La Gestione del Bambino Sovrappeso – Obeso: Terapia UOC Diabetologia, Nutrizione Clinica e Obesità in Età Pediatrica - Università e ULSS 20 Verona Claudio.

Presentazione sul tema: "La Gestione del Bambino Sovrappeso – Obeso: Terapia UOC Diabetologia, Nutrizione Clinica e Obesità in Età Pediatrica - Università e ULSS 20 Verona Claudio."— Transcript della presentazione:

1 La Gestione del Bambino Sovrappeso – Obeso: Terapia UOC Diabetologia, Nutrizione Clinica e Obesità in Età Pediatrica - Università e ULSS 20 Verona Claudio Maffeis 68° Congresso Nazionale Società Italiana di Pediatria Roma 9-11 Maggio 2012

2 Terapia dell’obesità del bambino Quando iniziare ? Quali obiettivi ? Cosa fare ?

3 de Onis M et al. Am J Clin Nutr 2010;92:1257-1264 global prevalence and trends of overweight and obesity among preschool children.

4 50 0 persistence of obesity from childhood into adulthood Maffeis C et al. J Clin Endocrinol Metab 2002;87:71-76 normal weight total sample (%) measured in adulthood over weight obese 25 relative BMI at baseline (%) reciprocal of adult BMI 100 r = -0.52, P<0.01 0.06 0.04 0.02 135170205240

5 Adolescent BMI Trajectory and Risk of Diabetes versus Coronary Disease Tirosh A, et al. NEJM 2011;364:1315-25

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7 Mortalità Prematura da Cause Endogene 1.00 0.95 0.90 0.85 0102030405060 Sopravvivenza (%) Età (anni) I quartile BMI IV quartile BMI PW Franks et al. NEJM 2010 P <0.01

8 Terapia dell’obesità del bambino Quando iniziare ? Quali obiettivi ? Cosa fare ?

9 ECTOPIC FAT ACCUMULATION OBESITY INFLAMMATION INSULIN RESISTANCE INSULIN RESISTANCE METABOLIC SYNDROME a * * * m d d d d d a Franzese A, Vajro P, et al. Dig Dis Sci 1997 Sbarbati M, Maffeis C, et al. Pediatrics 2006 Hypertension dislipidemia IGT – T2D

10 Girls Normal weight (n = 501) Overweight (n = 116) Obese (n = 122) P Age (years)10.7 (2.1)10.4 (2.1)10.5 (2.2)NS BMI (kg/m 2 )17.2 (2.1)21.8 (2.2)28.7 (4.3)<.001 BMI z score−0.4 (0.8)1.3 (0.4)2.6 (0.5)<.001 Waist circumf. (cm)59.1 (6.2)68.6 (7.1)84.9 (10.8)<.001 Systolic bp (mm Hg) 109.2 (12.9)114.1 (12.1)117.8 (13.5)<.001 Diastolic bp (mm Hg) 65.3 (10.4)70.2 (10.1)70.4 (9.8)<.001 Triacylglycerol (mg/dL) 66.3 (26.1)78.4 (41.1)100.3 (59.8)<.001 HDL cholesterol (mg/dL) 59.1 (13.8)53.5 (13.4)46 (11.8)<.001 Glucose (mg/dL)88.3 (8.3)87.9 (8.4)87.8 (8.3)NS Maffeis C, et al. J Pediatr 2008 Physical characteristics of children divided into normal weight, overweight, and obese

11 Maffeis C, et al. J Pediatr 2008 Odds ratio to have the metabolic syndrome in subjects with a W/Hr >0.5 within normal-weight, overweight, and obese BMI categories Childhood Obesity Group of the Italian Society of Pediatric Endocrinology & Diabetology Metabolic syndrome Risk to develop metabolic syndrome Independent variablesNoYesOR (95% CI) Normal weight with W/Hr <0.5938221 Normal weight with W/Hr >0.51314.01 (0.49-32.97) Over weight with W/Hr <0.5132103.34 (1.52-7.37) * Over weight with W/Hr >0.572168.16 (3.87-17.23) ** Obese with W/Hr >0.52086712.11 (7.08-20.71) ** W/Hr = waist/height ratio * P <.05. ** P <.001. W H

12 130 120 110 100 80 70 fasting plasma glucose (mg/dl) 140 fasting plasma glucose and impaired glucose tolerance in obese children 86 Maffeis et al Obesity 2009 NO OGTT OGTT NPP >95%

13 Maffeis C, et al. JPGN 2011;53: 590–593 Biochemical Parameters and Anthropometry Predict NAFLD in Obese Children

14 therapy of obesity in children and adolescents Diet Exercise motivation adherence efficacy maintenance open questions: main target Drug Surgery behavior change < 6 years > 6 years weight maintenence weight loss (weight loss if weight-related complications) Dietz & Robinson NEJM 2005

15 Terapia dell’obesità del bambino Quando iniziare ? Quali obiettivi ? Cosa fare ?

16 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) Target behaviors Breastfeeding Breakfast Family meals (fast food) Balanced macronutrients diet (RDA) Fruits and vegetables, Fiber Energy density Portion size Sugar-sweetened beverages (Calcium) TV other screen exposition Physical activity

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18 A parent-led family-focused tretment program for overweight children aged 5 to 9 years: the PEACH RCT Magarey AM, et al. Pediatrics 2011 Intervention: 6 months: 12 90-120-min group sess. (parents) + 4 teleph. sess. BMI z-score 3.4 3.0 2.6 2.2 baseline 6mo12mo18mo24mo waist BMI

19 Bach-Faig A, Serra-Majem L, et al Public Health Nutr 2011

20 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

21 25 15 5 FAT MASS (%) 0 9 18 AGE (years) PHYSICAL ACTIVITY AND BODY FAT 3 1.5 0 PHYSICAL ACTIVITY LEVEL (PAL) Maffeis C, 2005

22 physical activity energy expenditure predicts progression toward methabolic syndrome indipendently of aerobic fitness in middle aged healthy caucasians Metabolic Syndrome (z score) <4444-7071-100>100 kJ/kg/FFM/d Ekelund U et al. Diabetes Care 2005 energy expenditure for physical activity 0 0.1 0.2 0.3 0.4

23 Maffeis, C. et al. J Clin Endocrinol Metab 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

24 the role of free-living daily walking in human weight gain and obesity Levine JA et al. Diabetes 2008

25 Two-year Follow-up in 21,784 Overweight Children and 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 24 100 80 60 40 20 0 (%) lost of follow-up SDS BMI reduction <0.5 SDS BMI reduction >0.5 time (months) 6 12 24 129 treatment centers 5 centers with the highest success rate

26 The Socioecological Framework Caprio S, et al Obesity 2008

27 Capitolo 9. OBESITA’ PEDIATRICA Società Italiana Obesità Claudio Maffeis (coordinatore) Società Italiana Nutrizione Pediatrica Andrea Vania Società Italiana Endocrinologia e Diabetologia Pediatrica Giuliana Valerio Società Italiana Pediatria Graziella Sapia Società Italiana Medicina Adolescenza Michele De Simone Società Italiana Pediatria Preventiva e Sociale Sergio Bernasconi Associazione Culturale Pediatri Maurizio Iaia Federazione Italiana Medici Pediatri Giampiero Chiamenti Confederazione Italiana Pediatri Giuseppe Gullotta Associazione Dietetica e Nutrizione Clinica Italiana Giuseppe Morino

28 Take home message Fare diagnosi precoce Iniziare prevenzione dalla nascita Stretto follow-up i soggetti a rischio Terapia multidimensionale Controllo delle complicanze

29 Verona 14-15 settembre 2011 5° Congresso SIP FIMP Nutrizione, Metabolismo e Diabete nel Bambino e nell’Adolescente. Aula Magna Policlinico

30 10-year-old obese boy: MRI L4 VAT: visceral adipose tissue SAT: subcutaneous adipose tissue SAT VAT

31 rete di assistenza pediatrica per l’obesità del bambino PLS II liv III liv