This presentation provides a better understanding of the biologic REALities and impact of weight bias on pediatric obesity management. The paradigm shift in pediatric obesity management is also explored, with a review of Health At Every Size (HAES) and the use of the Edmonton Obesity Staging System to help guide management.
Statistical modeling in pharmaceutical research and development.
Managing obesity the rea lities striking a balance
1. Managing Obesity: The REALities
Striking a Balance... Weigh in with Knowledge,
Research, Practice SYMPOSIUM
September 30th 2013
2. The REALities: Objectives
• Biologic REALities
• Psychosocial REALities
• Impact of Weight Bias
• Debunking Common Myths
• Paradigm Shift
• Health At Every Size (HAES)
• Edmonton Obesity Staging System
• The Pediatric 5A’s
4. Limitations of BMI
• Not sensitive/ specific for:
• Presence of obesity related risk factors
• Health behaviours
• Co-morbid conditions
• Psychopathology
• Global functioning
• Global health
• Quality of Life
6. Obesity is….
• A sign or symptom
• A disorder of energy balance
• Adaptive/ Maladaptive?
• A risk factor for disease
• Modifiable through health behaviours
7. Obesity is not….
• A sensitive indicator of health
• A sensitive indicator of health behaviours
• A character flaw
• A lack of will power
8. WEIGHT = ENERGY CONSUMPTION – ENERGY EXPENDITURE
Genetics
SES
Culture
Stress
Sleep
Media
Parental
influence
Peer influence
School
environment
Neighbourhoods
Gender
Policy
Medications
Microbes
Environmental
Toxins
Built Environment
Safety
Screen Invasion
Food Insecurity
Automobile
Reliance
Societal Influences
Education
Access
Perinatal
programming
Mental health
Eating disorders
Body Image
11. Digging Deeper
Connectedness
electronic
virtual
Time pressures
more work hours
sleep less
cook less
increased stress
Income Inequality
food insecurity
neighbourhood safety
Economic Policy
urban sprawl
agricultural subsidies
food industry
media/advertising
Our Way of Life
Societal Values
Whitaker R, Arch Pediatr Adol Med (2011)
12. Impact of Social Values
• Obesity
• Mental Health
• Eating Disorders
• Bullying, Stigma
• Health of our environment
Common Ground/Partnerships
Whitaker R, Arch Pediatr Adol Med (2011)
20. Are Obese Kids less Active?
• No marked difference in physical activity between
overweight and lean kids
• Overweight and obese girls had the same minutes of
moderate to vigorous physical activity as lean girls
• Overweight boys had 14 min and obese boys had 22
min less of daily activity than lean boys
Colley R et al, Health Reports (2011)
21. Obesity-Chronic Disease Paradox
• Overweight and moderate obesity (BMI < 35), is not
associated with a decrease in life expectancy
• Overweight is associated with increased longevity
• Survival advantage:
• Renal Failure
• Heart Failure
• Type 2 Diabetes
McGee DL et al, Ann Epidemiol (2005)
Curtis JP et al, Arch Int Med (2005)
Beddhu S, Seminars in Dyalisis (2004)
Doehner et al, Int J Cardiology (2011)
22. Obesity Chronic Disease Paradox
5202 patients with T2DM
and pre-existing CVD:
• Lowest mortality: BMI 30-35 kg/m2
• Weight loss associated with increased
total mortality, cardiovascular
mortality
Doehner et al, Int J Cardiol (2011)
23. Abdulla J et al. Eur Heart J (2008)
Myocardial Infarction (MI)
Heart Failure (HF)
21,570 patients admitted for MI or HF
All cause mortality after 10 year follow
up
• BMI > 35 associated with increased
risk in MI but not HF
• BMI 30-35 not associated with
increased risk
24. Edmonton Obesity Staging System(Kuketal,2011)
• New risk-stratification system that classifies adult obese
individuals into 5 graded categories based on morbidity
and health-risk profiles
• EOSS independently predicted increased mortality even
after adjustment for common methods of classifying
obesity (Padwal et al., 2011)
27. Kuk et al, App. Physiol. Nutr. Metab. (2011)
29, 533 obese individuals Morbidity and
Mortality Risk based on EOSS at 16 year
follow up compared to normal weight
controls
28. Padwal R S et al. CMAJ (2011)
EOSS BMI Class
Survival Curves diverge
when stratified by EOSS
score but not by BMI Class
29. Padwal R S et al. CMAJ (2011)
EOSS-prediction
of all cause
mortality across
BMI classes
30. Expected Change in BMI (6-12 months)
Lifestyle Medication
(orlistat)
Surgery
Δ BMI (kg/m2) -1.9-3.3 -0.85 -8.5
USPSTF Task Force, Pediatrics (2010)
Journal of Pediatric Surgery (2010)
32. Psychosocial REALities
Overweight youth:
• Are stigmatized
• Are often bullied by peers
• Tend to have poor body image
• Tend to have lower self-confidence, self- esteem and
higher incidence of mental health problems
Puhl et al. Obesity (2009)
Storch et al. J. Pediatr. Psychol. (2007)
33. Bullying
• 30% of overweight girls and 25% of overweight boys
experience weight focused peer victimization
• 60% of the most severely overweight kids report
harassment
• 40% of youth report that obesity is the primary
reason why peers are teased or bullied
• 37% reported being gay or lesbian as the primary
reason
• 10% reported race, ethnicity, disability, religion
Eisenberg M et al Arch Pediatr Adolesc Med (2003)
Puhl RM et al, J Sch Health (2011)
34. Weight Bias at home
• 47% of overweight girls and 34% of overweight boys
report being teased about their weight by their
parents
• 72% of overweight adults reported they had
experienced weight bias from family members as
children
Puhl RM et al, J Sch Health (2011)
Puhl RM et al, Psych Bull (2007)
35. Societal Pressures
• In Western Society the media is a powerful influence
and pressure on youth today
• Body image messages are ever present and typically
state:
• Thin women are beautiful, successful and happy
• Muscular, lean men are handsome and successful
Grabe et al. Psychological Bulletin (2003)
38. Body Image in Youth Today
• 40-50% of girls aged 11-15 say they need to lose
weight
• 61% of grade 7/8 students trying to lose weight
Canadian study: Jones et al. 2001
40. Youth Often Feel
• Angry
• Frustrated
• Sad
• Helplessness
• Hopelessness
• Anxious
• Worried
41. Families Often Feel
• Guilty
• Helpless
• Frustrated
• Tired
• A desire to try and fix or “control” things
• A loss of trust with the youth
42. The Diet Industry Culture
Familiar Claims:
“Lose weight quickly”
“Reset your genetic code”
“Eat all you want – Lose up to 30 pounds in 3 weeks”
“Scientifically sound”, “Based on proven studies”
Private weight loss industry in the US estimated at
$58.6 billion annually
(Marketdata Enterprises, 2009)
Pawlak, 2009
44. Set Point Theory
Our bodies have a Set Point (range) it wants to stay
at and would if we eat “normally”
• Our bodies are self-regulating
• Think of shoe size, height and body temperature
• Set point is a range & genetically determined
• Our body works hard to keep us in the range
• Altering metabolic rate
Wilmore et al. (1999)
45. Restraint Theory
• Research has examined eating behaviour of Dieters
vs. Non-Dieters
• Laboratory studies demonstrated that Dieters are
more likely to ‘overeat’ or disinhibit when
exposed to:
• Stress
• Emotional Cues
• Food Cues
Herman & Polivy, 1985
46. Restraint Theory
Results in “What the Hell Effect”
BATTLE
Dieters cognitive or
mental efforts to
resist that drive
Dieters physiological
drive to eat (e.g.,
hormones & peptides)
47. Culture of Valuing
Thinness
• High body self-consciousness
• Healthy body esteem
• High weight preoccupation
• Increased overeating
• Emotional eating
• Binge eating
• Dieting practices
• Weight loss strategies
Feelings of shame, guilt, anger, sadness
Increased weight over time
Negative Spiral
48. The Impact of Living with Weight
Management Issues in Today’s World
Puhl RM et al, J Sch Health (2011)
Puhl RM et al, Psych Bull (2007
Low body satisfaction
High depressive symptoms
Isoloation/withdrawal
Poor-self-perception of physical appearance
Disordered eating
Poor academic outcomes
Poor peer relationships
Increase risk & unhealthy behaviours
School absences
49. Medical Versus Self Esteem Concerns
Most Kids:
• Want to lose weight to make the teasing and
harassment stop
• They would prefer to have diabetes and be thin than
to be “fat” and “healthy”
But by suggesting that children focus on weight as an
outcome we are setting them up for weight
preoccupation, dieting and likely weight gain
50. A paradigm shift…
A growing trans-disciplinary movement called:
Health at Every Size
HAES challenges the value of promoting weight
loss and argues for a shift in focus to weight-
neutral outcomes
52. The HAES Approach
The HAES approach is associated with statistically and clinically
relevant improvements in:
Physiological measures (e.g. blood lipids)
Health behaviours (e.g. eating & activity habits)
Psychosocial outcomes (e.g. self esteem and body
image)
Bacon L et al, 2011
63. CHAL Team
Dr. Stasia Hadjiyannakis – Pediatric Endocrinologist
Dr. Katie Baldwin– Pediatrician
Dr. Annick Buchholz – Psychologist
Dr. Laurie Clark – Psychologist
Jane Rutherford – Exercise Specialist
Nicole Charette – Registered Dietitian
Shaun Reid – Child & Youth Counsellor
Maura Manuel– Social Worker
Michèle Levasseur – Registered Nurse, Case Manager
Corrie Raymond – Administrative Assistant
Charmaine Mohipp – Research Associate
64. Mission
To improve the health and quality of life of
children with weight related health
complications and support them and their
families in achieving a healthy active lifestyle.
68. PHASE I
Family Education Group (for teens 14-18 yrs + parents)
Education on Family approach to healthy living and lifestyle change
6 weeks
Parent Group (for parents of children ≤ 13 yrs)
Education on parenting approaches to healthy living and lifestyle change
8 weeks
What is the REAL Program?
69. What is the REAL Program
PHASE II
Family Group (for teens 14-18 yrs + parents)
Skill building for families to make lifestyle changes together
Topics include:
Healthy Eating & Active Living
Problem Solving and Practical Solutions to meet goals
12 weeks (parents attend 5 weeks)
70. What is the REAL Program?
PHASE III
Teen & Parents Alumni Groups
Peer support for maintaining lifestyle changes
Skill building for “slips” and “getting back on track”
Theme based modules
Offered in 4 week modules
71. REAL Program Goals
• Improve quality of life
• Decrease medical and psychological co-morbidities
• Improve eating behaviours
• Improve fitness, increase activity levels
• Decrease sedentary behaviour
• Empower/strengthen families
• Stabilize BMI trajectory
73. Conclusions
• Understand your patients’ REALities
• Focus on health behaviours and well being
• Health is possible across a range of BMI
• Help without harming
• Weight bias increases risk for co-morbidities
• Take your time- no quick fixes
Hinweis der Redaktion
Here we have Shaq at his peak as a Laker (before he played for the HEAT, SUNS, Cavs and finally as an anathema to all Laker fans the Celtics). and while Keith is exceptionally resilient most would agree that Shaq is living a more traditionally healthy lifestyle and has better overall global health.
While weight gain occurs when energy consumption exceeds energy expenditure there are a myriad of influencers in this seemingly simple well known equation. A significant # of these influencers are non-modifiable on an individual level. WE know that our genetic programming plays a large role in our risk for weight gain. Children of obese parents are 6-8 times more likely to be obese and when looking at biologic offspring parent pairs and adoptive offspring parent pairs, BMI is more highly correlated with biologic parent BMI. WE continue to learn more and more about the role of intrauterine exposures in risk for obesity. Our very own Dr. Kristi Adamo is doing work in this area. Exposure to diabetes in utero, maternal smoking, maternal weight and gestational weight gain have all been associated with increased risk for weight gain and obesity.
Biology plays a very big role in how our bodies will respond to obesigenic stimuli in our environment. This figure also demonstrates the broader determinants of health at play- our mental health has plays a significant role in obesity and is influenced by our social surroundings. Our ability to be active is affected by our built environment, Our food consumption/choices are heavily influenced by food production and the food insustry
We all live in an obesogenic environment and engage to some degree in obesogenic behaviours. The impact of these obesogenic stimuli our modified through our genetics and pre-natal programming- leading to continued weight stabilization in some, weight gain and weight gain + complications in others,
Lets dig deeper and ask our selves how we got here. Dr. Whitaker did just that in a recent commentary published in Archives of Pediatr Adol Medicine. He asked how our societal values and way of life might give way to obesigenic environments and behaviours. A deeper look at The why behind our physical activity levels and the food choices we make Connectedness is critical to well being. While we are more connected on a global level than ever before, we are less connected on a more local level- to our cities, our communities and our neighbourhoods. Communication/contact occurs more and more through electronic media. Time pressures are increasing we are working more than ever (even southern Europeans), Increased work hours means less time for sleep, play, cooking etc. Income inequality has reached levels not seen since the Great Depression- This leads to increasing food insecurity, social unrest and possible decreased neighbourhood safety. Economic Policy has affected the way we design our cities- urban sprawl, Agricultural subsidies and food industry lobbyists, Media and advertising and the billion $ diet industry affect our food choices
These changes to our social fabric, way of life, our values can affect health on multiple levels- rising raies of obesity but also mental health disorders, eating disorders, bullying, stigma and negatively impact our environment
Zooming in now- looking at the biology REALities behind the energy balance equation. The drive to eat/burn or store energy is to a large extent hardwired. Our bodies were designed to protect against starvation NOT obesity. Our body will therefore defend the highest weight attained through a complex neuroendocrine system. There are peripheral signals of short term and long term nutritional status that our integrated within the ventromedial hypothalamus where neuropeptides that stimulate or decrease appetite are secreted and where there is a drive towared energy expenditure or energy storage. We will focus on just a few of these today. Ghrelin is secreted by the stomach and increases at meal times and acts at the VMH to promote secretion of appetitie stimulating hormones to make us feel hungry- in response to a meal Ghrelin levels will decrease. PYY3-36 is secreted by the intestine to let you know when you have had enough to eat. It acts at the level of the VMH to stimulate production of neuropeptides that signal satiety. Leptin is secreted by your adiposites and is a long term signal of nutritional status. In the presence of lots of leptin your body should feel like it is ok to spend energy and not feel hungry. A drop in leptin with increase secretion of appetite signaling neuropeptides- making you feel hungry and will cause your body to want to store energy.
Leptin is your body’s long term signal of nutritional status – Obese individuals are Leptin RESISTANT- so there Leptin set point is higher than non-obese individuals= this results in defense of a higher weight.Obese individuals have lower levels of PYY3-36- now remember- PYY3-36 is the peripheral signal that tells your body you’ve had enough to eat at a meal time- perhaps this signal is muted in obese individuals as they have lower levels- leading to increased intake?
Hormonal adaptations to weight loss promote weight REGAIN. These adaptations are present up to a year post weight loss. Ghrelin your hunger hormone- the peripheral signal to the VMH to increase secretion of appetitie stimulating neuropeptides increases after weight loss. A stronger stimulus of hunger- leading us to eat more and regain weight
In the face of weight loss Leptin levels decrease- this drop in leptin increases secretion of appetite stimulating neuropeptides and decreases secretion of anorexic neuropeptides making us feel more hungry – A drop in Leptin also results in promotion of energy storage and a decrease in energy expenditure.
Any decrease in body weight results in decreased day to day energy expenditure- it takes less energy for yoru body to function since it is now smaller and weighs less. At the same time hormonal adaptations to weight loss lead to increased energy conservation. This means for your body to continue to lose weight you will need to decrease your intake further and ramp up your physicial activity more- this becomes untenable. Remember if you have a patient whose lost weight and now has plateaud or re-gained the weight- it may not be because they are no longer engaging in the health behaviiours you discussed with them- but rather secondary to the biologic realities of weight loss.
Many feel that a contributing factor to weight gain in obese kids is the fact that they are less active. Well through the work of HALO’s Rachel Colley, looking at CHMS data at Health Canada we can see that there is no marked difference in physical activity levels between overweight and lean kids.
We all recognize obesity as a risk factor for some chronic diseases- but increasingly we are seeing evidence of the obesity chronic disease paradox in the literature. = In fact OWT and moderate obesity is NOT associated with a decrease in life expectancy and may provide a survival advantage in a # of chronic diseases including Renal Failure, Heart Failure, T2DM
In this study by Dohner- they looked at all cause mortality (A) and all cause mortality and hospitalization in 5000 patients with T2DM and pre-existing CVD and found that the lowest mortality was in those patients with BMI of 30-35. Weight loss was associated with increased total mortality and cardiovascular mortality.
Stage 0 patients have no obesity related risk factor, physical, psychological symptoms and no functional limitationsStage 1 have sibclinical obesity related risk factors, mild physical symptoms- not requiring medical treatment for comorbidities. Mild obesity related psychological disturbance. Or mild impairment in well being- Stage 4 have severe end stage form of obesity related chronic disease, severe disabling psych symptoms or severe functional impairment.
EOSS is compared to the more classic classification of obesity based on BMI developed by the WHO – Class I- 30-35, ClassII 35-40, ClassIII>40