Obesity Interventions That Work The Molten Moment Double check graphs for C&P Tracy Flood MD, PhD Director of the Statewide Obesity Surveillance System University of Wisconsin Madison

About Me

Social, Organizational Community, Public Policy About Us Individual Social, Organizational Community, Public Policy Built environment The Socio Ecological Model Cellular

Question: How do we decrease obesity? Clinic 1 v 1 Populations vs.

Why? If rising OW/OB trends continue, by 2030 it will reach Unhealthy Weight Gain Obesity “Toxic” Obesity = Metabolic Syndrome (MetS) If rising OW/OB trends continue, by 2030 it will reach 16-18% of total health-care costs in the United States. (Wang, Beydoun, Liang, Caballero, Kumanyika, 2008) Currently, the world’s leading causes of death are the Atherosclerosis-related dz: Ischemic heart disease (IHD) Stroke (Lopez & Mathers, 2006; Mathers et al., 2009). OW/OB  Increases Risk Factors Risk Factors  Atherosclerosis Atherosclerosis begins at a young age Cardiovascular Dz (CVD) = Death

Goal Provide how-to-steps on how to move the needle on obesity & prevent premature death from cardiovascular disease.

Outline WHY should we care? Metabolic Syndrome, CVD, etc! Ok, we care. Let’s take action! Let’s Design an intervention that works (review the lit reviews) WHEN = Molten Moment WHERE = Clinic vs. Community WHAT WORKS?* *Informed by Biology The Story of the Fat Cell

When do we act? The Molten Moment

The Molten Moment Cold, Solid HOT, Malleable

The Molten Moment Where do you strike For the biggest impact?

The Molten Moment Where do you strike For the biggest impact? birth 15 25+ 10 20 Age: Where do you strike For the biggest impact?

Where do we act? ? The Molten Moment Design an Intervention

Pick an Obesity Intervention

Pick an Obesity Intervention Individual Organizational (ex. Schools, worksites) Policy & Built environment

Will the Intervention work? 1000+ Studies 35 Systematic Reviews & Meta-analyses & What Works for Health = Evidence-based Interventions

Will the Intervention work? Define “What Works” Change Key* Behaviors Obesity CVD MetS *Will define key behaviors for each case

The Story of The Fat Cell What Works? ? The Molten Moment The Story of The Fat Cell Design an Intervention

The Story of The Fat Cell

Little Cell, Big Problem U.S. Prevalence of Overweight & Obesity % Describe the incidence and prevalence of overweight and obesity from birth through adulthood Pediatric Definition Adult Definition Data from NHANES 2011-12 Ogden, Carroll, Kit, Flegal 2014

Defining Obesity CHILDREN ADULTS Obese 30 Over- weight Normalweight 30 25 Obese BMI ≥ 95th percentile Overweight BMI 85th – 94th percentile > CHILDREN ADULTS

The Story of The Fat Cell BMI The Story of The Fat Cell OB Glucose spike OW Glucose  Fat insulin Fat Cell NW Stem Cells can become Fat Cells (Arner Spalding 2010; Spalding, Arner 2008)

Let’s Begin!

Pick an Obesity Intervention Normal weight 35 yo with an obese preschooler Obese 15 yo girl who is otherwise healthy Obese 55 yo man with Metabolic Syndrome

with Metabolic Syndrome Pick an Obesity Intervention Diet + Exercise Good Advice Rx Obese 55 yo man with Metabolic Syndrome

Results of Intervention Advice Alone 13 lbs Exercise Alone Diet Alone Orlistat Diet+Exercise Sibutramine Very Low Cal Diet Average weight loss of subjects completing a minimum 1-year weight-management intervention; based on review of 80 studies (N=26,455; 18,199 completers [69%]). (Franz et al, 2007) Note: Built environment & surgery not included

Results of Intervention 5’6” weight BMI OB 13 lbs 190 lb 30 OW 160 lb 25 NW

Meta-Analysis & Reviews Behaviors: Physical Act/ Active Transport Balanced Diet Multi-component Individualized programs Weight (~4-8 lbs) prevent wt Obesity Worksite Wellness Programs CVD MetS Built environment associated with active transport  weight loss and decreased CVD CVD improves, With minimal weight loss? Zoning for Active Living (Mixed use, good streetscape) Ref What Works for Health

The Story of The Fat Cell Glucose spike insulin Stressed fat cells = Metabolic Syndrome (Arner Spalding 2010; Spalding, Arner 2008)

The Story of The Fat Cell Result: Higher TG Lower HDL Fatty Liver TG HDL TG HDL is the good cholesterol Scavenges Xtra TG then is destroyed FA FA TG TG (Fat) Used for fuel if active Origins of Metabolic Syndrome (Arner Spalding 2010; Spalding, Arner 2008)

The Story of The Fat Cell High TG, Low HDL Hypertension Diabetes =Metabolic Syndrome Insulin Resistance FAT

The Story of The Fat Cell Insulin Resistance Body Type & Risk = Metabolic Syndrome

The Story of The Fat Cell BMI Obese Normal weight Metabolic Health Good Poor

with Metabolic Syndrome The Story of The Fat Cell Obese 55 yo man with Metabolic Syndrome

The Story of The Fat Cell Glucose spike insulin Relief with 7-10% Weight Loss (Arner Spalding 2010; Spalding, Arner 2008)

The Story of The Fat Cell 5’6” I’m HUNGRY!! BMI I’m HUNGRY!! FEED me!! OB 30 OW 25 Rebellion with >10% Weight Loss (Arner Spalding 2010; Spalding, Arner 2008) NW

The Story of The Fat Cell I’m HUNGRY!! FEED me!! EAT MORE! BURN LESS! Rebellion with >10% Weight Loss (Martins, Robertson, Morgan 2008)

30 min of moderate exercise x 5 days a week to maintain x 7 d/wk to maintain weight loss lebeauleblog.wordpress.com I’m HUNGRY!! FEED me!! (Martins, Robertson, Morgan 2008)

The Molten Moment Behavior Change Modest Weight CVD Risk Decreases

Behavior Change Possible The Molten Moment Behavior Change Possible CVD Risk Decreases birth 15 25+ 10 20 Age:

Pick an Obesity Intervention Normal weight 35 yo with an obese preschooler Obese 15 yo girl who is otherwise healthy Obese 55 yo man with Metabolic Syndrome

Pick an Obesity Intervention School based Behav Therapy Neighbor- hood Obese 15 yo girl who is otherwise healthy

Results of Intervention Adult Obesity

Meta-Analysis & Reviews Behaviors: Physical Act Sedentary Behav (SB) Sugar-Sweetened Beverage Individualized Behav programs Clinic-based counseling (SB) Weight gain TV Monitoring Devices (SB) Obesity Multi-Component School-based Enhance/Expand Physical Ed Physically Active Classrooms & Structured Recess But will she remain obese for life? Reductions in sedentary Behavior BMI changes with intense behaviroal Policy & envi  diet & PA CVD MetS Competitive Pricing in Schools Safe Routes to School & Walking Schoolbus Access to Places for PA (Mixed use, streetscape, Rec Facilities) What Works For Health N=13 meta-analysis & Systematic reviews

The Story of The Fat Cell

Finished w/ Linear Growth The Story of The Fat Cell Very High Risk of Future CVD Trajectory above the 75th percentile Ventura, Loken, & Birch (2009) Link between Childhood BMI and adult CV death Begins as early as: 8 yo in boys 13 yo in girls BMI child  CIMT adult. Further adjustment for adult cardiovascular risk factors did not change the relationship (linear regression coefficient=2.1 microm/s.d.; 95% CI: 1.0; 3.1) between adult (28 yo) CIMT and adolescent BMI. Adjustment for adult BMI attenuated the association (linear regression coefficient=0.9 microm/s.d.; 95% CI: -0.3; 2.2) as the majority of overweight and obese adolescents remained overweight or became obese young adults. (Oren et al., 2003). Elevated BMI in boys as early as 8 and girls as early as 13 is significantly associated with developing metabolic syndrome at >or=30 years. OR 14-18 y/o males 1.8 (1.3, 2.5 95% CI) and females 2.8 (1.9 to 4 95% CI). However, “elevated” BMI is along the 75th%ile of boys’ 12-17 CDC chart and girls 13-17 60th percentile…. much much lower than the Expert Committee cutoffs. (Sun, Liang, Huang, Daniels, et al 2008) Denmark: Childhood BMI (7-13 y/o boys, 10-13 y/o girls) is associated with adult CHD (a fatal or nonfatal event) (adult >=25 y/o). As BMI increased, the risk increased. Each 1 unit increase in BMI (5.6 kg (12.3 lbs) boys, 6.3 kg (13.9 lbs) girls) increased the risk for fatal cardiac events with a hazards ratio adjustede for bw, in 13 y/o boys (HR 1.24) and girls (HR 1.23) (Baker, Olsen, Sørensen, 2007). BMI at 13 y/o predicts cholesterol and glucose resistance in adulthood (Steinberger, Moran, Hong 2001)  ‘Overweight’ in adolescents (13-18 y/o) predicts CHD morbidity in men and women (Must, Jacques, Dallal, Bajema, Dietz,1992). Harvard Longitudinal Study. 1922-1935 to 1988. Overweight=”75th percentile in subjects of the same age and sex in a large national survey”  ‘Overweight; in adolescents (13-18 y/o) predicts mortality in men (not women): RR of 1.8 for all-cause mortality and 2.3 RR for CHD mortality. (Must, Jacques, Dallal, Bajema, Dietz, 1992). Harvard Longitudinal Study. 1922-1935 to 1988. Overweight=”75th percentile in subjects of the same age and sex in a large national survey”  Norway: 227,003 14-19 y/o followed for 31.5 years. Increased risk of mortality became apparent after the age of 30. (Engeland, Bjorge, Sogaard, Tverdal 2003) - Mortality in males (vs. 25th-75%iles CDC charts): -85-95% 30% increased risk ->95% 80% increased risk - Mortality in females ->95% 100% increased risk  White-black cohort of Bogalusa Heart Study 13-17 y/o Srinivasan SR, Bao W, Wattigney WA, Berenson GS. Teenage OW (BMI>=75%ile (as compared to 25-50th%ile)) increases risk of adulthood(27 to 31 y/o): - Hypertension: Prevalence increased 8.5-fold - Dislipidemia: Prevalence increased 3.1 to 8.3-fold Finished w/ Linear Growth Increased BMI = Increased Risk of CVD CVD Risk: Sun et al., 2008 Trajectory: Ventura, Loken, & Birch, 2009

DECREASE Mortality risk in adulthood for OW/OB adolescents If OW/OB teen Normal Weight by adulthood Risk Factors & Atherosclerosis associated with adiposity DECREASE (Oren et al., 2003; Weiss et al., 2009) But our patient has a 92% chance of remaining obese at the age of 40. (Nader, 2008) Trajectory above the 75th percentile Ventura, Loken, & Birch (2009) Link between Childhood BMI and adult CV death Begins as early as: 8 yo in boys 13 yo in girls BMI child  CIMT adult. Further adjustment for adult cardiovascular risk factors did not change the relationship (linear regression coefficient=2.1 microm/s.d.; 95% CI: 1.0; 3.1) between adult (28 yo) CIMT and adolescent BMI. Adjustment for adult BMI attenuated the association (linear regression coefficient=0.9 microm/s.d.; 95% CI: -0.3; 2.2) as the majority of overweight and obese adolescents remained overweight or became obese young adults. (Oren et al., 2003). Elevated BMI in boys as early as 8 and girls as early as 13 is significantly associated with developing metabolic syndrome at >or=30 years. OR 14-18 y/o males 1.8 (1.3, 2.5 95% CI) and females 2.8 (1.9 to 4 95% CI). However, “elevated” BMI is along the 75th%ile of boys’ 12-17 CDC chart and girls 13-17 60th percentile…. much much lower than the Expert Committee cutoffs. (Sun, Liang, Huang, Daniels, et al 2008) Denmark: Childhood BMI (7-13 y/o boys, 10-13 y/o girls) is associated with adult CHD (a fatal or nonfatal event) (adult >=25 y/o). As BMI increased, the risk increased. Each 1 unit increase in BMI (5.6 kg (12.3 lbs) boys, 6.3 kg (13.9 lbs) girls) increased the risk for fatal cardiac events with a hazards ratio adjustede for bw, in 13 y/o boys (HR 1.24) and girls (HR 1.23) (Baker, Olsen, Sørensen, 2007). BMI at 13 y/o predicts cholesterol and glucose resistance in adulthood (Steinberger, Moran, Hong 2001)  ‘Overweight’ in adolescents (13-18 y/o) predicts CHD morbidity in men and women (Must, Jacques, Dallal, Bajema, Dietz,1992). Harvard Longitudinal Study. 1922-1935 to 1988. Overweight=”75th percentile in subjects of the same age and sex in a large national survey”  ‘Overweight; in adolescents (13-18 y/o) predicts mortality in men (not women): RR of 1.8 for all-cause mortality and 2.3 RR for CHD mortality. (Must, Jacques, Dallal, Bajema, Dietz, 1992). Harvard Longitudinal Study. 1922-1935 to 1988. Overweight=”75th percentile in subjects of the same age and sex in a large national survey”  Norway: 227,003 14-19 y/o followed for 31.5 years. Increased risk of mortality became apparent after the age of 30. (Engeland, Bjorge, Sogaard, Tverdal 2003) - Mortality in males (vs. 25th-75%iles CDC charts): -85-95% 30% increased risk ->95% 80% increased risk - Mortality in females ->95% 100% increased risk  White-black cohort of Bogalusa Heart Study 13-17 y/o Srinivasan SR, Bao W, Wattigney WA, Berenson GS. Teenage OW (BMI>=75%ile (as compared to 25-50th%ile)) increases risk of adulthood(27 to 31 y/o): - Hypertension: Prevalence increased 8.5-fold - Dislipidemia: Prevalence increased 3.1 to 8.3-fold Figure. Mortality in adulthood (<55 y/o) of OW/OB adolescents (males and females) compared to normal weight peers. Note: Subjects with BMI 25th to 75th percentile (CDC charts) were the referent group. Adapted from Bjorge, Engeland, Tverdal, & Smith (2008).

The Story of The Fat Cell The Immortal Cell… sort of (Arner Spalding 2010; Spalding, Arner 2008)

The Molten Moment Behavior Change Possible Behavior Change Possible Altered growth trajectory Decrease CVD Risk birth 15 25+ 10 20 Age:

Pick an Obesity Intervention Normal weight 35 yo with an obese preschooler Obese 15 yo girl who is otherwise healthy Obese 55 yo man with Metabolic Syndrome

with an obese preschooler Pick an Obesity Intervention Early childcare based Behav Therapy Neighbor- hood Normal weight 35 yo with an obese preschooler

Results of Intervention

Meta-Analysis & Reviews Behaviors: Sugar-Sweetened Beverage Provision of Health Food & Removal of Unhealthy Food Sedentary Behavior Sleep Intervention to reduce SB Obesity Nutrition & PA Interventions in Preschool & Early Childcare Allow me to Explain CVD MetS Access to Places for PA (Mixed use, streetscape, Rec Facilities) What Works For Health N=13 meta-analysis & Systematic reviews

The Story of The Fat Cell

The Story of The Fat Cell I’m Learning about the world! Sugar-sweetened beverages Skipping Meals Sedentary Behavior Sleep Fat Cell of a Preschooler

Behavioral Plasticity Preschoolers mimic parents’: Fruit & Vegetable consumption Portion sizes Snacking frequency TV Physical activity Grocery shopping “When mothers improve their diets in order to control their weight, their child (1-3 y/o) improves their diet as well, even if that was not the original intent” (Klohe-Lehman, et al., 2007)

Synthesis of Evidence

Synthesis: Behavior (Wahi, et al., 2011) Meta-Analysis. RCT to reduce SB. 13 studies in review

Synthesis: BMI Change 6-12 yo OB OB OB ns OW OW OW NW NW NW (Waters, et al., 2011) Cochrane review of 55 studies. Meta-analysis on 37 studies, 27,946 children.

Synthesis: Success Intervention Success Rates defined as enough BMI change to reduce CVD risk Danielsson et al., 2012 (0.5 SD BMI) Kraschnewski et al., 2010

BMI Percentile Chart Behavior BMI Change Success

Thinnest Weight Borderline Risk High Risk Moldable Habits Successful Community Interventions

The Molten Moment Behavior Change Possible Behavior Change Possible  Obesity Alter growth trajectory Decrease CVD Risk birth 15 25+ 10 20 Age: MOLTEN MOMENT Prevention of Obesity

New Goal Provide how-to-steps on how to move the needle on obesity & prevent premature death from cardiovascular disease. behavior &

Summary Obesity is associated with MetS, CVD, & Death Small changes at any time = CVD Small changes at the Molten Moment = Obesity The 1v1 AND Population Interventions work We must all work together, doing what we can

FOR MORE INFORMATION: What Works for Health County Health Rankings.org

Thank You! Questions/Comments? tflood@wisc.edu For M