Role of HCPs

in the Prevention of Obesity

Dr. Abdul Jabbar

Visiting Professor, The Aga Khan University

Consultant Endocrinologist, Medcare Hospital, UAE
Diabetes, Senior Medical Advisor, Eli Lilly & Co. USA
Sixteen-year-old Hina is a high school
student who loves movies, the local pizza
parlor and music.
She is young but has the health risks of
someone three times her age.
With a BMI > 95th percentile for age, Hina
has many of the features of metabolic
syndrome and may be only months from
displaying the symptoms of type 2 diabetes.
Hina is one of 8.8 million youth who are
overweight or obese.
Obesity is perhaps the most pervasive medical problem
faced by health care providers today.

It is a common condition in any patient population in

countries with a western diet and lifestyle.

It affects disease burden in virtually every medical

specialty, has broad exposure in the media and popular
press, and is the subject of intense research in biomedical,
epidemiologic, sociologic, and psychological fields.

Each such theory falls short of explaining the full spectrum

of disease and its resistance to treatment.
The overweight/obese child is metaphorically a
"canary in the coal mine" of an increasingly toxic
environment.
Health care providers face the daunting task of
preventing childhood obesity, a "pandemic of
the new millennium."

Although some people are genetically

predisposed to obesity and its comorbid
cardiovascular and metabolic diseases, the
causes of obesity are both social and biological.

Preventing obesity requires an understanding of

the ways in which two and a half million years
of genetic evolution have made people
vulnerable to rapid social and environmental
changes of the past 50 years.
 Obesity and CVD are diseases that originate in utero and
take hold during infancy or in early childhood.

Therefore, prevention efforts must continue across the lifespan, with

particular attention directed to three critical periods of development:

Prenatally

The age of adiposity rebound (usually between the ages of 4 and 7

years, when BMI reaches its nadir and then begins to increase), and

During puberty (when insulin resistance increases).

Ideally, obesity prevention and treatment plans for patients should

incorporate the entire family and should include assessment of family
dynamics. The guidelines presented below describe a workable approach.
 BMI
Associated Risk Disease
Classification BMI (kg/m2) Risk
Underweight <18.5 Increased
Normal 18.5-22.9 Normal
Overweight 23.0 26.9 Increased
Obese I 27.0 30.0 High
II 30.1 34.9 Very high
III 35 Extremely high
Additional risks:
Large waist circumference (men 90 cm; women 80 cm)
Poor aerobic fitness
Specific races and ethnic groups
Clinical Guidelines on the identification, Evalution, and Treatment of Overweight and
Obesity in Adults The Evidence Report. Obes Res. 1998/6 (suppt 12)
The concept of metabolic programming first arose from
epidemiologic studies in which it was observed that

infants with low birth weight had a higher risk of developing diabetes
and heart disease during adulthood.
Studies of the Dutch famine provide evidence that nutritional factors
in utero have a causal relationship with subsequent metabolic
phenotype.
The Dutch population was abruptly subjected to famine conditions for
5 months in the winter of 1944-45.

Children who were exposed to the famine in utero had higher risks of
glucose intolerance and type 2 diabetes later in life, compared with
infants who were in utero just before or after the famine.[35]
Comparison with other famines suggests that abrupt restoration of
adequate nutrition after birth further increases the risk for metabolic
disease.[36]

Animal studies lend further support to the idea of metabolic

programming
Just 3 hrs of walk

Just 2 hrs of walk

Just 1 hr of walk
FACT:

Link Between Television and Overweight in Children is

Discovered: this is the first time a research team has found
evidence for a mechanism explaining that relationship.

Researchers from the Harvard School of Public Health

(HSPH) and Children's Hospital Boston found that kids who
spend more time watching television also eat more of the
calorie-dense, low-nutrient foods advertised on television.
 Previous studies had demonstrated that children
who watch more television are more likely to be
overweight. study provides evidence that
television is effective in getting kids to eat the
foods that are advertised, and this drives up their
total calorie intake.

" The results of the study showed that each

hour of increased television viewing over
baseline was associated with a total energy
increase of 167 calories -- just about the
amount of calories in a soda or a handful of
snack food.

Archives of Pediatric and Adolescent Medicine. April 2006

Creative Non-Drug Technology-Driven Treatment Approaches for
Childhood Obesity

An Internet-facilitated intervention and automated controls on TV

viewing and computer use were each associated with reducing
BMI.
The search for effective strategies for treatment of childhood
obesity is challenging.
In two studies, investigators report modest success using
technology-driven interventions.
Researchers randomized families of 70 children (age range, 47
years) who had body-mass indexes >75th percentile to two
groups:
One group had devices installed at their homes that recorded and
blocked TV and computer use after a specified amount of time,
which was aimed at reducing viewing by 50%;
the other group received newsletters that featured advice on
reducing childrens TV and computer use and was allowed
unlimited viewing.

Epstein LH et al. A randomized trial of the effects of reducing television viewing and computer use on body mass index in
young children. Arch Pediatr Adolesc Med 2008 Mar; 162:239.
At the end of the 2-year study, mean weekly
viewing time had declined by 17 hours in the
intervention group and by 5 hours in the control
group.

Significant differences from baseline in mean

BMI favored the intervention group at 6 and 12
months but not at 24 months.

In families with low socioeconomic status,

significant differences in BMI favored the
intervention group at 6, 12, and 24 months.
Statistics show that in spite of all our efforts to
date, diabetes is still out of control, under-funded
and under-recognized. The projected increases
in the number of diabetics will outstrip the ability
of health systems to cope and will jeopardize the
health of millions.

Type 2 Diabetes Rising Among U.S.

Adolescents
Some 59,000 adolescents in the United States
already have obesity-linked type 2 diabetes, and
nearly 3 million more may have blood sugar
levels that could spur diabetes and other health
problems, researchers report.
Curbing obesity can help avert a public health
crisis, experts say
"Steps to prevent and treat the substantial
number of adolescents who have impaired
fasting glucose [blood sugar] from developing
type 2 diabetes are required now," said lead
researcher Glen E. Duncan, an assistant
professor in the Department of Epidemiology,
Nutritional Sciences Program at the University of
Washington in Seattle. "These steps are well
known and well established preventative
measures -- namely to increase daily physical
activity levels and improve nutrition, and to avoid
excess body weight."
One expert believes a major public health effort is
needed to stem the obesity epidemic and prevent
the rise of a generation plagued by type 2
diabetes.

"The clearest evidence of the harms of epidemic

obesity comes in the form of rising rates of
diabetes in both adults and children," said Dr.
David L. Katz, an associate professor of public
health and director of the Prevention Research
Center at Yale University School of Medicine.
Just 2000 Steps and 100 Calories Can Impact
Children's Lives And Prevent Disease
According to health statistics, one-third of all
children in the United States are either
overweight or dangerously close to becoming
so.
Walking 2000 more steps a day and reducing
your calories by 100 per day can prevent weight
gain for overweight children.

The study results proves that this approach can

help counter obesity crisis. The study used 216
families who had a child who was defined as
overweight by their body mass index (BMI). BMI
Calculator for Children.
Small steps. Its the little things that matter.

For example: Do youtake the elevator or

steps?

...buy soda or drink water?

use sugar or sweetener?

choose regular or super-duper-size?

All of your daily decisions add up.

Here are just a few daily choices that can lead to a
fitter you:

Add a 0-calorie substitute to your coffee or tea

9,000 cal/yr. (1.28 kg)
Drink water instead of soda or juice (once a day)
36,000 cal/yr. (5 kg)
Do 5 minutes of exercise/walk a day 10,000
cal/yr. (1.6 kg)
Walk / run fifteen minutes a day (3x per week)
30,000 cal/yr. (4.2 kg)
These four small steps alone will help you shed
nearly 15 kilos in a year!
Extreme measures, such as ketogenic diets and
surgery, have been tried to deal quickly with
obesity, but recidivism is high.

There are no quick preventions or cures. The

answerpermanent behavior changeis
amazingly simple in description but formidable in
implementation.

Obesity prevention will require radical lifestyle

change across the lifespan. Such change takes
time, discipline, perseverance, and daily effort.
And if it is not viewed as permanent, the efforts
will be in vain.
Provide parents with simple recommendations and
advice
Create a daily schedule with regard to eating, physical
activity, homework, and bedtime.

Decreased sleep leads to insulin resistance and

decreased serotonin levels, which in turn cause
carbohydrate craving and exacerbate depression.

Lack of sleep also increases ghrelin and decreases

leptin, thus stimulating the appetite and decreasing
satiety.
Eat three meals and one to two snacks each day, finishing
each meal in 3045 minutes and never eating in front of the
television or computer.

Eat as many meals as possible together as a family, with

wholesome food choices and positive family interactions.

Portion sizes are critical and should be monitored carefully.

For overweight children, a food and exercise log is
recommended.

Read food labels carefully with regard to both portion size

and content.
Decrease portion sizes of starchy foods, such as rice,
potatoes, bread, and pasta. Include more colorful
vegetables.

Choose whole-wheat or other whole-grain breads.

When children want "seconds," have them choose only

one item (not one serving of each item) from the meal
before adding any additional food.

Perhaps that one extra food might be a glass of skim milk,

fruit, or a vegetable.

These are also ideal bedtime snacks if the child is hungry

before sleeping.
Children 12 years of age should be given whole or 2%
milk to aid in myelination of the nervous system.
Older children should drink nonfat milk. Younger children
require 2 cups of milk per day, and adolescents need 3
cups per day to meet their daily recommended calcium
requirements.
It is now being recognized that the daily recommended
amount of vitamin D may not be adequate. As a
safeguard, children should have daily careful exposure to
sunlight as well as foods fortified with vitamin D.

Limit saturated fats, such as butter, margarine, chicken

skin, bacon, and sausage.

Oils such as olive, canola, and peanut are to be used in

moderation, and lean meats are preferred over fatty ones.

These should be steamed, broiled, baked, or grilled, but

not fried.
Season foods with herbs and spices rather than
sugar, salt, and fat.

Salt is an acquired taste. Do not add salt to any

foods offered to infants.

Because thirst and fatigue can be mistaken for

hunger, offer children water or fat free milk if
they complain of hunger between meals.
Strictly limit or reserve for special occasions foods of low
nutritional value, including cakes, cookies, candies, chips, French
fries, and sugared beverages.

Limit fast food and processed or prepared food such as TV

dinners to no more than once a week.

Also, prepare school lunches at home, including only

unprocessed foods such as apples, carrots, and skim milk and
avoiding excessive saturated fat and carbohydrates.

Good desserts might include fruit, sugar-free jello or pudding,

and canned fruits drained of any syrup.

Ration sugary, fatty treats at holidays and discard leftovers,

including candies with a long shelf life, after 35 days.

Discourage eating in the car, giving only water to drink while in

transit.
Avoid using food as a reward.

Get daily physical activity.

Younger children should walk or play outside for at

least 30 minutes a day, and older children need at
least an hour of physical activity.

Limit media use to < 1 hour/day.

This includes watching television, talking on the phone,
playing sedentary video games, and using the computer
other than for homework assignments.
These media should not be available in children's
bedrooms.
 Encourage active parenting
Children need parents, not buddies.

Health care providers should call on

parents to reclaim their roles as those in
charge of and responsible for their children.

Children mirror the behaviors of their

parents.
 Prevention of Type 2 Diabetes
Diet + Exercise Intervention for IGT
Reduction in progression
to diabetes (%)
Diabetes Prevention Program
N=3234, 2.8 years
Low-fat diet + exercise 58

Finnish Study
N=522, 3.2 years
Low-fat diet + exercise 58

Da Qing Study
N=577, 6.0 years
Diet and/or exercise 3146
DPP Research Group. N Engl J Med. 2002;346:393-403; Tuomilehto J et al.
N Engl J Med. 2001;344:1343-1350; Pan XR et al. Diabetes Care. 1997;20:537-544
 Prevention of Type 2 Diabetes
Pharmacotherapy for IGT
Reduction in progression
to diabetes (%)
Diabetes Prevention Program
N=3234, 2.8 years
Metformin 850 mg bid 31

STOP-NIDDM trial
N=1429, 3.3 years
Acarbose 100 mg tid 25

TRIPOD study
N=236, 2.5 years
Troglitazone 400 mg qd >50
DPP Research Group. N Engl J Med. 2002;346:393-403; Chiasson J-L et al.
Lancet. 2002;359:2072-2077; Buchanan TA et al. Diabetes. 2002;51:2796-2803
 Prevention of Type 2 Diabetes
Recommendations
Identify populations at high risk for pre-diabetes
Age >30 years + body mass index >25 kg/m2
Consider younger persons with family history, prior GDM, non-
Caucasian ancestry, dyslipidemia, hypertension, CVD, or PCOS
Screen with FPG or 2-h 75-g oral glucose tolerance test (OGTT)
Confirm IFG or IGT with a second test
Intervene with diet, weight loss, and physical activity
Retest every 1 to 2 years

GDM=gestational diabetes mellitus; CVD=cardiovascular disease;

PCOS=polycystic ovarian syndrome; FPG=fasting plasma glucose;
IFG=impaired fasting glucose; IGT=impaired glucose tolerance
ADA/NIDDK. Diabetes Care. 2004;27(suppl 1):S47-S54;
ACE Consensus Statement. Endocr Pract. 2002;8(suppl 1):5-11
 Prevention of Type 2 Diabetes
Lifestyle Intervention
Nutrition
Seek 5% to 7% weight reduction
(50% and 43% achieved this in Diabetes Prevention Program
and Finnish trials, respectively)
<30% calories from fat

Physical activity
Moderate exercise, 150 to 210 min/week
(equivalent to 30-min sessions 5 to 7 days/week;
74% and 86% achieved this in Diabetes Prevention Program
and Finnish trials, respectively)

DPP Research Group. N Engl J Med. 2002;346;393-403;

Tuomilehto J et al. N Engl J Med. 2001;344:1343-1350
Obtain genetic information and
medical history
When treating obese children, clinicians should
obtain a thorough family history in order to identify
the presence of any of these high-risk ethnicities.

It is also helpful to have a history of any genetic

and endocrine disorders that may be present,
such as Prader-Willi syndrome, Down's syndrome,
Cushing's disease, pseudohypoparathyroidism, or
hypothyroidism.

A strong positive family history for diabetes is

cause for concern that an obese child may
progress more rapidly to development of diabetes.
The family history should include psychiatric as well
as medical issues, because there is an increased
incidence of depression in the obese, and this
condition may either precede or follow the
development of obesity.

Certain medicines, including psychotropics (e.g.,

resperidol and other second-generation antipsychotic
medications), contraceptives (e.g.,
medroxyprogesterone acetate), antiepileptics (e.g.,
valproic acid or gabapentin), and anti-inflammatory
agents (e.g., prednisone), can predispose individuals
to increased weight gain.

A careful review of all prescribed medicines and their

potential side effects is always indicated. Over-the-
counter medicines and herbal products should be
included in this comprehensive history.
Counsel about comorbid conditions

Though scare tactics are not a wise strategy for

patient care, it is important to educate parents
and older pediatric patients about comorbid and
premorbid conditions associated with abnormal
weight gain. In presenting the list of comorbid
conditions to pediatric patients and their families,
clinicians should explain that their goal is not to
frighten them, but rather to inform them that
obesity is a serious disease and that it is
associated with other very serious diseases
 Monitor BMI regularly
A BMI >85th percentile but < the 95th percentile is
considered overweight, whereas a BMI >95th
percentile is considered obese. These are
standardized for age and sex by Centers for Disease
Control and Prevention growth curves.
In a study by Beeman et al.,19 neither parents,
nurses, resident physicians in training, nor attending
physicians could accurately assess whether a child
was overweight by appearance alone. This
underscores the need for regularly measuring and
tracking BMI.
http://www.cdc.gov/nccdphp/dnpa/growthcharts/training/modules/modu
les.htm
Address diet and exercise issues
throughout childhood
Breastfeeding.
Clinicians should encourage breastfeeding of infants because it helps
prevent obesity in infancy and offers a protective factor against obesity
(and possibly cardiovascular disease) in later childhood. A 60% increase
in obesity has been observed in children who are not breastfed.

Sweets in infancy.

40% had received sweets daily by the age of 78 months and 70% had
received them by the age of 1518 months. By the age of 2 years, 43% of
infants are given soft drinks daily. One can of nondiet soft drink contains
150 calories, the equivalent to 10 teaspoons of sugar. Soft drinks also
displace nutrient-rich milk in the diets of children who drink them.
Vending machines in schools.
One of the most detrimental and ubiquitous additives found in snack
foods is the sweetener high fructose corn syrup, which is used in
place of or in addition to sucrose. Although it is classified as a
carbohydrate, high fructose corn syrup is metabolized as a fat.

Family meals and family activity.

An important preventive factor for the entire spectrum of eating
disorders from obesity to anorexia nervosa. Family meals have been
shown to reduce unhealthy eating patterns, including binge eating
disorder, which is seen in a high percentage of overweight people,
because emotional needs for nurturing are met through meaningful
family interaction in a pleasant and relaxed setting.

Families should also be encouraged to be physically active together.

Individualized nutrition and exercise plans Simple diet sheets
with calorie counts are not recommended for obese pediatric
patients. Instead, nutrition education must be individualized and
focused on the entire family.

Physical activity is a vital component of obesity prevention. But

when it comes to exercise, one size does not fit all.
Address the psychological aspects of obesity
Motivation. When patients lack the desire to
effect what often can be radical lifestyle
changes, nothing can be accomplished.

Depression. Challenging to Diagnose in

Paediatrics. The authors have identified a
condition they call Paliacchi syndrome, or
smiling depression, seen predominantly in
overweight individuals who act as "class
clowns" but inside are experiencing intense
emotional pain. Depression also can lead to
overeating, both for biological reasons (i.e.,
efforts to increase serotonin levels) and to
provide emotional comfort.
Eating disorders. The incidence of binge eating,
including binge eating disorder, is increased among
the overweight and obese .
According to Eaton et al.,40 "numerous studies have
found that adolescents with unhealthy weight
control practices are at increased risk for suicidal
ideation, suicide attempts, and death by suicide." A
recent study of U.S. high school students with
perceived high BMI showed increased suicidal
ideation and attempts.40

Media Counseling. Educating and counseling

families of obese children about their media use is
vital. Excessive use of the Internet, television, and
electronic games contributes to a sedentary lifestyle
and can have negative psychological effects on
children. Rich also reported that 8- to 18-year-olds
spend an average of 6 hours and 43 minutes per day
using mediamore time than they spend in school
or with parents
Work within the community.
The need for a multidisciplinary team approach in
preventing childhood obesity cannot be stressed
enough.

Homes, grocery stores and restaurants.

The information they need on food labels is essential.
Products labeled "no fat" may well be high in calories or
contain high fructose corn syrup. Those labeled "low
calorie," may be high in harmful fats.

Community resources and initiatives.

Disseminate a list of community resources for the
families of obese children.
Provide parents with simple
recommendations and advice
Create a daily schedule with regard to eating,
physical activity, homework, and bedtime.
Decreased sleep leads to insulin resistance and
decreased serotonin levels, which in turn cause
carbohydrate craving and exacerbate depression.
Lack of sleep also increases ghrelin and
decreases leptin, thus stimulating the appetite
and decreasing satiety.
Eat three meals and one to two snacks each day,
finishing each meal in 3045 minutes and never
eating in front of the television or computer.
Eat as many meals as possible together as a
family, with wholesome food choices and positive
family interactions.
Portion sizes are critical and should be monitored
carefully. For overweight children, a food and
exercise log is recommended.
Read food labels carefully with regard to both
portion size51 and content. Avoid high fructose
corn syrup. Decrease portion sizes of starchy
foods, such as rice, potatoes, bread, and pasta.
Include more colorful vegetables.
Choose whole-wheat or other whole-grain breads.
When children want "seconds," have them choose
only one item (not one serving of each item) from
the meal before adding any additional food.
Perhaps that one extra food might be a glass of
skim milk, fruit, or a vegetable. These are also
ideal bedtime snacks if the child is hungry before
sleeping.
Children 12 years of age should be given whole or 2%
milk to aid in myelination of the nervous system. Older
children should drink nonfat milk. Younger children
require 2 cups of milk per day, and adolescents need 3
cups per day to meet their daily recommended calcium
requirements. Lactose-free milk is an option for milk-
intolerant children, and yogurt and cheese might also
be substituted.
It is now being recognized that the daily recommended
amount of vitamin D may not be adequate. As a
safeguard, children should have daily careful exposure
to sunlight as well as foods fortified with vitamin D.
Limit saturated fats, such as butter, margarine, chicken
skin, bacon, and sausage. Oils such as olive, canola,
and peanut are to be used in moderation, and lean
meats are preferred over fatty ones. These should be
steamed, broiled, baked, or grilled, but not fried. In
order to increase cardio-protective omega-3 fatty acids,
certain nuts (almonds and walnuts, preferably unsalted)
and fish (salmon, light tuna, catfish, or shrimp) should
be included.
Season foods with herbs and spices rather
than sugar, salt, and fat. Salt is an
acquired taste. Do not add salt to any
foods offered to infants.
Because thirst and fatigue can be
mistaken for hunger, offer children water
or fat free milk if they complain of hunger
between meals.
Strictly limit or reserve for special occasions
foods of low nutritional value, including cakes,
cookies, candies, chips, French fries, and
sugared beverages.
Limit fast food and processed or prepared food
such as TV dinners to no more than once a week.
Also, prepare school lunches at home, including
only unprocessed foods such as apples, carrots,
and skim milk and avoiding excessive saturated
fat and carbohydrates. Good desserts might
include fruit, sugar-free jello or pudding, and
canned fruits drained of any syrup.
Ration sugary, fatty treats at holidays and discard
leftovers, including candies with a long shelf life,
after 35 days.
Discourage eating in the car, giving only water to
drink while in transit.
Avoid using food as a reward.
Get daily physical activity. Younger children
should walk or play outside for at least 30
minutes a day, and older children need at
least an hour of physical activity, perhaps
including indoor activities such as video
games featuring dancing or exercising.52
Limit media use to < 1 hour/day. This
includes watching television, talking on the
phone, playing sedentary video games, and
using the computer other than for homework
assignments. These media should not be
available in children's bedrooms.
Encourage active parenting
Children need parents, not buddies. Health care providers should
call on parents to reclaim their roles as those in charge of and
responsible for their children. Children mirror the behaviors of their
parents.

Children of affluent families can face equally challenging problems,

however. Despite abundant material resources, they may not have
proper parenting with regard to nutrition, exercise, and high-risk
behaviors or may suffer from "affluenza,"55 or overindulgence
resulting in insatiability. Often, these children become detached from
self-absorbed parents who have not properly focused on their
children's emotional and spiritual needs. Personal responsibility is
not fostered in a materialistic environment of immediate gratification.
This results in families' desires for a magic cure or easy prevention
strategy and lack of willingness to focus on a disciplined and
balanced lifestyle plan.
So what do we know, and what can we do?

We know that overweight adolescents are at high

risk of becoming obese adults. We know that this is
a problem that may begin in utero, and insulin
resistance and oxidative endothelial cell damage are
basic to the disease. We know that obesity is a
disease of all ages and all nationalities, not just
those with thrifty genes.

The morbidity and mortality associated with this

pandemic and their concomitant costs are
monumental, with the potential of bankrupting the
health care delivery and Social Security disability
systems if the situation is not curbed. Human
suffering associated with obesity further feeds the
epidemic through depression, resulting lack of
motivation to change, increased emotional eating
and social isolation, and decreased physical activity.
Hopelessness prevails among health care
professionals trying to care for these patients.
Their lament: "Nothing works."And indeed, there
is little evidence thus far for success, at least not
in the long term. There is an extreme paucity of
evidence-based study, but the few trials
reporting success, albeit short term, are
multidisciplinary, involving psychological, dietary,
and exercise components.
The American Academy of Pediatric policy statement on
prevention of childhood overweight and obesity focuses on
health supervision and advocacy in bringing about desperately
needed societal changes. This statement calls for
individualization of the plan for each child within the broader
context of societal reforms related to issues ranging from vending
machines to safe playgrounds to sound public health policies.
Also suggested are advocacy efforts to obtain reimbursement for
delivery of preventive medical care and education and funding for
further research.

The power of health care professionals to impact the lives of their

patients cannot be overstated. When careful compassionate
words create an informed, positive environment, this voice is
heard above the media din, and the self-fulfilling prophecy of
hope37 can begin its mission. We must be optimistic enough to
believe in the ability of people to change and heal. Despite
occasional steps backward, meaningful and permanent lifestyle
changes can be effected. If we do not believe this to be so, neither
will our patients.