Managing Obesity: The REALities
Striking a Balance... Weigh in with Knowledge, Research, Practice SYMPOSIUM
September 30th 2013
The REALities: Objectives
• Biologic REALities• Psychosocial REALities• Impact of Weight Bias• Debunking Common Myths• Paradigm Shift
• Health At Every Size (HAES)
• Edmonton Obesity Staging System
• The Pediatric 5A’s
Obesity is Defined as BMI > 95th%
Limitations of BMI• Not sensitive/ specific for:
• Presence of obesity related risk factors• Health behaviours• Co-morbid conditions• Psychopathology• Global functioning• Global health• Quality of Life
Limitations of BMI
BMI= 32 kg/m2 BMI= 21 kg/m2
Obesity is….
• A sign or symptom• A disorder of energy balance
• Adaptive/ Maladaptive?
• A risk factor for disease• Modifiable through health behaviours
Obesity is not….
• A sensitive indicator of health
• A sensitive indicator of health behaviours
• A character flaw
• A lack of will power
WEIGHT = ENERGY CONSUMPTION – ENERGY EXPENDITURE
Genetics
SES
Culture
Stress
Sleep
Media
Parental influence
Peer influence
School environment
Neighbourhoods
Gender
Policy
Medications
Microbes
Environmental Toxins
Built Environment
Safety
Screen Invasion
Food Insecurity
Automobile Reliance
Societal Influences
Education
Access
Perinatal programming
Mental health
Eating disorders
Body Image
Obesogenic Environment
Obesogenic behaviours
Weight Gain
Weight Stable
Weight Gain &Co-morbidities
Sensitivity to obesogenic environments and behaviours modified through genetic and pre-natal programming
Beyerlein et al, PLoS one (2011)
Digging Deeper
Connectednesselectronic
virtual
Time pressuresmore work hours
sleep lesscook less
increased stress
Income Inequalityfood insecurity
neighbourhood safety
Economic Policyurban sprawl
agricultural subsidiesfood industry
media/advertising
Our Way of LifeSocietal Values
Whitaker R, Arch Pediatr Adol Med (2011)
Impact of Social Values
• Obesity• Mental Health• Eating Disorders• Bullying, Stigma• Health of our environment
Common Ground/Partnerships
Whitaker R, Arch Pediatr Adol Med (2011)
A Lot on My PlateJack Lightfoot aka Heavyhand
Neuroendocrine Control of Energy Balance
Science, Feb 7, 2003
Neuroendocrine Differences: Lean vs. Obese
PYY3-36
Batterham, R. L. et. al. N Engl J Med 2003;349:941-948
Leptin
Hormonal Adaptations to Weight Loss: Ghrelin
Cummings, D. E. et. al. N Engl J Med 2002;346:1623-1630
Hormonal Adaptations to Weight Loss: Leptin
Decrease in Body Weight
Decreased Energy
Expenditure
Increased Energy
Conservation
Additional weight loss can only be achieved by a more severe diet and further increases in
physical activity
Katan B et al JAMA (2010)
Debunking Some Myths
Are Obese Kids less Active?
• No marked difference in physical activity between overweight and lean kids • Overweight and obese girls had the same minutes of
moderate to vigorous physical activity as lean girls• Overweight boys had 14 min and obese boys had 22
min less of daily activity than lean boys
Colley R et al, Health Reports (2011)
Obesity-Chronic Disease Paradox
• Overweight and moderate obesity (BMI < 35), is not associated with a decrease in life expectancy• Overweight is associated with increased longevity
• Survival advantage:• Renal Failure• Heart Failure• Type 2 Diabetes
McGee DL et al, Ann Epidemiol (2005)Curtis JP et al, Arch Int Med (2005)Beddhu S, Seminars in Dyalisis (2004)Doehner et al, Int J Cardiology (2011)
Obesity Chronic Disease Paradox
5202 patients with T2DM and pre-existing CVD:
• Lowest mortality: BMI 30-35 kg/m2• Weight loss associated with increased
total mortality, cardiovascular mortality
Doehner et al, Int J Cardiol (2011)
Abdulla J et al. Eur Heart J (2008)
Myocardial Infarction (MI)
Heart Failure (HF)
21,570 patients admitted for MI or HFAll cause mortality after 10 year follow up• BMI > 35 associated with increased
risk in MI but not HF• BMI 30-35 not associated with
increased risk
Edmonton Obesity Staging System (Kuk et al, 2011)
• New risk-stratification system that classifies adult obese individuals into 5 graded categories based on morbidity and health-risk profiles
• EOSS independently predicted increased mortality even after adjustment for common methods of classifying obesity (Padwal et al., 2011)
Sharma AM & Kushner RF. Int J Obes 2009
Sharma AM & Kushner RF. Int J Obes 2009
Kuk et al, App. Physiol. Nutr. Metab. (2011)
29, 533 obese individuals Morbidity and Mortality Risk based on EOSS at 16 year follow up compared to normal weight
controls
Padwal R S et al. CMAJ (2011)
EOSS BMI Class
Survival Curves diverge when stratified by EOSS
score but not by BMI Class
Padwal R S et al. CMAJ (2011)
EOSS-prediction of all cause
mortality across BMI classes
Expected Change in BMI (6-12 months)
Lifestyle Medication(orlistat)
Surgery
Δ BMI (kg/m2) -1.9-3.3 -0.85 -8.5
USPSTF Task Force, Pediatrics (2010)Journal of Pediatric Surgery (2010)
The Psychosocial REALities
What is it like for children and youth who have a higher
BMI?
Psychosocial REALities
Overweight youth:• Are stigmatized• Are often bullied by peers• Tend to have poor body image• Tend to have lower self-confidence, self- esteem and
higher incidence of mental health problems
Puhl et al. Obesity (2009)
Storch et al. J. Pediatr. Psychol. (2007)
Bullying
• 30% of overweight girls and 25% of overweight boys experience weight focused peer victimization• 60% of the most severely overweight kids report
harassment
• 40% of youth report that obesity is the primary reason why peers are teased or bullied • 37% reported being gay or lesbian as the primary
reason• 10% reported race, ethnicity, disability, religion
Eisenberg M et al Arch Pediatr Adolesc Med (2003)Puhl RM et al, J Sch Health (2011)
Weight Bias at home
• 47% of overweight girls and 34% of overweight boys report being teased about their weight by their parents
• 72% of overweight adults reported they had experienced weight bias from family members as children
Puhl RM et al, J Sch Health (2011)Puhl RM et al, Psych Bull (2007)
Societal Pressures
• In Western Society the media is a powerful influence and pressure on youth today
• Body image messages are ever present and typically state:• Thin women are beautiful, successful and happy• Muscular, lean men are handsome and successful
Grabe et al. Psychological Bulletin (2003)
THIN, THIN, THIN
MUSCLE, MUSCLE, MUSCLE
Body Image in Youth Today
• 40-50% of girls aged 11-15 say they need to lose weight
• 61% of grade 7/8 students trying to lose weight
Canadian study: Jones et al. 2001
Weight Based Teasing and Discrimination
Youth Often Feel
• Angry• Frustrated• Sad• Helplessness• Hopelessness• Anxious• Worried
Families Often Feel
• Guilty• Helpless• Frustrated• Tired• A desire to try and fix or “control” things• A loss of trust with the youth
The Diet Industry Culture
Familiar Claims:
“Lose weight quickly” “Reset your genetic code” “Eat all you want – Lose up to 30 pounds in 3 weeks” “Scientifically sound”, “Based on proven studies”
Private weight loss industry in the US estimated at $58.6 billion annually
(Marketdata Enterprises, 2009)
Pawlak, 2009
Mixed Messages in the Media around Food
Set Point Theory
Our bodies have a Set Point (range) it wants to stay at and would if we eat “normally”
• Our bodies are self-regulating• Think of shoe size, height and body temperature
• Set point is a range & genetically determined
• Our body works hard to keep us in the range• Altering metabolic rate
Wilmore et al. (1999)
Restraint Theory
• Research has examined eating behaviour of Dieters vs. Non-Dieters
• Laboratory studies demonstrated that Dieters are more likely to ‘overeat’ or disinhibit when exposed to:
• Stress• Emotional Cues• Food Cues
Herman & Polivy, 1985
Restraint Theory
Results in “What the Hell Effect”
BATTLE
Dieters cognitive or mental efforts to resist that drive
Dieters physiological drive to eat (e.g.,
hormones & peptides)
Culture of Valuing Thinness
• High body self-consciousness• Healthy body esteem• High weight preoccupation
• Increased overeating• Emotional eating• Binge eating
• Dieting practices• Weight loss strategies
Feelings of shame, guilt, anger, sadnessIncreased weight over time
Negative Spiral
The Impact of Living with Weight Management Issues in Today’s World
Puhl RM et al, J Sch Health (2011)Puhl RM et al, Psych Bull (2007
Low body satisfaction
High depressive symptoms
Isoloation/withdrawal
Poor-self-perception of physical appearance
Disordered eating
Poor academic outcomes
Poor peer relationships
Increase risk & unhealthy behaviours
School absences
Medical Versus Self Esteem Concerns
Most Kids:• Want to lose weight to make the teasing and
harassment stop• They would prefer to have diabetes and be thin than
to be “fat” and “healthy”
But by suggesting that children focus on weight as an outcome we are setting them up for weight
preoccupation, dieting and likely weight gain
A paradigm shift…
A growing trans-disciplinary movement called:
Health at Every Size
HAES challenges the value of promoting weight loss and argues for a shift in focus to weight-
neutral outcomes
Bacon & Aphramor (2011)
The HAES ApproachThe HAES approach is associated with statistically and clinically relevant improvements in:
Physiological measures (e.g. blood lipids)
Health behaviours (e.g. eating & activity habits)
Psychosocial outcomes (e.g. self esteem and body image)
Bacon L et al, 2011
Key Principles
Key Principles
Obesity Management is About Improving Health and Well-
being, and not Simply Reducing Numbers on the Scale
Weight bias can be a barrier to weight management
Key Principles
Interventions should include addressing ‘root causes’ of
obesity and removing roadblocks for families to
make healthy changes
Key Principles
A Child’s ‘Best’ BMI May Never Be His or Her ‘Ideal’ BMI
Key Principles
Success is different for every child and family
Key Principles
The 4Ms of Pediatric Obesity
Mental
AnxietyDepressionBody image
ADHDLearning disorder
Sleep disorderEating disorder
Trauma
Mechanical
Sleep apneaMSK pain
Reflux diseaseEnuresis
EncopresisIntertrigo
Metabolic
IGT/T2DMDyslipidemiaHypertension
Fatty liverGallstones
PCOSMedication
Genetics
Milieu
Parent health/disabilityFamily stressorsFamily income
Bullying/StigmaSchool attendance
School supportNeighbourhood
safetyMedical insuranceAccessible facilitiesFood EnvironmentOpportunities for physical activity
ASSESS
Questions?
CHAL TeamDr. Stasia Hadjiyannakis – Pediatric Endocrinologist
Dr. Katie Baldwin– Pediatrician
Dr. Annick Buchholz – Psychologist
Dr. Laurie Clark – Psychologist
Jane Rutherford – Exercise Specialist
Nicole Charette – Registered Dietitian
Shaun Reid – Child & Youth Counsellor
Maura Manuel– Social Worker
Michèle Levasseur – Registered Nurse, Case Manager
Corrie Raymond – Administrative Assistant
Charmaine Mohipp – Research Associate
Mission
To improve the health and quality of life of children with weight related health
complications and support them and their families in achieving a healthy active lifestyle.
Severe Complex Obesity• BMI > 99th% AND/OR• Complications of obesity requiring subspecialty care
• Hyperlipidemia requiring pharmacotherapy• Hypertension requiring pharmacotherapy• OSA/Sleep Disordered Breathing• PCOS• NAFLD• T2DM/Persistent IGT
• Hypothalamic Obesity• Obesity Syndromes
Referral
Invitation to Information
Session
Full Day Assessment/Care
Plan
Treatment Options
Care Plan
REAL Program
Care CoordinationClinic visits to assess
readinessCommunity Resources
PHASE I
Family Education Group (for teens 14-18 yrs + parents) Education on Family approach to healthy living and lifestyle change 6 weeks
Parent Group (for parents of children ≤ 13 yrs) Education on parenting approaches to healthy living and lifestyle change 8 weeks
What is the REAL Program?
What is the REAL ProgramPHASE II
Family Group (for teens 14-18 yrs + parents) Skill building for families to make lifestyle changes together Topics include:
Healthy Eating & Active Living Problem Solving and Practical Solutions to meet goals
12 weeks (parents attend 5 weeks)
What is the REAL Program?
PHASE III
Teen & Parents Alumni Groups Peer support for maintaining lifestyle changes Skill building for “slips” and “getting back on track” Theme based modules Offered in 4 week modules
REAL Program Goals• Improve quality of life• Decrease medical and psychological co-morbidities• Improve eating behaviours• Improve fitness, increase activity levels• Decrease sedentary behaviour• Empower/strengthen families• Stabilize BMI trajectory
Baseline Mental Health Concerns
Diagnosis Frequency
ADHD and/or LD 25.7%
Anxiety Disorder 24.2%
Developmental Delay/Autism 11.4%
Depression 11.4%
TOTAL 60%
Conclusions• Understand your patients’ REALities• Focus on health behaviours and well being• Health is possible across a range of BMI• Help without harming• Weight bias increases risk for co-morbidities• Take your time- no quick fixes
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