obesità nel bambino: epidemiologia e prevenzione · obesità nel bambino: epidemiologia e...
Transcript of obesità nel bambino: epidemiologia e prevenzione · obesità nel bambino: epidemiologia e...
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obesità nel bambino: epidemiologia e prevenzione
Obesità, Nutrizione e Stili di vita.
Trento 31 Marzo 2007
Claudio MaffeisDipartimento Materno Infantile e Biologia-Genetica
Sezione di Pediatria - Università di Verona
Overweight
0,0%
5,0%
10,0%
15,0%
20,0%
25,0%
National reference I.O.T.F. C.D.C.
males
females
totale
Obesity
0,0%
2,0%
4,0%
6,0%
8,0%
10,0%
12,0%
14,0%
16,0%
18,0%
National reference I.O.T.F. C.D.C
males
females
totale
PREVALENCE OF OVERWEIGHT AND OBESITY
IN 2-6-YEAR-OLD ITALIAN CHILDREN
Maffeis C et al. Obes Res, 2006
50
0
persistence of obesity from childhood into adulthood
Maffeis C et al. J Clin Endocrinol Metab 2002;87:71-76
normalweight
totalsample
(%)measured
in
adulthood
overweight
obese
25
relative BMI at baseline (%)
reciprocalof
adult BMI
100
r = -0.52, P<0.01
0.06
0.04
0.02
135 170 205 240
2
Erikson JG, et al. BMJ 1999;318:427-31
relation between obesity from childhood to adulthood and the metabolic syndrome: population based study
non-obese adults*
obese adults
men
women
total
Odds ratio
2
0
2
1
4
3
7
16
12
9
21
56
non-obese In childhood °
obese In childhood
* BMI <27.7 m, <26.6 w. ; ° BMI <15.8 b, <15.6 g.
adipose tissue: a regulator of inflammation.
Energy storage
WAT
Metabolism
Inflammation
Regulation of food intake
Energy homeostasis
Body weight control
Leptin, IL-6, IL-1/IL-1Ra
Sensitivity to insulin
TNFa, IL6, IL1/ILRa, Adiponectin, Leptin,
Resistin
Control of inflammation
IL1/IL1Ra,TNFa,IL6,IL8,MC
P1, RANTES,IP10
Adipocyte differentiation
IL;ILRa,TNFa,MCP1
Cardiovascular protection
Adiponectin, L1Ra,IL10Adiponectin, L1Ra,IL10
Vascular inflammation?
IL8,MCP1,RANTES,IP10,
Resistin
Juge-Aubry C et al., 2005
a
a
aa
aa
l
v
**
*
*
*
*
** m
d
dd
d d
v
g
v
m
a
a
a adipocytes m macrophage
v vessel g granulocyte
* degenerating adipocytes
l lymphocyte
d lipid droplets
Obesity and Inflammation: Evidence for an Elementary LesionElectron microscopic features of subcutaneous adipose tissue in obese children.
Sbarbati A, Maffeis C et al. Pediatrics 2006
3
60
40
20
FATMASS
(%)
metabolic consequences of fat gain in children
Maffeis C 2007
SAT
VAT
LIPOTOXICITY
HIGH BLOODPRESSURE
IGT
HIGH TRIGLYCERIDES
DIABETESINSULIN
RESISTANCE
the virtuous quartet
WAT
pancreas muscle liver
abnormalities in FA metabolism may result in inappropriate ectopic accumulation of lipids, which is involved in the development of insulin resistance
fat mass (%)
0-0.1-0.2 2 4 6 8 10 12 14 16 18
Age (years)
35
30
25
20
15
10
5
0
-0.8
male
female
pregnancy firstyear
adiposity rebound puberty
Dietz WH Am J Clin Nutr 1994
4
birth weight and type 2 diabetesin Pima Indian children and young adults
Dabelea D et al. Diab Care 1999;22:944
20
15
10
5
0
< 2.5
2.5 - 3.5
Prevalence (%)
3.5 - 4.5
birth weight (kg)
> 4.5
25
age group (years)
5 - 9 10 - 14 15 - 19 20 - 29
(Mantel-Haenszel X2 test, controlled for age and sex)
70
30
prevalence(%)
childen:
normal weight
overweight, obese
Kral JG et al. Pediatrics 2007
large maternal weight loss from obesity surgery prevents transmission of obesity to children
who were followed for 2 to 18 years
before maternalsurgery
after maternalsurgery
rapid weight gain during infancy and obesity in young adulthood in a cohort of African Americans
Stettler N, et al. Am J Clin Nutr 2003
obese in young adulthood:
rapid weight gain category
(0 to 4 months):
sex (F)
birth weight (kg)
gestational age (wk)
firstborn status
birth year
maternal BMI (kg/m2)
maternal age (y)
maternal education (y)
5.22
6.57
17.6
0.77
2.33
3.43
1.2
0.93
0.97
155, 17.6
1.83,23.5
2.22,140
0.35,1.68
0.54,10.2
1.01,11.7
1.04,1.39
0.83,1.03
0.69,1.37
0.008
0.004
0.007
0.5
0.3
0.049
0.013
0.16
0.9
Adjusted analysis
OR 95% CI P
5
adiposity rebound
adequate sleep among adolescents in positively associated with health status and health-related behaviors
Chen MY, et al. BMC Public Health 2006
Dependent variable:
Health responsability (higher vs lower)
Stress managment (higher vs lower)
Nutrition (higher vs lower)
Exercise (higher vs lower)
Body size (Non-overweight vs Overweight)
1.6 (1.2-2.2)
7.6 (5.3-10.8)
3.0 (2.2-4.1)
2.1 (1.6-3.0)
1.7 (1.3-2.4)
Independent variable:
adequate sleep (higher vs lower)
OR (95% c.i.)
NUTRIENT
BALANCE
OBESITY
BEHAVIOUR
GENE
ENVIRONMENT
NEUROENDOCRINE SYSTEM
Maffeis C, 2006
6
long-term weight loss maintenance
Definition: “individuals who have intentionally lost at least 10% of their body weight and kept it off at least one year”.
20% of overweight individuals are successful weight losers.
THE NATIONAL WEIGHT CONTROL REGISTRY
diet + physical activity: 89% diet: 10%
physical activity: 1%
strategies very consistently reported:
consuming a low-calorie (1800 kcal/day), low-fat (25%) dietdoing high levels of physical activity (3000 kcal/week)
weighing themself frequentlyconsuming breakfast daily
50
25
0
fatmass
(%)
10 30 50
lipid intake (% of energy intake)
Maffeis C et al. Int J Obes ‘96
r = 0.28 P< 0.01
Gazzaniga JM, et al.AJCN ‘93
Klesges RC et al. AJCN ‘94
covert manipulation of dietary fat and energy density: effect on substrate flux and food intake in men eating ad libitum
0
- 5
0
5
10
15
1 2 3 4
fat balance
time (days)
Stubb RJ, et al. AJCN 1995; 62:316-29.
- 10
20
5 6 7 0
- 5
0
5
10
15
1 2 3 4
energy balance
time (days)
- 10
20
5 6 7
MJ MJ
high fat
medium fat
low fat
7
reduction in portion size and energy density of foods are
additive and lead to sustained decreases in energy intake
Rolls BJ et al. , 2006
energy intake(kcal)
5000
4000
2000
0
Day 1
3000
1000
Day 2
breakfast
lunch
dinner
snack
breakfast
lunch
dinner
snack
100% ED, 100% portion
100% ED, 75% portion
75% ED, 100% portion
75% ED, 75% portion
- 2
-1
0
high-fibre, low-fat diet predicts long-term weight loss and decreased type 2 diabetes risk:
the Finnish Diabetes Prevention Study
Lindstrom J, et al. Diabetologia 2006
mean
adjusted mean *- 3
- 4
weightchange
(kg)from
baseline to yearthree
low-fat/high fibre
low-fat/low fibre
high-fat/high fibre
high-fat/low fibre
* group assignment, age, sex, baseline BW, fat, fibre, VLDL-use, & baseline and follow-up period physical activity
high-fibre, low-fat diet predicts long-term weight loss and decreased type 2 diabetes risk:
the Finnish Diabetes Prevention Study
Lindstrom J, et al. Diabetologia 2006
mean
adjusted mean *
1
0
Hazard ratiofor
diabetes
low-fat/high fibre
low-fat/low fibre
high-fat/high fibre
high-fat/low fibre
* group assignment, age, sex, baseline BW, fat & fibre intake, baseline 2-h glucose, baseline and follow-up period physical activity
# + weight change
2
3
4
5
6
adjusted mean #
8
Comparison of the Atkins, Ornish, Weight Watchers, and Zone diets for weight loss and heart disease risk reduction
Dansinger ML, et al. JAMA 2005
- 3
0
weighchange
(kg)
Atkins (n.40)
- 2
- 1
Zone (n.40)
WeightWatchers
(n.40)
Ornish (n.40)
Energy
CHO (%)
Fat (%)
Prot (%)
Fiber (g)
1700
16
50
34
8
1420
45
34
21
18
1480
47
34
19
15
1400
65
17
18
20
2 months
6 months
12 months
- 4
Morningsnack
Afternoonsnack
0
10
20
30
40
Breakfast Lunch DinnerNight snack
daily patterns of energy intake in children
Maffeis C, et al. Int J Obes 1999
energyintake (%)
9
1900 1950 2000
energy expenditure
energy (kcal)
years
energy intakethresold
of energy
expenditure
Hill & Wyatt J Appl Physiol , 2005
25
15
5
FA
T M
AS
S (
%)
0 9 18
AGE (years)
PHYSICAL ACTIVITY AND BODY FAT
3
1.5
0
PH
YS
ICA
L A
CT
IVIT
Y L
EV
EL (P
AL)
association of family environment with children’s TV viewing and with low levels of physical activity
Davidson KK, et al. Obes Res 2005
0.8
0.4
0.0
BMIz-score
5 8 11
daughter’s age (years)
obesogenic
non obesogenic
Family cluster: FM (%), Fat intake (%), TV (h/day)
10
parents’ obesity-related behaviors predict girls change in BMI
Stein RI, et al. Obes Res 2005
70
50
30
percentoverweight
0 6 12
time (months)
father acceptance decreasing
father acceptance increasing
paternal but not maternalparenting style was related to child weight outcome
fathers’ increase in acceptance period maybe especially powerfulbecause it is contrary to the usual developmentaltrend at this age, which is for children to perceive their parents as less accepting over time
Maffeis, C. et al. J Clin Endocrinol Metab 2005;90:231-236
Nutrient oxidation measured during walking at speeds of 4, 5, and 6 km/h, respectively, in a group of obese prepubertal children
240
160
80
visceraladiposetissue(cm3)
20 40 60
total physical activity (accelerometer hours/week)
Saelens BE et al. Am J Clin Nutr 2007
r = -0.43 P< 0.01
visceral abdominal fat is correlated with whole-body fat and physical activity among 8-y-old children at risk of obesity
11
baseline
14
0
flow-mediatedvasodilation
(%)
Meyer AA et al. J Am Coll Card 2007
improvement of early vascular changes and cardiovascularrisk factors in obese children after a six-month exercise program
lean obese
after 6 months
intervention control
P <0.001
P <0.001
P = ns
4000
3000
2000
1000
0
Energyrequirement(kcal/day)
Recommanded Dietary Allowances: are they appropriate?
Maffeis C 2007
BASAL
PHYSICAL ACTIVITY
GROWTH
THERMOGENESIS
age, gender, fat-free mass, fat mass, thyroid function, food intake
PAL = 1.7
PAL = 1.4
Recommanded Dietary Allowances: are they appropriate?
Maffeis C 2007
PAL = INDEX OF PHYSICAL ACTIVITY
= TOTAL ENERGY EXPENDITURE / BASAL ENERGY EXPENDITURE
= 1.7 SAFE LEVEL FOR WEIGHT MAINTENANCE IN ADULTS
Case 1: 10-year-old boy, BW= 30 kg, BMR: 1200 kcal/day RDA: 2200 kcal/day. Estimated PAL: 2200/1200 = 1.8
Case 2: 10-year-old boy, BW= 40 kg, BMR: 1400 kcal/dayRDA: 2200 kcal/day. Estimated PAL: 2200/1400 = 1.6
Case 3: 10-year-old boy, BW= 25 kg, BMR: 1000 kcal/dayRDA: 2200 kcal/day. Estimated PAL: 2200/1000 = 2.2
However, the mean PAL in 10-year-old boys is 1.5. Therefore, in allthe three cases the RDA overestimate requirements and expose to fat gain.
12
TAKE HOME MESSAGE
Maffeis C 2007
Approaching prevention and treatment of obesity in the single individual do not usethe RDA to estimate energy requirementsbut use the factorial method.