The Molten Moment

The

Molten

Moment

The Moment Where ObesityInterventions Have The Greatest Impact

Tracy Flood, MD, PhD

© 2013, All rights reserved

OutlineBackground

• Define the Molten Moment• Obesity as a Growing Concern• Define Obesity in Children

1) Story of Fat Cell • Not too Big = Metabolic Synd• Not too small = Hunger• But Just Right

2) Many interventions reduce Metabolic Risk & CVD

3) Only interventions performed at the MOLTEN MOMENT can “cure” obesity forever.

The Molten Moment

Background

The Obesity Crises

Defining Obesity

The Molten Moment

A Cold Iron, Solid A HOT Iron, Malleable

DEFINITION of Mol-ten: liquefied by heat; having warmth and brilliance, glowing

The Molten Moment

Where do you strikeFor the biggest impact?

The Molten Moment


The Molten Moment


The Molten Moment


Obesity is a Growing problem

7%

20%

1980 2008

Children aged 6-11 yo

5%

18%

1980 2008

Adolescents aged 12-19 yo

Since 1980, Childhood Obesity

rates have tripled

Prevalence Rates of Childhood Obesity

Obesity=Bad

If rising OW/OB trends continue, by 2030 it will reach 16-18% of total health-care costs in the United States. (Wang, Beydoun, Liang, Caballero, Kumanyika, 2008)

Obesity is a Growing problem

Atherosclerosis

Currently, the world’s leading causes of death are the Atherosclerosis-related dz:

1. Ischemic heart disease (IHD)2. Stroke (Lopez &Mathers, 2006; Mathers et al., 2009).

OW/OB Increases Risk FactorsRisk Factors AtherosclerosisAtherosclerosis begins at a young age

Prevalence of Obesity

Throughout the Lifespan

0

0.1

0.2

0.3

0.4

0.5

0-2 yrs 2-5 yrs 6-11 yrs 12-19 yrs 20-39 yrs 40-59 yrs 60+ yrs Males

FemalesPediatric Definition Adult Definition

Obese

Over-weight

Normalweight

Body Mass Index=BMI

30

25

ADULTSCHILDREN

>

Defining Obesity

Obese

Over-weight

Normalweight

Body Mass Index=BMI

30

25

ADULTSCHILDREN

>

Defining Obesity

Obese

Over-weight

Normalweight

Body Mass Index=BMI

30

25

ADULTSCHILDREN

>

Defining Obesity

NOTE: An Obese Preschooler is as Thin as a Normal

Weight Adult

The Story of the Fat Cell

Stem Cells can become Fat Cells

Fat Cell

Triglyceride(TG)FA

FAFA

How do we become Obese?

OB

OW

NW

BMI



Fat Cell

Triglyceride(TG)FA

FAFA


OB

OW

NW

BMI



Fat Cell

Triglyceride(TG)FA

FAFA


OB

OW

NW

BMI

Who Would You Target

For Intervention?

lebeauleblog.wordpress.com Bvwellness.com Friendlyhouseinc.org

Obese 15 yo girl who isotherwise healthy

Normal weight 35 yo mother wanting to lose “baby weight”

Obese 55 yo man with Metabolic Syndrome

Obesity with

Metabolic Syndrome

lebeauleblog.wordpress.com


a TOXIC type of obesity

How Does a Person DevelopMetabolic Syndrome?



Fat CellFA = Fatty Acids

Triglyceride(TG)FA

FAFA


Triglyceride(TG)FA

FAFA



FAFA FA

Triglyceride(TG)FA

FAFA



FA

Fatty LiverTG

TG

HDLTG

TG

Used for fuel if active

FAFAFA

Result:Higher TG

Lower HDLHDL is the good cholesterolScavenges Xtra TG then is destroyed


TG

TG

High TG, Low HDLHypertensionDiabetes=Metabolic Syndrome

Insulin Resistance

TG



Insulin Resistance

TG

TG

TG

AtherosclerosisCardiovascular DiseasePremature Death


Insulin Resistance

= Metabolic Syndrome

Body Type& Risk

Obesity with

Metabolic Syndrome



a TOXIC type of obesity

He wants to be healthier:

--Americans spend over $60 billion/yr on

weight loss (Marketdata, 2010)

--1 in 3 adults are attempting weight loss

Testing the Effects

of Interventions

DIET EXERCISE

GOOD ADVICEMEDICATIONS


STARVATION

Results of Intervention

Advice Alone

Sibutramine

Very Low Cal Diet

Average weight loss of subjects completing a minimum 1-year weight-management intervention; based on review of 80 studies (N=26,455; 18,199 completers [69%]).

(Franz et al, 2007)

3-6kg

Note: Built environment intervention not included


160 lb

weight

5’6”

BMI

190 lb 30

25

OB

OW

NW

MAX6 kg13 lb


After 4 years of 26,455 people undergoing

weight-loss intervention,

the average weight loss was 13 lbs

and the obese were still obese.

160 lb

weight

5’6”

BMI

190 lb 30

25

OB

OW

NW

MAX6 kg13 lb


After 4 years of 26,455 people undergoing

weight-loss intervention,

the average weight loss was 13 lbs

and the obese were still obese.

160 lb

weight

5’6”

BMI

190 lb 30

25

OB

OW

NW

MAX6 kg13 lb Results:

Exercise aloneExercise behavior can be maintained

in obese participants following intervention(Gourlan et al, 2011)

Primary Care SettingBest results with Doctor & Dietician = 6 kg (Flodgren, et al 2010)

Built EnvironmentGood evidence for affecting physical activityLess evidence for affecting BMI

(Durand et al 2011)

Meta-Analyses & Reviews


FAFA FA

Fat Cells

7-10% weight loss = Less Insulin Resistance


Fat Cells

7-10% weight loss = Less Insulin Resistance


TG

TG


Insulin Resistance

TG

Meta-Analyses: Exercise alone (Shaw et al., 2006)

hypertensiontriglyceridesfasting glucose & risk of diabetes

Diet alone (i.e. Low Fat Diets) (Avenell et al., 2004)

hypertensionrisk of developing diabetes

Diet + Exercise (Avenell et al.; Witham et al., 2009)

risk of CVD (HR 0.65, 95% CI 0.50–0.85 in those >60 yo)

7-10% weight loss = Improved Outcomes


7-10% weight loss = Improved Outcomes

“Clinically Significant” Weight Loss

16%

In 100 Adults (20-65 yo) Getting Treatment for Obesity 16% will have

clinically significant weight loss

10% Weight loss

No Weight loss

Increasing Weight Loss

lebeauleblog.wordpress.com Page2live, TopGun

Reeeeally was hoping to get back to pre-weight gain weightI want to lose more than 13 lbs


Fat Cell

If you try to lose more than 10%... Uh oh!

160 lb

weight

5’6”

BMI

190 lb 30

25

OB

OW

NW


Fat Cell

If you try to lose more than 10%... Uh oh!

I’m HUNGRY!!

I’m HUNGRY!!

FEED me!!

160 lb

weight

5’6”

BMI

190 lb 30

25

OB

OW

NW


I’m HUNGRY!!

I’m HUNGRY!!

I’m HUNGRY!!

EAT MORE!BURN LESS!


EAT MORE!BURN LESS!


Losing weight

I’m HUNGRY!!

I’m HUNGRY!!

I’m HUNGRY!!

30 minof moderate exercisex 5 days a week to maintain

60-90 minof moderate exercisex 7 d/wk to maintain weight loss

Summary of Adult Interventions

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A) Weight gain is a wheel and ratchet= Uni-directional

B) Behavioral change is possible

C) 7-10% Weight loss is improves CVD risk

Is adulthood a Molten Moment? NO






For Intervention?

Bvwellness.com

Obese 15 yo girl who isotherwise healthy The Obese Teen

An Obese Teenager is already at risk for early death & disease

Risk for Early Death

Bvwellness.com

Obese 15 yo

Note: Subjects with BMI 25th to 75th percentile (CDC charts) were the referent group. Adapted from Bjorge, Engeland, Tverdal, & Smith (2008).

Figure. Mortality in adulthood (<55 y/o) of OW/OB adolescents (males and females) compared to normal weight peers.

The health risk in adulthood for OW/OB adolescents

If OW/OB teen Normal Weight by adulthoodRisk Factors & Atherosclerosis associated with adiposity

DECREASE (Oren et al., 2003; Weiss et al., 2009)

Risk for Early Death

Bvwellness.com

Obese 15 yo

Note: Subjects with BMI 25th to 75th percentile (CDC charts) were the referent group. Adapted from Bjorge, Engeland, Tverdal, & Smith (2008).

Figure. Mortality in adulthood (<55 y/o) of OW/OB adolescents (males and females) compared to normal weight peers.

The health risk in adulthood for OW/OB adolescents

If OW/OB teen Normal Weight by adulthoodRisk Factors & Atherosclerosis associated with adiposity

DECREASE (Oren et al., 2003; Weiss et al., 2009)

But our patient has a 92% chanceof remaining obese at the age of 40.

(Nader, 2008)

BMI nadir

BMI associated with CVD

Early pressures = Later Disease

Link between Childhood BMI and adult CV deathBegins as early as:

8 yo in boys 13 yo in girls

Every 12 lb increase associated with risk of fatal cardiac death

CVD Risk: Sun et al., 2008Trajectory: Ventura, Loken, & Birch, 2009

BMI Percentile Chart

Very High Risk o’ Future CVD

Finished w/ Linear Growth

Increased Adiposity = Increased Risk of CVD

5’6”

BMI %ile

95th %ile

85th %ile

OB

OW

NW

Meta-Analyses (Teens)

MAX3

kg/m2

5’6”

BMI %ile

95th %ile

85th %ile

OB

OW

NW


MAX3

kg/m2

5’6”

BMI %ile

95th %ile

85th %ile

OB

OW

NW

Treatment of Obesity in Teens & Older Childrenboth treatment and controls gained weight

Behavioral Interventionsup to 3.3 kg/m2lighter vs. controls (Whitlock et al, 2010)

Clinic-Based Interventionsup to 2.4 kg/m2lighter vs. controls (Whitlock et al., 2010)


Prevention in Teens

Cochrane Review of 55 Obesity Prevention EffortsBMI change not significant in teenagers(Waters et al., 2011)

Sedentary Behavior Decreased = <1 hr/wk(Wahi et al., 2011)

MAX3

kg/m2





TEEN INTERVENTION:Alters TrajectoryPrevents wgt gainMinimal Decr BMI





TEEN INTERVENTION:Alters TrajectoryPrevents wgt gainMinimal Decr BMI

Intervene


Adult Obesity

20%

In 100 Teens (11-15 yo) Getting Treatment for

Obesity 20% have clinicallySignificant weight loss

Summary of TEEN Interventions

WARMER

A) Behavioral change is achievableB) Prevention of excessive weight gain is achievableC) After adult height is reached, weight loss may be challenging

birth 10 20+ 5 15

Age:






for intervention?

The Mother of a

Preschooler

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Parents and Adult Caretakers must be the agent of change in this age group.

Preschoolers mimic parents’:

Fruit & Vegetable consumptionPortion sizesSnacking frequencyTVPhysical activityGrocery shopping Adult Intervent’n= Preschooler Intervent’n

The Mother of a

Preschooler

Friendlyhouseinc.org


“When mothers improve their diets in order to control their weight, their child(1-3 y/o) improves their diet as well, even if that was not the original intent”

(Klohe-Lehman, et al., 2007)

The BMI nadir and “Adiposity Rebound” are good predictors of future OW/OB

The Preschooler

At the nadir

High TG, Low HDLHypertensionInsulin Resistance=Metabolic Syndrome

The BMI nadir and “Adiposity Rebound” are good predictors of future OW/OB

The Preschooler

At the nadir

Intervene

The Preschooler

a Problem of Perception

80% of Parents & 50% of all adults cannot see OW/OB in Preschoolers(Baughcum, Chamberlin et al., 2000)

5’6”

BMI %ile

95th %ile

85th %ile

OB

OW

NW

Promising Interventions:Diet+Exercise

Educational Setting Interventions, changing culture Parental Support for home activities (Waters et al., 2011)

Interventions to Decrease Sedentary Behavior= 4 hr/wk in Preschooler (Wahi et al., 2011)

Meta-Analyses (Children)

0

1

2

3

4

5

Preschooler Teenager

Hours Less of Sedentary Behavior After Intervention

Interventions during preschool are needed

5’6”

BMI %ile

95th %ile

85th %ile

OB

OW

NW

Built Environment (Review)Walkability& Access to Recreation = Activity (Ding et al., 2011)

Cochrane Review of 55 Obesity prevention effortsTeens BMI change not significant in teenagers

6-12 yo BMI change by 0.15 kg/mg2, significant0-5 yo BMI change by 0.26 kg/mg2, significant(Waters et al., 2011)

Meta-Analyses (Children)

6-12 yo

Intervention and Average BMI Change

OB

OW

NW

OB

OW

NW

OB

OW

NW

-0.3

-0.25

-0.2

-0.15

-0.1

-0.05

0

0-5 yrs 6-12 yrs 13-18 yrs

Weight Change After Intervention by Age (in kg/m2)

ns

20% 16%

90%

Danielsson et al., 2012 (0.5 SD BMI)

Intervention and % Success of

clinically significant weight loss

Kraschnewskiet al., 2010


Beh

avio

rB

MI C

han

geSu

cces

s





Behavior

CVD Risk

Behavior Behavior

Less Wt Gain True Change

High RiskBorderlineThinnest Weight

Successful Interventions

Moldable Habits



Moldable Habits



Moldable Habits

Moldable Habits

birth 10 20+ 5 15

Age:

MOLTEN MOMENT

Prevention of Obesity

High Risk


Thinnest Weight

birth 10 20+ 5 15

Age:

Define The Molten Moment

MOLTEN MOMENT

Prevention of Obesity

Strike now.

The iron is hot.

Summary

20+ birth 10 5 15Age:

MOLTON MOMENTIntervention = Prevention of OB

Behavior Change PossibleCan Improve Outcomes

Summary

Molten Moment

1) Story of Fat Cells• Not too Big = MetS• Not too small = Hunger• Just Right via Prevention

2) Metabolic Risk can be Reduced3) The MOLTEN MOMENT for

obesity is in preschool &sooner.

Part 2: The Big 5

The 5 Behaviors that protect your fat cells

Eat Five Times a Day

Recommendations: Do not skip Breakfast(Skipping Meals in General)= BMI

Eat 5x a day (3 meals, 2 snacks)Eat Family Meals at Home 5x a week

Television

Recommendations:1) Watch TV ≤ 2 hrs/day2) Those under age 2 should not watch TV3) Remove TV from where children sleep

Physical Activity

Recommendations:1 hour of physical

activity or active play accumulated

throughout the day.

Sweetened Beverages

Sweetened Beverages

Each Serving of Sugar-Sweetened Beverages per day is associated with an increase in BMI (Forshee, Anderson,Storey, 2008) Meta-analysis

Recommendations: No zero zilch sweetened beveragesand ≤ 4 oz of 100% Fruit Juice per day

Half a Plate

7 “ plate for children

How to Assess

1: What do you do after school?

Do you live in a safe neighborhood?

2: How often is the TV on?

What are your favorite shows?

Is there a TV in the bedroom?

0: What do you drink?

1/2: Is half of everything you eat a fruit

or a vegetable?

5: Describe what you eat on a regular day?

Questionnaires like REAP & WAVE

Part 2: The Big 5

SUMMARY:

You can’t kill a fat cellAfter 8 is too late.

5, 2, 1, 0… And half a plate.

Part 1: Molten Moment

THANK YOU!

Questions, Comments? Hatemail?

Contact me: [email protected]

The Molten Moment

Health & Medicine