It s just puppy fat Tackling obesity in children and adolescents

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1 It s just puppy fat Tackling obesity in children and adolescents Webinar, SPH, Usyd, September 2013 Louise A Baur University of Sydney: Discipline of Paediatrics & Child Health, Sydney Medical School, and Sydney School of Public Health The Children s Hospital at Westmead: Weight Management Services

2 Descriptions of obesity one of today s most blatantly visible yet most neglected public health problems the public health equivalent of climate change (Lang T, Rayner G. Obes Rev 2007; 8(Suppl 1): ) the Millennium Disease aboutiotf/

3 ! What I will cover in a whirlwind tour: How much of a problem is child/adolescent obesity? Prevalence globally, in Australia, in health systems, waist vs BMI Treating those who are already affected by obesity Chronic disease care pyramid Early childhood obesity prevention The Healthy Beginnings Trial

4 So, how much of a problem is childhood obesity? Global prevalence

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9 Like many other countries, obesity prevalence in children and young people in Australia is high

10 For a 100 year view of what has been happening to the prevalence of obesity in Australian children

11 Norton K et al, Int J Pediatr Obes : Prevalence of overweight and obesity for 5-15 yr old Australian children 40 % overweight or obese What happened in the 1980s? raw data all data Year

12 Over the past 25 years in school-aged children

13 Prevalence of combined overweight and obesity in 5-15 year olds in New South Wales based on body mass index (BMI) Percentage overweight and obesity Males Females Trends Hardy LH et al 2012; International Obesity Taskforce (IOTF) cutpoints

14 Prevalence of combined overweight and obesity in 5-15 year olds in New South Wales based on body mass index (BMI) Percentage overweight and obesity Currently: 1 in 4 children & adolescents overweight or obese For obesity alone: 6-8% affected Is it now plateauing? Males Females Trends Hardy LH et al 2012; International Obesity Taskforce (IOTF) cutpoints

15 But it seems that waistlines (abdominal obesity) are changing more rapidly than overall obesity

16 Changing BMI and waist for Australian children aged 7-15 years: 1985 to 2007 Garnett SP et al, Obes Rev 2011

17 BMI z-score 7 to 15y Median Percent BMI z-score Z scores calculated using CDC 2000 Garnett SP et al, Obes Rev 2011

18 BMI z-score 7 to 15y Median Percent BMI z-score Z scores calculated using CDC 2000 Garnett SP et al, Obes Rev 2011

19 BMI z-score 7 to 15y Median Percent BMI z-score Z scores calculated using CDC 2000 Garnett SP et al, Obes Rev 2011

20 BMI z-score 7 to 15y % 25 20% 20 Median 10% 13% 12% 22% 22% 25% 27% Percent % children with a BMI >85 th centile Girls Boys BMI z-score Z scores calculated using CDC 2000 Garnett SP et al, Obes Rev 2011

21 Waist to height ratio 7 to 15y Percent 15 Median WHtR Garnett SP et al, Obes Rev 2011

22 Waist to height ratio 7 to 15y Percent 15 Median WHtR Garnett SP et al, Obes Rev 2011

23 Waist to height ratio 7 to 15y Percent Median WHtR Garnett SP et al, Obes Rev 2011

24 Waist to height ratio 7 to 15y % 25 10% 18% 18% 20 6% 9% 7% 9% 9% 14% 14% Percent Median % children with WHtR Girls Boys WHtR Garnett SP et al, Obes Rev 2011

25 Waist to height ratio 7 to 15y % Percent Is there a disjunction between waist circumference / waist:height ratio Median (abdominal obesity) and BMI (overall body fatness)? % 6% 9% 7% 9% 9% 14% 14% 18% 18% % children with WHtR 0.5 Girls Boys WHtR Garnett SP et al, Obes Rev 2011

26 And obese children and adolescents are presenting often to the health system

27 In Australia, of every 200 children presenting to their family doctor, 60 are overweight or obese (23 obese) and 1 is offered weight management intervention BEACH data set, Annual national random survey of 1,000 family doctor surgeries (data on 100 consecutive patients, of all ages); , >40,000 children aged 2-17 years, Self-reported heights & weights; Cretikos M et al, Medical Care 2008; 46: ; background prevalence of O&O

28 In Australia, of every 200 children presenting to their family doctor, 60 are overweight or obese (23 obese) and 1 is offered weight management intervention BEACH data set, Annual national random survey of 1,000 family doctor surgeries (data on 100 consecutive patients, of all ages); , >40,000 children aged 2-17 years, Self-reported heights & weights; Cretikos M et al, Medical Care 2008; 46: ; background prevalence of O&O

29 In Australia, of every 200 children presenting to their family doctor, 60 are overweight or obese (23 obese) and 1 is offered weight management intervention BEACH data set, Annual national random survey of 1,000 family doctor surgeries (data on 100 consecutive patients, of all ages); , >40,000 children aged 2-17 years, Self-reported heights & weights; Cretikos M et al, Medical Care 2008; 46: ; background prevalence of O&O

30 In Australia, of every 200 children presenting to their family doctor, 60 are overweight or obese (23 obese) and 1 is offered weight management intervention So, overweight & obese children and adolescents present frequently to primary (secondary & tertiary) care in Australia but they aren t usually treated for the problem BEACH data set, Annual national random survey of 1,000 family doctor surgeries (data on 100 consecutive patients, of all ages); , >40,000 children aged 2-17 years, Self-reported heights & weights; Cretikos M et al, Medical Care 2008; 46: ; background prevalence of O&O

31 What can be done to treat those already affected by obesity?

32 Obesity and the chronic disease care pyramid Tertiary care facilities & special obesity clinics; specialist teams; key worker case manages & joins up care Level 3 Complex patients Case management Secondary level care facilities; multidisciplinary teams; group programs Level 2 High risk patients Care management Self-care supported by primary care doctors, other primary care, group programs Level % of overweight/obese patients Self-care & community based care Primary prevention & health promotion

33 Obesity and the chronic disease care pyramid Tertiary care facilities & special obesity clinics; specialist teams; key Services at all worker case manages & joins up care levels are needed Secondary level care facilities; multidisciplinary teams; group programs Level 3 Level 2 High risk patients Care management Complex patients Case management Self-care supported by primary care doctors, other primary care, group programs Level % of overweight/obese patients Self-care & community based care Primary prevention & health promotion

34 Issues in health service delivery Many services are disjointed, with little coordination between and across regions and levels of care Paediatric obesity and its cardio-metabolic complications are new morbidities for most paediatric health care services Most health professionals are poorly trained in managing paediatric obesity and its complications Issues of equity and access to services for affected individuals eg only 3 of 6 states in Australia have a multidisciplinary tertiary service*; many services have long waiting lists (e.g. up to 12 months); similar situation in NZ, in parts of the USA, and probably many other countries. * Spilchak et al, J Paediatr Ch Health 2008

35 Obesity and the chronic disease care pyramid some of the RCTs undertaken RESIST + health professional education strategies Metformin Trial Level 3 Level 2 High risk patients Care management Level % of o wt/obese patients Self-care & community based care Primary prevention & health promotion

36 Tertiary care facilities & special obesity clinics; specialist teams; key worker case manages & joins up care Level 3 Complex patients Case management Secondary level care facilities; multidisciplinary teams; group programs Level 2 High risk patients Care management Self-care supported by primary care doctors, other primary care, group programs Level % of overweight/obese patients Self-care & community based care Primary prevention & health promotion

37 Preventing obesity in early childhood

38 The Healthy Beginnings Trial A staged, home-based early intervention in the first two years Delivered by early childhood nurses Aim: To compare the effect of a home-based early intervention for first-time mothers with newborn babies, versus usual care, on: At age 6 & 12 months: Breastfeeding At age 2 years: BMI, child and family eating patterns, TV viewing, physical activity Delivered in southwestern Sydney some of the most socially & economically disadvantaged areas of Sydney Funded by NHMRC x 2

39

40 Results of the Healthy Beginnings Trial At 12 months: Improvements in breastfeeding and other aspects of infant feeding At 24 months: Improvement in fruit & vegetable intake Decreased TV time Improvements in maternal food and physical activity AND Decreased BMI Wen LM et al, Arch Pediatr Adol Med 2011; Wen LM et al, BMJ y BMI distributions of children at 2 years old by treatment P<0.04, ITT analysis blue/dash -- for control. red/solid -- for intervention equivalent to adult BMI 25. First study to show an impact of an intervention on BMI in early life and the first to address home visiting on obesity in early life

41 So, what now? Follow-up at ages 3.5 and 5 years with costeffectiveness analyses (LM Wen et al) Pilot study in Shanghai just finishing use of SMS and phone calls to support pregnant women and new mothers (M Li et al) Early Prevention of Obesity in CHildhood (EPOCH) prospective meta-analysis (L Askie et al) Combining individual patient data from 4 Australasian early intervention trials. Approximate n=2000 at age 2 years; will allow sufficient sample size to look at changes in obesity prevalence rates

42 Summary Child & adolescent obesity Globally prevalent, with the Asia-Pacific region affected Plateauing in Australia and some other countries? Central adiposity may be worsening Treating those who are affected Affected children & adolescent present frequently to health care facilities but are rarely treated for it Many barriers to provision of clinical care Early childhood obesity prevention Healthy Beginnings Trial provides evidence that early intervention may be important in obesity prevention Many unanswered questions cost-effectiveness?, other modes of delivery?, how early is necessary?

43 A final comment!

44 Societal policies and processes influencing the population prevalence of obesity INTERNATIONAL FACTORS NATIONAL/ REGIONAL COMMUNITY LOCALITY WORK/SCHOOL/ HOME INDIVIDUAL POPULATION Transport Public Transport Leisure Activity/ Facilities Globalization of markets Development Media programs & advertising National perspective Urbanization Health Social security Media & Culture Education Food & Nutrition Public Safety Health Care Sanitation Manufactured/ Imported Food Agriculture/ Gardens/ Local markets Labour Infections Worksite Food & Activity Family & Home School Food & Activity Energy Expenditure Food intake : Nutrient density % OBESE AND OVER- WEIGHT Most of the focus on childhood obesity interventions has been in this domain Modified from Ritenbaugh C, Kumanyika S, Morabia A, Jeffery R, Antipatis V. IOTF website 1999:

45 Societal policies and processes influencing the population prevalence of obesity INTERNATIONAL FACTORS NATIONAL/ REGIONAL Transport COMMUNITY LOCALITY Public Transport The challenge will be in WORK/SCHOOL/ tackling INDIVIDUAL the upstream POPULATION HOME determinants of obesity Leisure Activity/ Facilities Globalization of markets Development Media programs & advertising Urbanization Health Social security Media & Culture Education Public Safety Health Care Sanitation Manufactured/ Imported Food Labour Infections Worksite Food & Activity Family & Home Energy Expenditure Food intake : Nutrient density % OBESE AND OVER- WEIGHT Food & Nutrition Agriculture/ Gardens/ Local markets School Food & Activity National perspective Modified from Ritenbaugh C, Kumanyika S, Morabia A, Jeffery R, Antipatis V. IOTF website 1999:

46 Acknowledgements Members of The Children s Hospital at Westmead Weight Management Services team, and the CHW Obesity Research Group PIs, CIs and members of the following research teams: Healthy Beginnings, HIKCUPS, LEAP, Metformin trial, PEACH, RESIST, Loozit Specific CHW, USyd & SSWAHS colleagues: Dr Shirley Alexander, A/Prof Lisa Askie. Prof Adrian Bauman, Prof Ian Caterson, Prof Chris Cowell, Dr Sarah Garnett, A/Prof Tim Gill, Dr Louise Hardy, Ms Lesley King, A/Prof Mu Li, Prof Chris Rissel, Prof Kate Steinbeck, Dr Li Ming Wen.. Members of the Prevention Research Collaboration at the University of Sydney Members of the Australasian Child & Adolescent Obesity Research Network International Association for the Study of obesity

47 Thank you Acknowledgements Members of The Children s Hospital at Westmead Weight Management Services team, and the CHW Obesity Research Group PIs, CIs and members of the following research teams: Healthy Beginnings, HIKCUPS, LEAP, Metformin trial, PEACH, RESIST, Loozit Specific CHW, USyd & SSWAHS colleagues: Dr Shirley Alexander, A/Prof Lisa Askie. Prof Adrian Bauman, Prof Ian Caterson, Prof Chris Cowell, Dr Sarah Garnett, A/Prof Tim Gill, Dr Louise Hardy, Ms Lesley King, A/Prof Mu Li, Prof Chris Rissel, Prof Kate Steinbeck, Dr Li Ming Wen.. Members of the Prevention Research Collaboration at the University of Sydney Members of the Australasian Child & Adolescent Obesity Research Network International Association for the Study of obesity

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