Ueda2015 prevention of obesity dr.mohamed abuel-ghate

1. Prevention of Obesity Prof. Dr. Mohamed Aboulghate Professor, Cairo University Secretary General, Egyptian Medical Association for the Study of Obesity

2. Introduction Comorbidities Causes Prevention

3. What is Obesity  Obesity is the disease in which fat has accumulated to such an extent that health may be adversely affected  Obesity is a chronic relapsing disease (WHO 1997) Introduction Comorbidities Causes Prevention

4. Diagnosing Obesity Weight (kg) Height (m) x Height (m) BMI = Adult Under 5 5-19 Overweight 25-29.9 > 2 SD above the WHO growth standard median > 1 SD above the WHO growth standard median Obese ≥ 30 > 3 SD above the WHO growth standard median > 2 SD above the WHO growth standard median Introduction Comorbidities Causes Prevention

5. Prevalence of Obesity Introduction Comorbidities Causes Prevention

6. “Obesity, the epidemic of the 21st century” World Health Organization Introduction Comorbidities Causes Prevention

9. Obesity in Egypt Overweight Obese 5-9 20.5 15.1 10-14 28.4 9.9 15-19 25.2 4.9 Men 58.8 (53.6-64.0) 22.4 (19.9-24.8) Women 66.2 (59.9-72.5) 41.6 (35.5-47.7) Introduction Comorbidities Causes Prevention

10. Complicationsof Obesity

11. Complications of obesity Introduction Comorbidities Causes Prevention

12. Wolf et al 1998 Introduction Comorbidities Causes Prevention Type 2 DM 61% Hypertension 17% Coronary Heart Disease 30% Gallbladder disease 30% Osteoathritis 24% Brast cancer 11% Endometrial cancer 34% Colon cancer 11% Proportion of disease prevalence attributable to obesity

13. Willett et al 1999 Introduction Comorbidities Causes Prevention

14. Chan et al 1994 Introduction Comorbidities Causes Prevention

15. Diabetes vs Waist Circumference & BMI <25 25-30 >30 0 5 10 15 20 <84 84-92 92-99 99-107 >107 <25 25-30 >30 BMI Waist circumference (cm) Diabetesprevalence)%( Balkau et al. 2007 Introduction Comorbidities Causes Prevention

16. Health Benefits of Weight and Visceral Fat Reduction • A 2.5 cm decrease in WC is associated with improvement in:  Glucose control  Blood pressure  Lipid levels • Modest weight loss (2-3%) is associated with improvement in clinical markers  Fasting plasma glucose: -3.8 mg/dl Triglycerides: -29.2 mg/dl SBP: -1.1 mmHg DBP: -1.3 mmHg Noria et al. 2004 Introduction Comorbidities Causes Prevention

17. Causes of Obesity

18. Causes of Obesity Disturbed Energy Balance •Energy Input (Diet) • Energy Output (Physical activity) Body Predisposition •Genes •Prenatal Influences •Childhood influences Introduction Comorbidities Causes Prevention

19. Balanced, Healthy, Eucaloric Diet  Fats: Unsaturated  Dairy: Skimmed  Protein: Lean  Carbohydrates: Complex  Choose minimally processed, whole foods— whole grains, vegetables, fruits, nuts, healthful sources of protein (fish, poultry, beans), and plant oils.  Limit sugared beverages, refined grains, potatoes, red and processed meats, and other highly processed foods, such as fast food. Energy Balance - Diet My Plate, USDA 2011 Introduction Comorbidities Causes Prevention

20. Energy Balance - Physical Activity • Increases total energy expenditure • Decreases fat around the waist and total body fat, slowing the development of abdominal obesity. • Builds muscle mass, increasing BMR • Reduces depression and anxiety, which may motivate people to stick with their exercise regimens over time. U.S. Dept. of Health and Human Services 2008. Introduction Comorbidities Causes Prevention

22. • Single Gene Mutations : Rare forms of obesity eg. genes that code for the hormone leptin • Multiple Genes Variations: Common Obesity More than 30 candidate genes on 12 chromosomes have been associated with BMI Genes O’Rahilly 2009; Heid 2010 Introduction Comorbidities Causes Prevention

24. • Maternal Smoking During Pregnancy: 50% higher risk of childhood obesity • Gestational Weight Gain: 4 times the risk of being overweight • Gestational Diabetes Increased risk of obesity and overweight Pre-natal Influences Oken 2008; Oken 2007; Ludwig 2010; Hillier 2007 Introduction Comorbidities Causes Prevention

26. • Rapid Weight Gain:  higher risk of later obesity • Breastfeeding:  13-22% reduced risk of obesity • < 12 hours sleep  double the odds of being overweight at age 3 Childhood Influences • In 2008, a study conducted on 1,100 mother–child pairs: – Maternal smoking during pregnancy – gestational weight gain – duration of breastfeeding – infant sleep All variables +ve All -ve % obese at age 3 6% 29% Baird 2005; Arenz 2004; Owen 2005; Taveras 2008 Introduction Comorbidities Causes Prevention

27. Causes of Obesity Disturbed Energy Balance •Energy Input (Diet) • Energy Output (Physical activity) Body Predisposition •Genes •Prenatal Influences •Childhood influences The Obesogenic Environment Introduction Comorbidities Causes Prevention

28. The Obesogenic Environment • Families: – Excess gestational weight gain – Increased smoking among women – Food choices (convenience, affordability, preferences and tradition) – Less breast feeding (women entering work-force) – Electronic leisure (TV, computers, internet, videogames) – Household applinces(washing machines, vacum cleaners, microwaves) • Worksite: – Accessible unhealthy food – Automation – Office jobs (mental vs physical) – Work stress – Lunch break culture – On-site PA facilities Introduction Comorbidities Causes Prevention

29. The Obesogenic Environment • Schools: – Junk food and sweetened beverages – Peer-pressure – Few PE sessions – Unequipped PA facilities • Neighborhood: – Greater access to stores and fast food outlets – Scarcity of safe, appealing walking paths, parks, PA facilities – Inconvenience of public transportation • Food marketing Introduction Comorbidities Causes Prevention

31. Prevention of Obesity

32. Prevention 1- Families • Avoid excess gestational weight gain • Smoking cessation • Breast feeding • Weight monitoring • Healthy food at home (pre-meal snacks, air fryers) • School meals • Physical activity • Role models Introduction Comorbidities Causes Prevention

33. Prevention 2- Nurseries and child care • Age-appropriate healthy foods • Active play, in fun, short bursts • Keeping televisions turned off and away from areas where children sleep. • Educating parents about healthy eating and activity habit Introduction Comorbidities Causes Prevention

34. Prevention 3- Schools • PA sessions • Healthy food choices • Limiting availability and marketing of unhealthy foods • Health education of students Introduction Comorbidities Causes Prevention

35. Prevention 4- Health Care Systems 1. Health Care Providers a. Paediatricians b. Obstetricians c. Internists 2. Hospitals 3. Health Care Funders/Insurers 4. Health Care Training Institutions Introduction Comorbidities Causes Prevention

36. The Role of Health Care Providers Harvard School of Public Health: Recommendations for Obesity Prevention by Health Care Providers Introduction Comorbidities Causes Prevention

37. Paediatrics • Measure patients’ BMI percentile for age at every well-child visit for children ages 2 and older; for younger children, measure weight-for-length percentile • Counsel all patients and their families on healthy eating, physical activity, and healthy growth, regardless of current weight status • Counsel all patients and their families to limit television time to no more than two hours per day and to remove televisions from children’s bedrooms • Counsel all patients and their families to limit consumption of sugar-sweetened beverages and encourage other healthful eating behaviors: – Eating breakfast daily – Limiting restaurant eating, especially fast-food restaurants – Eating meals as a family – Limiting portion sizes • Counsel all patients and their families to help children achieve 60 minutes of moderate to vigorous physical activity per day • Establish procedures for follow-up assessment (including laboratory tests), counseling, and treatment plans for children who are overweight or obese • Establish policies to avoid weight bias in pediatric clinics, such as by requiring all employees to be trained on weight-bias prevention Introduction Comorbidities Causes Prevention

38. Obstetrics, Pre- and Post-natal care • Counsel patients on the importance of being at a healthy weight before pregnancy and gaining weight at a healthy rate during pregnancy • Recommend that mothers breastfeed and provide training and support for breastfeeding • Counsel patients on the importance of avoiding smoking during pregnancy • Screen pregnant women for gestational diabetes Introduction Comorbidities Causes Prevention

39. Internal Medicine • Routinely measure BMI in all adult patients • Order appropriate follow-up laboratory tests for patients who are overweight and obese and prescribe a long-term treatment strategy, which may include: – Counseling/coaching/behavioral interventions on diet/lifestyle change – Weight loss medication for appropriate individuals who have been unable to lose weight through conventional therapy and who have no contraindications – Bariatric surgery for patients with severe obesity unable to lose weight through conventional therapy and who have no contraindications • Design physician offices to avoid stigmatizing overweight or obese patients, such as by providing private weighing areas and using scales that can measure weights greater than 300 pounds Introduction Comorbidities Causes Prevention

40. Weight gain with conventional T2D therapies Kahn et al 2000 84 86 88 90 92 94 96 98 0 0.6 1.2 1.8 2.4 3 3.6 4.2 4.8 Roziglitazone Metformin Glibenclamide 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 10 11 12 Conventional (n=411) Glibenclamide (n=277) Metformin (n=342) Insulin (n=409) Weight(Kg) Changeinweight(Kg) Years Years 1 2 3 4 5 Introduction Comorbidities Causes Prevention

41. Potential mechanisms behind insulin-induced weight gain •Treatment induced reduction of renal glycosuria •Changes in energy metabolism (5-10%) •Defensive snacking •Reduced satiety signaling in arcuate nucleus •General anabolic effect of insulin •Non-physiological pharmacokinetics Introduction Comorbidities Causes Prevention

42. Liraglutide: A T2D-therapy, now approved for weight loss 0 10 20 30 40 50 60 Liraglutide 3.0mg Liraglutide 1.8mg Placebo >5% weight loss >10% weight loss Davies et al 2014 Introduction Comorbidities Causes Prevention

43. Liraglutide •Liraglutide 3.0 was superior to liraglutide 1.8 and placebo with respect to mean and categorical weight loss •Liraglutide 3.0 also provided significantly greater improvements in HbA1c vs. placebo •More overweight/obese individuals with liraglutide 3.0 mg vs. liraglutide 1.8 mg and placebo reached HbA1c target of <6.5% •Liraglutide was generally well tolerated •No differences between liraglutide 3.0 and 1.8 mg were noted in safety/tolerability, except for gastro-intestinal adverse events Davies et al 2014 Introduction Comorbidities Causes Prevention

44. Healthy Hospitals • Encourage healthy eating • Offer healthy food • Promote breastfeeding Introduction Comorbidities Causes Prevention

45. Health Insurance Providers • Cover obesity-related conditions • Incentivise healthy behaviors • Fund obesity prevention efforts Introduction Comorbidities Causes Prevention

46. Health Care Professional Training • Provide training in obesity prevention and lifestyle counseling, such as – Interpreting BMI percentile for age – Counseling on nutrition and physical activity – Motivational interviewing skills • Distribute position statements and other evidence- based information on obesity prevention • Encourage members to be role models for healthy eating and activity Introduction Comorbidities Causes Prevention

47. Prevention 5- Worksites • Onsite PA facilities and changing rooms • Access to nutritionists and other counselors • Worksite or company-wide policies that provide healthier food options • Reimbursing exercise-related expenses Introduction Comorbidities Causes Prevention

48. Prevention 6- Local and national policy • Agriculture policy: Planting and buying of fresh fruits and vegetables • Revenue policy: Taxing unhealthy foods and subsidizing healthy choices • Zoning regulations: Bringing supermarkets to low-income neighborhoods and limiting fast-food restaurants • Mass-communication policy: Restricting advertising to youth about unhealthy food • Food regulations: Standerdising food labelling to include calorie-per- serving and recommended daily limits • Public health marketing: Developing social marketing campaigns to promote healthy living • Community design: Planning to promote active transportation. Build, maintain and increase access to walk/cycle paths, parks and recreation facilities • Transportation: Improving infra-structure for public transportation Introduction Comorbidities Causes Prevention

52. Thank you Prof .Dr. Mohamed Aboulghate Professor, Cairo University Secretary General, Egyptian Medical Association for the Study of Obesity

Ueda2015 prevention of obesity dr.mohamed abuel-ghate

Ueda2015 prevention of obesity dr.mohamed abuel-ghate

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