A FLAVOUR OF WHAT’S TO COME…

DEVELOPMENT, PREVENTION & MANAGEMENT OF OVERWEIGHT/OBESITY ACROSS THE LIFESPAN Suna Kassier PhD, RD (SA) Dietetics and Human Nutrition

INTRODUCTION World Bank (2015); Van den Berg et al (2014); World Health Organization ( 2014); FAO (2010) Overweight/obesity: → among children & adolescents = global epidemic → health consequences track into adulthood: Non Communicable Diseases of Lifestyle (NCDs) Lesotho: → 50% of adolescents 15 years and older overweight/obese → ↑ prevalence of overweight/obesity in adult women (24.0%) → ↑ prevalence of hypertension: adult males (32.9%), adult females (33.5%) → 13% of infants born with low birth weight → LBW infants and stunted children ↑ risk NCDs

INTRODUCTION (Cont.) Van den Berg et al (2014); World Bank (2015); Gupta et al (2012); FAO (2010); Qi & Cho (2008) Development of childhood overweight/obesity: → attributed to complex interplay between genetics & environmental factors Developing countries: → advertising, ↓ cost of energy dense foods, ↑ purchasing power, ↑ leisure indoor activities & entertainment, unsafe neighborhoods, lack of open spaces children/adolescents more sedentary

INTRODUCTION (Cont.) Van den Berg et al (2014); World Bank (2015); FAO (2010); Qi & Cho (2008) Causes of overweight/obesity in Lesotho: → ↓ progress in improving community infrastructure & sound public health systems → urbanization → adoption of diets ↑ in carbohydrates, saturated fats & sugars → more sedentary lifestyle → cultural factors, perceptions & beliefs regarding body weight

INTRODUCTION (Cont.) Van den Berg et al (2014); World Bank (2015); FAO (2010) Study on 16 year olds in Maseru: → 27.2% (girls); 8.3% (boys) overweight/obese → 39.8% insuffiently active/inactive → fruits, vegetables, dairy, meat, legumes & traditional foods consumed weekly/less often → majority bought from tuck shops (18.6% daily; 54.3% weekly) → gaps in knowledge, perceptions & practices that could be addressed by education

OVERVIEW Pre-pregnancy Pregnancy Postpartum Infancy Pre-schoolers Childhood Adolescence Prevention, especially in the young - universally viewed as best approach to reversing increasing global prevalence of obesity Limited evidence regarding most effective means - prevention of obesity in children Han et al (2010)

CRITICAL PERIODS FOR PREVENTION Perinatal period - intrauterine over-nutrition predicts life long obesity - maternal obesity → prime factor in foetal over-nutrition Infancy - BMI ↑ during 1 st year of life → ↓ to minimum at ± 5-6 years - Point of minimum BMI = “adiposity rebound”/BMI rebound - Earlier “adiposity rebound” → ↑ risk for later obesity - Only independent predictor of early adiposity rebound: → parental obesity Adolescence Pregnancy Han et al (2010); Lawlor & Chatuvell (2006)

OBESITY THROUGHOUT THE LIFESPAN Kassier (2014)

THE VISCIOUS CYCLE OF OBESITY THROUGHOUT THE LIFESPAN Kassier (2015) Obese Offspring Obese Adult Obese Child

Paternal weight and weight history Rapid weight gain during infancy → ↑ risk of adult onset obesity Tracking of BMI from infancy → adolescence → adulthood An overweight parent → risk factor for obesity ↔ modelling → physical activity, dietary preference, macronutrient intake, values & beliefs about eating, exercise & general attitude towards obesity → social rather than genetic inheritance CHOOSE YOUR PARENTS WISELY! Wells et al (2005); Goulding et al (2003); Rosenberg et al (2003); Senekal et al (2003); Siervogel et al (2003); Singhal et al (2003);

PRE-PREGNANCY “… an individual is born at conception and not at delivery” (Yajnik 2014) Women with ↑ pre-pregnancy BMI: - least likely to have inadequate weight gain during pregnancy - most likely to experience excessive weight gain - ↑ rate of maternal and neonatal complications Results of a systematic review: - dietary & physical activity counselling at pre-conception → ↓ in gestational weight gain High maternal-recalled pre-pregnancy BMI & extremes of recalled gestational weight gain: → associated with ↑ risk of adolescent and adult obesity, especially when mother is overweight Agha et al (2014); Chen et al (2010); Phelan (2010); Stuebe et al (2009); Brawarsky et al (2005)

PRE-PREGNANCY (cont.) Phelan (2010); Olson et al (2009); Krummel (2007); Krishnamoorthy et al (2006); Salsberry & Reagan (2005) Maternal pre-pregnancy obesity : - strongest predictor of excess gestational weight gain and future obesity - ↑ risk of children (2-4 years) having BMI +3 z-scores by 40% - predicts BMI in her offspring 15 years later Reducing maternal BMI during preconception in overweight women & prevention of ↑↑ weight gain during pregnancy: - appropriate strategies to address childhood obesity in offspring Obese women advised to aim for moderate weight loss prior to conception - loss of 4.5 kg can ↓ risk of gestational diabetes, neural tube defects Recommendation: - weight management between pregnancies i.e. > 18 months

PREGNANCY Tanentsapf et al (2011); Oken et al (2008); Amorim et al (2007); ↑ gestational weight gain: - children heavier in childhood & adolescence - relationship independent of parental characteristics, potentially mediating peri-partum factors affecting birth weight, obesogenic behaviours in childhood → suggesting sustained effect of intrauterine environment Women who gain excessive gestational weight: - ↑ long-term BMI Behavioural changes attained during pregnancy: - may persist after childbirth & possibly throughout the woman’s life - dietary advice during pregnancy → effective in ↓ gestational weight gain & ↓ long-term postpartum weight retention

PREGNANCY (cont.) Phelan (2010); Kinnunen et al (2007); Oken et al (2007); Whitaker (2004) Intervention r.e. individual counselling on diet & physical activity - maintenance of high fibre bread intake - ↑ fruit, vegetable & fibre intake - inability to prevent excessive gestational weight gain Maternal obesity in 1 st trimester doubles obesity risk in children 2-4 years Adequate or excessive gestational weight gain ↑ odds of having child with BMI +3 z-scores 4-fold when compared to inadequate weight gain Alteration of intrauterine environment: - amount of weight gained during pregnancy influences foetal growth and persistent programming of childhood weight

PREGNANCY (cont.) Krishnamoorthy et al (2006); Lawlor & Chaturvedi (2006) Antenatal period: - unique period when women possibly more receptive to health promotion & disease prevention - presents “teachable moment” Pre-pregnancy BMI, BMI at first antenatal visit in 1 st trimester & regular monitoring of gestational weight gain throughout pregnancy NB Benefits of consistent support and advice: - prevention of excessive weight gain - supported by written information - regular visits to dietitian r.e. dietary and lifestyle advice Techniques used in successful interventions: - physical activity & dietary counselling - motivational talks regarding weight management - feedback regarding progress & weight monitoring

PREGNANCY (cont.) Agha et al (2014) Most effective dietary counselling in terms of gestational weight gain (GWG): - combination of diet, physical activity & weight monitoring at each visit Interventions where dietary & physical activity counselling not combined: - intense diet counselling up to 10 x - duration of 1 hour Interventions delivered in early pregnancy - better results Interventions more likely to impact on GWG in high-risk participants Observed effects: - related to mode of intervention delivery rather than intervention per se Interventions based on clinical evidence & delivered by healthcare professionals: - more likely to have impact on wellbeing of mother and foetus

PREGNANCY (cont.) Phelan (2010) Weight gain during pregnancy & weight changes first year post delivery: - independently related to overweight/weight gain at 10 & 15 year follow-ups Attainment of pre-pregnancy weight by 6 months post delivery: - predictor of gains → 2.4kg over next 10 years Retention of weight post delivery: - predictor of gains → 8.3kg over next 10 years ↑ gestational weight gain & postpartum weight retention - sets stage for future weight gain & development of obesity At risks groups for higher pregnancy weight gain: - younger women, primiparity - nonsmokers, low income

PREGNANCY (cont.) Phelan (2010); Phelan (2009); Institute of Medicine Report (2009) Lack of clarity regarding how Institute of Medicine (IOM) (2009) recommendations should be implemented: Recommended total gestational weight gain BMI Category (kg/m²)kg < >305-9

POSTPARTUM Krummel (2007); Lawlor & Chaturvedi (2006); Rooney et al (2005); Walker et al (2005) Excessive gestational weight gain: - strong predictor of postpartum weight retention and related NCDs Excessive gestational weight gain & inability to lose pregnancy-related weight by 6 months postpartum: - predictor of obesity in mid life Postpartum period critical for weight management: - assess readiness, intention of behavioural change and related barriers Obese women more likely to: - eat in response to emotional vs physiological cues - RDs can assist clients in creating awareness of cues & suggest alternative behaviours

POSTPARTUM (cont.) FAO (201)0); Phelan (2010); Krummel (2007) Assess lactation status, dietary intake and activity levels: - breastfeed for at least 12 weeks → ↓ BMI later in life (only about 1/6 of children under 6 months exclusively breastfed in Lesotho) Amount of weight gained during pregnancy: - strongest predictor of 1-year postpartum weight retention

INFANCY Breastfeeding may exert protective effect against later adiposity: - slows down growth and reduces body fat during infancy Systematic review & meta-analysis: - while mean BMI in later life ↓ in subjects who were breast-fed → difference small & likely to be strongly influenced by publication bias & confounding factors - however: conclusion supported by findings of large cluster RCT regarding promotion of breastfeeding Race Overweight Obese Martin et al (2014): Arendas et al (2008); Lawlor & Chaturvedi (2006): Owen et al (2005)

INFANCY Infants born to overweight/obese mothers: - rapid growth during 1 st year of life despite breastfeeding - effect of maternal obesity most pronounced during 1 st six months of life - effect of maternal obesity mediated through composition/amount of breast milk Women with BMI > 30kg/m² : - significantly less likely to initiate breastfeeding - more likely to discontinue sooner - overweight/obese women ↓ prolactin response to suckling → ↓ ability to produce milk → ↓ lactation - delay in lactogenesis - breast morphology Race Overweight Obese Martin et al (2014): Arendas et al (2008); Lawlor & Chaturvedi (2006)

INFANCY (cont.) Paul et al (2009); Lederman et al (2004) Antenatal period, infancy & early childhood: - stages of particular vulnerability to development of obesity → unique periods of cellular differentiation and development → unique vulnerability creates possibility that actions taken during this stage may determine future course of adiposity Numerous studies: - association between rapid/accelerated infant weight gain & subsequent obesity with associated NCDs - overweight infants/toddlers → ↑ increased risk of remaining overweight as they age

INFANCY (cont.) Paul et al (2009); Lederman et al (2004) Overnutrition in infancy adversely “programs” components of metabolic syndrome & way energy is stored - especially those born to overweight parents → genetic & familial influences, pregnancy weight gain strongly associated with obesity in offspring Role of health professionals: - play closer attention to growth patterns during early childhood & way parents interpret infant growth - understand healthy infant growth patterns & communicate information regularly & accurately to parents → A CHUBBY BABY IS NOT A HEALTHY ONE

INFANCY (cont.) Paul et al (2009) Infant feeding mode: - breastfeeding offers modest protection against obesity versus formula feeding - exclusivity & duration of breastfeeding strengthen the association - optimal breastfeeding practices promoted through variety of avenues → health care system, work place, community & broader society → education to ↑ breastfeeding knowledge & skills during prenatal, intrapartum & postpartum period

INFANCY (cont.) Paul et al (2009) Sleep - link between short sleep duration & childhood obesity - short sleep duration during early childhood (3 – 5 years) associated with → overweight/obesity, ↑ % body fat at school going age - sleep duration of ↓ 12 hours during infancy → risk factor for overweight & adiposity in preschoolers - early development of sleeping through the night & association with weight status: → children unable to achieve sleep duration of 6 hours by age 5 months ↑ risk of short sleep duration & sleep problems later in childhood

INFANCY (cont.) Paul et al (2009) Sleep (cont.) HOWEVER - breastfeeding → ↓sleep segments, ↑ night waking, ↓total daily sleep → can persists post weaning Solution: - interventions designed to ↑ sleep duration - gradually lengthen intervals between night feeds by resorting to alternative caregiving behaviours prior to feeding → re-swaddling, diapering, rocking, “white noise” (e.g. fan) → ↓ nocturnal milk consumption made up with ↑ early morning feed

INFANCY (cont.) Paul et al (2009) Sleep (cont.) -breastfeeding “on demand”: → no uniform definition & interpreted in variable ways → ↑ability to distinguish hunger cues from other distress cues

INFANCY (cont.) Paul et al (2009) Parental regulation of distress - fussy infants & problems related to soothing them → rapid weight gain during childhood → adult BMI - developmental theorists → soothing environment alleviates immediate infant distress → facilitates infant infant’s development of self-regulation → soothing distressed infant models emotion regulatory strategies → parents using feeding to soothe distressed infant: consequences → using food to reward/punish: binge eating & ↑ adult weight

INFANCY (cont.) Paul et al (2009) Parental regulation of distress (cont.) - use non-food items to soothe during early infancy - use non-food rewards for good behavior during later infancy - praise or reward older infants with non food items: toys, reading stories, singing songs etc. - irritable infants: → recognize infant distress as signal to act → respond quickly → use strategies e.g. rocking, alternative activities ↓ Demonstrates how child might self-regulate own emotions in future

INFANCY (cont.) FAO (2010); Paul et al (2009) Introduction of solid foods In Lesotho: - complementary foods often introduced too early/too late Infants placed in childcare < 3 months - 2x as likely to receive solids < 4months Cereal added to infant’s bottle leads to ↑ weight gain Giving cereal at bedtime to improve sleep → no evidence regarding effectivity

INFANCY (cont.) Paul et al (2009) Introduction of solid foods (cont.) More focused studies: - overweight at 13 weeks → extra energy provided by solids early in life - overweight status at 13 weeks tracks up to 1 year of age - introduction of solids < 4 months: ↑ risk of overweight at 5-6 years - relationship between maternal obesity and greater weight gain in 1 st year → nearly eliminated by breastfeeding for more than 40 weeks & delaying introduction of complementary foods until > 20 weeks.

INFANCY (cont.) Paul et al (2009) Introduction of solid foods (cont.) Method of introduction of solid food: - infants need several opportunities to sample new foods before intake ↑ - liking of food flavours not dominated by sweet/salty tastes must be learned - infants’ neophobic response transient → 1-2 exposures/5-10 exposures required for acceptance of new food depending on age - repeated exposures necessary for acceptance of new foods if not too sweet/salty - cues for fullness: → pursed lips, closed mouth, spitting food out, turning head, leaning back

LATER INFANCY & EARLY TODDLER YEARS Paul et al (2009) Parental feeding style - early feeding practices → linked to patterns of food acceptance & developing controls of food intake - feeding style using coercion → unsuccessful in short term → can result in unhealthy weight status in long term - coercive feeding practices → pressurizing children to finish vegetables → restricting access to sweets and junk food → using sweets/junk food as rewards

LATER INFANCY & EARLY TODDLER YEARS Paul et al (2009) Parent feeding style (cont.) - promotes dislike for healthy food - ↑ liking & wanting restricted junk food - promotes dysregulation of intake by promoting over eating & learning to eat in response to the presence of food e.g. “finish your vegetables” Solution: - educate parents that learning to like new food takes time - repeatedly offer new foods over a period of 5 or 10 days - coercive feeding engenders resistance and foster dislikes - parents can serve as positive role models during infant transition to table foods

LATER INFANCY & EARLY TODDLER YEARS Paul et al (2009) Physical activity and sedentary behaviours - recommendations for infants: → interact with caregivers in daily physical activities promoting movement & exploration of environment → engage in activities that promote development of movement skills and large muscle activities in safe settings → do not restrict physical activity for prolonged periods

LATER INFANCY & EARLY TODDLER YEARS Paul et al (2009) Physical activity and sedentary behaviours (cont.) - environmental risk factors associated with sedentary activities during early infancy & toddler years: → may predispose children to ↓ levels of physical activity in later childhood → restricting infants in car seats, swings, carriers, strollers, small play spaces for ↑ periods limits motor development → delays physical activities e.g. crawling & walking ↓ Children who slept < 12 hours/day & watched TV for 2 hours/day or more: → probability of obesity 3 years of age: 17%

LATER INFANCY & EARLY TODDLER YEARS Paul et al (2009); American Academy of Pediatrics (2001) Physical activity and sedentary behaviours (cont.) - one clear target for intervention is television watching - most children watch TV by 2 years of age - educational efforts and interventions regarding limiting TV/video viewing must be implemented before this age to have impact on obesity - discourage TV watching for children < 2 years - television must not be placed in children’s bedrooms Pre-school aged child care & community based interventions: - pre-school identified as critical point for obesity prevention → young children more willing to change behaviour than older ones

CHILDREN Results of evidence-based systematic review of school-based primary prevention interventions for prevention of childhood overweight/obesity: Multicomponent school-based interventions including physical activity and nutrition education: → may be effective in improving adiposity as opposed to addressing components in isolation Results dependent on wide range of intervention design factors, population and context. Hoelscher et al (2013)

CHILDREN Summary of recommendations from review of child obesity primary prevention literature: - Integrate education with supportive environmental change - include nutrition education and physical activity education - build in parent engagement for younger children - promote community engagement in schools & child care - policies that limit food availability show promise - dose and continuity is important Hoelscher et al (2013)

ADOLESCENCE Transition years from childhood to adolescence → time for marked behavioural changes, including a relatively quick decline in physical activity Obesity interventions for which there is some evidence: - family support, a developmentally appropriate approach, long-term behaviour modification, dietary change, ↑ physical activity, ↓sedentary behaviour Prevention of obesity in children & adolescents: - range of strategies involving changes in microenvironment (housing, neighbourhoods, recreational opportunities) & macroenvironment (food marketing, transport systems, urban planning) Spruijt-Metz (2011); Potwarka et al (2008); Batch& Baur (2005)

SO WHAT IS MAKING OUR CHILDREN FAT? TV and computer games, eating supper while watching TV Skipping breakfast, ↓ energy intake at breakfast, ↑ energy intake at supper Buying lunch at school High fat diets: fast chip-eating hands (Jimmy Carr: UK Comedian) Lack of physical activity SANHANES-1 (2013) (children aged years): → lacked ability to correctly identify a “normal weight” → majority selected “fat image” as ideal body weight Shisana et al (2013); Van Baak & Astrup (2009); Drewnowski & Bellisle (2007); Moreno & Rodriguez (2007); Sun & Empie (2007); Almiron-Roig et al (2003)