1

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.