1. OBESITY – THE NEW EPIDEMIC AN EPIDEMIC OF UNKNOWN ORIGINS? Current Concepts in Pediatrics16.October.2009 KM Morrison MD, FRCPC

2. OBJECTIVES  Understand the elements which have contributed to the rise in childhood and adolescent obesity  Discuss the health consequences related to childhood obesity  Describe the current best practice approach to intervention

3. Overweight and obesity in Canadian children

4. Canadian children – 2 – 17 years Change from 1979 to 2004 CCHS, Statistics Canada, 2005

5. HEALTH ISSUES IN OVERWEIGHT YOUTH Ebbeling CB, et al. Lancet. 2002;360:473-482.

6. QUESTION #1  What proportion of children presenting for weight management have multiple metabolic complications related to obesity? a) 5 - 10% b) 25 – 30% c) 45 – 50% d) 65 – 70%

7. HEALTH ISSUES IN OVERWEIGHT YOUTH Ebbeling CB, et al. Lancet. 2002;360:473-482. 1 IN 2 WITH MULTIPLE CVRF 25% WITH PRE- DIABETES IN HAMILTON OTHER?

8. 14-FOLD RISK Children with CV risk factors are more likely to have heart attacks and strokes as adults Cardiovascular event rate by age 30-48 according to CV risk factors at age 6-19 1.5% 19.4% % # risk factors* at age 6-19 y/o * obesity  blood pressure  glucose  triglycerides  HDL-cholesterol Morrison et al. Pediatrics 2007 120:340

9. TAKE HOME MESSAGE  27% OF CHILDREN IN OUR REGION ARE OVERWEIGHT OR OBESE  HEALTH CONSEQUENCES ARE COMMON  METABOLIC HEALTH CONSEQUENCES IN YOUTH PREDICT HEAVY HEALTH BURDEN IN ADULTHOOD

10. A simple imbalance between input and output… Storage

11. Gale J Nutr 2004 134:295 Appetite And Satiety

13. Understanding causation in youth Fetal Infant Child Adolescent Adult Morrison KM

14. FETAL ORIGINS OF OBESITY AND CVD Diabetes in pregnancy Maternal obesity Smoking in pregnancy Pre-eclampsia Fetal

15. Infant Nutrition Breast feeding -Protective? Mary Cassatt, Louise Breastfeeding her Child, 1899 Infant

16. Nutritional problems Fruit and vegetables Sugared drink consumption Large portion size Child Adolescent

17. Physical Activity and obesity Low physical activity associated with obesity Less than 20% of Canadian youth met physical activity targets (60 min of activity 6+ days per week) Janssen et al, 2005 Child Adolescent

18. Obesity, overweight & screen time: 6 – 11 y – CCHS, 2004 NOTE: 36% of children had > 2 h / d screen time 0 10 20 30 40 <1 h /d1 - 2 h/d> 2 h / d Screen timePrevalence of overweight or obesity Obese Overwt 5 7 11* 13 15 24* *

19. Prevention: Early Childhood Determinants  Genetic  Maternal diabetes during pregnancy  Low birth weight?  Breast feeding may be protective  Family environment Families and children that have these characteristics are in particular need of ANTICIPATORY guidance

20. QUESTION # 2  According to the Canadian Clinical Practice Guideline for the Prevention and Treatment of obesity in children, obesity in adolescents is classified by: a) Waist circumference > 90 cm b) Body mass index > 25 kg / m2 c) Body mass index > 90 th percentile for age and gender d)Body mass index > 95 th percentile for age and gender

21. Age: 5 yrs BMI = 20 kg/m 2 Age: 15 yrs BMI = 20 kg/m 2 28 26 24 22 20 18 16 14 12 2468101214161820 Age (yrs) BMI (kg/m 2 ) Assessing Bodyweight in Children and Adolescents BMI= weight (kg)/height 2 (m 2 ) 50 85 95 BMI= weight (lb)/ height 2 (in 2 )*703 Dissemination

22. Obesity classification in childhood - CDC 2000 BMI  Obesity: > 95 th percentile for age and gender  Overweight: >85 th percentile for age and gender OBESITY OVERWEIGHT

23. Approach to prevention ALL YOUTH > 2 y Measure height, weight, BMI Plot on growth curve (CDC) <85% PREVENTION Less than 2 hr TV / d Less than 1 c sugared drink per day Daily activity – min 30 min ≥ 85 th Percentile for age and gender Dissemination

24. CANADIAN CLINICAL PRACTICE GUIDELINES ON THE MANAGEMENT AND PREVENTION OF OBESITY IN ADULTS AND CHILDREN MANAGEMENT OF OBESITY Lau D et al, CMAJ 177 (11): 1391, 2007 Dissemination

25. Obesity treatment - 2008 Healthy Balanced Nutrition Regular physical activity Family based behavioural therapy Pharmaco- therapy SURGERY TEAM – MUST BE RD FAMILY FOCUSSED GOAL SETTING MOTIVATIONAL INTERVIEWING

26. Intervening in childhood obesity – meta- analyses 64 RCTs 5230 participants Meta-analysis results: reduction in overweight at 6 and 12 months with: - Lifestyle modification in children - Lifestyle modification in adolescents +/- meds CONCLUSION: “combined behavioural lifestyle interventions compared to standard care or self-help can produce a significant and clinically meaningful reduction in overweight in children and adolescents”:

27. EG. Addressing nutritional problems Fruit and vegetables Sugared drink consumption Large portion size Child Adolescent

28. RNAO BPG, 2005 Implementing change? Fetal Infant Child Adolescent Adult Morrison KM

29. kmorrison@mcmaster.ca THANK YOU!

30. Management: Pharmacotherapy Sibutramine (Anorectic agent)  Nonselective inhibitor of neuronal serotonin and norepinephrine uptake  ONE RCT in adolescents – n=82  With behavioural therapy, lost 7.8 kg vs. 3.2 kg  44% of those on RX. had to decrease dose or discontinue due to increased blood pressure Berkowitz RI et al JAMA 2003;289:1805. NOT READY FOR ROUTINE USE

31. Management: Pharmacotherapy Orlistat Inhibits lipase that breaks down triglyceride in gut prior to absorption…thus inhibiting fat absorption  One RCT – Chanoine J et al 2005  539 obese adolescents 12 – 16 yr x 52 WKS  Orlistat – 120 mg tid vs placebo 26.5% had 5% or more reduction in BMI compared to 15.7% with placebo Chanoine, J.-P. et al. JAMA 2005;293:2873-2883.