Shiriki Kumanyika

Overweight in Children and Adolescents Pathophysiology, Consequences, Prevention, and Treatment

The prevalence of overweight among children and adolescents has dramatically increased. There may be vulnerable periods for weight gain during childhood and adolescence that also offer opportunities for prevention of overweight. Overweight in children and adolescents can result in a variety of adverse health outcomes, including type 2 diabetes, obstructive sleep apnea, hypertension, dyslipidemia, and the metabolic syndrome. The best approach to this problem is prevention of abnormal weight gain. Several strategies for prevention are presented. In addition, treatment approaches are presented, including behavioral, pharmacological, and surgical treatment. Childhood and adolescent overweight is one of the most important current public health concerns.

Will All Americans Become Overweight or Obese? Estimating the Progression and Cost of the US Obesity Epidemic

We projected future prevalence and BMI distribution based on national survey data (National Health and Nutrition Examination Study) collected between 1970s and 2004. Future obesity‐related health‐care costs for adults were estimated using projected prevalence, Census population projections, and published national estimates of per capita excess health‐care costs of obesity/overweight. The objective was to illustrate potential burden of obesity prevalence and health‐care costs of obesity and overweight in the United States that would occur if current trends continue. Overweight and obesity prevalence have increased steadily among all US population groups, but with notable differences between groups in annual increase rates. The increase (percentage points) in obesity and overweight in adults was faster than in children (0.77 vs. 0.46–0.49), and in women than in men (0.91 vs. 0.65). If these trends continue, by 2030, 86.3% adults will be overweight or obese; and 51.1%, obese. Black women (96.9%) and Mexican‐American men (91.1%) would be the most affected. By 2048, all American adults would become overweight or obese, while black women will reach that state by 2034. In children, the prevalence of overweight (BMI ≥ 95th percentile, 30%) will nearly double by 2030. Total health‐care costs attributable to obesity/overweight would double every decade to 860.7–956.9 billion US dollars by 2030, accounting for 16–18% of total US health‐care costs. We continue to move away from the Healthy People 2010 objectives. Timely, dramatic, and effective development and implementation of corrective programs/policies are needed to avoid the otherwise inevitable health and societal consequences implied by our projections.

Long term effects of dietary sodium reduction on cardiovascular disease outcomes: observational follow-up of the trials of hypertension prevention (TOHP)

Objective To examine the effects of reduction in dietary sodium intake on cardiovascular events using data from two completed randomised trials, TOHP I and TOHP II. Design Long term follow-up assessed 10-15 years after the original trial. Setting 10 clinic sites in 1987-90 (TOHP I) and nine sites in 1990-5 (TOHP II). Central follow-up conducted by post and phone. Participants Adults aged 30-54 years with prehypertension. Intervention Dietary sodium reduction, including comprehensive education and counselling on reducing intake, for 18 months (TOHP I) or 36-48 months (TOHP II). Main outcome measure Cardiovascular disease (myocardial infarction, stroke, coronary revascularisation, or cardiovascular death). Results 744 participants in TOHP I and 2382 in TOHP II were randomised to a sodium reduction intervention or control. Net sodium reductions in the intervention groups were 44 mmol/24 h and 33 mmol/24 h, respectively. Vital status was obtained for all participants and follow-up information on morbidity was obtained from 2415 (77%), with 200 reporting a cardiovascular event. Risk of a cardiovascular event was 25% lower among those in the intervention group (relative risk 0.75, 95% confidence interval 0.57 to 0.99, P=0.04), adjusted for trial, clinic, age, race, and sex, and 30% lower after further adjustment for baseline sodium excretion and weight (0.70, 0.53 to 0.94), with similar results in each trial. In secondary analyses, 67 participants died (0.80, 0.51 to 1.26, P=0.34). Conclusion Sodium reduction, previously shown to lower blood pressure, may also reduce long term risk of cardiovascular events.

Obesity prevention: the case for action.

Contents1. Obesity and the global burden of disease2. Prevalence, trends and economics3. Targets for action4. The action agenda5. Potential solutions6. Tracking outcomes7. Glossary of terms8. Key references and further reading9. Case studies: Available on Nature website at www.naturesj.com/ijo/index.html

A Policy-Based School Intervention to Prevent Overweight and Obesity

BACKGROUND. The prevalence and seriousness of childhood obesity has prompted calls for broad public health solutions that reach beyond clinic settings. Schools are ideal settings for population-based interventions to address obesity. OBJECTIVE. The purpose of this work was to examine the effects of a multicomponent, School Nutrition Policy Initiative on the prevention of overweight (85.0th to 94.9th percentile) and obesity (>95.0th percentile) among children in grades 4 through 6 over a 2-year period. METHODS. Participants were 1349 students in grades 4 through 6 from 10 schools in a US city in the Mid-Atlantic region with ≥50% of students eligible for free or reduced-price meals. Schools were matched on school size and type of food service and randomly assigned to intervention or control. Students were assessed at baseline and again after 2 years. The School Nutrition Policy Initiative included the following components: school self-assessment, nutrition education, nutrition policy, social marketing, and parent outreach. RESULTS. The incidences of overweight and obesity after 2 years were primary outcomes. The prevalence and remission of overweight and obesity, BMI z score, total energy and fat intake, fruit and vegetable consumption, body dissatisfaction, and hours of activity and inactivity were secondary outcomes. The intervention resulted in a 50% reduction in the incidence of overweight. Significantly fewer children in the intervention schools (7.5%) than in the control schools (14.9%) became overweight after 2 years. The prevalence of overweight was lower in the intervention schools. No differences were observed in the incidence or prevalence of obesity or in the remission of overweight or obesity at 2 years. CONCLUSION. A multicomponent school-based intervention can be effective in preventing the development of overweight among children in grades 4 through 6 in urban public schools with a high proportion of children eligible for free and reduced-priced school meals.

The joint WHO/FAO expert consultation on diet, nutrition and the prevention of chronic diseases: process, product and policy implications.

Nutrition Planning, Assessment and EvaluationService, Food and Nutrition Division, FAO, Rome, ItalyThe Joint WHO/FAO Expert Consultation on diet,nutrition and the prevention of chronic diseases tookplace in Geneva from 28 January to 1 February 2002. Theoverall objective of the Consultation was to review andupdate current international recommendations on diet,nutrition and the prevention of chronic diseases byevaluating the latest scientific evidence and lessonslearned from implementing national interventionstrategies to reduce the burden of these diseases. Specificobjectives included:1. Reviewing the changes in the dietary and healthpatternsworldwideandexaminingtheirrelationshiptoemergence of chronic diseases, particularly obesity,type 2 diabetes, hypertension and cardiovasculardiseases, cancer, dental disease, and osteoporosis.2. Reviewing the latest scientific evidence on therelationship between diet, nutrition and chronicdiseases.3. Examining diet, nutrition and health issues from a lifecourse perspective.4. Considering gene/nutrient interactions and theirimplications.5. Formulating recommendations concerning diet andnutrition for the prevention of chronic diseases toassist countries in developing and implementingeffective evidence-based multisectoral policies andstrategies.6. Identifying further research needs.The selection of the expert participants followed standardcriteria, including geographic and sex balance, inconsultation with regional offices. Thirty experts wereidentified,halffromdevelopingcountriesandcountriesineconomic transition where diet-related chronic diseasesare an increasing public health problem. Before beingofficially invited to participate, all were requested todeclare possible conflicts of interest to ensure the qualityand neutrality of each expert’s contributions.Four working groups composed of world-renownedexperts prepared background papers on majordiet-related chronic diseases, such as obesity, type-2diabetes,cardiovasculardiseasesandcancer,thatincludedcurrent trends for each disease, a review of the strengthand weakness of the scientific evidence linking diet anddisease, and its policy implications. Other experts wereresponsible for papers on dental diseases and osteoporo-sis while WHO staff prepared a paper on the life courseapproach and FAO staff prepared a review of the globaland regional food consumption patterns and trends.Each background paper was peer-reviewed; papers weresubmitted, together with comments by peer-reviewers(some 20 in all), to the Expert Consultation as a generalframework for discussion.Report preparationFollowinground-tableconsultationswithnongovernmen-tal organizations and industry associations in April 2002to obtain feedback on the Expert Consultation’s initialdraftreport,thedraftreportwasmadeavailableonWHO’swebsite for review and comment by all interested partiesuntil June 2002.In August 2002, the Consultation’s Chairperson, Vice-Chairperson and rapporteurs met in Geneva with theWHO/FAO secretariat members as well as with severalexpertsonphysicalactivitytoreviewmorethan120setsofcomments from governments of FAO/WHO MemberStates, representatives of the scientific community,nongovernmental organizations, commercial enterprisesandinterestedindividuals.Thesecommentswerelikewiseposted in their entirety on WHO’s website for publicscrutiny. In October 2002, several members of the ExpertConsultationmetwiththeChairpersonandtheWHO/FAOSecretariatto finalize severalpending issues. In December2002, the final draft report was sent to the members of theExpert Consultation for review and final approval. Thereport was then finalized and published in the WHOTechnical Report Series (TRS 916)

Weight-related attitudes and behaviors of black women

Weight-related attitudes and practices of women who attended health department clinics or who worked for a health and human services agency were assessed by means of an anonymous, self-administered questionnaire. Black women who were 25 to 64 years old and were not pregnant or had not given birth within the past year were included in this analysis (n = 500). The overweight women perceived themselves as being overweight. They were less likely to be satisfied with their weight and more likely to have dieted and to be currently dieting than nonoverweight women. Awareness of obesity-related health risks was high, but the perceived psychosocial consequences of being overweight were somewhat limited. Approximately 40% of moderately and severely overweight women considered their figures to be attractive or very attractive, which indicates a relatively positive body image. The overweight women were less likely to exercise, less likely to skip meals, and more likely to eat between meals than the nonoverweight women. Among the subset who had ever attempted to lose weight (n = 368), the overweight women were significantly more likely to have regained all or more of the weight lost during their most recent attempt. The findings of this exploratory survey suggest that although overweight black women are weight conscious, the absence of strong negative social pressure combined with a relatively positive body image may limit the extent to which weight loss efforts are sustained. Findings about eating and exercise patterns suggest some specific factors that may interfere with the effectiveness of weight control among black women.

Obesity prevention: a proposed framework for translating evidence into action

Obesity as a major public health and economic problem has risen to the top of policy and programme agendas in many countries, with prevention of childhood obesity providing a particularly compelling mandate for action. There is widespread agreement that action is needed urgently, that it should be comprehensive and sustained, and that it should be evidence‐based. While policy and programme funding decisions are inevitably subject to a variety of historical, social, and political influences, a framework for defining their evidence base is needed. This paper describes the development of an evidence‐based, decision‐making framework that is particularly relevant to obesity prevention. Building upon existing work within the fields of public health and health promotion, the Prevention Group of the International Obesity Task Force (IOTF) developed a set of key issues and evidence requirements for obesity prevention. These were presented and discussed at an IOTF workshop in April 2004 and were then further developed into a practical framework. The framework is defined by five key policy and programme issues that form the basis of the framework. These are: (i) building a case for action on obesity; (ii) identifying contributing factors and points of intervention; (iii) defining the opportunities for action; (iv)evaluating potential interventions; and (v) selecting a portfolio of specific policies, programmes, and actions. Each issue has a different set of evidence requirements and analytical outputs to support policy and programme decision‐making. Issue 4 was identified as currently the most problematic because of the relative lack of efficacy and effectiveness studies. Compared with clinical decision‐making where the evidence base is dominated by randomized controlled trials with high internal validity, the evidence base for obesity prevention needs many different types of evidence and often needs the informed opinions of stakeholders to ensure external validity and contextual relevance.

A Randomized Controlled Trial of Weight Reduction and Exercise for Diabetes Management in Older African-American Subjects

OBJECTIVE To evaluate a weight loss and exercise program designed to improve diabetes management in older African-Americans. RESEARCH DESIGN AND METHODS Overweight African-Americans (n = 64) ages 55–79 years with NIDDM were randomized to either an intervention (12 weekly group sessions, 1 individual session, and 6 biweekly group sessions) or usual care (1 class and 2 informational mailings). Clinical and behavioral variables were assessed at 0, 3, and 6 months of treatment. RESULTS Significant net differences in the intervention versus usual care were observed for weight (−2.0 kg, P = 0.006), physical activity, and dietary intake of fat, saturated fat, cholesterol, and nutrition knowledge at 3 months (all P < 0.05) and for weight at 6 months (−2.4 kg; P = 0.006) and mean HbA1c values at 3 and 6 months (respectively, −1.6 and −2.4%, both P < 0.01). After the adjustment for changes in weight and activity, the intervention participants were ∼ twice as likely to have a one unit decrease in HbA1c value as those in usual care. Blood pressure increase sin usual care participants resulted in net differences (intervention minus control) at 3 and 6 months of −3.3 (P = 0.09) and −4.0 (P = 0.05) mmHg diastolic, respectively, and −8.4 (P = 0.06) and −5.9 (P > 0.10) mmHg systolic, respectively. Blood lipid profiles improved more in intervention than usual care participants, but not significantly. CONCLUSIONS The intervention program was effective in improving glycemic and blood pressure control. The decrease in HbA1c values was generally independent of the relatively modest changes in dietary intake, weight, and activity and may reflect indirect program effects on other aspects of self-care.

A Two-Year Randomized Trial of Obesity Treatment in Primary Care Practice

BACKGROUND Calls for primary care providers (PCPs) to offer obese patients behavioral weight-loss counseling have not been accompanied by adequate guidance on how such care could be delivered. This randomized trial compared weight loss during a 2-year period in response to three lifestyle interventions, all delivered by PCPs in collaboration with auxiliary health professionals (lifestyle coaches) in their practices. METHODS We randomly assigned 390 obese adults in six primary care practices to one of three types of intervention: usual care, consisting of quarterly PCP visits that included education about weight management; brief lifestyle counseling, consisting of quarterly PCP visits combined with brief monthly sessions with lifestyle coaches who instructed participants about behavioral weight control; or enhanced brief lifestyle counseling, which provided the same care as described for the previous intervention but included meal replacements or weight-loss medication (orlistat or sibutramine), chosen by the participants in consultation with the PCPs, to potentially increase weight loss. RESULTS Of the 390 participants, 86% completed the 2-year trial, at which time, the mean (±SE) weight loss with usual care, brief lifestyle counseling, and enhanced brief lifestyle counseling was 1.7±0.7, 2.9±0.7, and 4.6±0.7 kg, respectively. Initial weight decreased at least 5% in 21.5%, 26.0%, and 34.9% of the participants in the three groups, respectively. Enhanced lifestyle counseling was superior to usual care on both these measures of success (P=0.003 and P=0.02, respectively), with no other significant differences among the groups. The benefits of enhanced lifestyle counseling remained even after participants given sibutramine were excluded from the analyses. There were no significant differences between the intervention groups in the occurrence of serious adverse events. CONCLUSIONS Enhanced weight-loss counseling helps about one third of obese patients achieve long-term, clinically meaningful weight loss. (Funded by the National Heart, Lung, and Blood Institute; POWER-UP ClinicalTrials.gov number, NCT00826774.).