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Obesity A Weighty Problem. The “Top 10” The Associated Press.

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Presentation on theme: "Obesity A Weighty Problem. The “Top 10” The Associated Press."— Presentation transcript:

1 Obesity A Weighty Problem

2 The “Top 10” The Associated Press

3 The “Top 10” alternative reasons for obesity: 1.Inadequate sleep. (Average sleep amounts have fallen, and many studies tie sleep deprivation to weight gain.)

4 The “Top 10” alternative reasons for obesity: 2. Endocrine disruptors, which are substances in some foods that might alter fats in the body.

5 The “Top 10” alternative reasons for obesity: 3. Nice temperatures. (Air conditioning and heating limit calories burned from sweating and shivering.)

6 The “Top 10” alternative reasons for obesity: 4. Fewer people smoking. (Less appetite suppression.)

7 The “Top 10” alternative reasons for obesity: 5. Medicines that cause weight gains

8 The “Top 10” alternative reasons for obesity: 6. Population changes. (More middle-agers and Hispanics, who have higher obesity rates.)

9 The “Top 10” alternative reasons for obesity: 7. Older birth moms. (That correlates with heavier children.)

10 The “Top 10” alternative reasons for obesity: 8. Genetic influences during pregnancy

11 The “Top 10” alternative reasons for obesity: 9. Darwinian natural selection. (Fat people out survive skinny ones).

12 The “Top 10” alternative reasons for obesity 10. Assortative mating, or like mating with like,” Allison puts it. Translation: fat people procreating with others of the same body type, gradually skewing the population toward the heavy end.

13 Obesity Related Morbidity The estimated number of deaths attributable to obesity among US adults is approximately 280,000.

14 Obesity Related Morbidity The estimated number of deaths attributable to obesity for nonsmokers is approximately 325,000

15 Obesity AHA and NIH have recognized obesity as a major modifiable risk factor for CHD Obesity is a risk factor for development of hypertension, diabetes, and dyslipidemia Obesity also linked to insulin resistance, particular intraabdominal fat estimated by waist circumference

16 The Theories of Obesity Fall Into Three Categories

17 Genetic Influence of Human Variation in Body Fat

18 Defining Obesity Body Mass Index (BMI)= Weight divided by Height squared (kg/m 2). Normal Weight: 18.5 to 24.9 Overweight: 25.0 to 29.9 Obese I: 30.0 to 34.9 Obese II: 35.0 to 39.9 Obese III: > 40

19 Relationship Between Cardiovascular Disease and Their Risk Factors

20 Disease Risk Associated with Overweight and Obesity “Disease risk in early life is associated with respiratory conditions and several risk factors for coronary heart disease and is predictive of hypertension, diabetes, coronary heart disease and all-cause mortality.” Other risk factors include certain types of cancers, high blood cholesterol level, gall bladder disease, and osteoarthritis.

21 Prevalence and Risk of Obesity NHANES III shows approximately 60% of men and 50% of women are obese or overweight, with 20% of men and 25% of women having a BMI of 30 or greater BMI 27-29 associated with a RR of total mortality of 1.6, BMI 29-32 RR 2.1, and BMI >=32 RR 2.2 vs. BMI <19 from Nurses’ Health Study.

22 Increasing Prevalence of Overweight and Obesity Obesity has increased in every state, in both sexes, across all age groups, educational levels, and smoking statuses. Over the last 3 decades there has been a 25% increase in the number of people who qualify as overweight.

23 Percentage of Overweight and Obesity in the United States For adults 25 years and older the percentage of people who qualify as overweight is 63% for men and 55% for women. Specifically, 42% of men and 28% of women are overweight. While 21% of men and 27% of women are obese.

24 Prevalence of Obesity among US Adults From Years 1991, 1993, 1995, and 1998

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26 Increasing Prevalence of Overweight in U.S. Adults and of Obesity

27 Age-Adjusted Standardized Prevalence of Overweight (BMI 25–29.9) and Obesity (BMI >30) BMI > 30BMI 25–29.9 CDC/NCHS, United States, 1960-94, ages 20-74 years Percent

28 NHANES III Age-Adjusted Prevalence of Hypertension* According to BMI *Defined as mean systolic blood pressure  140 mm Hg, as mean diastolic  90 mm Hg, or currently taking antihypertensive medication. Brown C et al. Body Mass Index and the prevalence of Risk Factors for Cardiovascular Disease (in preparation). Percent

29 NHANES III Age-Adjusted Prevalence of High Blood Cholesterol* According to BMI *Defined as > 240 mg/dL. Brown C et al. Body Mass Index and the Prevalence of Risk Factors for Cardiovascular Disease (in preparation). Percent

30 NHANES III Age-Adjusted Prevalence of Low HDL-Cholesterol* According to BMI *Defined as <35 mg/dL in men and <45 mg/dL in women. Brown C et al. Body Mass Index and the Prevalence of Risk Factors for Cardiovascular Disease (in preparation). Percent

31 Carbo-Lipo-Terrorism in the U.S. A Report To: Orange County On: 2/18/04

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34 Percent Overweight Children U.S. & Orange County Percent Overweight (>95% weight/height) Year Data from the CDC & Prevention, NCHS, NHANES, HHNES, NHES, Report on the Conditions of Children in Orange County, 2002

35 No Data 10% Obesity (> 120%tile ideal body weight) in U.S. Adults 1992 Diabetes in U.S Adults 1992

36 Obesity 1994 No Data 10% Diabetes 1994

37 Obesity 1996 No Data 10% Diabetes 1996

38 Obesity 1998 No Data 10% Diabetes 1998

39 Obesity 1999 No Data 10% Diabetes 1999

40 Obesity 2000 No Data 10% Diabetes 2000

41 Tracking BMI-for-Age from Birth to 18 Years with % of Overweight Children who Are Obese at Age 25 Whitaker et al. NEJM: 1997;337:869-873

42 > 95 th percentile Overweight 85 th to < 95 th Risk of overweight percentile < 5 th percentile Underweight BMI-for-Age Cutoffs

43 National Longitudinal Survey of Youth Prospective Cohort Study of 8270 Children (4-12 years old) - 1999 Risk of Overweight Overweight > 85 th %ile BMI> 95 th %ile BMI African American38.4% 21.5% Hispanics 37.9% 21.8% Caucasian 25.8% 12.3%

44 Secular Increases in Relative Weight and Adiposity in Children (5-14 years old) - Bogalusa Heart Study - Study yearsWeight (kg) Height (cm) BMI (kg/m 2 ) 1973-197435.914017.6 1992-199441.014219.5 Change*+3.4+1.6+1.5 * Change adjusted for height, age, race, and sex Source: Pediatrics 99:420-426, 1997

45 Prevalence of Overweight and Obesity Among US Children (6-19 years old) 1999-2002 1999-20002001-2002  85 th percentile BMI 29.9%31.5%  95 th percentile BMI 15.0%16.5% Source: Hedley et al., JAMA 291:2847-2850, 2004

46 Overweight in Children* (> 95 th percentile BMI) 1971-19741988-19941999-2002 2-5 years5.07.210.4 6-11 years4.011.315.3 12-19 years6.110.515.5** * 4722 children from NHANES; overweight > 95 th adjusted for age ** > 23% of African American and Mexican American adolescents Source: Ogden et al., JAMA 288:1728-1732, 2002

47 Correlations of Weight and BMI at 7.7 and 23.6 Years Source: Minneapolis Children’s BP Study, Circulation 99:1471, 1999 r=0.605r=0.612

48 Example: 95th Percentile Tracking Age BMI 2 yrs 19.3 4 yrs 17.8 9 yrs 21.0 13 yrs 25.1 For Children, BMI Changes with Age Boys: 2 to 20 years BMI

49 BMI = 18 Age 4 years: >95th BMI Changes with age Boys: 2 to 20 years BMI Age 8 years: 85th Age 13 years: <50th

50 Can you see risk? This boy is 3 years, 3 weeks old. Is his BMI-for-age - >85 th to <95 th percentile: at risk for overweight? Photo from UC Berkeley Longitudinal Study, 1973

51 Measurements: Age=3 y 3 wks Height= 100.8 cm (39.7 in) Weight= 18.6 kg (41 lb) BMI = 18.3 BMI-for-age= >95 th percentile overweight Plotted BMI-for-Age Boys: 2 to 20 years BMI

52 Can you see risk? This girl is 4 years old. Is her BMI-for-age - >85 th to <95 th percentile: at risk for overweight? Photo from UC Berkeley Longitudinal Study, 1973

53 Measurements: Age=4 y Height= 99.2 cm (39.2 in) Weight= 17.55 kg (38.6 lb) BMI=17.8 BMI-for-age= between 90 th –95 th percentile At risk for overweight Plotted BMI-for-Age Girls: 2 to 20 years BMI

54 5 1/2 year old boy Weight: 41.5 lb Height: 43 in BMI= 15.8 BMI-for-age=50 th %tile Inaccurate height measurement: 42.25 BMI=16.3 BMI-for-age=75 th %tile Accurate Measurements are Critical Boys: 2 to 20 years BMI

55 Childhood Overweight 2003 BMI (Body Mass Index) is Now Defining Tool BMI Calculated as Weight / Height Squared Used to judge appropriateness of weight for height Replaces weight for height charts and % ideal body wt For a child, BMI > 95% is obese BMI 85-95% is “at risk” BMI data from retrospective analysis: 1. Reflect increasing fatness 2. Predict adult risk

56 Prevalence of Overweight, U.S. Adults, 1988 to 1991

57 Overweight Adults 20-74 Years of Age, 1988-1994

58 Overweight Prevalence by Race/Ethnicity for Adolescent Boys and Girls

59 Targeted History & Physical for the Obese Child The Identification, Management & Treatment of the Obese Child

60 History Birth –Weight: LGA & SGA Risk factor for Diabetes Mellitus –Decreased tone, poor feeding Concern regarding Prader Willi Family History (below are RF for DM & dysmetabolic syndrome) –Diabetes (1 vs 2, gestational) –Obesity (calculate parents BMI) –Hypertension –Dyslipidemia –Premature cardiovascular disease Male < 55 yoFemale < 65 yo

61 Medical history/Review of Systems Possible Underlying Endogenous Cause of Obesity Decreased growth velocity or abnormal height Abnormal pubertal development Abnormal Developmental history –Prader Willi, Bardet Biedl, Sotos Dysmorphic Features Hypothyroidism: cold, fatigue, dry skin, hair loss, constipation

62 Medical History/Review of Systems for the Obese Child Sleep –snoring, stops breathing, daytime sleepiness Menstrual History –Amenorrhea, Irregular Menses Leg pain –Hip, knee, tibial (SCFE, Blounts) Blood pressure Lipid Levels Recurrent yeast infections Polyuria, Polydipsia

63 Directed Exam for Obese Youth Ht____cmWt_____KgBMI (kg/m2)____ (>85%  Dietician) (BMI>40 or > 95%  Endo) BP_____ (HTN: Y/N) Dyspnea at rest vs exertion Tanner stage____ Normal Pubertal development: Y/N Skin: Acanthosis: Y/N Hirsutism: Y/N Ext: Hip, knee, valgus or varus deformity

64 The A, B, C Intervention AActivity 1.Minimum of 60 min/day of minimum intensity of a brisk walk. 2.Limit screen time (not associated with school work) < 1 hour BBeverages 1.No regular soda or sugar/corn syrup sports drinks/punch 2.< 6 ounces juice/day 3.Increase water & non-or low fat milk (or other calcium containing food) consumption CChange=Goal 1.Family changes eating & activity habits 2.Reasonable, achievable, step wise goals 3.Minimum nursing visits every 3-4 months: check progress & reinforce goals. Phone follow-up

65 Who to Test for IGT & Diabetes Obese: BMI>85% Age: Earliest of the following, > 10 years of age or onset of puberty And 2 of the following: –Family history of T2DM in 1 st or 2 nd degree relative –Ethnicity: Native American; African-American; Latino; Asian; Pacific Islander –Conditions assoc. with or signs of insulin resistance: acanthosis nigricans; hypertension, dyslipidemia, PCOs Based on ADA Recs: Diabetes Care 2003

66 Impaired Glucose Tolerance & Diabetes NormalIFG or IGTDiabetes FPG <100 mg/dlFPG= 100 - 125 mg/dl (IFG) FPG > 126 mg/dl 2-h PG <140 mg/dl2-h PG=140- 199mg/dl (IGT) 2-h PG > 200 mg/dl Symptoms of diabetes & casual plasma glucose concentration 200 mg/dl Based on ADA Recs: Diabetes Care 2004 In the absence of unequivocal hyperglycemia, a diagnosis of diabetes must be confirmed, on a subsequent day, by measurement of FPG, 2-h PG, or random plasma glucose (if symptoms are present). The FPG test is greatly preferred because of ease of administration, convenience, acceptability to patients, and lower cost. Fasting is defined as no caloric intake for at least 8 h. This test requires the use of a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water. 2-h PG, 2-h postload glucose

67 Do You Know How Food Portions Have Changed in 20 Years? National Heart, Lung, and Blood Institute Obesity Education Initiative

68 BAGEL 20 Years Ago Today 140 calories 3-inch diameter How many calories are in this bagel?

69 140 calories 3-inch diameter Calorie Difference: 210 calories 350 calories 6-inch diameter BAGEL 20 Years Ago Today

70 How long will you have to rake leaves in order to burn the extra 210 calories?* *Based on 130-pound person Maintaining a Healthy Weight is a Balancing Act Calories In = Calories Out

71 If you rake the leaves for 50 minutes you will burn the extra 210 calories.* *Based on 130-pound person Calories In = Calories Out

72 CHEESEBURGER 20 Years Ago Today 333 caloriesHow many calories are in today’s cheeseburger?

73 Calorie Difference: 257 calories 590 calories CHEESEBURGER 20 Years Ago Today 333 calories

74 Maintaining a Healthy Weight is a Balancing Act Calories In = Calories Out How long will you have to lift weights in order to burn the extra 257 calories?* *Based on 130-pound person

75 If you lift weights for 1 hour and 30 minutes, you will burn approximately 257 calories.* *Based on 130-pound person Calories In = Calories Out

76 SPAGHETTI AND MEATBALLS 20 Years AgoToday 500 calories 1 cup spaghetti with sauce and 3 small meatballs How many calories do you think are in today's portion of spaghetti and meatballs?

77 Calorie Difference: 525 calories 1,025 calories 2 cups of pasta with sauce and 3 large meatballs 20 Years AgoToday 500 calories 1 cup spaghetti with sauce and 3 small meatballs SPAGHETTI AND MEATBALLS

78 How long will you have to houseclean in order to burn the extra 525 calories?* *Based on 130-pound person Maintaining a Healthy Weight is a Balancing Act Calories In = Calories Out

79 *Based on 130-pound person If you houseclean for 2 hours and 35 minutes, you will burn approximately 525 calories.* Calories In = Calories Out

80 FRENCH FRIES 20 Years AgoToday 210 Calories 2.4 ounces How many calories are in today’s portion of fries?

81 610 Calories 6.9 ounces Calorie Difference: 400 Calories FRENCH FRIES 20 Years AgoToday 210 Calories 2.4 ounces

82 How long will you have to walk leisurely in order to burn those extra 400 calories?* *Based on 160-pound person Maintaining a Healthy Weight is a Balancing Act Calories In = Calories Out

83 *Based on 160-pound person If you walk leisurely for 1 hour and 10 minutes you will burn approximately 400 calories.* Calories In = Calories Out

84 85 Calories 6.5 ounces How many calories are in today’s portion? SODA 20 Years AgoToday

85 Calorie Difference: 165 Calories 250 Calories 20 ounces 85 Calories 6.5 ounces SODA 20 Years AgoToday

86 How long will you have to work in the garden to burn those extra calories?* *Based on 160-pound person Maintaining a Healthy Weight is a Balancing Act Calories In = Calories Out

87 If you work in the garden for 35 minutes, you will burn approximately 165 calories.* *Based on 160-pound person Calories In = Calories Out

88 320 caloriesHow many calories are in today’s turkey sandwich? TURKEY SANDWICH 20 Years AgoToday

89 Calorie Difference: 500 calories 820 calories320 calories TURKEY SANDWICH 20 Years AgoToday

90 How long will you have to ride a bike in order to burn those extra calories?* *Based on 160-pound person Maintaining a Healthy Weight is a Balancing Act Calories In = Calories Out

91 *Based on 160-pound person If you ride a bike for 1 hour and 25 minutes, you will burn approximately 500 calories.* Calories In = Calories Out

92 Thank you for participating in Portion Distortion ! For more information about Maintaining a Healthy Weight visit www.nhlbi.nih.gov

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96 TOO MUCH SODA  Coke glass bottle (8 fl. oz.) = 100 kcals.  Coke can (12 fl. oz) = 150 kcals.  Coke plastic bottle (20 fl. oz. ) = 250 kcals.  Super Big Gulp (44 fl. oz.) = 550 kcals.  ***1 big gulp a day = 57 pounds /year!!!!  What does the future hold??

97 Do You Know How Food Portions Have Changed in 20 Years? National Heart, Lung, and Blood Institute Obesity Education Initiative

98 COFFEE 20 Years Ago Coffee (with whole milk and sugar) Today Mocha Coffee (with steamed whole milk and mocha syrup) 45 calories 8 ounces 350 calories 16 ounces Calorie Difference: 305 calories

99 How long will you have to walk in order to burn those extra 305 calories?* *Based on 130-pound person Maintaining a Healthy Weight is a Balancing Act Calories In = Calories Out

100 If you walk 1 hour and 20 minutes, you will burn approximately 305 calories.* *Based on 130-pound person Calories In = Calories Out

101 MUFFIN 20 Years AgoToday 210 calories 1.5 ounces How many calories are in today’s muffin?

102 How long will you have to vacuum in order to burn those extra 290 calories?* *Based on 130-pound person Maintaining a Healthy Weight is a Balancing Act Calories In = Calories Out

103 If you vacuum for 1 hour and 30 minutes you will burn approximately 290 calories.* *Based on 130-pound person Calories In = Calories Out

104 PEPPERONI PIZZA 20 Years AgoToday 500 calories How many calories are in two large slices of today ’ s pizza?

105 How long will you have to play golf (while walking and carrying your clubs) in order to burn those extra 350 calories?* *Based on 160-pound person Maintaining a Healthy Weight is a Balancing Act Calories In = Calories Out

106 If you play golf (while walking and carrying your clubs) for 1 hour you will burn approximately 350 calories.* *Based on 160-pound person Calories In = Calories Out

107 CHICKEN CAESAR SALAD 20 Years AgoToday 390 calories 1 ½ cups How many calories are in today’s chicken Caesar salad?

108 How long will you have to walk the dog in order to burn those extra 400 calories?* *Based on 160-pound person Maintaining a Healthy Weight is a Balancing Act Calories In = Calories Out

109 If you walk the dog for 1 hour and 20 minutes, you will burn approximately 400 calories.* *Based on 160-pound person Calories In = Calories Out

110 20 Years AgoToday 270 calories 5 cups POPCORN How many calories are in today’s large popcorn?

111 20 Years AgoToday 270 calories 5 cups POPCORN 630 calories 11 cups Calorie Difference: 360 calories

112 How long will you have to do water aerobics in order to burn the extra 360 calories?* *Based on 160-pound person Maintaining a Healthy Weight is a Balancing Act Calories In = Calories Out

113 *Based on 160-pound person If you do water aerobics for 1 hour and 15 minutes you will burn approximately 360 calories.* Calories In = Calories Out

114 CHEESECAKE 20 Years AgoToday 260 calories 3 ounces 640 calories 7 ounces Calorie Difference: 380 calories

115 How long will you have to play tennis in order to burn those extra 380 calories?* *Based on 130-pound person Maintaining a Healthy Weight is a Balancing Act Calories In = Calories Out

116 *Based on 130-pound person If you play tennis for 55 minutes you will burn approximately 380 calories.* Calories In = Calories Out

117 CHOCOLATE CHIP COOKIE 20 Years Ago Today 55 calories 1.5 inch diameter How many calories are in today’s large cookie?

118 CHOCOLATE CHIP COOKIE 20 Years Ago Today 55 calories 1.5 inch diameter 275 calories 3.5 inch diameter Calorie Difference: 220 calories

119 How long will you have to wash the car to burn those extra 220 calories?* *Based on 130-pound person Maintaining a Healthy Weight is a Balancing Act Calories In = Calories Out

120 *Based on 130-pound person If you wash the car for 1 hour and 15 minutes you will burn approximately 220 calories.* Calories In = Calories Out

121 CHICKEN STIR FRY 20 Years Ago Today 435 calories 2 cups How many calories are in today’s chicken stir fry?

122 CHICKEN STIR FRY 20 Years Ago Today 435 calories 2 cups 865 calories 4 ½ cups Calorie Difference: 430 calories

123 How long will you have to do aerobic dance to burn those extra 430 calories?* *Based on 130-pound person Maintaining a Healthy Weight is a Balancing Act Calories In = Calories Out

124 *Based on 130-pound person If you do aerobic dance for 1 hour and 5 minutes you will burn approximately 430 calories.* Calories In = Calories Out

125 Thank you for participating in Portion Distortion II! For more information about Maintaining a Healthy Weight visit www.nhlbi.nih.gov

126 KID FRIENDLY SNACKS?  Super Pretzel and 16 fl. oz. Snapple Fruit Punch = 630 kcals.  24 fl. oz. Banana Berry Jamba Juice = 470 kcals.  Venti Vanilla Creme Frappacchino = 870 kcals.

127 WHAT ABOUT SCHOOL?

128 PRACTICAL SUGGESTIONS  Encourage parents to limit contribution of calories from beverages (only milk required).  Encourage 5 a day program.  Suggest Stoplight Diet (Epstein)  Stress Family Commitment- entire family needs to follow new eating habits.

129 FAST FOOD MAKEOVERS  Big Mac Value Meal = 1250 kcals.  If you super size….. Add 360 kcals!  Hamburger Happy Meal with regular coke = 640 kcals.  If you switch to diet or water subtract 150 kcals.

130 FAST FOOD MAKEOVERS  Del Taco Combo Burrito Meal = 1090 kcals.  2 Del taco soft chicken tacos = 320 kcals.

131 SERVING SIZES  GRAIN = 1 slice of bread, ½ cup cooked rice or pasta.  FRUIT = 1 piece of fruit, ¾ cup juice.  VEGETABLE = ½ cup cooked or 1 cup raw.  MILK = 1 cup milk  MEAT = 2-3 oz. cooked lean meat or fish.  FATS and SWEETS: use sparingly.

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133 Cardiovascular Complications of Obesity Jody Kranz M.D. Div. Endocrinology & Diabetes CHOC Stan Bassin Ed.D Div. Cardiology UCI The Identification, Management and Treatment of the Obese Child

134 Cardiovascular Complications of Obesity Cardiovascular Disease (CVD) –Atherosclerosis –Obesity –Hypertension –Lipids Inflammatory Factors Homocysteine & Other Risk Factors Guidance for Practitioners –Guidelines/Schedule for cardiovascular health –Proper blood pressure measurement –Charts for determining hypertension

135 Cardiovascular Disease Leading cause of death in the United States –Half a million deaths year Atherosclerosis: disease of large & medium sized vessels that leads to decrease blood flow to the myocardium, brain and extremities. Atherosclerosis begins in childhood –Same risk factors as in adults

136 Atherosclerosis Begins in Childhood PDAY- Pathologic Determinants of Atherosclerosis in Youth  Autopsy Evaluations of CVD Risk Factors  Progression of atherosclerosis from fatty streaks to raised lesions in persons > 15 years of age  10-20% of 15-19 year olds have intermediate lesions  Risk factors: High non-HDL cholesterolLow HDL cholesterol SmokingHypertension HbA1C > 8%Obesity (BMI > 30 kg/m 2 )

137 Atherosclerosis Risk Factors –Increasing Blood Pressure –Dyslipidemia –Inflammatory factors –Homocysteine –Diabetes –Tobacco exposure –Family History –Male gender –Obesity –Sedentary Lifestyle

138 Obesity & Hypertension

139 Clinical Presentation of Hypertension High blood pressure = BP > 90th percentile for age gender and height. Hypertension= BP > 95th percentile for age, gender and height. Primary Hypertension –most common cause of Hypertension in Children over 6 years of age <6 years of age Secondary Hypertension –Renal disease –Aortic Coarctation Primary isolated systolic –Isolated systolic hypertension is an independent risk factor for cardiovascular disease –50% prevalence in obese

140 Prevalence of Hypertension in Children vs Distribution of BMI (%) BMI centile Percent with Hypertension (%)

141 Blood Pressure & CVD Blood pressure is positively correlated with cardiovascular risk across the entire BP range –Evidence from autopsy studies –Increase in carotid intima media thickness in adolescents with hypertension Increase in Left Ventricular Mass/ Mass index indicating hypertrophy There is a synergistic effect on CVD with lipids Increases the risk for renal disease which in turn increases the risk for CVD

142 Treatment of Hypertension Weight loss –Demonstrated in observational & interventional studies –Decrease of 8/7 to16/9 mmHg for children with 3.9kg weight loss vs 10% weight loss respectively Exercise –May have additive effect –Decrease of 10mm Hg with regular exercise Medication

143 Obesity & Dyslipidemia

144 Increased Risk of Abnormal Lipid Levels in Overweight vs. Normal Weight Teens

145 Atherosclerosis & Dyslipidemia Evidence from adult studies Evidence in Children & Adolescents –PDAY –In vivo studies decreased compliance of arteries increased IMT in adolescents with dyslipidemia

146 Treatment of Dyslipidemia Weight loss Exercise Nutrition –Saturated fat <10% of calories –Total fat < 20-30% of calories –< 300mg cholesterol/day –Increase fiber intake Medication

147 Obesity & Inflammatory Factors

148 Prevalence of Elevated CRP (>0.22mg/dL) by BMI centile

149 TNF-alpha Levels in Obese & Non-obese Adolescents Moon et al. NASO, Oct. 2003

150 Homocysteine & other CVD Risk Factors in Youth Homocysteine –An independent risk factor for CVD – > 10-12 umol/L increases CVD risk 2-4 fold –Not increased with obesity –Treatment: Folate 0.4 mg/day; B12 400-1000 ug/day; Vit. B6 400 mg/day Tobacco exposure: 1 st & 2 nd Hand

151 Preventing Cardiovascular Disease Regular exercise (4-5 times/week) –Decreases weight gain –Increases HDL –Decreases blood pressure –Decreases inflammatory factors Healthy eating patterns –Minimize saturated fat Cigarette Smoking Prevention

152 Adolescent Obesity and its Effects into Adulthood

153 Obesity and CVD Risk In Nurses’ Health Study, 14-year CHD risk increased about 3.5-fold for BMI >29 vs. 20 kg associated with 2.5-fold increased risk. NHANES I follow-up showed a 1.5-fold greater risk of CVD in those women with a BMI >29 vs. <21. A waist circumference of >35 inches in women, and >40 inches in men is also associated with greater CHD risk.

154 Weight Related Risks for CHD and Stroke

155 Obesity and Hypertension For every 1 kg/m2 increase in BMI, increased risk of hypertension in Nurses’ Health Study was 12% Those with a BMI >31 RR=6.3 for developing HTN compared with BMI <19. Study showed each 10 kg weight to be associated with an increase of 3mmHg SBP and 2.2mHg DBP. Increased insulin levels may explain relation of obesity with HTN, as compensatory increases in insulin are required to maintain glucose homeostasis, and insulin may elevate BP by affecting renal sodium retention, raising peripheral resistance.

156 Obesity and Diabetes Obesity worsens insulin sensitivity, eventually exhausting pancreatic production of insulin, causing hyperglycemia and diabetes.

157 Obesity and Diabetes In Pima Indians (approx 50% of adults diabetic), incidence (per 1000 person-years) was 0.8 if BMI 40. In Nurses’ Health Study, BMI 23-23.9 showed a RR=3.6 for diabetes compared with BMI 35kg 17-fold. In Health Professionals Study among men, BMI >35 associated with RR=42 for developing diabetes.

158 Obesity and Dyslipidemia Rates of cholesterol synthesis correlate with excess body mass Data suggest a 10kg/m2 increment in BMI is associated with a 3.2 mg/dl (women) to 10 mg/dl (men) lower HDL-C and about a 10 mg/dl greater LDL-C

159 Obesity and Dyslipidemia Obesity is associated with higher LDL-C and triglycerides, and lower HDL-C.

160 Obesity and Dyslipidemia Weight loss reduces triglycerides, increases HDL-C, and lowers LDL-C

161 Absolute Fat and Lean Changes per Decade as a Function of Age in Men

162 Absolute Fat and Lean Changes per Decade as a Function of Age in Women

163 Definitions Body Mass Index (BMI) describes relative weight for height: weight (kg)/height (m 2 ) Overweight = 25–29.9 BMI Obesity = > 30 BMI

164 Age-Adjusted Standardized Prevalence of Overweight (BMI 25–29.9) and Obesity (BMI >30) BMI > 30BMI 25–29.9 CDC/NCHS, United States, 1960-94, ages 20-74 years Percent

165 NHANES III Age-Adjusted Prevalence of Hypertension* According to BMI *Defined as mean systolic blood pressure  140 mm Hg, as mean diastolic  90 mm Hg, or currently taking antihypertensive medication. Brown C et al. Body Mass Index and the prevalence of Risk Factors for Cardiovascular Disease (in preparation). Percent

166 NHANES III Age-Adjusted Prevalence of High Blood Cholesterol* According to BMI *Defined as > 240 mg/dL. Brown C et al. Body Mass Index and the Prevalence of Risk Factors for Cardiovascular Disease (in preparation). Percent

167 NHANES III Age-Adjusted Prevalence of Low HDL-Cholesterol* According to BMI *Defined as <35 mg/dL in men and <45 mg/dL in women. Brown C et al. Body Mass Index and the Prevalence of Risk Factors for Cardiovascular Disease (in preparation). Percent

168 Requires two steps: Assessment Management Care of Overweight/Obese Patients

169 Assessment of Overweight and Obesity Body Mass Index –Weight (kg)/height (m 2 ) –Weight (lb)/height (in 2 ) x 703 – Table Waist Circumference –High risk: Men >102 cm (40 in.) Women >88 cm (35 in.)

170 Classification of Overweight and Obesity by BMI

171 Determine Absolute Risk Status Evaluate: Disease conditions (e.g., CHD, type 2 diabetes, sleep apnea) (+ = very high risk) Other obesity-associated diseases (e.g., gynecological abnormalities, osteoarthritis) Cardiovascular risk factors: smoking, hypertension, high LDL, low HDL, IGT, family hx (>3 = high risk) Other risk factors: –Physical inactivity –High serum triglycerides (>200 mg/dL)

172 Adolescent and Adult Interventions Decrease Television viewing Decrease consumption of high fat foods Increase fruit and vegetable intake Increase moderate and vigorous physical activity

173 Weight Control and Risk Reduction Weight loss improves BP, dyslipidemia, and diabetes. Clinical trials show normotensive overweight persons on a hypocaloric diet had a lowering of blood pressure and reduced incidence of hypertension. DASH diet high in vegetables and fruits showed significant lowering of SBP and DBP both in persons with and without HTN. Weight control also lessens hyperglycemia and has been shown to be related to reduced diabetes-related mortality and improvements in glucose and insulin levels. Among Indian coronary patients, those randomized to low saturated fat, high fruit and vegetable diet plus weight-loss advice, compared to usual care, showed a 50% reduction in cardiac events and 45% lower mortality in those who lost more than 5kg.

174 Weight Control and Risk Reduction Meta-analysis of 70 randomized controlled trials shows correlation between fall in LDL-C and amount of weight loss (Dattilo et al., 1992) Combined programs of weight loss and exercise are associated with greater increases in HDL-C and more significant loss of weight and fat. Findings are less consistent in women, however, and often LDL-C/HDL-C ratio worsens. While HDL-C is inversely related to CHD risk in populations, low rates of CHD are seen in populations with low-fat diets who have lower levels of both LDL-C and HDL-C.

175 Fat vs. Caloric Restriction While fat from calories has been reduced from 40-42% to 34% over the past 30 years, recent data show we consume more calories Message of caloric restriction needs to be coupled with dietary fat reduction, with greater emphasis on fruit and vegetable consumption Greater availability of low-fat and fat-free foods allows for substitution away from traditional higher-fat alternatives. Fat and calorie restriction needs to be individualized to patient need and risk-factor profile.

176 Hypocaloric Diets Such diets allow for 1000-1200 kcal/day, with very low-calorie diets providing only 400-500 kcal/day. Initial weight loss may be more rapid with the very low-calorie diet, but amount of weight loss over one year is similar with either plan and adherence better with the moderate diet. Combination of low calorie diet plus exercise is more successful than either strategy alone.

177 Health Benefits of Weight Loss Decreased cardiovascular risk Decreased glucose and insulin levels Decreased blood pressure Decreased LDL and triglycerides, increased HDL Decrease in severity of sleep apnea Reduced symptoms of degenerative joint disease Improved gynecological conditions

178 Treatment Algorithm Patient Encounter Hx of 25 BMI?  Measure weight, height, and waist circumference Calculate BMI Examination Brief reinforcement/ educate on weight management Periodic weight check Advise to maintain weight/address other risk factors Clinician and patient devise goals and treatment strategy for weight loss and risk factor control Assess reasons for failure to lose weight Maintenance counseling: Dietary therapy Behavior therapy Physical activity : Treatment Assess risk factors No Yes 1 2 14 1513 12 1110 16 3 46 5 7 8 9 Yes No Yes No Hx BMI 25?  No Yes No Does patient want to lose weight? Yes No Progress being made/goal achieved? BMI 25 OR  waist circumference > 88 cm (F) > 102 cm (M) BMI  30 OR {[BMI 25 to 29.9 OR waist circumference >88 cm (F) >102 cm (M)] AND 2 risk  factors} BMI measured in past 2 years?

179 No BMI  30 OR {[BMI 25 to 29.9 OR waist >88 cm (F) >102 cm (M)] AND  2 risk factors} Treatment Algorithm (Part 1 of 3) Patient Encounter Hx of  25 BMI? Measure weight, height, and waist circumference Calculate BMI Assess risk factors No Yes 1 2 3 4 6 5 7 No BMI measured in past 2 years? BMI  25 OR waist > 88 cm (F) > 102 cm (M)  Yes  Examination Treatment

180 Devise goals and treatment strategy for weight loss and risk factor control Assess reasons for failure to lose weight Maintenance counseling 12 11 10 8 9 No Yes No Desire to lose weight? Yes No Progress made? BMI  30 OR {[BMI 25 to 29.9 OR waist >88 cm (F) >102 cm (M)] AND  2 risk factors}   Examination Treatment 7 Periodic weight check Advise to maintain weight Address other risk factors 13 16 Treatment Algorithm (Part 2 of 3)

181 Brief reinforcement Educate on weight management Periodic weight check Advise to maintain weight Address other risk factors 14 15 13 16 5 Yes No Yes No Hx BMI  25?  BMI  25 OR waist > 88 cm (F) > 102 cm (M) Examination Treatment Treatment Algorithm (Part 3 of 3) * This algorithm applies only to the assessment for overweight and obesity and subsequent decisions based on that assessment. It does not include any initial overall assessment for cardiovascular risk factors or diseases that are indicated.

182 Goals of Weight Management/Treatment Prevent further weight gain (minimum goal). Reduce body weight. Maintain a lower body weight over long term.

183 Target Weight: Realistic Goals Substitute “healthier weight” for ideal or landmark weight. Accept slow, incremental progress to goal. —Short-term goal: 5 to 10 percent loss, 1 to 2 lb per week. —Interim goal: Maintenance. —Long-term goal: Additional weight loss, if desired, and long-term weight maintenance.

184 Weight Loss Goals Goal: Decrease body weight by 10 percent from baseline. If goal is achieved, further weight loss can be attempted if indicated. Reasonable timeline: 6 months of therapy. – Moderate caloric deficits – Weight loss 1 to 2 lb/week

185 Weight Loss Goals Start weight maintenance efforts after 6 months. –May need to be continued indefinitely. If unable to lose weight, prevent further weight gain.

186 Strategies for Weight Loss and Maintenance Dietary therapy Physical activity Behavior therapy “Combined” therapy Pharmacotherapy Weight loss surgery

187 Whenever possible, weight loss therapy should employ the combination of Low-calorie/low-fat diets Increased physical activity Behavior modification Weight Loss Therapy

188 Dietary Therapy (1 of 5) Low-calorie diets (LCD) are recommended for weight loss in overweight and obese persons. Evidence Category A. Reducing fat as part of an LCD is a practical way to reduce calories. Evidence Category A.

189 Dietary Therapy (2 of 5) Low-calorie diets can reduce total body weight by an average of 8 percent and help reduce abdominal fat content over a period of 6 months. Evidence Category A.

190 Dietary Therapy (3 of 5) Although lower fat diets without targeted calorie reduction help promote weight loss by producing a reduced calorie intake, lower fat diets coupled with total calorie reduction produce greater weight loss than lower fat diets alone. Evidence Category A.

191 Dietary Therapy (4 of 5) Very low-calorie diets produce greater initial weight loss than low-calorie diets. However, long-term (>1 year) weight loss is not different from an LCD. Evidence Category A.

192 Dietary Therapy (5 of 5) Very Low-Calorie Diets (less than 800 kcal/day): Rapid weight loss Deficits are too great Nutritional inadequacies Greater weight regain No change in behavior Greater risk of gallstones

193 Low-Calorie Step I Diet NutrientRecommended Intake Calories500 to 1,000 kcal/day reduction Total Fat30 percent or less of total calories SFA8 to 10 percent of total calories MUFA Up to 15 percent of total calories PUFAUp to 10 percent of total calories Cholesterol<300 mg/day

194 Low-Calorie Step I Diet (continued) NutrientRecommended Intake Protein~ 15 percent of total calories Carbohydrate55 percent or more of total calories Sodium ChlorideNo more than 100 mmol/day (~ 2.4 g of sodium or ~ 6 g of sodium chloride) Calcium1,000 to 1,500 mg Fiber20 to 30 g

195 Source: U.S. Bureau of the Census, decennial census and population projections Percent Percent of the Population by Race/Ethnicity 1990, 2000, 2025 and 2050

196 Source: Johnson, California’s Demographic Future, Public Policy Institute of California, 2003 California’s Population by Race and Ethnicity California leads the nation in diversity. The state is challenged with a substantial leadership role in assuring a diverse workforce and designing and maintaining quality care for all populations.

197 Challenges for the Nation’s Workforce Insufficient numbers of staff; Unsatisfactory skill and proficiency levels; Inappropriate training to deal with a changed delivery environment; Racial and ethnic diversity; Racial and ethnic disparities in access to and quality of care.

198 Winds that are blowing... A national crisis is looming for health workforce but it has as much to do with lack of innovation, as it does with shortages of workers

199 Four Challenges Enhancing Public Participation in Clinical Research Developing Information Systems An Adequately Trained Diverse Workforce Funding

200 1. What is the benefit of increasing representation of women and minorities in the clinical research workforce? 2. Will increased diversity improve translation of the results of clinical research in minority communities? 3. What are the needs of the private and public sector? 4. Are the current approaches to training clinical investigators meeting the needs of academia, industry, and public health? Source: IOM: Opportunities to Address Clinical Research Workforce Diversity Needs for 2010, 2006 New paradigms in clinical research and research training

201 5. Where is demand exceeding supply? 6. What training programs and career tracks appear to foster the development and retention of women and minorities in the clinical research workforce? 7. What research related to evaluation of existing training efforts needs to be funded? 8. What are the key outcome measures? Source: IOM: Opportunities to Address Clinical Research Workforce Diversity Needs for 2010, 2006 New paradigms in clinical research and research training

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