Overvekt og fedme hos barn og unge

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1 U N I V E R S I T E T E T I B E R G E N Overvekt og fedme hos barn og unge Pétur B. Júlíusson, Overlege og postdoktor Haukeland Universitetssykehus og Universitetet i Bergen Disposisjon Hvordan definere overvekt og fedme? Hvor mange barn har overvekt/fedme? Hvorfor er fedme et problem? Hvordan oppstår overvekt/fedme? Går det an å behandle overvekt/fedme? Norske retningslinjer 1

2 U N I V E R S I T E T E T I B E R G E N Hvordan definere overvekt og fedme? Hvordan definere overvekt og fedme? International Obesity Task Force (IOTF) Cole T et al. BMJ 2000;320: Cole T et al. BMJ 2007;335:166-7 WHO growth standard Acta Paediatrica 2006;95:suppl 450 Vekststudien i Bergen 2

3 Vekststudien i Bergen Vekststudien i Bergen KMI-kurver Kroppsmasseindeks (kg/m 2 ) 3

4 U N I V E R S I T E T E T I B E R G E N Hvor mange barn har overvekt og fedme? The Bergen Growth Study Comparisons of weight-for-height and triceps and subscapularis skinfold measurements between and , in children aged 4-15 years from the city of Bergen Júlíusson PB, Roelants M, Eide GE, Hauspie R, Waaler PE, Bjerknes R. Overweight and obesity in Norwegian children: Secular trends in weightfor-height and skinfolds. Acta Pædiatrica 2007;96: Cohort: 4115 healthy children aged 4-15 years, of Norwegian/Nordic origin Weight-for-height p Boys Mean increase (95% CI) 0.48 (0.34, 0.62) kg/m (p<0.001) 8% > 97.5 p from % > 90 p from % < 10 p from % < 2.5 p from Girls Mean increase (95% CI) 0.92 (0.77, 1.06) kg/m (p<0.001) Weight (kg) Height groups 7.2% > 97.5 p from % > 90 p from % < 10 p from % < 2.5 p from

5 Percentage > 97.5 p weight-for-height Boys Girls Skinfold triceps p Boys Mean increase (95% CI) 1.8 (1.6, 2.0) mm (p<0.001) 30.2% > 90 p from % < 10 p from Girls Mean increase (95% CI) 2.0 (1.8, 2.2) mm (p<0.001) 28% > 90 p from % < 10 p from The Bergen Growth Study Current prevalence of overweight and obesity Júlíusson PB, Roelants M, Eide GE, Hoppenbrouwers K, Bjerknes R. Growth of Belgian and Norwegian children compared to the WHO growth standards: Prevalence below -2 and above +2 standard deviatons and the effect of breastfeeding. Arch Dis Child 2010; published online November 30, 2009 Cohort: 2231 healthy children aged 0-5 years of Norwegian/Nordic ethnicity Júlíusson PB, Eide GE, Roelants M, Waaler PE, Hauspie R, Bjerknes R. Overweight and obesity in Norwegian children: prevalence and sociodemographic risk factors. Acta Paediatrica 2010;99:900-5 Cohort: 6386 healthy children aged 2-19 years 5

6 Forekomst av overvekt og fedme hos 2-19 år gamle barn (IOTF) Overvekt (inkludert fedme) 13.8% Fedme 2.3% GUTTER JENTER Júlíusson PB et al. Acta Paediatrica 2010 Ordinal logistic regression of IOTF weight status on potential risk factors in 3793 Norwegian children The Bergen Growth Study Parental perception on their children s weight status Júlíusson PB, Roelants M, Markestad T, Bjerknes R. Parental perception of overweight and underweight in children and adolescents. Acta Paediatrica 2010; Accepted for publication Cohort: 3770 children 2-19 year-old with anwered questionnaire 6

7 Antall barn (%) oppfattet som for tynne eller for tykke av sine foreldre sammenlignet med målt høyde og vekt (KMI) Júlíusson PB et al. Acta Paediatrica OECD: FIT NOT FAT Lobstein T. The size and risk of the international epidemic of child obesity. In OECD report 2010: Fit not fat 7

8 OECD: FIT NOT FAT OECD: FIT NOT FAT U N I V E R S I T E T E T I B E R G E N Hvorfor er fedme et problem? 8

9 Tracking Ebbeling C Lancet 2002 Freedman DS Pediatrics

10 Obesity Family history T2DM Born SGA Puberty (transient) Sedentary lifestyle Ethnic background Visceral fat Subcutaneous fat Hepatic fat IMCL Lipid partitioning Visceral fat Subcutaneous fat Hepatic fat IMCL Insulin resistance Hyperinsulinemia Mild hyperinsulinemia Pancreas Liver Kidney Vasculature CNS Ovary Metabolic syndrome Normal metabolic phenotype Adapted from Weiss Endocr Dev 2010 If current trends continue, obesity will soon surpass smoking in the U.S. as the biggest single factor in early death, reduced quality of life and added health care costs Scientific American, February 2011 U N I V E R S I T E T E T I B E R G E N Hvordan oppstår overvekt/fedme hos barn? 10

11 Energibalansen Energibalansen: Kronisk overskudd «Energy expenditure: Resting metabolic rate (60-70%) Thermogenesis (10%) Physical activity» (20-30%) Lav «resting metabolic rate» en risikofaktor? Risikofaktorer Genetikk Overvekt i familien. Etnisitet. Epigenetikk? In utero forhold. SGA med rask innhentingsvekst. Omgivelsesfaktorer: Sosioøkonomiske forhold. Kostvaner. Kaloririk billig mat. Sukker. Endret spisemønster. Aktivitetsvaner. Økt passivitet. Spontan aktivitet. Skjermtid. Tidsklemme. Rytmeforstyrrelse. Måltider. Søvn. Tarm-hjerne aksen (Ghrelin, adiponectin, leptin) Brunt fettvev viktig? Tarmbakterier? Risikofaktorer Syndromer Prader-Willi, AHO, Bardet-Biedl Mutasjoner i enkeltgener Leptin, POMC, PC1, MC4R Hypothalamus defekt Endokrinologiske sykdommer Immobilitet Hemmet skjelettvekst Medikamenter 11

12 Anamnese Vekstkurven. Lengdevekst økt i «simple obesity». Fødselsvekt, tidlig vekst, hvortid vektøkning? Andre trekk? Kostanamnese, spisevaner, mellommåltider? Aktivitet. Passivitivet. Skjermtid. Ko-morbiditet? Medikamenter? Mistanke om hypothalamus/hypofyse dysfunksjon? Mistanke om endokrinologisk forstyrrelse? Familieanamnese. Klinisk undersøkelse Måling av høyde og vekt og mageomfang. Plotting av målinger inn på kurven. Acanthosis nigricans? Måling av BT Trekk som peker på en underliggende årsak. Syndrom? Endokrinologisk sykdom? Prøver: Fastende blodprøver: blodsukker, insulin, HbA1c, totalt-kolesterol, HDL, LDL, TG, TSH, ft4, leverprøver. 3 x døgnurin for måling av fritt kortisol. Urinstiks. Andre prøver på indikasjon. U N I V E R S I T E T E T I B E R G E N Går det an å forebygge eller behandle overvekt/fedme? 12

13 Infrequent Support in Primary Care Setting is Insufficient LEAP (Live, Eat, and Play) Program Screening, followed by 4 consultations with PCPs over 12 weeks to target behavior change in overweight or mildly obese 5-10 year olds No improvements in BMI, physical activity, or nutrition compared to usual care Wake 2009 BMJ Lifestyle Interventions: The Influence of Family Involvement and Age Targeting family Targeting children (-0.88, ) (-0.40, 0.05) Majority 8 years or less Majority aged 9-18 years (-1.00, -0.40) (-0.81, -0.18) McGovern 2008 JCEM 13

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15 U N I V E R S I T E T E T I B E R G E N Treatment of obesity in children at Haukeland University Hospital Pétur B. Júlíusson MD, postdoc University of Bergen Haukeland University Hospital Disposition Department of Pediatrics, HUS New Obesity Outpatient Clinic i February 2012 Family-based Behavioral Social Facilitation Treatment ongoing study Conclusions 15

16 HUS The intervention Tuesday Wednesday Thursday Friday 08:00-09:00 Calorimetry Endothel test, CIMT og 2xBP 09:00-10:00 Blood samples Treadmill test Nurse OGTT Physician Social worker Embletta Summary meeting Patient/family, Physician, Nurse, Nutritionist, Physiotherapist Contract Nutritionist 24h blood pressure Nurse Physiotherapist Psychiatrist Psychologist Physiotherapist HUS Children population Obese children, BMI >3 SDS (ref: Karlberg et al.) with overweight-related co-mobidity Age < 15 years HUS Follow-up Outpatient clinic: Monthly measurement of height and weight by a nurse Evaluation by pediatrician every 6th month 16

17 HUS Conclusions Children younger than 10 years of age at the start of treatment experienced more reduction in BMI SDS Treatment was not «harmful» Need for more effective treatment option Need for treatment option adjusted to adolescents New Obesity Outpatient Clinic i February 2012 Februar 2012 FABO-logistics PBJ_Seminar_Obesity Outpatient Clinic_June_

18 Toward a normal weight a treatment program for obese children and adolescence IOTF>35 or obesity with comorbidity 1 Pediatric evaluation 2 A multidisciplinary team evaluates each child Pediatrician Psychologist Nutritionist Physiotherapist Multidisciplinary team concludes on treatment plan, recommendations and goals for each child 3 Hospital nurse/paediatrician presents the treatment plan and recommendations for each child and family Hospital nurse establishes contact with public health nurse Follow up in the primary care: Primary health care nurse: monthly measurement of weight/height and supporting the child and family to follow the treatment plan using motivational interview technique Follow up in the outpatient hospital clinic: Pediatrician: Biannual clinic visits- Examination, registration and evaluation of each child and its treatmentplan Total follow up: 2 years Treatment of severely obese children and adolescents in common health care settings: An effectiveness study employing Family-based Behavioral Social Facilitation Treatment A waiting-list control study Yngvild Sørebø Danielsen, PhD, Cand. Psychol., Section for Eating Disorders, Haukeland University Hospital; Department of Clinical Psychology, University of Bergen Rachel Kolko, MA, PhD student, Weight Management and Eating Disorders Program, Washington University in St. Louis Denise Wilfley, Professor, Department of Psychiatry, Washington University School of Medicine, St. Louis Trond Markestad, MD, Professor, Department of Clinical Science, University of Bergen, Department of Pediatrics Ståle Pallesen, Professor, Dr. Psychol., Department of Psychosocial Science, University of Bergen Petur B. Juliusson, Project leader, MD, Post doc, Department of Clinical Science, University of Bergen, Department of Pediatrics, Haukeland University Hospital Family-based Behavioral Social Facilitation Treatment Session-specific Components and Goals 03/18/13 For more information, please contact: Rachel Kolko, MA Doctoral Candidate in Clinical Psychology Washington University in St. Louis Weight Management and Eating Disorders Program kolkor@psychiatry.wustl.edu 18