Managing Obesity: The REALities

Striking a Balance... Weigh in with Knowledge, Research, Practice SYMPOSIUM

September 30th 2013

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

Obesity is Defined as BMI > 95th%

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

Limitations of BMI

BMI= 32 kg/m2 BMI= 21 kg/m2

Obesity is….

• A sign or symptom• A disorder of energy balance

• Adaptive/ Maladaptive?

• A risk factor for disease• Modifiable through health behaviours

Obesity is not….

• A sensitive indicator of health

• A sensitive indicator of health behaviours

• A character flaw

• A lack of will power

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

Obesogenic Environment

Obesogenic behaviours

Weight Gain

Weight Stable

Weight Gain &Co-morbidities

Sensitivity to obesogenic environments and behaviours modified through genetic and pre-natal programming

Beyerlein et al, PLoS one (2011)

Digging Deeper

Connectednesselectronic

virtual

Time pressuresmore work hours

sleep lesscook less

increased stress

Income Inequalityfood insecurity

neighbourhood safety

Economic Policyurban sprawl

agricultural subsidiesfood industry

media/advertising

Our Way of LifeSocietal Values

Whitaker R, Arch Pediatr Adol Med (2011)

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)

A Lot on My PlateJack Lightfoot aka Heavyhand

Neuroendocrine Control of Energy Balance

Science, Feb 7, 2003

Neuroendocrine Differences: Lean vs. Obese

PYY3-36

Batterham, R. L. et. al. N Engl J Med 2003;349:941-948

Leptin

Hormonal Adaptations to Weight Loss: Ghrelin

Cummings, D. E. et. al. N Engl J Med 2002;346:1623-1630

Hormonal Adaptations to Weight Loss: Leptin

Decrease in Body Weight

Decreased Energy

Expenditure

Increased Energy

Conservation

Additional weight loss can only be achieved by a more severe diet and further increases in

physical activity

Katan B et al JAMA (2010)

Debunking Some Myths

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)

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)

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)

Abdulla J et al. Eur Heart J (2008)

Myocardial Infarction (MI)

Heart Failure (HF)

21,570 patients admitted for MI or HFAll 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

Edmonton Obesity Staging System (Kuk et al, 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)

Sharma AM & Kushner RF. Int J Obes 2009

Sharma AM & Kushner RF. Int J Obes 2009

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

Padwal R S et al. CMAJ (2011)

EOSS BMI Class

Survival Curves diverge when stratified by EOSS

score but not by BMI Class

Padwal R S et al. CMAJ (2011)

EOSS-prediction of all cause

mortality across BMI classes

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)

The Psychosocial REALities

What is it like for children and youth who have a higher

BMI?

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)

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)

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)

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)

THIN, THIN, THIN

MUSCLE, MUSCLE, MUSCLE

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

Weight Based Teasing and Discrimination

Youth Often Feel

• Angry• Frustrated• Sad• Helplessness• Hopelessness• Anxious• Worried

Families Often Feel

• Guilty• Helpless• Frustrated• Tired• A desire to try and fix or “control” things• A loss of trust with the youth

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

Mixed Messages in the Media around Food

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)

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

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)

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, sadnessIncreased weight over time

Negative Spiral

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

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

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

Bacon & Aphramor (2011)

The HAES ApproachThe 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

Key Principles

Key Principles

Obesity Management is About Improving Health and Well-

being, and not Simply Reducing Numbers on the Scale

Weight bias can be a barrier to weight management

Key Principles

Interventions should include addressing ‘root causes’ of

obesity and removing roadblocks for families to

make healthy changes

Key Principles

A Child’s ‘Best’ BMI May Never Be His or Her ‘Ideal’ BMI

Key Principles

Success is different for every child and family

Key Principles

The 4Ms of Pediatric Obesity

Mental

AnxietyDepressionBody image

ADHDLearning disorder

Sleep disorderEating disorder

Trauma

Mechanical

Sleep apneaMSK pain

Reflux diseaseEnuresis

EncopresisIntertrigo

Metabolic

IGT/T2DMDyslipidemiaHypertension

Fatty liverGallstones

PCOSMedication

Genetics

Milieu

Parent health/disabilityFamily stressorsFamily income

Bullying/StigmaSchool attendance

School supportNeighbourhood

safetyMedical insuranceAccessible facilitiesFood EnvironmentOpportunities for physical activity

ASSESS

Questions?

CHAL TeamDr. 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

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.

Severe Complex Obesity• BMI > 99th% AND/OR• Complications of obesity requiring subspecialty care

• Hyperlipidemia requiring pharmacotherapy• Hypertension requiring pharmacotherapy• OSA/Sleep Disordered Breathing• PCOS• NAFLD• T2DM/Persistent IGT

• Hypothalamic Obesity• Obesity Syndromes

Referral

Invitation to Information

Session

Full Day Assessment/Care

Plan

Treatment Options

Care Plan

REAL Program

Care CoordinationClinic visits to assess

readinessCommunity Resources

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?

What is the REAL ProgramPHASE 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)

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

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

Baseline Mental Health Concerns

Diagnosis Frequency

ADHD and/or LD 25.7%

Anxiety Disorder 24.2%

Developmental Delay/Autism 11.4%

Depression 11.4%

TOTAL 60%

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