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EIP EXCELLENCE IN PAEDIATRICS

EIP EXCELLENCE IN PAEDIATRICS. CHILDHOOD OBESITY IN SPAIN. Rosaura Leis Professor of Paediatrics Unidad de Investigación en Nutrición, Crecimiento y Desarrollo Humano de Galicia. Unidad de Gastroenterología, Hepatología y Nutrición Pediátrica. Hospital Clínico Universitario de Santiago.

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EIP EXCELLENCE IN PAEDIATRICS

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  1. EIP EXCELLENCE IN PAEDIATRICS CHILDHOOD OBESITY IN SPAIN Rosaura Leis Professor of Paediatrics Unidad de Investigación en Nutrición, Crecimiento y Desarrollo Humano de Galicia. Unidad de Gastroenterología, Hepatología y Nutrición Pediátrica. Hospital Clínico Universitario de Santiago. Universidad de Santiago de Compostela España

  2. The Obesity Epidemic: Public Health Crisis Obesityisthemainnutritionaldisease in Childhood WHO Regional Office forEurope2007 ~20% children and adolescents are overweight. 1/3 are obese. Spain: One of thecountrieswiththehighestprevalenceoverweight and obesity. GENES + ENVIRONMENT = AMBIOMA Consequence: Chronic positive energy balance: adiposity, obesity. Genome, thrifty genes, nutrigenetics, nutrigenomics, epigenetics: 50-70% genetic basis

  3. AESAN-NAOS-MSC, 2011 Main Results Prevalence Study Principales resultadosEstudio de prevalencia sobrepeso y obesidad Prevalence Study Thinness Normal weight Overweight Obesity % calculated according to WHO growth standards. Weight excess 45,2% Base: 7.923 children. “ALADINO” Study 3

  4. AESAN-NAOS-MSC, 2011 Main results Prevalence evolution Evolution prevalence children 6 to 9 years (According Orbegozo’s tables) Overweight Since 1999 the prevalence of obesitystabilized at 35.5% -35.8% in adults and16.9% for children and adolescents. Obesity Livingston E. JAMA 2012; 307: 970-71 • % overweight • enKid: 30,4% • Aladino: 31,4% Aladino study: 7.923 children enKid study: 423 children 4

  5. Obesity in children 10-12 years of Galicia.1991 and 2001. GALINUT study R. Leis, R. Tojo. JPGN 2004; 39 (suppl. 1): S468

  6. P - 95 Reference standards of body mass index (BMI) for overweight and obesity in young boys BMI (Kg/m2) P - 85 Age(years)

  7. Changes in eating behavior (consumption of food and beverages) in children and adolescents • Increased consumption of food prepared outside the home. • Increased consumption of fast food. • Increased consumption of sugary drinks. • Increased consumption of energy-dense foods. • Increased consumption of foods high in saturated fat, trans, sugar and sodium. • Decreased of regular consumption of breakfast. • Decreased of number of daily meals. • Decreased of consumption of milk, fruits and vegetables. • Increased portion sizes. Krebs NF. Assessment of Child and Adolescent Overweight and Obesity. Pediatrics 2007;120 (Suppl. 4): S193-S228 Tojo R, Leis R. La obesidad en la infancia y adolescencia. Estrategia NAOS. MSC. Madrid 2007, pp. 69-122

  8. Changes in lifestyles • Reduce physical activity. • Increased sedentary leisure time. • Massive use ICT (TV, videos, computers, etc). Consequences • Chronic positive energy balance: Increased adiposity and obesity. Lobstein T. International Obesity Task Force (IASO) Obes Rev 2004; (suppl 1):4-104 Hassink SG. 2007. Swinburg, 2005. Jeffcoat R. Med Hypothesis 2007; 68:1159-71.Turnbaugh PJ. Nature 2006; 444:1027-41. Samigorski AM. Obesity 2007; 15:1908-12. Reilly JJ. Pediat Res 2007; 61:646-52. Tojo R, Leis R. E. NAOS. MSC. 2007; 69-112. Christakis NA. NEJM 2007; 357:370-9

  9. Validation Test Krece Plus Healthy Nutrition in Spanish child population of 4-14 years depending on the level of nutritional risk. NUTRITIONAL LEVEL High Low Medium Nutritional risk* Nutritional risk*= Less intake to 2/3 of IDR Serra Majem LL. Crecimiento y desarrollo. Estudio enKid. Krece Plus. Barcelona: Eds.Masson; 2003.

  10. LEVEL OF PHYSICAL ACTIVITY IN A SAMPLE OF CHILDREN AND ADOLESCENTS OF GALICIA. GALINUT Study. Time it takes to walk them • Outcomes: How are you going to school? years years Walking Driving Tojo R, Leis R. Estudio GALINUT, 2008

  11. Difference of daily physical activity in children who go to school on transport vehicles or on foot. Rating by accelerometer Physical activity Hours Cooper AR. Am J Prev Med 2003; 25:273-6

  12. ICTs in children from Galicia Television HOURS/DAY OF: Console Computer R. Leis, R. Tojo. Estudio GALINUT 2008.

  13. Evolution of weight, height and BMI in children 10 years of Galicia. 1979-2001. GALINUT study

  14. Evolution of BMI (k/m2) percentiles in children 10 years. 1979-2006. Gaussian curve progressively to the right. GALINUT study 35 GALINUT (2006) GALINUT (1991) GALINUT (2001) GALINUT (1979) 30 BMI 25 20 Obesity 1979: 5%, 2006:16% 15 10 P1 P5 P15 P50 P85 P95 P99 Percentiles Tojo R, Leis R. USC-HCU 2007

  15. BMI (Kg/m2) P 95 P 75 P 50 P 25 P 5 x x x 2008 BMI Percentile Evolution 1979-2001 of Galicia BMI of children 10 yearsold. GALINUT-08 Study More obese and increasingly more degree of adiposity in these R.Tojo, R.Leis. Estudio GALINUT, 2008

  16. Changes in anthropometric measures in girls 12 years 1991-2005 Arm +0.3cm Waist +5.2cm Hip-3.4cm Thigh +1.0cm Weight: +2.7 Kg BMI: +1.7 Kg/m2 R. Tojo, R. Leis. USC-HCU. Estrategia NAOS 2007

  17. Metabolically healthy obese Obese at risk High BMI High fat mass High visceral fat Low insulin sens. Low HDL and highTg High BMI High fat mass Low visceral fat High insulin sens. High HDL and low Tg Karelis A.D. J Clin endocrinol Metab, 2004; 89:2569-75

  18. Metabolically obese normal weight Metabolically healthy normal weight Low BMI Low fat mass High visceral fat High liver fat Low insulin sens. High Tg Low BMI Low fat mass Low visceral fat Low fat liver High insulin sens. Low Tg Karelis A.D. J Clin endocrinol Metab, 2004; 89:2569-75

  19. COMORBILITIES OF CHILDHOOD OBESITY Psychosocial Poor selfesteen Depression Eating disorders Neurological Pseudotumor cerebri skinintertrigoAcanthosis nigricans Pulmonary Sleep apnoea Asthma Exercise intolerance Cardiovascular Dislipidaemia Hypertensión Coagulopathy Chronic Inflammation Endothelial dysfunction Metabolic syndrome Gastrointestinal Gallstones Steatohepatitis Pancreatitis Hypovitaminosis D Renal Glomerulosclerosis Endocrine Tipo 2 diabetes Precocious puberty Polycystic ovary syndrome (♀) Hypogonadism (♂) Musculoskeletal Slipped capital femoral epiphysis Bount´s disease Forearm fracture Flat feet Nutritional defects: Calcium, Iodium Modified by Ebelling. R. Tojo, R. Leis. 2004.

  20. Association between obesity and comorbidities in children.GALINUT and BOGALUSA Study Freedman DJ. Pediatrics 1999; 103: 1175-82 Leis R, Tojo R. Acta Paediatr 1999; 88: 19-24

  21. Main Causes of Vitamin D Deficiency and Potencial Consequences for Health Pleiotropic Effect Holick MF. Am J Clin Nutr 2008; 87 (suppl): 1080S-6S

  22. Hypovitaminosis D PandemicHypovitaminosis D Prevalence in children and adolescents from Galicia 25 (OH) Vit. D ≥ 30 : 32.8 % R. Leis, R. Tojo, A. Gil et al. 2010 NHANES III (1988-1994) a NHANES 2001-2004: Levels of 25(OH)D <10 ng/ml (2% a 6%) ≥30ng/ml (45% a 23%).Ginde AA. Arch Intern Med 2009; 169: 626-632

  23. Annual season and geographical latitude influence in serum levels of 25 (OH)D in children and adolescents from Galicia, NW of Spain R. Tojo, 1983 As daily hours of sun as inclination angle of UV rays influence 25 (OH)D production in the skin Dong Y. Pediatrics 2010; 125: 1104-11. Saintoge S. Pediatrics 2009; 123: 797-803

  24. Severe expression of Rickets in children Weight percentiles in children with Rickets from Galicia, NW of Spain R. Tojo, 1980 Galicia, NW of Spain, 1970s

  25. 25(OH) D and BMI R= -0.160 p= <0.001 R. Leis, R. Tojo, A. Gil et al. 2010

  26. Hypovitaminosis D Prevalence according to BMI % 25 (OH) Vit. D NS ng/ml R. Leis, R. Tojo, A. Gil et al. 2010 Fat tissue could act as a scavenger of 25(OH)D. Saintonge S. Pediatrics 2009; 123: 797-803. Dong YD. Pediatrics 2010; 125: 1104-1111

  27. Nonalcoholic Hepatic Steatosis (NASH) in children and adolescents from Galicia. GALINUT-08 study Liñares M, Leis R, Tojo R. GALINUT 2008 Diffuse hepatic steatosis (sagittal section) Normal liver (sagittal section)

  28. Prevalence of Metabolic Syndrome in Adolescents of Galicia 12 to 19 From 4 definitions and BMI.GALINUT-08 study Cook S. Arch Pediatr Adolesc Med 2003; 157: 821-7 De Ferranti S. Circulation 2004; 110: 2494-7 Weiss R. N Engl J Med 2004; 350: 2362-74 International Diabetes Federation 2007 R. Leis, R. Tojo. Estudio GALINUT. 2008

  29. Dietary strategies for the AHA-AAP over 2 years. Recommended for the whole family • Eat more vegetables and fruits • Eat more bread and whole grain cereals than refined • Eat more legumes • Eat more fish: especially blue • Use vegetable oils especially olive and margarines low in saturated and trans fatty acids and rich in unsaturated • Use lower fat dairy or without fat • Limit intake juices • Reduce animal fats • Use lean meats and poultry without skin • Eating fewer meats and sugary foods and drinks • Reduce intake of salt including processed foods • Limit high calorie sauces • Preparing meals cooked, steamed or grilled rather than fried AHA-AAP. Guiding SS. Pediatrics 2006; 117:544-9 Tojo, R, Leis R. E. NAOS-MSC. 2007; 69-112

  30. Pyramid Atlantic Diet:Healthy, functional and bioactive The ANSWER IS: R. Tojo, R. Leis. 2009

  31. Characteristics of healthy traditional diet of Atlantic Galicia - I • Abundance of food from local, seasonal fresh and minimally processed. • Abundance of foods from plants: fruits, vegetables, potatoes, bread and cereals, nuts, chestnuts, honey, legumes. • Abundance consumption of fish and shellfish, especially sea but also river. • Moderate consumption of dairy products, particularly cheese. • Moderate consumption of meat, especially pork and beef and lower proportion of hunting. • Moderate consumption of eggs. • Moderate consumption of desserts, mainly of flour, eggs, nuts. R. Tojo. Fundación Dieta Atlántica. USC 2007

  32. Characteristics of healthy traditional diet of Atlantic Galicia- II Using sauces relatively low energy charge and high quality fat. Abundance of water from springs, many with a healthy mineral profile. Moderate consumption of wine, normally in foods Use olive oil and seasoned olive oil and lard for cooking Culinary preparation preferably steamed, oven, iron, stew rather than fry. Simplicity and ingenuity in preparing. Originality in the association of food. R. Tojo. Fundación Dieta Atlántica. USC 2007

  33. Proposal working groups

  34. Example of application of different strategies  in schools • Feeding • On the food and beverage offer at school • Menu • Cafeteria • Machine • water sources • Food Advertising on campus Physical ActivityOn the environment to meet the daily recommendations favor of P.A. Legislative Develop training programs for the promotion of P.A. Formative Responsible for the planning and development of the school menu With the municipality to implement interventions to promote P.A.: safe routes to schools, opening of sports facilities, etc. With the food industry for the implementation of new products reformulated Participative Surveillance Centre Lifestyle

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