Gestione multidisciplinare e integrata tra ospedale e territorio del paziente sovrappeso-obeso in età pediatrica

Trento, sabato 16 maggio 2015

Miti, presunzioni ed evidenze in obesità pediatrica

Claudio Maffeis

UOC Pediatria ad Indirizzo Diabetologico e Malattie del MetabolismoCentro Regionale Specializzato in Diabetologia Pediatrica

AOUI e Università di Verona

Prevalenza di sovrappeso ed obesità nei bambini di 8-9 anni in Italia

Okkioalla Salute 2014

Overweight

0,0%

5,0%

10,0%

15,0%

20,0%

25,0%

National reference I.O.T.F. C.D.C.

males

females

totale

Obesity

0,0%

2,0%

4,0%

6,0%

8,0%

10,0%

12,0%

14,0%

16,0%

18,0%

National reference I.O.T.F. C.D.C

males

females

totale

Prevalenza di sovrappeso e obesitàin Italia tra I 2 ed I 6 anni

Maffeis C et al. Obes Res, 2006

Il bambino obeso “brucia” meno calorie rispetto al bambino normopeso:

Ingrassa perché ha un difetto termogenetico!

total energy expenditure in normal weight

and obese prepubertal children

0

500

1000

1500

2000

2500

energy

expenditure

(kcal/day)

Nonobese Obese

Bandini & Dietz, Maffeis & Schutz, Butte NF, etc.

P<0,01

kcal/day

2,000

1,000

0

components of the total daily energyexpenditure of a 10-year-old boy

Thermogenesis

BMR

EEActivity

EEGrowth

60 %

10 %

30 %

< 2 %

energy

expenditure

adjusted for FFM

(kcal/day)

energy

expenditure

(kcal/day)

Maffeis C, et al. Int J Obes ‘92

1,000

1,300

1,000

1,300

basal energy expenditure of 9-year-old children

p = ns

p < 0.05

obese post-obese never-obese

obese

%

meal

energy

6

3

0

meal-induced thermogenesis

p = ns

Molnar D et al. Eur J Pediatr ‘85

Maffeis C et al. Eur J Clin Nutr ‘92

post-obese never-obese

Il bambino ha bisogno di tanta energia per crescere

Spesa energetica per l’accrescimento

Il bambino obeso non ha un vero problema di salute: ha solo qualche chilo di troppo!

ACCUMULO

ECTOPICO DI GRASSO

OBESITÀ

INFIAMMAZIONE

INSULIN RESISTANCE

INSULINORESISTENZA

SINDROMEMETABOLICA

a

*

** m

d

dd

dd

a

Franzese A, Vajro P, et al.

Dig Dis Sci 1997

Sbarbati M, Maffeis C, et al. Pediatrics 2006

Ipertensione

dislipidemia

IGT – T2D

Basta un po’ di volontà e il peso in piùsi perde facilmente!

primary care surveillance and intervention for overweight or obese 5-

10-year-old children: the LEAP 2 randomised controlled trial

INTERVENTION4 standard consultations over 12 weeks targeting change

in nutrition, physical activity, & sedentary behaviour, supported by purpose designed family materials

BMI(kg/m2)

15

20

25P = ns

intervention control

baseline

6 months

12 months

primary care screening followed by brief counselling is not effective In overweight or mildly obese children and it would be very costly if universally implemented

Wake M, et al BMJ 2009

Two-year Follow-up in 21,784 Overweight Childrenand Adolescents With Lifestyle Intervention

100

80

60

40

20

0

(%)

lost of

follow-up

SDS BMI

reduction

<0.5

SDS BMI

reduction

>0.5

Reinehr T, et al Obesity 2009

time (months)

6 12 24 6 12 24 6 12 24

100

80

60

40

20

0

(%)

lost of

follow-up

SDS BMI

reduction

<0.5

SDS BMI

reduction

>0.5

time (months)

6 12 24 6 12 24 6 12 24

129 treatment centers 5 centers with the highest success rate

Se un bambino nasce con basso peso bisogna alimentarlo con abbondanza per fargli recuperare presto il peso….. in difetto!

Fattori di rischio di obesità

Peso alla nascita

Peso a termine (kg)4.52.5

Odds ratio for childhood obesity by infant weight gain between 0 and 1 year adjusted for sex, age, a weight

Lakshman R, et al. Circulation 2012;126:1770-9.

Velocità di crescita primo anno

Lunghezza (cm)7545 6555

Peso (kg)

0

12

8

4

Se il latte della mamma scarseggia, diamo il latte di vacca che è buono e fa crescere bene!

FORMULA PROTEIN CONTENT AND WEIGHT GAIN

A RANDOMIZED CLINICAL TRIAL

Age(months)1 3 6 12 24

Weight/Lenght

(z score)

1.0

0.5

0

-0.5

-1.0

*

* High protein formula

Human Milk

Low protein formula

Socha P, et al. Am J Clin Nutr. 2011;94(6 Suppl):1776S-1784S

Se il bambino viene allattato al seno non diventerà mai obeso!

2013;368:446-54.

“…. Although existing data indicate that breast-feeding does nothave important antiobesity effects in children, it has otherimportant potential benefits for the infant and mother and shouldtherefore be encouraged. “

BREAST-FEEDING AND OBESITY

Se il piccolo ha tanta fame e cresce bene posso introdurre gli alimenti solidi anche presto, dopo i primissimi mesi di vita

Timing of Solid Food Introduction and Risk of Obesity in Preschool-Aged Children

Huh SY, et al. Pediatrics 2011;127:e544

Una caloria è una caloria: poco importa se è da proteine, grassi o carboidrati

nutrient requirements

Age (years)

0

350

0 186 12

g/day

250

150

50

carbohydrate

lipid

protein

50

25

0

fatmass(%)

10 30 50

lipid intake (% of energy intake)

Maffeis C et al. Int J Obes ‘96

r = 0.28 P< 0.01

Gazzaniga JM, et al.AJCN ‘93

Klesges RC et al. AJCN ‘94

fatty foodmore palatable

high energy density

less satiating

covert manipulation of dietary fat and energy density: effect on substrate flux and food intake in men eating ad libitum

0

- 5

0

5

10

15

1 2 3 4

fat balance

time (days)

Stubb RJ, et al. AJCN 1995; 62:316-29.

- 10

20

5 6 7 0

- 5

0

5

10

15

1 2 3 4

energy balance

time (days)

- 10

20

5 6 7

MJ MJ

high fat

medium fat

low fat

dietary pattern prospectively associated with increased adiposityduring childhood and adolescence

Ambrosini GL, et al. Int J Obes 2012;36:1299-1305

High RiskDietary Pattern

Energy-denseHigh-fatLow-fiber

high-fibre, low-fat diet predicts long-term weight loss and decreased type 2 diabetes risk: the Finnish Diabetes Prevention Study

Lindstrom J, et al. Diabetologia 2006

1

0

Hazard ratiofor Diabetes *

low-fat/high fibre

low-fat/low fibre

high-fat/high fibre

high-fat/low fibre

•Adjusted for: group assignment, age, sex, baseline BW, fat & fibre intake,baseline 2-h glucose, baseline and follow-up period physical activity, weight change

2

3

4

5

6

Joint classification of whole- and refined-grain intake on visceral adipose tissue (VAT) volume

McKeown N M et al. Am J Clin Nutr 2010;92:1165-1171

-30 60 120 180 2400

MIXED

MEAL

Time (min)

60

90

120

150

Blood glucose and triacylglycerol postprandial profile

Plasma

glucose &

TAG

(mg/dl)triacylglycerol

glucose

60

70

80

90

100

110

120

130

140

0' 60' 90' 120' 150' 180' 240' 300'

LF meal

HF meal

Time (min)

TAG(mg/dl)

p< 0.05

Postprandial triacylglycerol profile after two isocaloric, isoproteicmeals with different fat and carboidrate content in obese children

Maffeis C, et al. Obesity 2010

0 100 200 300

140

120

100

80

60

Fat/Carbohydrate

Fat/Carbohydrate

65

75

85

95

(U/l)P<0.05

P = ns

ox-LDL

Maffeis C, et al. Nutr Metab Cardiovasc Dis 2011

POSTPRANDIAL PRO-ATEROGENIC PROFILE: change of oxidized lipoprotein concentration in obese children after two isocaloric, isoproteic meals with a different fat and carbohydrate content

Fat/Carbohydrate

Fat/Carbohydrate

Time (h)0 5

Per calare si deve fare attivitàfisica ad elevata intensità!

Bravata DM, et al. JAMA 2007;298:2296-304.

Using pedometers to increase physical activity and improve health

Efficacy of a 12 Weeks Exercise Program withoutDiet in Reducing Obesity in Men

Ross R, et al. Ann Intern Med. 2OOO;133:92-1O3.

0 - 2 - 8- 4 - 6

Body weight (kg)

Waist circumference (cm)

Body fat (kg)

Subcutaneous abdominal fat (kg)

Visceral abdominal fat (kg)

- 10

Exercise: brisk walking/light jogging, 80% max HR, 700 kcal/day.

VO2max (L/min)

energy expenditure during walking and running in obese and nonobese prepubertal children

0 2 4 6 8 10

0

2.5

5

10

speed (km/h)

METs

7.5

Maffeis C, et al. J Pediatrics 1993

OBESE

NONOBESEP<0.05

the role of free-living daily walking in human weight gain and obesity

Levine JA et al. Diabetes 2008

Maffeis, C. et al. JCEM 2005;90:231-236

Nutrient oxidation measured during walking at speeds of 4, 5, and 6 km/h, respectively, in a group of obese prepubertal children

Lee D, et al. J Am Coll Cardiol 2014;64:472-81

Leisure-Time Running Reduces All-Cause and CardiovascularMortality Risk In a 15-year follow-up

Lee D, et al. J Am Coll Cardiol 2014;64:472-81

Leisure-Time Running Reduces All-Cause and CardiovascularMortality Risk In a 15-year follow-up

Running, even 5 to 10 min/day and atslow speeds <6 miles/h, is associatedwith markedly reduced risks of death

from all causes and cardiovasculardisease

Non preoccupiamoci: se la “dieta” fallisce ci sono farmaci e chirurgia

Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent

Overweight & Obesity: Summary Report

Barlow SE & the Expert Committee Pediatrics 2007 (suppl.) (modified)

Obiettivi comportamentali della terapia

Allattamento al seno

Colazione

Pasti consumati in famiglia (vs Fast Food)

Alimentazione bilanciata in nutrienti (RDA)

Frutta e vegetali, Fibra

Densità energetica dei cibi e dei pasti

Porzioni

Bevande zuccherate

(Calcio)

Video-esposizione

Attività fisica

Take home message

L’obesità è una malattia, che va prevenuta e

curata con attenzione.

Gli obiettivi per l’intervento sono chiari.

Gli strumenti: accanto all’alimentazione, l’attività

fisica svolge un ruolo di assoluto rilievo.

Il risultato potrà essere favorevole nel medio-lungo

termine solamente se famiglia, pediatra, scuola (e

società) collaboreranno attivamente e con

pazienza allo scopo.

VIII° CONGRESSO NAZIONALE:

NUTRIZIONE, METABOLISMO E DIABETE NEL BAMBINO E NELL’ADOLESCENTE

La pediatria dà i… “numeri”?

Hotel CTC Best Western

Verona, 25-26 settembre 2014

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