1. OBESITY REVIEW Mariel Arvizu, MD Doctoral Candidate Nutrition Deapartment Harvard School of Public Health

2. Overview of Obesity How is it measured and why this matters : different adults and children Epidemiology of Obesity Pathophysiology: hormones in obesity Risk factors and Consequences

3. WHO Definition of Obesity: Adults Body Mass Index (BMI) (kg/m 2 ) Underweight< 18.50 Normal range18.50 – 24.99 Overweight25.00 – 29.99 Obese≥ 30.00 World Health Organization 1995

4. CDC growth chart BMI-for-age Underweight< 5 th percentile Healthy weight5 th - <85 th percentile Overweight *≥ 85 th and < 95 th percentile Obesity *≥ 95 th percentile Barlow SE and Expert Committee. Pediatrics 2007

5. Obesity Surveillance in U.S. National Health and Nutrition Examination Survey (NHANES) - Cross-sectional studies since 1999 - Nationally representative - In person interview and exam

6. NHANES Obesity trends among adults

7. Age-adjusted Obesity by race/ethnicity

8. NHANES trends in Childhood obesity

9. Age-adjusted childhood Obesity trends

10. Global burden of Obesity Ng et al. Lancet 2014; 384: 766-81

11. Alternate measure of Obesity Reference methods: CT, MRI, DEXA Densitometry Bod-Pod: air displacement plethysmography Field Methods: Biolectrical Impedence Analysis (BIA) Anthropometry: Height, weight, and adiposity indexes Waist circumference and waist-hip ratio (WHR) Skinfolds

12. Nurse’s Health Study and Health Professional Study

13. Causes of Childhood Obesity Diet Activity/Inactivity: video games and TV Sleep: 70% of teens are sleep deprived Developmental theories of Obesity DOHaD – developmental origins of health and disease Pre-natal and pre-conception factors predict child obesity and cardiovascular outcomes Maternal smoking, gestational diabetes, gestational weight gain Maternal diet before pregnancy > important than during

14. Maternal-child relationship with Obesity

15. Risk factors for Developing Obesity Sleep: duration Diet: calorie intake > metabolic expenditure = excess calories Physical activity: protects against obesity Environmental factors: SES, race/ethnicity, genetics, migration

16. Pathophysiology of Obesity ↑ Total energy Lack PA: TV inactivity TV ads promote ↑ calorie intake Increase Leptin Decrease Gharlin Increase Cortisol ↑ Hunger ↓ Satiety Alteration thermoregulation and Fatigue Diet: SSBs increase calorie content No satiety Sleep deprivation ↑ opportunities to eat ↓ energy expenditure OBESITY

17. Sleep and Obesity Sleep habits by: Age: decrease during teen years By race: African americans and Hispanics sleep less than whites By profession: night shifts

18. Occupation modifies sleep patterns by race Chandra Jackson, Am J Epidem 2013

19. Mechanism of Sleep and Obesity Zimberg Cell Biochem 2012

20. Leptin and Ghrelin interaction Van Cauter E J Endo 2008

21. Increase cortisol in sleep deprivation insomniacs with low total sleep time (  ) vs. those with high total sleep time (  )

22. Physical activity and Obesity

23. Exercise effects on Obesity

24. Current guidelines for PA http://www.health.gov/paguidelines/

25. Physical activity prevents disease CRC: 17% ↓ risk T2Dm: 31% ↓ risk, without accounting for BMI differences 17% ↓ risk, after accounting for BMI differences

26. How much is too much?

27. Nutrition and Obesity

28. Nurse’s Health Study: F & V

29. Whole Grains Liu et al., AJCN 2003;78:920-927 Increased Fiber intake: Satiety met Decreased energy bioavailability

30. Nuts and CHD

31. Nuts and Obesity Jiang et al. JAMA 2002

34. Sweetened-sugar beverages 21% of total energy intake from beverages Contribution to total energy intake (%) Modified from Duffey & Popkin. Obesity 2007; 15:2739-2747.

35. High-Fructose Corn syrup 55% fructose 41 % Glucose Maltose 2 % Higher saccharides 2%

38. Which has more sugar? Source: www.thecoca-colacompany.com/presscenter/imagegallery.html, www.pepsiproductfacts.com/infobyproduct.php, http://www.welchs.com/products/juices-and-drinks/100- percent-grape-juice/100-percent-grape-juice, http://pomwonderful.com/products/

39. 150 calories 195 calories 255 calories 240 calories Tablespoons of sugar

40. Cardiometabolic disease and Obesity Diagnosis of Metabolic Syndrome: 3/5 ATP III criteria Risk FactorDefining Level Abdominal obesity (Waist circumference) Men Women >102 cm (>40 in) >88 cm (>35 in) TG  150 mg/dl HDL-C Men Women <40 mg/dl <50 mg/dl Blood pressure  130/  85 mm Hg Fasting glucose  110 mg/dl Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA 2001;285:2486-2497.

41. Metabolic Syndrome Increases Risk for CHD and Type 2 Diabetes Coronary Heart Disease Type 2 Diabetes High LDL-C Metabolic Syndrome From Steve Haffner

42. Cancer and Obesity:BMI and Cacner Mortality Women 40 Relative Risk n = 57,145 deaths Men

43. Potential mechanisms Insulin and insulin-like growth factors (IGFs): ↑ insulin levels resulting in ↓ synthesis of IGF binding proteins and ↑ free IGF-I levels Mutagenic and anti-apoptotic Sex steroids: ↑activity of aromatase (converts androgens to estradiol in adipose tissue) Adipokines ↑leptin levels (mitogenic, anti-apoptotic, pro- angiogenic, pro-inflammatory) ↑adiponectin levels (anti-proliferative, pro- apoptotic, anti-angiogenic) ↑ Inflammation

44. Cancers associated to Obesity Post-menopausal Breast cancer Endometrial cancer Prostate Cancer Colo-rectal cancer

45. Proposed mechanism for CRC