesity and the Media, Pediatrics 2011;128;201; originally published online June 27, 2011;

Evidence Based News

*First A December 2010 study --examined 3039 possible meal combinations at a dozen

restaurant chains and found only 12 meals that met nutrition criteria for preschoolers.

--The same study found that 84% of parents had purchased fast food for their children in the previous week.

--More than 80% of all advertisements in children’s programming are for fast foods or snacks,

--For every hour that children watch TV, they see an estimated 11 food advertisements

Source: Children, Adolescents, Obesity and the Media, Pediatrics 2011;128;201; originally published online June 27, 2011;

Evidence Based conclusion

SECOND STUDY IN LEBANON

--2,541 participants, aged 15 to 23, from across the United State --viewed a random set of frames of fast food ads with brand name removed. --Conclusion – 1)Obese teens and young adults may be more receptive to TV fast food ads than those who aren't obese . 2)The study could not determine which comes first Being receptive to TV fast food ads or obesity Further research is needed to better understand the link between food

advertising and obesity risk.

Ref: SOURCE: Dr. Auden McClure, of the Norris Cotton Cancer Center at the Dartmouth-Hitchcock Medical Center in Lebanon, N.H., said in a center news release. Norris Cotton Cancer Center, news release, Oct. 23, 2013

What’s New in Etiology?

2)Over- involvement with new & latest gadgets like smart mobile phones, video games , remote controlled outdoor games like Wi Sport gadget , leading to drastic reduction in physical activity.

What’s New in Etiology?

3)That genes play a major role in influencing a person's weight and may be useful for developing new ways to treat people who are heavy and develop diabetes

New & Latest Evidence

Researchers in Britain --conducted genetic analyses--more than 2,100 severely obese youngsters.--Found that those with mutations in the KSR2

gene had larger appetites and slower metabolism than those with a normal copy of the gene

-- the study published in the Oct. 24 issue of the journal Cell.

--This work adds to growing evidence of gentic basis

SOURCE: Cell, news release, Oct. 24, 2013

What’s New in Etiology?

4)Obesity isn't all about eating and inactivity, says an international group of researchers.  

Source- David B. Allison, PhD, director of the University of Alabama at Birmingham clinical nutrition research center, and his colleagues.

Etiology has manifolds- Part 1

The Alabama group gives 10 "additional explanations" for obesity: 

1. Sleep debt. Getting too little sleep can increase body weight.

2. Pollution. Hormones control body weight. And many of today's pollutants affect our hormones. 

3. Air conditioning. You have to burn calories if your environment is too hot or too cold for comfort. But more people than ever live and work in temperature-controlled homes and offices. 

4. Decreased smoking. Smoking reduces weight.

5. Medicine. Many different drugs — including contraceptives, steroid hormones, diabetes drugs, some antidepressants, and blood pressure drugs — can cause weight gain. Use of these drugs is on the upswing. 

Etiology has many folds -Part2

6. Population age, ethnicity. Middle-aged people and Hispanic-Americans tend to be more obese than young European-Americans. Americans are getting older and more Hispanic. 

7. Older moms. There's some evidence that the older a woman is when she gives birth, the higher her child's risk of obesity.

8. Ancestors' environment. Some influences may go back two generations. Environmental changes that made a grandparent obese may "through a fetally driven positive feedback loop" visit obesity on the grandchildren. 

9. Obesity linked to fertility. There's some evidence obese people are more fertile than lean ones. If obesity has a genetic component, the percentage of obese people in the population should increase. 

10. Unions of obese spouses. Obese women tend to marry obese men. If there are fewer thin people around — and if obesity has a genetic component — there will be still more obese people in the next generation

Measuring Obesity--What’s New ?

BMI retains the Title “The Golden Measure ”for Obesity

Skinfold thickness and waist circumference have been proposed as alternatives for quantifying adiposity in overweight and obese adolescents but, not recommended in youth with severe obesity.

Latest Guidelines by AAP:( published in Journal of Family physicians)

Tests Recommended :

1)If BMI 85 –94thPercentile with no risk factor Fasting Lipid profile 2) If BMI 85th- 94th with risk factors Fasting lipid profile + AST,ALT +Fasting Blood sugar3) If BMI> 95th percentile All above + BUN, S. Creatinine

Breaking News !!!!

Screening needs to be done for all – obese or not !!

What’s New? - Consequences of Obesity in Adolescents

Global spread of type 2 diabetes in childhood.

Type 2 diabetes may become the most common form

10% of newly diagnosed DM are in age group of 10 – 18 years

An increased risk of nephropathy and retinopathy in young type 2 diabetes as compared to young people with type 1 diabetes,

Recent data indicate early sign of cardiovascular disease in youth with type 2 diabetes.

Ref: Venkatnarayan KM. Type 2 Diabetes in Children: A problem lurking for India ? Indian Pediatr (editorial) 2001; 38: 701-704

Ref: Indian J Med Res 132, November 2010, pp 598-607

Obesity leading to DOHaD

20-25% of obese adolescents : hypertension, dyslipidemia & PCOS

FOAD now DOHaD – “Developmental Origins of Health & disease”

Hypothesis for D O H a D 1)Multiphasic Nutritional Insult

2)Genes + early Under nutrition + subsequent Over nutrition

3)Fetal origins or later lifestyles or both `

Ref: Gupta AK, Ahmad I. Childhood obesity and hypertension. Indian Pediatr 1990; 27: 333-337

:Yajnik CS. The insulin resistance epidemic in India: Fetal origins, Later lifestyle, or both ? Nutr Rev 2001; 59: 1-9

Maternal malnutrition

FETAL UNDERNUTRITION(Nutrient demand exceeds supply)

HYPERLIPIDAEMIA

HYPERTENSIONCENTRAL OBESITY INSULIN

RESISTANCE

Type 2 Diabetes and CHD

Muscle mass Cortisol Impaired development Fat mass (Liver, Pancreas, Blood vessels)

Placental transfer

Fetal genome

Altered body composition Early maturation Brain sparing

Down regulation of growth

Fall CHD. The fetal and early origins of adult disease. Review. Indian Pediatr 2003; 40:480-502

Developmental origins of adult disease: hypothesis

Pharmacotherapy --What’s New ?

Till date, 4 drugs evaluated for the treatment of Adolescent obesity -- sibutramine , orlistat , metformin, and exenatide.

Metformin and exenatide are not FDA-approved.

Sibutramine, originally approved for patients ≥16 years of age, was withdrawn in 2010.

Sibutramine, -- most effective , in terms of weight/BMI reduction, -- removed from US market because of CVS concerns.  A meta-analysis of 5 studies (with treatment periods ≥6 months) that

used metformin in children and adolescents reported a placebo-subtracted reduction in BMI of 1.42 kg/m2.Metformin has a strong safety track record, and gastrointestinal side effects (mainly nausea and vomiting), although common, are usually mild in severity.

Breaking News!!!

Orlistat – the only medication approved by the FDA for use in adolescents

(≥12 years). Orlistat, - a lipase inhibitor , - blocks the absorption of fat, - is administered orally 3 times per day, - Has modest weight loss efficacy in obese adolescents. The largest study (n=539) of orlistat in obese adolescents reported

a placebo-subtracted reduction in BMI of 0.86 kg/m2 (BMI reduction of ≈2.4%) over a treatment period of 1 year.

 No cardiometabolic benefits were observed other than a small reduction in diastolic blood pressure. 

On the Forefront – Bariatric Surgery

“NEW KID ON THE BLOCK “- BARIATRIC SURGERY

Why?1) Limited effectiveness of lifestyle and pharmacological

interventions2) Severe degree of obesity (Poirier et al)- choicest treatment

for selected adolescents, suffering from the health and psychosocial effects of severe obesity.

3) The most common procedures used for adolescents with severe obesity include roux en Y gastric bypass (RYGB), adjustable gastric banding (AGB), and the more recently introduced vertical sleeve gastrectomy (VSG), which is being used with increasing frequency.

4) Published experience with bariatric procedures suggests that weight loss outcomes, comorbidity outcomes, and patient safety are comparable or better for adolescents than those seen in adults.

Latest Recommendations –2013 , November NHLBI-conceived American College of Cardiology (ACC)/American Heart

Association (AHA)/Obesity Society

To help primary-care providers address weight management as a pathway to promoting the health of their patients.

The new recommendations retains the body mass index (BMI) as the best measure.

Emphasis on use of waist circumference as an indicator of risk for type 2 diabetes & cardiovascular disease

For the Diet control – evidence has proven that “No one particular eating plan is recommended ,over any other” Patient preferences and their health status should guide the choice.

Latest Recommendations 2013 contd..

Pharmacotherapy gets a backseatOnly "for those unable to achieve and sustain

weight loss with comprehensive lifestyle interventions alone

For those - BMI of >30 - BMI > 27 with comorbidities It is recommended that drugs to be used only for

12 weeks, at which point patients should be evaluated to determine whether they are losing weight. "If they are not, they should not be continued, as they are ineffective”.

Latest Recommendations 2013 contd.

Finally, the recommendation advises physicians that

in patients with a BMI of >35 and 1 comorbidity

a BMI of 40 or more“Bariatric surgery may be an appropriate

option to improve health,"

Remember!!!!!!!!!!!!!!

“The implications” of this globalphenomenon on futuregenerations will be disastrousunless appropriate action isTaken “NOW”

THANKS

FOR A PATIENT LISTENING !!!

Take Home Messages

1) We need to Evaluate unique approaches to lifestyle modification and physical activity interventions esp. in adolescents in order, to have sustained interest.

2)We need to assess safety and efficacy of new pharmacotherapies for the treatment of obesity in adolescents

Take Home Message

3)The treatment of overweight and obesity in children and adolescents requires a multidisciplinary, multi-phase approach.

4)Holistic approach involves policy makers and legislation, establishing public- private coalitions , empowering primary providers and enhancing individual awareness and skills.

References

Prevention of pediatric overweight and obesity. Committee on Nutrition. American Academy of Pediatrics. Pediatrics 2003; 112:424-430.

Yanovski JA, Yanovski SZ. Treatment of pediatric and adolescent obesity. JAMA 2003; 289:1851-1853.

Hill J, Peters J. Environmental contributions to the obesity epidemic. Science 1998; 280:1371-1374.  Robinson TN, Dietz WH. Weight gain: Overeating to obesity. In: Rudolph CD, Rudolph AM, editors. Rudolph’s Pediatrics, 21st ed., NY McGraw-Hill, 2003:p. 476-481.

 Robinson TN, Dietz WH. Weight gain: Overeating to obesity. In: Rudolph CD, Rudolph AM, editors. Rudolph’s Pediatrics, 21st ed., NY McGraw-Hill, 2003:p. 476-481.

Preventing chronic diseases: A vital investment. World Global Report. Geneva: World Health Organization; 2005. World Health Organization.

The American Heart Association requests that this document be cited as follows: Kelly AS, Barlow SE, Rao G, Inge TH, Hayman LL, Steinberger J, Urbina EM, Ewing LJ, Daniels SR; on behalf of the American Heart Association Atherosclerosis, Hypertension, and Obesity in the Young Committee of the Council on Cardiovascular Disease in the Young, Council on Nutrition, Physical Activity and Metabolism, and Council on Clinical Cardiology.

References

American Diabetes Association. Type 2diabetes in children and adolescents. Pediatrics2000;105:671-80. Pinhas-Hamiel O, Zeitler P. The global spread of type 2 diabete mellitus in children andadolescents. J Pediatrics 2005; 146 : 693-700.

Atkinson RL. Use of drugs in the treatment of obesity. Ann Rev Nutr 1997; 17:383–403.

Atkinson RL. Obesity surgery as a model for understanding the regulation of food intake and bodyweight. Am J Clin Nutr 1997; 66:184–185.

References

Daily dietary fat and total food-energy intakes: Third National Health and Nutrition Examination Survey Phase 1, 1988–91. MMWR Morb Mortal Wkly Rep.1994 ;43:116–125.

 Medline ↵ Willett WC. Is dietary fat a major determinant of body fat? Am J Clin

Nutr.1998 ;67:556S–562S.  Abstract/FREE Full Text ↵ Rolls BJ, Bell EA, Castellanos VH, et al. Energy density but not fat content of

foods affected energy intake in lean and obese women. Am J Clin Nutr.1999 ;69:863–871.

 Abstract/FREE Full Text ↵ Bell EA, Rolls BJ. Energy density of foods affects energy intake across multiple

levels of fat content in lean and obese women. Am J Clin Nutr.2001;73:1010–1018.  Abstract/FREE Full Text ↵ Schoeller DA. Limitations in the assessment of dietary energy intake by self-

report. Metabolism.1995 ;44:18–22.  Medline

References

Am J Clin Nutr 2013 98: 5 1298-1308;First published online September 4, 2013. Activity Pediatrics - American Academy of Pediatrics

http://aappolicy.aappublications.org/cgi/content/full/pediatrics;117/5/1834

Screening and interventions for overweight in children and adolescent:

recommendation statement U.S. Preventive Services Task Force:

Recommendations and Rationale http://www.aafp.org/afp/20060101/us.htmlDietz WH. Overweight in childhood and adolescence. New

England Journal of Medicine2004;350:855-857.

References

World Health Organization. 1. Preventing chronic diseases: A vital investment. World Global Report. Geneva: World Health Organization; 2005.

Wang G, Dietz WH. Economic burden of obesity in youths 2. aged 6 to 17 years: 1979-1999. Pediatrics 2002; 109 : E81-1.

Donohoue PA. Obesity. In: Behrman RE, Kleigman RM, 3. Jenson HB, editors. Nelson textbook of pediatrics, 17th ed. Philadelphia: WB Saunders; 2004. p. 173-7.

Kosti RI, Panagiotakos DB. The epidemic of obesity in 4. children and adolescents in the world. Cent Eur J Public Health 2006; 14 : 151-9.

Hedley AA, Ogden CL, Johnson CL, Carroll MD, Curtin LR, 5. Flegal KM. Prevalence of overweight and obesity among US children, adolescents, and adults, 1999-2002. JAMA 2004; 291 : 2847-50.

Liasons for the Future

A holistic approach to tackle the adolescent as well as childhood obesity epidemic .

Influencing policy makers and legislation Guiding private practices, empowering

doctors, imparting community education Enriching and reinforcing individual

awareness and skills.