Secular Growth Trends in Greece: Childhood Obesity,

a Social Phenomenon

George P. Chrousos

Athens University Medical School

Secular Growth Trends

Secular Trends in Obesity

Mascie-Taylor and Goto, 2007

90th Centile Abdominal Circumference in cm

Brambilla IJO 2007

Obesity Epidemic in Childhood and Adolescence,

the First Reports, USA

• >100% increase in the number of children diagnosed as overweight (OW) and obese (OB) during the past 30 years

• 1983: 18.6% preschoolers OW, 8.5% OB 2000: 22.6% OW, 10.3% OB Rocchini, NEJM, 2002

• NHANES 1999-2002: 31% and 16% of 6-19 years old in the USA are overweight and obese

Hannon, Pediatrics, 2005

Global Prevalence of Overweight and Obesity

Country, Year

Criteria of Definition

Age

group

Prevalence of OW and OB %

Increase of OW and OB % (time interval)

Australia, 1995

IOTF 4-6

7-11

12.8, 3.6

14.4, 5

(1985-1995)

OW:38%, OB:190%

Brazil, 1997

IOTF 6-9

10-18

17.4

12.6

(1974-1997)

OW: 250%

China, 1997

IOTF 6-9

10-18

11.3

6.2

(1991-1997)

OW: 7.6%, 38%

UK,

1994

IOTF 4-11 11.2, 2.1 (1984-1994)

OW: 44.5%

Germany,

1997

IOTF 5-6 12, 2.8 (1982-1997)

OW: 44%

Japan,

1996

120% of standard weight

6

12

4.5

9.5

(1970-1996)

OW: 185%, 188%

USA,

2000

CDC 2-19 27, 13.7 (1971-2000)

OB: (6-11) 283%,

(12-19):154%

Prevalence of BMI≥85th and ≥ 95th Percentile of 15 y of Age: Consensus Statement, 2004

Speiser, 2005

Secular Trends in Height and Weight, Males, Greece, 1978-2001

Height, Boys Weight, Boys

Chiotis, Ann Clin Ped Univ Ath 2003

Secular Trends in Height and Weight, Females, Greece, 1978-2001

Chiotis, Ann Clin Ped Univ Ath 2003

Weight, GirlsHeight, Girls

Secular Growth Trends in Greece,1978-2001, Conclusions

• Same methodology and research center

• Same area and origins

3th percentile

50th percentile

97th percentile

Height +2 cm +1 cm +3 cm

Weight +4 kg +6 kg +15 kgDifferences in males, 1978-2001,aged 18

Differences in females, 1978-2001aged 18

3th percentile

50th percentile

97th percentile

Height - - +1 cm

Weight - - +7 kg

Secular Growth Trends in Greece,2001 in Relation to USA, 2000

3th percentile

50th percentile

97th percentile

Height +3 cm +1 cm +1.5cm

Weight +6 kg +7 kg +6 kg

3th percentile

50th percentile

97th percentile

Height +3 cm +1 cm +1 cm

Weight +2 kg +2 kg -4 kg

Differences in males, aged 18

Differences in females, aged 18

BMI curves, 2001

Boys Girls

BMI Curves in Relation to BMI 25 or 30

Boys Girls

Evidence from Greece, Males, 2001:

BMI and prevalence of obesity in 10.925 subjects (5.537 males) of Hellenic origin aged 0-18 years, living in the

Athens area

Chiotis, Ann Clin Ped Univ Ath, 2004

Age years Normal% OW% OB%

0-1 87.05 2.88 10.07

1-6 79.95% 10.88 9.17

7-12 72.10 18.48 9.42

13-18 67.5 20.63 11.80

Total 72.11 17.48% 10.40%

OW: 25<BMI≤30, extrapolatedOB: BMI>30, extrapolated

Evidence from Greece, Females, 2001:

BMI and prevalence of obesity in 10.925 subjects (5.388 females) of Hellenic origin aged 0-18 years, living in the

Athens area

Chiotis, Ann Clin Ped Un Ath, 2004

Age years Normal% OW% OB%

0-1 81.68 9.16 9.16

1-6 88.68 8.00 3.31

7-12 81.82 14.49 3.69

13-18 81.87 14.48 3.65

Total 83.22 13.05% 3.73%

OW: 25<BMI≤30, extrapolatedOB: BMI>30, extrapolated

Other Reports from Greece

• Thessaloniki, 2001: aged 6-17 years• N=2.458

Age Normal% OW% OB%

6-10 69.1 25.3 5.6

11-17 78.4 19 2.6

Total 73.7 22.2 4.1

Krassas, 2001

• Crete, 1982-2002: aged 12.1 ± 0.1 y,

• N=528, N=620

Other Reports from Greece

Manios, 2005

Associated Nosology

Metabolic Syndrome Χ, 1988

Reaven and colleagues: clustering of: obesity insulin resistance arterial hypertension dyslipidemia glucose intolerance

Increased cardiovascular risk

NCEP Definition(National Cholesterol Education Panel)

• ≥3 criteria

• Central obesity (Waist Circumference M>102 cm, F> 88 cm)• Impaired fasting glucose (>110mg/dl)• Low HDL (Α<40 mg/dl, Γ<50 mg/dl)• High Triglycerides (>150 mg/dl)• Arterial Hypertension >130/85 mmHg

JAMA 2001

IDF Definition(International Diabetes Federation)

ΝCEP + Waist Circumference:

• Fixed component: M>94 cm, F>80 cm Alberti K et al. , Lancet 2005

WHO Definition(World Health Organization)

• Impaired glucose tolerance, diabetes, insulin resistance

+ ≥2 Arterial Hypertension ≥ 140/90 mmHg ΗDL: M<40 mg/dl, F<50mg/dl ΤG ≥ 150mg/dl Central Obesity –waist circumference or ΒΜΙ>30 Μicroalbuminuria Alberti K et al Diabet Med, 1998

NHANES III (1988-1994)

Metabolic Syndrome

0

5

10

15

20

25

30

35

40

20's 30's 40's 50's 60's 70's 80's

Age (years)

Pre

vale

nce

Park et al., 2003

Total: 4.2%

OB: 28.7%OW: 6.1%NW: 0.1%

Επίπτωση

Risk FactorsArterial Hypertension, Obesity, Insulin Resistance,

Dyslipidemia, Chronic stress (real or perceived)

Metabolic Markers Cholesterol, LDL, HDL, Tg, Lp(a), Apo-A1, Apo-B, Glucose, HbA1c, Insulin, Albumin

Adiponectin, hsCRP

Metabolic Syndrome

Diabetes Type II

Cardio-VascularDisease

BackgroundAge, Gender, Developmental History (SGA, LGA), Diet, Physical Activity,Genes

GENET IC BACKGROUND, RACE

SOCIAL &DEVELOPMENTAL

FACTORS

SOCIAL ENVIRONMENT & CULTURE

PERINATAL & DEVELOPMENTAL

PARAMETERS

UNFAVORABLE CLINICAL CHARACTERISTICS:

+Body fat, -- Lean mass, + Visceral fat

OBESITY RELATED DIABETES OF THE

YOUNG

CARDIOVASCULARDISEASE

METABOLIC SYNDROME

(PREDISEASE)

3 of: IR, IFG, IGT Hypertension Obesity Dyslipidaemia

SECONDARY METABOLIC

ABNORMALITIES: Hypoadiponectinaemia Urine microalbuminuria

Liver disease

BEHAVIOR PSYCHOLOGYChronic stress

Eating disordersDepression

CLINICALPHENOTYPE(OBESITY)

DIETARYBEHAVIOR

PHYSICALACTIVITY

Published pediatric papers concerning the metabolic

syndrome

15 published reports from 1999 to 2006• No of criteria: 3, or 4

• Adiposity: BMI or waist circumference • Cut-off points: 75th, 85th, or 95th

centile

• Glucose metabolism: IFG, IGT, HOMA,

Fasting Insulin

Methods: Children & Adolescents

≥3

-BMI > 95th percentile -ΤG > 95th percentile, -HDL < 5th percentile , -Systolic or Diastolic Blood Pressure >95th percentile -Impaired glucose tolerance: • impaired fasting glucose >105 mg/dl or >140 mg/dl but < 200 mg/dl, 2 hours after the OGTT Weiss R, NEJM 2004 Sharma AM, Acta Diabet 2005

Data from a Childhood-Adolescence Obesity Clinic

• 420 Greek children (198 girls, 222 boys)• White race• Mean age 10.2 years (3-16)• 75.8% prepubertal boys and • 54.2% prepubertal girls

Data from a Childhood-Adolescence Obesity Clinic

Defined as having the MS when ≥3 were positive:

BMI > 95th percentile ΤG > 95th percentile, HDL < 5th percentile , Systolic or Diastolic Blood Pressure >95th percentile Impaired glucose tolerance: impaired fasting glucose >105 mg/dl or >140 mg/dl but < 200 mg/dl, 2 hours after the OGTT Weiss R, NEJM 2004

• Additional 29% of boys and 30% of girls had partial MS (2 criteria)

• 44% of the entire population had at least one metabolic abnormality

• 15% of boys and 16% of girls had the full MS

Data from a Childhood-Adolescence Obesity Clinic

• Low HDL was the most common abnormality associated with obesity

Pervanidou, ECOG 2007

100

% M

etab

olic

Syn

drom

e

00

90

80

70

60

50

40

30

20

10p< 0.001

N=31 N=36 N=36 N=35

Metabolic s. Prevalence across BMI z-score Quartiles among Males

% M

etab

olic

S

yndr

ome

100

00

90

80

70

60

50

40

30

20

10

Metabolic s. Prevalence across BMI z-Score Quartiles among Females

p< 0.001

N=55 N=56 N=55 N=56

100

% M

etab

olic

Syn

drom

e

00

90

80

70

60

50

40

30

20

10

Metabolic s. Prevalence across Insulin Quartiles (μU/ml) among Males

N=25 N=24 N=27 N=25

P=0.018

100

00

% M

etab

olic

Syn

drom

e

90

80

70

60

50

40

30

20

10

Metabolic s. Prevalence across Insulin Quartiles (μU/ml) among Females

p< 0.001

N=48 N=50 N=50 N=50

Prevalence of the Metabolic Syndrome and Metabolic Abnormalities in 420 Greek Children and Adolescents Assessed for Simple Obesity: preliminary results

Depression & Obesity: age 14-19

Shape up America, NHANES IIIMartin & Moore, 2002

30%

20%

Obesity and Depression

CDI, depressive symptomatology

• 22% of the entire population (N=73, aged 8-14) had depressive symptoms

Obesity and Life Events

2/3 presented with one or more stressful lifeevents during the last year

24 H SAMPLING OVERNIGHTDEXAMETHASONE TEST

A.

B.

PL

AS

MA

CO

RT

ISO

L

8 am 8 pm 8 am

TARGET TISSUE SENSITIVITY

TA

RG

ET

TIS

SU

E R

ES

PO

NS

E

CORTISOL CONCENTRATION

HS N R THRESHOLDFOR HARMFULNESS

-D

-D

+D

+D

NS CS

NS CS

24 H

CO

RT

ISO

L

DARK

Influence of Circadian Clockon HPA Axis

SCNCircadian Center

PVN

CRH AVP

ACTH

F/B

TARGETTISSUES

StressOther Inputs

Cir

cula

tin

g F

/BT

arg

et T

iss

ue

Eff

ect

Time

Circadian fluctuation

-

-A circadian rhythm indirectly regulates the functions of all organs/tissues through modulation of glucocorticoid actions.

«Συμπάσχει η ψυχή τω σώματι νοσούντι και τεμνομένω, το δε σώμα τη ψυχή»

“The soul suffers when the body is diseased or traumatized, while the body suffers when the soul is ailing”

Aristotle

«Παχέες ταχυθάνατοι μάλλον των ισχνών»

“Obese people die earlier than thin ones”

Hippocrates

Conclusions

• Greece, like the US and other EU countries, has an increase of its OW and OB population in childhood and adolescence

• These changes resulted in increased prevalence of MS traits in childhood and forecast an increased morbidity and mortality in later life

Stress System and the Metabolic Syndrome

_________________________________

Cushing SyndromePseudocushing SyndromeMelancholic DepressionMetabolic Syndrome“Benign” Premature Adrenarche Linkage StudiesMonkey StudiesAIDS-related insulin resistance/lipodystrophy Seasonal Depression Atypical Depression

__________________________________________

PREGNANCY

FETUS

NutritionGestational diabetes

Nutrition /Stress

Insulin IGF-1

cortisol catecholamines insulin

LGASGA

Visceral AdiposityMetabolic Syndrome

Depression

visceral fat

cortisol

catecholamines

Melancholic Atypical

Metabolic Syndrome

visceral fat

lean body mass

bone mass

cortisol

catecholamines

insulin

  70-75

Προσδόκιμο Ζωής (1998)

  75-80

  65-70   60-65   55-60

  under 55

  NA

Age adjusted death rates for CAD by country and sex, age 35-74 Age adjusted death rates for CAD by country and sex, age 35-74 (British Heart Foundation, Statistics Database 2003)(British Heart Foundation, Statistics Database 2003)

Greek Trends: Athens GMA

• C-Sections >70% <20%

• Breast Feeding <20% >90%

Real Expected