Obesity Epidemiological Concerns

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1 Obesity Epidemiological Concerns H.S. Teitelbaum, DO, PhD, MPH, FAOCOPM (dist.) Special Session, OMED Chicago, Illinois Dean Designee California Central Valley College of Osteopathic Medicine Obesity Often termed an EPIDEMIC Technical term More cases than EXPECTED Assumes we know what the Normal is. There is a tacit assumption that MEDICINE will solve the epidemic A pill for every ill Suggestion is we approach the problem like a medical epidemic HST 2016 AOA-AOCOPM Steps in Investigation 1. Verify the Diagnosis 2. Compare it to a baseline 3. Case Definition 4. Person, Place Time 5. Identify populations at elevated risk 6. Hypotheses generation 7. Case-Control 8. Control and Surveillance HST 2016 AOA-AOCOPM Common measure of obesity 1 BMI most common for office practices Waist circumference waist-to-hip ratio skinfold thicknesses bioelectrical impedance clinics, community settings and research studies Underwater Weighing (Densitometry) Air-Displacement Plethysmography Dual energy X-ray absorptiometry (DEXA) CT, MRI 1. Hu F. Measurements of Adiposity and Body Composition. In: Hu F, ed. Obesity Epidemiology. New York City: HST Oxford 2016 University Press, 2008; AOA-AOCOPM Organization World Health Organization Definitionof ChildhoodObesity WHO Child Growth Standards (birth to age5) (2) Obese: Body mass index (BMI) > 3 standard deviations above the WHO growth standard median Overweight: BMI > 2 standard deviations abovethe WHO growth standard median Underweight: BMI < 2 standard deviations below the WHO growth standard median WHO Reference 2007 (ages 5 to 19) (3) Obese: Body mass index (BMI) > 2 standard deviations above the WHO growth standard median Overweight: BMI > 1 standard deviationabove the WHO growth standard median Underweight: BMI < 2 standard deviations below the WHO growth standard median U.S. Centers for Disease Control and Prevention CDC Growth Charts (4) In children ages 2 to 19, BMI is assessed by age- and sex-specific percentiles: Obese: BMI > 95th percentile Overweight: BMI > 85th and < 95th percentile Normal weight: BMI > 5th and < 85th percentile Underweight: BMI < 5th percentile In children from birth toaoa-aocopm age 2, the 2016CDC uses a modified version of the WHO criteria 5 (5) HST 2016 References 2. de Onis M, Onyango AW, Borghi E, Siyam A, Nishida C, Siekmann J. Development of a WHO growth reference for school-aged children and adolescents. Bull World Health Organ. 2007;85: World Health Organization. World Health Organization Child Growth Standards Accessed March 5, Kuczmarski R, Ogden CL, Grummer-Strawn LM, et al. CDC Growth Charts: United States. Hyattsville, MD: National Center for Health Statistics; HST 2016 AOA-AOCOPM A-1

2 CDC Definitions Using BMI for Childhood overweight and obesity CDC ADULT CUT-OFF If your BMI is less than 18.5, it falls within the underweight range. If your BMI is 18.5 to <25, it falls within the normal. If your BMI is 25.0 to <30, it falls within the overweight range. If your BMI is 30.0 or higher, it falls within the obese range. Obesity is frequently subdivided into categories: Class 1: BMI of 30 to < 35 Class 2: BMI of 35 to < 40 Class 3: BMI of 40 or higher. Class 3 obesity is sometimes categorized as extreme or severe obesity. HST 2016 AOA-AOCOPM HST 2016 AOA-AOCOPM Baseline? Because of their public health importance, the trends in child obesity should be closely monitored. Trends are, however, difficult to quantify or to compare internationally, as a wide variety of definitions of child obesity are in use, and no commonly accepted standard has yet emerged. Establishing a standard definition of child overweight and obesity worldwide:internationalsurvey. BMJ 2000, May 6; 320(7244:1240 Problem with Baseline is what year should we choose? If the numbers keep rising, we will be comparing to a moving target and overall trends will be difficult to interpret. Sooner or later we have to admit that all Baselines are arbitrary. Teitelbaum, H.S Seminar, Lincoln Memorial University- DeBusk College of Osteopathic Medicine HST 2016 AOA-AOCOPM Baseline? HST 2016 AOA-AOCOPM Prevalence of Overweight Children and Adolescents Ages 2-19 Years BRFSS-CDC Establishing a standard definition for child overweight and obesity worldwide: international survey. Cole TJ 1, Bellizzi MC, Flegal KM, Dietz WH. BMJ May 6; 320(7244): Percent HST 2016 AOA-AOCOPM HST 2016 AOA-AOCOPM A-2

3 Facts CDC For children and adolescents aged 2-19 years, the prevalence of obesity has remained fairly stable at about 17% and affects about 12.7 million children and adolescents for the past decade. (1) A 2014 study of overweight and obesity in children and adults from found that worldwide, the proportion of overweight or obese adults increased, and prevalence also increased substantially in children and adolescents in both developed and developing countries. (3) These jumps in child and adult obesity rates show no sign of stopping without dedicated efforts to combat the epidemic. (CDC) References 1.Cynthia L. Ogden, PhD 1 ; Margaret D. Carroll, MSPH 1 ; Brian K. Kit, MD, MPH 1,2 ; Katherine M. Flegal, PhD Prevalence of Childhood and Adult Obesity in the United States, JAMA. 2014;311(8): doi: /jama Ng M, Fleming T, Robinson M, et.al. Global Burden of Disease Study Lancet (9945): HST 2016 AOA-AOCOPM HST 2016 AOA-AOCOPM TRENDS Obesity is more common in boys than girls (19 percent versus 15 percent). Obesity rates in boys increased significantly between 1999 and 2010, especially among non-hispanic black boys; but obesity rates in girls of all ages and ethnic groups have stayed largely the same. Hispanic (21 percent) and non-hispanic black (24 percent) youth have higher rates of obesity than non-hispanic white youth (14 percent), a continuing trend. Nearly 10 percent of U.S. infants had a high weight for recumbent length -a measure that s similar to the body mass index but used in children from birth to age 2. From 1999 to 2010, Mexican American infants were 67 percent more likely to have a high weight for recumbent length than non-hispanic white infants. Prevalence of Childhood and Adult Obesity in the United States, FREE Cynthia L. Ogden, PhD 1 ; Margaret D. Carroll, MSPH 1 ; Brian K. Kit, MD, MPH 1,2 ; Katherine M. Flegal, PhD 1 [+-] Author Affiliations 1 National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, Maryland 2 United States Public Health Service, Rockville, Maryland JAMA. 2014;311(8): doi: /jama Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity and trends in body mass indexhst among 2016 US children and adolescents, AOA-AOCOPM JAMA. 2012;307: HST 2016 AOA-AOCOPM CDC Facts Although the rate of obesity has plateaued in recent years for some groups, the overall prevalence of the condition remains high for all U.S. residents, and disparities persist in the prevalence of obesity. Continued monitoring of obesity prevalence and further research are needed to identify and understand the factors that influence individual behaviors, especially among high-priority groups, and to augment current population-based approaches with interventions that are tailored to their needs HST 2016 AOA-AOCOPM High Risk Groups Low Levels of Educational Attainment Mexican-American Boys Non-Hispanic Black Girls and Women (Please note that attention must be given to Non-modifiable risk factors) emphasis mine -HST Race/ethnicity, Gender Must consider which dietary and physical activity behaviors contribute to the differences as well as how those behaviors are influenced by social and cultural factors Source: MMWR Supplement/Vol. 62/No.3 CDC Health Disparities and Inequalities Report- United States, 2013 HST 2016 AOA-AOCOPM A-3

4 Study Designs Most studies are cohort studies understandable BUT danger is in generalizing from one group to many groups Tried to indicate that there are some groups that are at higher risk than others. Thus, presumed risk factors must be judged by both Physiological and Metabolic principles, to help eliminate confounding by cultural, ethnic and other environmental variables. MUST have a uniform definition of terms. This is a major concern when looking at longitudinal as well as comparative studies Example: HIV, Autism and NOW OBESITY Surveillance an ABSOLUTE MUST HST 2016 AOA-AOCOPM HST 2016 AOA-AOCOPM Why Follow-up? Diet versus Exercise in The Biggest Loser Weight Loss Competition Kevin D. Hall, Obesity (Silver Spring). Obesity (Silver Spring) May; 21(5): Nearly half of Americans believe that television shows like The Biggest Loser will have a positive effect on the obesity epidemic (5). Obesity experts generally disagree, arguing that the show perpetuates weight bias, raises false expectations for weight loss, and depicts an intervention that is unrealistic for most people (6 8). To help address the latter point, I quantified the diet and exercise intervention using a validated computational model to quantitatively integrate the experimental data. Follow-up Continued The role of diet and exercise for the maintenance of fat-free mass and resting metabolic rate during weight loss. Stiegler P 1, Cunliffe A. "There used to be a mythology that if you just exercised enough you could keep your metabolism up, but that clearly wasn't the case, these folks were exercising an enormous amount and their metabolism was slowing by several hundred calories per day," HST 2016 AOA-AOCOPM HST 2016 AOA-AOCOPM Follow-up "When that fat mass is diminished (either by eating less or exercising more) most of us respond by changes in brain circuitry that increase our tendency to eat and changes in neural and endocrine systems, and especially muscle, that make us more metabolically efficient - it costs fewer calories to do the same amount of work," HST 2016 AOA-AOCOPM Follow-up Metabolism appears to act like a spring, Hall said: the more effort you exert to lose weight, the more it stretches out, and the harder it will spring back, regaining and holding onto the fat that was lost. Dr. Michael Rosenbaum, Columbia University Medical Center HST 2016 AOA-AOCOPM A-4

5 What do the existing studies suggest as to where to whom does one look for a solution General Statement THERE IS ENOUGH BLAME TO GO AROUND Probably true but not very insightful High risk groups Basic scientific understanding Is MEDICINE the Solution Osteopathic Approach Interrelated components of the Cause of the epidemic There will inevitably be a continuing debate between Societal good and Individual Responsibility. HST 2016 AOA-AOCOPM Ecological model of health behavior Individual beliefs and behaviors occur in a social context health promotion may be more effectively achieved through changing the social environment. The ecological model examines how the social environment (including interpersonal, organizational, community, and public policy) supports and maintains unhealthy behaviors. HST 2016 AOA-AOCOPM Societal (Environmental) factors The current thought in public health promotion is that public health programs must focus less on individual behavior and more on changing the environment in order to be effective. Whereand to whomdoes the problemand solutionlie? Government Medicine and other sciences Changing the physical and social environment to make it easier for people to lead healthy lives. Commercial Behavioral, psych and individual responsibility The environmental perspective forces people to think of public health problems as social and political issues that require collective action. HST 2016 AOA-AOCOPM HST 2016 AOA-AOCOPM Society Medicine Behavioral Society Commercial Government A-5

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