Obesity A Weighty Problem

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Obesity, and its Related Diseases Prevention
Begins in Childhood
Stanley Bassin Ed.D Center For The Study Of
Health Effects Of Exercise In Children University
Childrens Hospital, UCI College of Medicine,
Orange, CA.
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ObesityA Weighty Problem
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The Anthropology of Physical Activity
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The Agricultural Period
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The Industrial Period
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The Electronics Age
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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

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The Top 10 alternative reasons for obesity

• Inadequate sleep. (Average sleep amounts have
  fallen, and many studies tie sleep deprivation to
  weight gain.)

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The Top 10 alternative reasons for obesity

• 2. Endocrine disruptors, which are substances in
  some foods that might alter fats in the body.

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The Top 10 alternative reasons for obesity

• 3. Nice temperatures. (Air conditioning and
  heating limit calories burned from sweating and
  shivering.)

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The Top 10 alternative reasons for obesity

• 4. Fewer people smoking. (Less appetite
  suppression.)

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The Top 10 alternative reasons for obesity

• 5. Medicines that cause weight gains

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The Top 10 alternative reasons for obesity

• 6. Population changes. (More middle-agers and
  Hispanics, who have higher obesity rates.)

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The Top 10 alternative reasons for obesity

• 7. Older birth moms. (That correlates with
  heavier children.)

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The Top 10 alternative reasons for obesity

• 8. Genetic influences during pregnancy

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The Top 10 alternative reasons for obesity

• 9. Darwinian natural selection. (Fat people out
  survive skinny ones).

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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.

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Obesity Related Morbidity

• The estimated number of deaths attributable to
  obesity among US adults is approximately 280,000.

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Obesity Related Morbidity

• The estimated number of deaths attributable to
  obesity for nonsmokers is approximately 325,000

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The Theories of Obesity Fall Into Three Categories
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Genetic Influence of Human Variation in Body Fat
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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 gt 40

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BMI-for-Age Cutoffs

• gt 95th percentile Overweight
• 85th to lt 95th Risk of overweight
• percentile
• lt 5th percentile Underweight

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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.

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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 gt32 RR 2.2 vs.
  BMI lt19 from Nurses Health Study.

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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.

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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.

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Source http//www.cnn.com/SPECIALS/2007/fit.natio
n/obesity.map/
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Source http//www.cnn.com/SPECIALS/2007/fit.natio
n/obesity.map/
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Source http//www.cnn.com/SPECIALS/2007/fit.natio
n/obesity.map/
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Source http//www.cnn.com/SPECIALS/2007/fit.natio
n/obesity.map/
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Source http//www.cnn.com/SPECIALS/2007/fit.natio
n/obesity.map/
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Source http//www.cnn.com/SPECIALS/2007/fit.natio
n/obesity.map/
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Source http//www.cnn.com/SPECIALS/2007/fit.natio
n/obesity.map/
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Age-Adjusted Standardized Prevalence of
Overweight(BMI 2529.9) and Obesity (BMI gt30)
Percent
BMI gt 30
BMI 2529.9
CDC/NCHS, United States, 1960-94, ages 20-74 years
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NHANES III Age-Adjusted Prevalence of Low
HDL-Cholesterol According to BMI
Percent
Defined as lt35 mg/dL in men and lt45 mg/dL in
women.
Brown C et al. Body Mass Index and the
Prevalence of Risk Factors for Cardiovascular
Disease (in preparation).
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Carbo-Lipo-Terrorism in the U.S.
A Report To Orange County On 2/18/04
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Percent Overweight Children U.S. Orange County
Percent Overweight (gt95 weight/height)
Year
Data from the CDC Prevention, NCHS, NHANES,
HHNES, NHES, Report on the Conditions of Children
in Orange County, 2002
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Tracking BMI-for-Age from Birth to 18 Years with
of Overweight Children who
Are Obese at Age 25
Whitaker et al. NEJM 1997337869-873
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National Longitudinal Survey of Youth Prospective
Cohort Study of 8270 Children (4-12 years old) -
1999

• Risk of Overweight Overweight
• gt 85th ile BMI gt 95th ile BMI
• African American 38.4 21.5
• Hispanics 37.9 21.8
• Caucasian 25.8 12.3

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Secular Increases in Relative Weight and
Adiposity in Children (5-14 years old)- Bogalusa
Heart Study -
Change adjusted for height, age, race, and
sex Source Pediatrics 99420-426, 1997
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Prevalence of Overweight and Obesity Among US
Children (6-19 years old)1999-2002
Source Hedley et al., JAMA 2912847-2850, 2004
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Overweight in Children(gt 95th percentile BMI)
4722 children from NHANES overweight gt 95th
adjusted for age gt 23 of African American and
Mexican American adolescents Source Ogden et
al., JAMA 2881728-1732, 2002
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Correlations of Weight and BMI at 7.7 and 23.6
Years
r0.605
r0.612
Source Minneapolis Childrens BP Study,
Circulation 991471, 1999
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For Children, BMI Changes with Age
BMI
BMI
Example 95th Percentile Tracking Age
BMI 2 yrs 19.3 4 yrs 17.8 9 yrs
21.0 13 yrs 25.1
Boys 2 to 20 years
BMI
BMI
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BMI Changes with age
BMI 18 Age 4 years gt95th
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Can you see risk?

• This boy is 3 years, 3 weeks old.
• Is his BMI-for-age
• - gt85th to lt95th percentile at risk
  for overweight?

Photo from UC Berkeley Longitudinal Study, 1973
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Plotted BMI-for-Age
Measurements Age3 y 3 wks Height 100.8 cm
(39.7 in) Weight 18.6 kg (41 lb) BMI 18.3
BMI-for-age gt95th percentile
overweight
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Can you see risk?

• This girl is 4 years old.
• Is her BMI-for-age
• - gt85th to lt95th percentile at risk for
  overweight?

Photo from UC Berkeley Longitudinal Study, 1973
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Plotted BMI-for-Age
Measurements Age4 y Height 99.2 cm (39.2
in) Weight 17.55 kg (38.6 lb) BMI17.8 BMI-for-a
ge between 90th 95th percentile
At risk for overweight
BMI
BMI
Girls 2 to 20 years
BMI
BMI
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Accurate Measurements are Critical
5 1/2 year old boy Weight 41.5 lb Height 43
in BMI 15.8 BMI-for-age50th tile Inaccurate
height measurement 42.25 BMI16.3 BMI-for-age75t
h tile
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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 gt 95 is obese
• BMI 85-95 is at risk
• BMI data from retrospective analysis
• 1. Reflect increasing fatness
• 2. Predict adult risk

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Percent of the Population by Race/Ethnicity1990,
2000, 2025 and 2050

Percent
Source U.S. Bureau of the Census, decennial
census and population projections
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Californias 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.

Source Johnson, Californias Demographic Future,
Public Policy Institute of California, 2003
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Overweight Prevalence by Race/Ethnicity for
Adolescent Boys and Girls
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Cardiovascular Complications of Obesity
The Identification, Management and Treatment of
the Obese Child

• Jody Kranz M.D.
• Div. Endocrinology Diabetes
• CHOC
• Stan Bassin Ed.D
• Div. Cardiology
• UCI

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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

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Atherosclerosis Risk Factors

• Increasing Blood Pressure
• Dyslipidemia
• Inflammatory factors
• Homocysteine
• Diabetes

• Tobacco exposure
• Family History
• Male gender
• Obesity
• Sedentary Lifestyle

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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 gt 15 years of age
• 10-20 of 15-19 year olds have intermediate
  lesions
• Risk factors
• High non-HDL cholesterol Low HDL cholesterol
• Smoking Hypertension
• HbA1C gt 8 Obesity (BMI gt 30 kg/m2)

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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

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NHANES III Age-Adjusted Prevalence of High Blood
Cholesterol According to BMI
Percent
Defined as gt 240 mg/dL.
Brown C et al. Body Mass Index and the Prevalence
of Risk Factors for Cardiovascular Disease (in
preparation).
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NHANES III Age-Adjusted Prevalence of Low
HDL-Cholesterol According to BMI
Percent
Defined as lt35 mg/dL in men and lt45 mg/dL in
women.
Brown C et al. Body Mass Index and the
Prevalence of Risk Factors for Cardiovascular
Disease (in preparation).
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Obesity Hypertension
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Clinical Presentation of Hypertension

• High blood pressure BP gt 90th percentile for
  age gender and height.
• Hypertension BP gt 95th percentile for age,
  gender and height.
• Primary Hypertension
• most common cause of Hypertension in Children
  over 6 years of age
• lt6 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

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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 gt31 RR6.3 for developing HTN
  compared with BMI lt19.
• 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.

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Prevalence of Hypertension in Children vs
Distribution of BMI ()
Percent with Hypertension ()
BMI centile
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NHANES III Age-Adjusted Prevalence of
Hypertension According to BMI
Percent
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).
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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

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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

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Obesity Dyslipidemia
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Increased Risk of Abnormal Lipid Levels in
Overweight vs. Normal Weight Teens
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Obesity and CVD Risk

• In Nurses Health Study, 14-year CHD risk
  increased about 3.5-fold for BMI gt29 vs. lt21,
  weight gain of gt20 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 gt29 vs. lt21.
• A waist circumference of gt35 inches in women, and
  gt40 inches in men is also associated with greater
  CHD risk.

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Weight Related Risks for CHD and Stroke
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Obesity and Dyslipidemia

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

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Obesity and Dyslipidemia

• Weight loss reduces triglycerides, increases
  HDL-C, and lowers LDL-C

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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

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Atherosclerosis Dyslipidemia

• Evidence from adult studies
• Evidence in Children Adolescents
• PDAY
• In vivo studies
• decreased compliance of arteries
• increased IMT in adolescents with dyslipidemia

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Treatment of Dyslipidemia

• Weight loss
• Exercise
• Nutrition
• Saturated fat lt10 of calories
• Total fat lt 20-30 of calories
• lt 300mg cholesterol/day
• Increase fiber intake
• Medication

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Obesity Inflammatory Factors
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Prevalence of Elevated CRP (gt0.22mg/dL) by BMI
centile
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TNF-alpha Levels in Obese Non-obese Adolescents
Moon et al. NASO, Oct. 2003
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Homocysteine other CVD Risk Factors in Youth

• Homocysteine
• An independent risk factor for CVD
• gt 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 1st 2nd Hand

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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

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Preventing Type 2 Diabetes?
Francine Ratner Kaufman, MD Distinguished
Professor of Pediatrics The Keck School of
Medicine of USC Head, Center for Diabetes and
Endocrinology Childrens Hospital Los Angeles
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GLOBAL PROJECTIONS FOR THE DIABETES EPIDEMIC
2003-2025 (millions)
World 2003 194 million 2025 333
million Increase 72
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Obesity (gt 120tile ideal body weight) in U.S.
Adults 1992
Diabetes in U.S Adults 1992
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Obesity 1994
Diabetes 1994
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Obesity 1996
Diabetes 1996
112
Obesity 1998
Diabetes 1998
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Obesity 1999
Diabetes 1999
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Obesity 2000
Diabetes 2000
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Type 2 Diabetes Prediabetes Beta Cell Defect
Beta Cell Defect
Age Puberty
Obesity BP, Lipids
InsulinResistance
Genetics Ethnicity
Sedentary Lifestyle
Gender Girls Polycystic ovary syndrome
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Type 2 Diabetes Prediabetes Beta Cell Defect
Autoimmunity
Genetic Defect
Beta Cell Defect
Fat cell toxicity
Intrauterine IUGR, DM
Glucose toxicity
InsulinResistance
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Natural History of Type 2 Diabetes
Complications
Geneticsusceptibility Environmentalfactors
Onset ofdiabetes
Disability
20.8 million
40 million
224,100
PRE
Ongoing hyperglycemia
Obesity Insulin resistance
Death
Risk for Disease
Metabolic Syndrome
BlindnessRenal failureCHDAmputation
RetinopathyNephropathyNeuropathy
AtherosclerosisHyperglycemiaHypertension

• 0.5 of adolescents have diabetes
• 71 type 1 and 29 type 2
• 39,005 US teens with T2D

Cost 132 Billion/2002
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Obesity and Diabetes

• In Pima Indians (approx 50 of adults diabetic),
  incidence (per 1000 person-years) was 0.8 if BMI
  lt20, but 72 if BMI gt40.
• In Nurses Health Study, BMI 23-23.9 showed a
  RR3.6 for diabetes compared with BMI lt22.
  Weight again was very important, with weight
  again of 20-35kg associated with an 11-fold
  greater risk of diabetes, gt35kg 17-fold.
• In Health Professionals Study among men, BMI gt35
  associated with RR42 for developing diabetes.

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Obesity and Diabetes

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

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Impaired Glucose Tolerance Diabetes
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
Based on ADA Recs Diabetes Care 2004
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Who to Test for IGT Diabetes

• Obese BMIgt85
• Age Earliest of the following, gt 10 years of
  age or onset of puberty
• And 2 of the following
• Family history of T2DM in 1st or 2nd 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
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Absolute Fat and Lean Changes per Decade as a
Function of Age in Men
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Absolute Fat and Lean Changes per Decade as a
Function of Age in Women
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Definitions

• Body Mass Index (BMI) describes relative
• weight for height weight (kg)/height (m2)
• Overweight 2529.9 BMI
• Obesity gt 30 BMI

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Age-Adjusted Standardized Prevalence of
Overweight(BMI 2529.9) and Obesity (BMI gt30)
Percent
BMI gt 30
BMI 2529.9
CDC/NCHS, United States, 1960-94, ages 20-74 years
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NHANES III Age-Adjusted Prevalence of
Hypertension According to BMI
Percent
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).
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NHANES III Age-Adjusted Prevalence of High Blood
Cholesterol According to BMI
Percent
Defined as gt 240 mg/dL.
Brown C et al. Body Mass Index and the Prevalence
of Risk Factors for Cardiovascular Disease (in
preparation).
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NHANES III Age-Adjusted Prevalence of Low
HDL-Cholesterol According to BMI
Percent
Defined as lt35 mg/dL in men and lt45 mg/dL in
women.
Brown C et al. Body Mass Index and the
Prevalence of Risk Factors for Cardiovascular
Disease (in preparation).
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Care of Overweight/Obese Patients

• Requires two steps
• Assessment
• Management

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Assessment of Overweight and Obesity

• Body Mass Index
• Weight (kg)/height (m2)
• Weight (lb)/height (in2) x 703
• Table
• Waist Circumference
• High risk
• Men gt102 cm (40 in.)
• Women gt88 cm (35 in.)

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Classification of Overweight and Obesity by BMI
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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
  (gt3 high risk)
• Other risk factors
• Physical inactivity
• High serum triglycerides (gt200 mg/dL)

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The A, B, C Intervention

• Activity
• Minimum of 60 min/day of minimum intensity of a
  brisk walk.
• Limit screen time (not associated with school
  work) lt 1 hour
• Beverages
• No regular soda or sugar/corn syrup sports
  drinks/punch
• lt 6 ounces juice/day
• Increase water non-or low fat milk (or other
  calcium containing food) consumption
• ChangeGoal
• Family changes eating activity habits
• Reasonable, achievable, step wise goals
• Minimum nursing visits every 3-4 months check
  progress reinforce goals. Phone follow-up

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Do You Know How Food Portions Have Changed in 20
Years?
National Heart, Lung, and Blood Institute Obesity
Education Initiative
141
BAGEL
20 Years Ago
Today
140 calories 3-inch diameter
How many calories are in this bagel?
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BAGEL
20 Years Ago
Today
140 calories 3-inch diameter
350 calories 6-inch diameter
Calorie Difference 210 calories
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Maintaining a Healthy Weight is a Balancing
Act Calories In Calories Out
How long will you have to rake leaves in order to
burn the extra 210 calories?  
Based on 130-pound person
144
Calories In Calories Out
If you rake the leaves for 50 minutes you will
burn the extra 210 calories.
Based on 130-pound person
145
CHEESEBURGER
Today
20 Years Ago
333 calories
How many calories are in todays cheeseburger?
146
CHEESEBURGER
Today
20 Years Ago
590 calories
333 calories
Calorie Difference 257 calories
147
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
148
Calories In Calories Out
If you lift weights for 1 hour and 30
minutes,you will burn approximately 257
calories.
Based on 130-pound person
149
SPAGHETTI AND MEATBALLS
20 Years Ago
Today
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?
150
SPAGHETTI AND MEATBALLS
20 Years Ago
Today
1,025 calories 2 cups of pasta with sauce and 3
large meatballs
500 calories 1 cup spaghetti with sauce and 3
small meatballs
Calorie Difference 525 calories
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Maintaining a Healthy Weight is a Balancing
Act Calories In Calories Out
How long will you have to houseclean in order to
burn the extra 525 calories?
Based on 130-pound person
152
Calories In Calories Out
If you houseclean for 2 hours and 35 minutes,
you will burn approximately 525 calories.
Based on 130-pound person
153
FRENCH FRIES
20 Years Ago
Today
210 Calories 2.4 ounces
How many calories are in todays portion of fries?
154
FRENCH FRIES
20 Years Ago
Today
610 Calories 6.9 ounces
210 Calories 2.4 ounces
Calorie Difference 400 Calories
155
Maintaining a Healthy Weight is a Balancing
Act Calories In Calories Out
How long will you have to walk leisurely in order
to burn those extra 400 calories?
Based on 160-pound person
156
Calories In Calories Out
If you walk leisurely for 1 hour and 10 minutes
you will burn approximately 400 calories.
Based on 160-pound person
157
SODA
20 Years Ago
Today
85 Calories 6.5 ounces
How many calories are in todays portion?
158
SODA
20 Years Ago
Today
250 Calories 20 ounces
85 Calories 6.5 ounces
Calorie Difference 165 Calories
159
Maintaining a Healthy Weight is a Balancing
Act Calories In Calories Out
How long will you have to work in the garden to
burn those extra calories?
Based on 160-pound person
160
Calories In Calories Out
If you work in the garden for 35 minutes, you
will burn approximately 165 calories.
Based on 160-pound person
161
Thank you for participating in Portion
Distortion! For more information about
Maintaining a Healthy Weight visit
www.nhlbi.nih.gov
162
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??

163
Do You Know How Food Portions Have Changed in 20
Years?
National Heart, Lung, and Blood Institute Obesity
Education Initiative
164
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
165
Maintaining a Healthy Weight is a Balancing
Act Calories In Calories Out
How long will you have to walk in order to burn
those extra 305 calories?  
Based on 130-pound person
166
Calories In Calories Out
If you walk 1 hour and 20 minutes, you will burn
approximately 305 calories.
Based on 130-pound person
167
MUFFIN
20 Years Ago
Today
210 calories 1.5 ounces
How many calories are in todays muffin?
168
Maintaining a Healthy Weight is a Balancing
Act Calories In Calories Out
How long will you have to vacuum in order to burn
those extra 290 calories?
Based on 130-pound person
169
Calories In Calories Out
If you vacuum for 1 hour and 30 minutes you will
burn approximately 290 calories.
Based on 130-pound person
170
Calories In Calories Out
If you play golf (while walking and carrying your
clubs) for 1 hour you will burn approximately
350 calories.
Based on 160-pound person
171
Calories In Calories Out
If you walk the dog for 1 hour and 20 minutes,
you will burn approximately 400 calories.
Based on 160-pound person
172
CHOCOLATE CHIP COOKIE
20 Years Ago
Today
55 calories 1.5 inch diameter
How many calories are in todays large cookie?
173
CHOCOLATE CHIP COOKIE
20 Years Ago
Today
55 calories 1.5 inch diameter
275 calories 3.5 inch diameter
Calorie Difference 220 calories
174
Maintaining a Healthy Weight is a Balancing
Act Calories In Calories Out
How long will you have to wash the car to burn
those extra 220 calories?
Based on 130-pound person
175
Calories In Calories Out
If you wash the car for 1 hour and 15 minutes you
will burn approximately 220 calories.
Based on 130-pound person
176
CHICKEN STIR FRY
20 Years Ago
Today
435 calories 2 cups
How many calories are in todays chicken stir fry?
177
CHICKEN STIR FRY
20 Years Ago
Today
435 calories 2 cups
865 calories 4 ½ cups
Calorie Difference 430 calories
178
Maintaining a Healthy Weight is a Balancing
Act Calories In Calories Out
How long will you have to do aerobic dance to
burn those extra 430 calories?
Based on 130-pound person
179
Calories In Calories Out
If you do aerobic dance for 1 hour and 5 minutes
you will burn approximately 430 calories.
Based on 130-pound person
180
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.

181
FAST FOOD MAKEOVERS

• Del Taco Combo Burrito Meal 1090 kcals.
• 2 Del taco soft chicken tacos 320 kcals.

182
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.

183
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.

184
Adolescent and Adult Interventions

• Decrease Television viewing
• Decrease consumption of high fat foods
• Increase fruit and vegetable intake
• Increase moderate and vigorous physical activity

185
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.

186
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.

187
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.

188
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.

189
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

190
Treatment Algorithm
1
Patient Encounter
2
Hx of 25 BMI?
³
No
Yes
BMI measured in past 2 years?
3
4
6
BMI
³

30 OR

5
Measure weight,
³
7
BMI 25 OR

BMI 25 to 29.9
height, and waist

Assess risk factors
Yes
Yes
waist circumference
OR waist circumference
circumference
8
gt 88 cm (F)
gt88 cm (F) gt102 cm (M)

Calculate BMI
³
AND 2 risk

gt 102 cm (M)
Clinician and patient
factors
devise goals and
treatment strategy
No
for weight loss and
No
risk factor control
Does
14
12
Yes
Yes
patient want to
³
Hx BMI 25?

lose weight?
9
Progress
Yes
being made/goal
No
No
15
13
achieved?
Brief reinforcement/
Advise to maintain
No
educate on weight
weight/address
management
other risk factors
Examination
11
10
16
Treatment
Maintenance counseling Dietary therapy
Behavior therapy Physical activity
Assess reasons for
Periodic weight
failure to lose weight
check




191
Treatment Algorithm (Part 1 of 3)
1
Patient Encounter
Examination
2
Hx of ³ 25 BMI?
Treatment
No
Yes

3
BMI measured in past 2 years?
4
BMI ³ 30 OR BMI 25 to 29.9 OR waist gt88 cm
(F) gt102 cm (M) AND ³ 2 risk factors
7
6


Measure weight, height, and waist circumference
Calculate BMI
5

BMI ³ 25 OR waist gt 88 cm (F) gt 102 cm (M)
Yes
Yes
Assess risk factors


No
No

192
Treatment Algorithm (Part 2 of 3)
BMI ³ 30 OR BMI 25 to 29.9 OR waist gt88 cm
(F) gt102 cm (M) AND ³ 2 risk factors
7
Yes


8


Devise goals and treatment strategy for weight
loss and risk factor control
Examination
Treatment
No
12

Desire to lose weight?
No
Yes
9
Yes
Progress made?
13
Advise to maintain weight Address other risk
factors
No
11
10
16
Maintenance counseling
Assess reasons for failure to lose weight
Periodic weight check

193
Treatment Algorithm (Part 3 of 3)
5

BMI ³ 25 OR waist gt 88 cm (F) gt 102 cm (M)
Yes
Examination
Treatment
No
14
Yes
Hx BMI ³ 25?


No
15
13
Brief reinforcement Educate on
weightmanagement
Advise to maintain weight Address other risk
factors
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.
16
Periodic weight check
194
Goals of Weight Management/Treatment

• Prevent further weight gain (minimum goal).
• Reduce body weight.
• Maintain a lower body weight over long term.

195
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.

196
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

197
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.

198
Strategies for Weight Loss and Maintenance

• Dietary therapy
• Physical activity
• Behavior therapy
• Combined therapy
• Pharmacotherapy
• Weight loss surgery

199
Weight Loss Therapy

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

200
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.
201
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.
202
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.
203
Dietary Therapy (4 of 5)
Very low-calorie diets produce greater
initial weight loss than low-calorie diets.
However, long-term (gt1 year) weight loss is not
different from an LCD. Evidence Category A.
204
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

205
Low-Calorie Step I Diet

• Nutrient Recommended Intake
• Calories 500 to 1,000 kcal/day reduction
• Total Fat 30 percent or less of total calories
• SFA 8 to 10 percent of total calories
• MUFA Up to 15 percent of total
  calories
• PUFA Up to 10 percent of total calories
• Cholesterol lt300 mg/day

206
Low-Calorie Step I Diet (continued)

• Nutrient Recommended Intake
• Protein 15 percent of total calories
• Carbohydrate 55 percent or more of total calories
• Sodium Chloride No more than 100 mmol/day ( 2.4
  g of sodium or 6 g of sodium chloride)
• Calcium 1,000 to 1,500 mg
• Fiber 20 to 30 g

207
Physical Activity Prescription
208
Adults
209
Physical Fitness Continuum
210
Physical Activity, Exercise, and Physical Fitness

• Physical activity Any bodily movement produced
  by skeletal muscles that results in energy
  expenditure.
• Exercise A subset of physical activity That is
  planed, structured, and repetitive and is done to
  improve or maintain physical fitness.
• Physical fitness A set of attributes that are
  either health or skill related Health- endurance,
  strength, flexibility, Skill- balance, agility,
  power, reaction time, speed and coordination

211
How Active Are You?

• Your intensity ___ Your duration ___ Your
  frequency ___ Your activity index.

212
Intensity How Hard Do You Exercise?

• If your exercise results in Your intensity
  score is
• No change in pulse from resting level 0
• Little change in pulse from resting level 1
• as in slow walking, bowling, yoga
• Slight increase in pulse and breathing 2
• As in table tennis, active golf
• Moderate increase in pulse and breathing 3
• As leisurely bicycling, easy swimming, rapid
  working
• Intermittent heavy breathing and sweating 4
• As in tennis singles, basketball, squash
• Sustained heavy breathing and sweating 5
• As in jogging, cross country skiing, rope skipping

213
Duration How Long Do You Exercise?

• If each session continues for Your duration
  score is
• Less than 5 minutes 0
• 5-14 minutes 1
• 15-29 minutes 2
• 30-44 minutes 3
• 45-59 minutes 4
• 60 minutes 5

214
Frequency How Often Do You Exercise?

• If you exercise Your
  frequency score is
• Less than 1 time a week 0
• 1 time a week 1
• 2 times a week 2
• 3 times a week 3
• 4 times a week 4
• 5 times a week 5

215
Heres How You Can Translate Your Activity Index
Into Your Estimated Level of Activity

• If your activity index is Your
  estimated level of activity is
• Less than 15 sedentary
• 15-24 low active
• 25-60 moderate active
• 41-60 active
• Over 60 high active

216
Components of Physical Fitness

• Physical fitness component Definition
  
• Cardiorespiratory Ability to do moderately
  strenuous
• endurance activity over an extended
  period of time.
• Body composition Percentage of the body that is
  fat.
• Muscular strength Ability to exert maximum force
  in a single
• exertion.
• Muscular Ability to repeat movements over and
  over
• endurance or to hold a particular position for
  a prolonged period.
• Flexibility Ability to move a joint easily
  through its full range of motion.

217
The Activity Pyramid
218
Physical Activity Prescription
219
Comparison Between Exercise Therapy and Drug
Therapy
220
Guidelines For Training

• Train the way you want your body to change.
• Train regularly.
• Get in shape gradually.
• Warm up before exercising, and cool down
  afterward.
• Listen to your body.
• Try training with a partner.
• Train your mind.
• Keep your exercise program in perspective.

221
Challenges for the Nations 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.

222
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

223
Four Challenges

• Enhancing Public Participation in Clinical
  Research
• Developing Information Systems
• An Adequately Trained Diverse Workforce
• Funding

224
New paradigms in clinical research and research
training

• What is the benefit of increasing representation
  of women and minorities in the clinical research
  workforce?
• Will increased diversity improve translation of
  the results of clinical research in minority
  communities?
• What are the needs of the private and public
  sector?
• 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
225
New paradigms in clinical research and research
training

• Where is demand exceeding supply?
• What training programs and career tracks appear
  to foster the development and retention of women
  and minorities in the clinical research
  workforce?
• What research related to evaluation of existing
  training efforts needs to be funded?
• What are the key outcome measures?

Source IOM Opportunities to Address Clinical
Research Workforce Diversity Needs for 2010 , 2006
226
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227
Determining a Healthy Body Weight

• Assess your body composition.
• Choose a target value for BMI or percent body fat
  that is realistic for you and will ensure good
  health.
• Consult a physician if you have any known risk
  factors for disease.
• Determine the recommended body weight based on
  your BMI or percent body fat goal.
• Examine the body weight that the formulas
  generate for you and allow for individual
  genetic, cultural, and lifestyle factors.

228
Key Messages

• Adolescents and young adults, both male and
  female, benefit from physical activity.
• Physical activity need not be strenuous to be
  beneficial.
• Moderate amounts of daily physical activity are
  recommended for people of all ages. This amount
  can be obtained in longer sessions of moderately
  intense activities, such as brisk walking for 30
  minutes, or in shorter sessions of more intense
  activities, such as jogging or playing basketball
  for 15-20 minutes.
• Greater amounts of physical activity are even
  more beneficial, up to a point. Excessive amounts
  of physical activity can lead to injuries,
  menstrual abnormalities, and bone weakening.

229
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230
Eating Well and Feeling Good

• Be active
• Have fun!
• Feel good about yourself

231
All parts of the body which have a function,
used in moderation and exercised in labours in
which each is accustomed, become thereby healthy,
well-developed and age more slowly, but if unused
and left idle, they become liable to disease,
defective in growth and age quickly. -
Hippocrates
232
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