Role of HCPs in the Prevention of Obesity

Role of HCPs in the Prevention of Obesity Dr. Abdul Jabbar Visiting Professor, The Aga Khan University Consultant Endocrinologist, Medcare Hospital, UAE Diabetes, Senior Medical Advisor, Eli Lilly & Co. USA

Sixteen-year-old Hina is a high school student who loves movies, the local pizza parlor and music. She is young but has the health risks of someone three times her age. With a BMI > 95 th percentile for age, Hina has many of the features of metabolic syndrome and may be only months from displaying the symptoms of type 2 diabetes. Hina is one of 8. 8 million youth who are overweight or obese.

Obesity is perhaps the most pervasive medical problem faced by health care providers today. It is a common condition in any patient population in countries with a western diet and lifestyle. It affects disease burden in virtually every medical specialty, has broad exposure in the media and popular press, and is the subject of intense research in biomedical, epidemiologic, sociologic, and psychological fields. Each such theory falls short of explaining the full spectrum of disease and its resistance to treatment.

The overweight/obese child is metaphorically a "canary in the coal mine" of an increasingly toxic environment. Health care providers face the daunting task of preventing childhood obesity, a "pandemic of the new millennium. " Although some people are genetically predisposed to obesity and its comorbid cardiovascular and metabolic diseases, the causes of obesity are both social and biological. Preventing obesity requires an understanding of the ways in which two and a half million years of genetic evolution have made people vulnerable to rapid social and environmental changes of the past 50 years.

Obesity and CVD are diseases that originate in utero and take hold during infancy or in early childhood. Therefore, prevention efforts must continue across the lifespan, with particular attention directed to three critical periods of development: Prenatally The age of adiposity rebound (usually between the ages of 4 and 7 years, when BMI reaches its nadir and then begins to increase), and During puberty (when insulin resistance increases). Ideally, obesity prevention and treatment plans for patients should incorporate the entire family and should include assessment of family dynamics. The guidelines presented below describe a workable approach.

BMI Associated Risk Disease Classification BMI (kg/m 2) Risk Underweight Normal Overweight Obese I <18. 5 -22. 9 23. 0 – 26. 9 27. 0 – 30. 0 Increased Normal Increased High II 30. 1 – 34. 9 Very high III ≥ 35 Extremely high Additional risks: Large waist circumference (men ≥ 90 cm; women ≥ 80 cm) Poor aerobic fitness Specific races and ethnic groups Clinical Guidelines on the identification, Evalution, and Treatment of Overweight and Obesity in Adults – The Evidence Report. Obes Res. 1998/6 (suppt 12)

The concept of metabolic programming first arose from epidemiologic studies in which it was observed that infants with low birth weight had a higher risk of developing diabetes and heart disease during adulthood. Studies of the Dutch famine provide evidence that nutritional factors in utero have a causal relationship with subsequent metabolic phenotype. The Dutch population was abruptly subjected to famine conditions for 5 months in the winter of 1944 -45. Children who were exposed to the famine in utero had higher risks of glucose intolerance and type 2 diabetes later in life, compared with infants who were in utero just before or after the famine. [35] Comparison with other famines suggests that abrupt restoration of adequate nutrition after birth further increases the risk for metabolic disease. [36] Animal studies lend further support to the idea of metabolic programming

Just 3 hrs of walk Just 2 hrs of walk Just 1 hr of walk

FACT: Link Between Television and Overweight in Children is Discovered: this is the first time a research team has found evidence for a mechanism explaining that relationship. Researchers from the Harvard School of Public Health (HSPH) and Children's Hospital Boston found that kids who spend more time watching television also eat more of the calorie-dense, low-nutrient foods advertised on television.

Previous studies had demonstrated that children who watch more television are more likely to be overweight. study provides evidence that television is effective in getting kids to eat the foods that are advertised, and this drives up their total calorie intake. " The results of the study showed that each hour of increased television viewing over baseline was associated with a total energy increase of 167 calories -- just about the amount of calories in a soda or a handful of snack food. Archives of Pediatric and Adolescent Medicine. April 2006

Creative Non-Drug Technology-Driven Treatment Approaches for Childhood Obesity An Internet-facilitated intervention and automated controls on TV viewing and computer use were each associated with reducing BMI. The search for effective strategies for treatment of childhood obesity is challenging. In two studies, investigators report modest success using technology-driven interventions. Researchers randomized families of 70 children (age range, 4– 7 years) who had body-mass indexes >75 th percentile to two groups: One group had devices installed at their homes that recorded and blocked TV and computer use after a specified amount of time, which was aimed at reducing viewing by 50%; the other group received newsletters that featured advice on reducing children’s TV and computer use and was allowed unlimited viewing. Epstein LH et al. A randomized trial of the effects of reducing television viewing and computer use on body mass index in young children. Arch Pediatr Adolesc Med 2008 Mar; 162: 239.

At the end of the 2 -year study, mean weekly viewing time had declined by 17 hours in the intervention group and by 5 hours in the control group. Significant differences from baseline in mean BMI favored the intervention group at 6 and 12 months but not at 24 months. In families with low socioeconomic status, significant differences in BMI favored the intervention group at 6, 12, and 24 months.

Statistics show that in spite of all our efforts to date, diabetes is still out of control, under-funded and under-recognized. The projected increases in the number of diabetics will outstrip the ability of health systems to cope and will jeopardize the health of millions. Type 2 Diabetes Rising Among U. S. Adolescents Some 59, 000 adolescents in the United States already have obesity-linked type 2 diabetes, and nearly 3 million more may have blood sugar levels that could spur diabetes and other health problems, researchers report.

Curbing obesity can help avert a public health crisis, experts say "Steps to prevent and treat the substantial number of adolescents who have impaired fasting glucose [blood sugar] from developing type 2 diabetes are required now, " said lead researcher Glen E. Duncan, an assistant professor in the Department of Epidemiology, Nutritional Sciences Program at the University of Washington in Seattle. "These steps are well known and well established preventative measures -- namely to increase daily physical activity levels and improve nutrition, and to avoid excess body weight. "

One expert believes a major public health effort is needed to stem the obesity epidemic and prevent the rise of a generation plagued by type 2 diabetes. "The clearest evidence of the harms of epidemic obesity comes in the form of rising rates of diabetes in both adults and children, " said Dr. David L. Katz, an associate professor of public health and director of the Prevention Research Center at Yale University School of Medicine.

Just 2000 Steps and 100 Calories Can Impact Children's Lives And Prevent Disease According to health statistics, one-third of all children in the United States are either overweight or dangerously close to becoming so. Walking 2000 more steps a day and reducing your calories by 100 per day can prevent weight gain for overweight children. The study results proves that this approach can help counter obesity crisis. The study used 216 families who had a child who was defined as overweight by their body mass index (BMI). BMI Calculator for Children.

Small steps. It’s the little things that matter. For example: Do you…take the elevator or steps? . . . buy soda or drink water? …use sugar or sweetener? …choose regular or super-duper-size? All of your daily decisions add up.

Here are just a few daily choices that can lead to a fitter you: Add a 0 -calorie substitute to your coffee or tea – 9, 000 cal/yr. (1. 28 kg) Drink water instead of soda or juice (once a day) – 36, 000 cal/yr. (5 kg) Do 5 minutes of exercise/walk a day – 10, 000 cal/yr. (1. 6 kg) Walk / run fifteen minutes a day (3 x per week) – 30, 000 cal/yr. (4. 2 kg) These four small steps alone will help you shed nearly 15 kilos in a year!

Extreme measures, such as ketogenic diets and surgery, have been tried to deal quickly with obesity, but recidivism is high. There are no quick preventions or cures. The answer—permanent behavior change—is amazingly simple in description but formidable in implementation. Obesity prevention will require radical lifestyle change across the lifespan. Such change takes time, discipline, perseverance, and daily effort. And if it is not viewed as permanent, the efforts will be in vain.

Provide parents with simple recommendations and advice Create a daily schedule with regard to eating, physical activity, homework, and bedtime. Decreased sleep leads to insulin resistance and decreased serotonin levels, which in turn cause carbohydrate craving and exacerbate depression. Lack of sleep also increases ghrelin and decreases leptin, thus stimulating the appetite and decreasing satiety.

Eat three meals and one to two snacks each day, finishing each meal in 30– 45 minutes and never eating in front of the television or computer. Eat as many meals as possible together as a family, with wholesome food choices and positive family interactions. Portion sizes are critical and should be monitored carefully. For overweight children, a food and exercise log is recommended. Read food labels carefully with regard to both portion size and content.

Decrease portion sizes of starchy foods, such as rice, potatoes, bread, and pasta. Include more colorful vegetables. Choose whole-wheat or other whole-grain breads. When children want "seconds, " have them choose only one item (not one serving of each item) from the meal before adding any additional food. Perhaps that one extra food might be a glass of skim milk, fruit, or a vegetable. These are also ideal bedtime snacks if the child is hungry before sleeping.

Children 1– 2 years of age should be given whole or 2% milk to aid in myelination of the nervous system. Older children should drink nonfat milk. Younger children require 2 cups of milk per day, and adolescents need 3 cups per day to meet their daily recommended calcium requirements. It is now being recognized that the daily recommended amount of vitamin D may not be adequate. As a safeguard, children should have daily careful exposure to sunlight as well as foods fortified with vitamin D. Limit saturated fats, such as butter, margarine, chicken skin, bacon, and sausage. Oils such as olive, canola, and peanut are to be used in moderation, and lean meats are preferred over fatty ones. These should be steamed, broiled, baked, or grilled, but not fried.

Season foods with herbs and spices rather than sugar, salt, and fat. Salt is an acquired taste. Do not add salt to any foods offered to infants. Because thirst and fatigue can be mistaken for hunger, offer children water or fat free milk if they complain of hunger between meals.

Strictly limit or reserve for special occasions foods of low nutritional value, including cakes, cookies, candies, chips, French fries, and sugared beverages. Limit fast food and processed or prepared food such as TV dinners to no more than once a week. Also, prepare school lunches at home, including only unprocessed foods such as apples, carrots, and skim milk and avoiding excessive saturated fat and carbohydrates. Good desserts might include fruit, sugar-free jello or pudding, and canned fruits drained of any syrup. Ration sugary, fatty treats at holidays and discard leftovers, including candies with a long shelf life, after 3– 5 days. Discourage eating in the car, giving only water to drink while in transit.

Avoid using food as a reward. Get daily physical activity. Younger children should walk or play outside for at least 30 minutes a day, and older children need at least an hour of physical activity. Limit media use to < 1 hour/day. – This includes watching television, talking on the phone, playing sedentary video games, and using the computer other than for homework assignments. – These media should not be available in children's bedrooms.

Encourage active parenting Children need parents, not buddies. Health care providers should call on parents to reclaim their roles as those in charge of and responsible for their children. Children mirror the behaviors of their parents.

Prevention of Type 2 Diabetes Diet + Exercise Intervention for IGT Reduction in progression to diabetes (%) Diabetes Prevention Program N=3234, 2. 8 years Low-fat diet + exercise 58 Finnish Study N=522, 3. 2 years Low-fat diet + exercise 58 Da Qing Study N=577, 6. 0 years DPP Research Group. N Engl J Med. 2002; 346: 393 -403; Tuomilehto J et al. 31– 46 Diet and/or exercise Pan XR et al. Diabetes Care. 1997; 20: 537 -544 N Engl J Med. 2001; 344: 1343 -1350;

Prevention of Type 2 Diabetes Pharmacotherapy for IGT Reduction in progression to diabetes (%) Diabetes Prevention Program N=3234, 2. 8 years Metformin 850 mg bid 31 STOP-NIDDM trial N=1429, 3. 3 years Acarbose 100 mg tid 25 TRIPOD study N=236, 2. 5 years DPP Research Group. N Engl J Med. 2002; 346: 393 -403; Chiasson J-L et al. Lancet. 2002; 359: 2072 -2077; Buchanan TA et al. Diabetes. 2002; 51: 2796 -2803 Troglitazone 400 mg qd >50

Prevention of Type 2 Diabetes Recommendations • Identify populations at high risk for pre-diabetes – Age >30 years + body mass index >25 kg/m 2 – Consider younger persons with family history, prior GDM, non-Caucasian ancestry, dyslipidemia, hypertension, CVD, or PCOS • Screen with FPG or 2 -h 75 -g oral glucose tolerance test (OGTT) • Confirm IFG or IGT with a second test • Intervene with diet, weight loss, and physical activity • GDM=gestational diabetes mellitus; CVD=cardiovascular disease; Retest every 1 to 2 years PCOS=polycystic ovarian syndrome; FPG=fasting plasma glucose; IFG=impaired fasting glucose; IGT=impaired glucose tolerance ADA/NIDDK. Diabetes Care. 2004; 27(suppl 1): S 47 -S 54; ACE Consensus Statement. Endocr Pract. 2002; 8(suppl 1): 5 -11

Prevention of Type 2 Diabetes Lifestyle Intervention • Nutrition – Seek 5% to 7% weight reduction (50% and 43% achieved this in Diabetes Prevention Program and Finnish trials, respectively) – <30% calories from fat • Physical activity – Moderate exercise, 150 to 210 min/week (equivalent to 30 -min sessions 5 to 7 days/week; 74% and 86% achieved this in Diabetes Prevention Program and Finnish trials, respectively) DPP Research Group. N Engl J Med. 2002; 346; 393 -403; Tuomilehto J et al. N Engl J Med. 2001; 344: 1343 -1350

Obtain genetic information and medical history When treating obese children, clinicians should obtain a thorough family history in order to identify the presence of any of these high-risk ethnicities. It is also helpful to have a history of any genetic and endocrine disorders that may be present, such as Prader-Willi syndrome, Down's syndrome, Cushing's disease, pseudohypoparathyroidism, or hypothyroidism. A strong positive family history for diabetes is cause for concern that an obese child may progress more rapidly to development of diabetes.

The family history should include psychiatric as well as medical issues, because there is an increased incidence of depression in the obese, and this condition may either precede or follow the development of obesity. Certain medicines, including psychotropics (e. g. , resperidol and other second-generation antipsychotic medications), contraceptives (e. g. , medroxyprogesterone acetate), antiepileptics (e. g. , valproic acid or gabapentin), and anti-inflammatory agents (e. g. , prednisone), can predispose individuals to increased weight gain. A careful review of all prescribed medicines and their potential side effects is always indicated. Over-thecounter medicines and herbal products should be included in this comprehensive history.

Counsel about comorbid conditions Though scare tactics are not a wise strategy for patient care, it is important to educate parents and older pediatric patients about comorbid and premorbid conditions associated with abnormal weight gain. In presenting the list of comorbid conditions to pediatric patients and their families, clinicians should explain that their goal is not to frighten them, but rather to inform them that obesity is a serious disease and that it is associated with other very serious diseases

Monitor BMI regularly A BMI >85 th percentile but < the 95 th percentile is considered overweight, whereas a BMI >95 th percentile is considered obese. These are standardized for age and sex by Centers for Disease Control and Prevention growth curves. In a study by Beeman et al. , 19 neither parents, nurses, resident physicians in training, nor attending physicians could accurately assess whether a child was overweight by appearance alone. This underscores the need for regularly measuring and tracking BMI. http: //www. cdc. gov/nccdphp/dnpa/growthcharts/training/modules/mod ules. htm

Address diet and exercise issues throughout childhood Breastfeeding. Clinicians should encourage breastfeeding of infants because it helps prevent obesity in infancy and offers a protective factor against obesity (and possibly cardiovascular disease) in later childhood. A 60% increase in obesity has been observed in children who are not breastfed. Sweets in infancy. 40% had received sweets daily by the age of 7– 8 months and 70% had received them by the age of 15– 18 months. By the age of 2 years, 43% of infants are given soft drinks daily. One can of nondiet soft drink contains 150 calories, the equivalent to 10 teaspoons of sugar. Soft drinks also displace nutrient-rich milk in the diets of children who drink them.

Vending machines in schools. One of the most detrimental and ubiquitous additives found in snack foods is the sweetener high fructose corn syrup, which is used in place of or in addition to sucrose. Although it is classified as a carbohydrate, high fructose corn syrup is metabolized as a fat. Family meals and family activity. An important preventive factor for the entire spectrum of eating disorders from obesity to anorexia nervosa. Family meals have been shown to reduce unhealthy eating patterns, including binge eating disorder, which is seen in a high percentage of overweight people, because emotional needs for nurturing are met through meaningful family interaction in a pleasant and relaxed setting. Families should also be encouraged to be physically active together.

Individualized nutrition and exercise plans Simple diet sheets with calorie counts are not recommended for obese pediatric patients. Instead, nutrition education must be individualized and focused on the entire family. Physical activity is a vital component of obesity prevention. But when it comes to exercise, one size does not fit all.

Address the psychological aspects of obesity Motivation. When patients lack the desire to effect what often can be radical lifestyle changes, nothing can be accomplished. Depression. Challenging to Diagnose in Paediatrics. The authors have identified a condition they call Paliacchi syndrome, or smiling depression, seen predominantly in overweight individuals who act as "class clowns" but inside are experiencing intense emotional pain. Depression also can lead to overeating, both for biological reasons (i. e. , efforts to increase serotonin levels) and to provide emotional comfort.

Eating disorders. The incidence of binge eating, including binge eating disorder, is increased among the overweight and obese. According to Eaton et al. , 40 "numerous studies have found that adolescents with unhealthy weight control practices are at increased risk for suicidal ideation, suicide attempts, and death by suicide. " A recent study of U. S. high school students with perceived high BMI showed increased suicidal ideation and attempts. 40 Media Counseling. Educating and counseling families of obese children about their media use is vital. Excessive use of the Internet, television, and electronic games contributes to a sedentary lifestyle and can have negative psychological effects on children. Rich also reported that 8 - to 18 -year-olds spend an average of 6 hours and 43 minutes per day using media—more time than they spend in school or with parents

Work within the community. The need for a multidisciplinary team approach in preventing childhood obesity cannot be stressed enough. Homes, grocery stores and restaurants. The information they need on food labels is essential. Products labeled "no fat" may well be high in calories or contain high fructose corn syrup. Those labeled "low calorie, " may be high in harmful fats. Community resources and initiatives. Disseminate a list of community resources for the families of obese children.

Provide parents with simple recommendations and advice Create a daily schedule with regard to eating, physical activity, homework, and bedtime. Decreased sleep leads to insulin resistance and decreased serotonin levels, which in turn cause carbohydrate craving and exacerbate depression. Lack of sleep also increases ghrelin and decreases leptin, thus stimulating the appetite and decreasing satiety. Eat three meals and one to two snacks each day, finishing each meal in 30– 45 minutes and never eating in front of the television or computer. Eat as many meals as possible together as a family, with wholesome food choices and positive family interactions.

Portion sizes are critical and should be monitored carefully. For overweight children, a food and exercise log is recommended. Read food labels carefully with regard to both portion size 51 and content. Avoid high fructose corn syrup. Decrease portion sizes of starchy foods, such as rice, potatoes, bread, and pasta. Include more colorful vegetables. Choose whole-wheat or other whole-grain breads. When children want "seconds, " have them choose only one item (not one serving of each item) from the meal before adding any additional food. Perhaps that one extra food might be a glass of skim milk, fruit, or a vegetable. These are also ideal bedtime snacks if the child is hungry before sleeping.

Children 1– 2 years of age should be given whole or 2% milk to aid in myelination of the nervous system. Older children should drink nonfat milk. Younger children require 2 cups of milk per day, and adolescents need 3 cups per day to meet their daily recommended calcium requirements. Lactose-free milk is an option for milkintolerant children, and yogurt and cheese might also be substituted. It is now being recognized that the daily recommended amount of vitamin D may not be adequate. As a safeguard, children should have daily careful exposure to sunlight as well as foods fortified with vitamin D. Limit saturated fats, such as butter, margarine, chicken skin, bacon, and sausage. Oils such as olive, canola, and peanut are to be used in moderation, and lean meats are preferred over fatty ones. These should be steamed, broiled, baked, or grilled, but not fried. In order to increase cardio-protective omega-3 fatty acids, certain nuts (almonds and walnuts, preferably unsalted) and fish (salmon, light tuna, catfish, or shrimp) should be included.

Season foods with herbs and spices rather than sugar, salt, and fat. Salt is an acquired taste. Do not add salt to any foods offered to infants. Because thirst and fatigue can be mistaken for hunger, offer children water or fat free milk if they complain of hunger between meals.

Strictly limit or reserve for special occasions foods of low nutritional value, including cakes, cookies, candies, chips, French fries, and sugared beverages. Limit fast food and processed or prepared food such as TV dinners to no more than once a week. Also, prepare school lunches at home, including only unprocessed foods such as apples, carrots, and skim milk and avoiding excessive saturated fat and carbohydrates. Good desserts might include fruit, sugar-free jello or pudding, and canned fruits drained of any syrup. Ration sugary, fatty treats at holidays and discard leftovers, including candies with a long shelf life, after 3– 5 days. Discourage eating in the car, giving only water to drink while in transit.

Avoid using food as a reward. Get daily physical activity. Younger children should walk or play outside for at least 30 minutes a day, and older children need at least an hour of physical activity, perhaps including indoor activities such as video games featuring dancing or exercising. 52 Limit media use to < 1 hour/day. This includes watching television, talking on the phone, playing sedentary video games, and using the computer other than for homework assignments. These media should not be available in children's bedrooms.

Encourage active parenting Children need parents, not buddies. Health care providers should call on parents to reclaim their roles as those in charge of and responsible for their children. Children mirror the behaviors of their parents. Children of affluent families can face equally challenging problems, however. Despite abundant material resources, they may not have proper parenting with regard to nutrition, exercise, and high-risk behaviors or may suffer from "affluenza, "55 or overindulgence resulting in insatiability. Often, these children become detached from self-absorbed parents who have not properly focused on their children's emotional and spiritual needs. Personal responsibility is not fostered in a materialistic environment of immediate gratification. This results in families' desires for a magic cure or easy prevention strategy and lack of willingness to focus on a disciplined and balanced lifestyle plan.

So what do we know, and what can we do? We know that overweight adolescents are at high risk of becoming obese adults. We know that this is a problem that may begin in utero, and insulin resistance and oxidative endothelial cell damage are basic to the disease. We know that obesity is a disease of all ages and all nationalities, not just those with thrifty genes. The morbidity and mortality associated with this pandemic and their concomitant costs are monumental, with the potential of bankrupting the health care delivery and Social Security disability systems if the situation is not curbed. Human suffering associated with obesity further feeds the epidemic through depression, resulting lack of motivation to change, increased emotional eating and social isolation, and decreased physical activity.

Hopelessness prevails among health care professionals trying to care for these patients. Their lament: "Nothing works. "And indeed, there is little evidence thus far for success, at least not in the long term. There is an extreme paucity of evidence-based study, but the few trials reporting success, albeit short term, are multidisciplinary, involving psychological, dietary, and exercise components.

The American Academy of Pediatric policy statement on prevention of childhood overweight and obesity focuses on health supervision and advocacy in bringing about desperately needed societal changes. This statement calls for individualization of the plan for each child within the broader context of societal reforms related to issues ranging from vending machines to safe playgrounds to sound public health policies. Also suggested are advocacy efforts to obtain reimbursement for delivery of preventive medical care and education and funding for further research. The power of health care professionals to impact the lives of their patients cannot be overstated. When careful compassionate words create an informed, positive environment, this voice is heard above the media din, and the self-fulfilling prophecy of hope 37 can begin its mission. We must be optimistic enough to believe in the ability of people to change and heal. Despite occasional steps backward, meaningful and permanent lifestyle changes can be effected. If we do not believe this to be so, neither will our patients.