Overweight and Obesity

Validate Responses

1. "I understand you are not ready to lose weight now." 2. "The decision to lose weight is yours. Perhaps you may be more ready in the future" a. OR: 3. "I hear that you may be ready after the holidays." 4. "Give my staff a call so we can support you." a. OR: 5. "I'm pleased that you are ready to take action." 6. "Let's talk about how you are planning to do that."

SAFE RATE OF WEIGHT LOSS

1. 1-2 lb/week, which can be accomplished by cutting about 500-1000 calories a day 2. Weight loss should be divided into 2 phases-- the "weight-loss phase" that lasts approximately 6 months or until the patient achieves a 5% to 10% loss from initial baseline weight help patients maintain weightloss 3. RECOMMENDATION: The initial goal of weight loss therapy should be to reduce body weight by approximately 10% from baseline. With success, further weight loss can be attempted, if indicated through further assessment. Then "maintenance." 4. 1-2 lb/week, which can be accomplished by cutting about 500 calories a day 5. Weight loss should be about 1 to 2 lb/week for a period of 6 months with the subsequent strategy based on the amount of weight lost. Evidence Category B

Gene-Environment Interaction

1. A complex interaction involving at least as many as 250 obesity-associated genes and non-genetic, environmental factors cause predisposition to obesity 2. concept of 'susceptibility genes' whereby a particular genotype does not necessarily determine the development of obesity but increases risk of the disease given a particular environment 3. Genetics may impact energy intake (control of appetite & eating) and energy expenditure

Impact of APN Attitudes About Overweight and Obesity

1. APN's attitude about obesity can positively or negatively influence the clinical environment in which patients are treated 2. Often stigmatized - the APN should be aware of the negative stereotypes that are associated with obesity 3. Use terms such as "unhealthy body wgt," "BMI," and "wgt problem" rather than "fatness," "obesity," and "large size"

Weight Management by the APN

1. APN's have a unique opportunity to influence their patients nutrition & activity choices and thereby to play a pivotal role in weight-loss management 2. Beyond the usual medical assessment and monitoring, the secret is to motivate patients to change their behavior 3. APNs can help patients set and attain goals by creating an individualized weight-loss plan, monitoring weight changes between visits, and providing encouragement and support.........

Special Issues for Immigrant and Minority Populations

1. Adverse health consequences of obesity vary according to ethnic origin and because of cultural factors 2. Increased risks a/w obesity have been shown at lower BMI levels in Asians compared with Caucasians and these populations are predisposed to visceral or abdominal obesity 3. Controlling for differences in adiposity, US Black and Hispanic are at greater risk for DMII & CVD than their white counterparts 4. Caucasian girls are often more vulnerable to the psychosocial effects of obesity compared with girls from other ethnic groups.

Socioeconomic Status & Obesity

1. Among non-Hispanic black & Mexican-American men, those with higher incomes are more likely to be obese than those with lower income 2. Higher income women are less likely to be obese than low-income women (access to healthy foods) 3. There is no significant relationship between obesity & education among men. Among women, those with college education are less likely to be obese compared to less educated women

Aging & Obesity

1. BMI gradually increases a. Peaks at 50 - 59 for both sexes b. After 60, mean body weight and BMI decrease 2. Change in body composition a. Fat mass increases @ 60 -70 yrs b. Fat-free mass progressively decreases after 20-30, 40% (skeletal muscle) c. Both decrease after age 70 3. Hormonal changes w/aging a. Reduction of energy balance b. Decreased ability to regulate appetite

Recommend An Eating Plan

1. Because individuals respond differently to different diets, no single diet plan can be recommended for all persons—consider culture and background of eating and pick an appropriate diet that fits for them. 2. Select an enjoyable, palatable eating plan that can be incorporated into their daily lives 3. A year-long study comparing 4 popular diet plans (Atkins, Ornish, Weight Watchers, & The Zone) reported high dropout rates and similar weight-loss results at 1 year; underscored the importance of adherence to healthy eating, not the diet itself 4. The Dietary Guidelines for Americans state that "when it comes to weight control, calories do count" --not the proportions of CHO, fat, and protein in the diet 5. In this respect, fad diets may be less helpful as a weight-loss tools than a general awareness of the calories consumed and expended 6. Weightless: nutritional eating and portion control in addition to weight loss

New Vital Signs

1. Body Mass Index a. Weight (kg) x height (cm)2 OR b. Weight (lb) x 703 height (in)2 c. BMI >25 kg/m2 = Overweight d. BMI >30 kg/m2 = Obesity 2. Waist Circumference a. Measure only for patients with BMI between 25 - 34.9 b. Abdominal obesity: risk factor for CVD c. Measure abdomen horizontally at level of iliac crest d. Weight loss is a/w decrease in abd fat measured by WC e. Risk Categories: i. 40" male ii. 35" female

Possible Explanations for this Trend

1. Caloric intake greater than caloric expenditure through physical activity 2. Poor diet (e.g., dietary intake high in calories from sugar and fat) 3. Cultural or social pressure to gain weight 4. Decreased exercise because of lack of encouragement or opportunity (e.g., reduction in school PE resources, sports programs, community elimination of bike paths, closed stairwells in public buildings, lack of initiative ("couch potato syndrome") 5. Poor urban or neighborhood planning ("built environment")

Childhood Obesity

1. Childhood overweight is a risk factor for adult obesity; this relationship is direct 2. Persistence of childhood obesity into adulthood also related to age, parental obesity, & severity of obesity 3. If child is obese, adult obesity more severe 4. Childhood obesity is associated with a higher chance of premature death and disability in adulthood 1. CDC Growth Charts are used to determine the corresponding BMI-for-age and sex percentile. For children and adolescents (aged 2—19 years): 2. Overweight is defined as a BMI at or above the 85th percentile and lower than the 95th percentile for children of the same age and sex. 3. Obesity is defined as a BMI at or above the 95th percentile for children of the same age and sex.

Predictors of Obesity

1. Childhood1 a. Maternal obesity: best predictor b. Low family income c. Lower cognitive stimulation d. High fat/calorie intake e. Avid T.V. watching 2. Adult2 a. Strong associations found: i. Parental obesity ii. Birth weight iii. Timing or rate of maturation

Is The Obesity Issue Addressed?

1. Clinicians, however, frequently do not address the issue of obesity with obese patients 2. By screening we refer here to the conscious measurement of BMI by the clinician, with the purpose of addressing body weight in the clinical setting 3. Descriptive study by Miller, Alpert, & Cross (2008) found that although 93% of nurses acknowledge that obesity requires intervention, 76% did not pursue the topic with patients

Barriers to Weight Management-Patients

1. Confusion about calories in foods: "eat less"; "low fat"; "healthy"; "fast foods"; "snacks" 2. Confusion about portion sizes 3. Concern about reducing essential nutrients. Be specific with education 4. Desire not to omit eating "pleasures".. eliminate "favorite foods" 5. Concern about activity and changing lifestyleshort walk at lunch, use the stairs 6. Poor success with previous attempt(s)

Determinants of Dietary Choices

1. Convenience a. Demographics b. Work patterns 2. Personal preference a. Age b. Gender c. Education d. Family Background e. Income f. Ethnicity 3. Global food marketing

Identify the Main Areas of Concern

1. Cosmetic Concerns 2. Health Concerns 3. Specific Co-Morbid Condition 4. Quality of Life Issues

Obesity & Major Chronic Diseases

1. Diabetes mellitus 2. Insulin resistance 3. Hypertension 4. Dyslipidemia 5. Gout 6. Heart disease 7. Stroke 8. Venous thrombosis 9. Dementia 10. Hepatobiliary disease 11. GERD 12. Osteoarthritis 13. Respiratory diseases 14. Kidney disease 15. Endocrine changes 16. Cancer 17. Read an article that Nancy Jo posts before next exam on obesity

How to change patients weight loss expectations

1. Discuss likely outcome of treatment a. Describe the benefits of modest weight loss b. Ask patient's reaction to initial loss (5%-10%) c. Listen and empathize with possible disappointment d. Focus on what can be accomplished 2. Additional weight loss can be considered after maintaining initial loss for 6 months

Pharmacotherapy and Weight Loss Surgery

1. Drugs don't help unless there's lifestyle changes withit 2. For intractable obesity, pharmacotherapy is an adjunct to diet, exercise, and lifestyle modifications 3. 2 FDA approved drugs for long-term wgt management sibutramine (Meridia) and orlistat (Xenical) & others 4. Follow-up data from both sibutramine and orlistat trials confirm a greater efficacy of pharmacotherapy plus lifestyle modification versus pharmacotherapy alone 5. Patients receiving pharmacotherapy should remain in behavior modification programs & excercise 6. In appropriately selected patients, surgery is another effective means for producing long-term weight loss & reduction of obesity-related co morbidities a. Roux-en-Y gastric bypass is considered the gold standard of the various options that are available

Behavioral Therapy Findings

1. Efficacy a. Behavioral based treatment programs improve weight loss results 2. Choice of intervention a. High intensity program; at lease 12 sessions over 6 months with reinforcement is most effective. Make sure they have follow up visits 3. Social support a. Enhancing spousal/family support increase success b. Commercial weight loss clinics (Jenny Craig and weightwatchers)

Etiology of Childhood Obesity

1. Environmental factors 2. Genetics 3. Sugar-sweetened beverages 4. Television 5. Video games 6. Sleep 7. Medications 8. Toxins, e.g., bisphenol A 9. Endocrine disease 10. Metabolic programming 11. Nutrition or stressors during gestation & early in life 12. Maternal endocrine factors

USPSTF on Surgical Interventions

1. Evidence Statement: is an option for carefully selected adults with clinically severe obesity (BMI >40 or a BMI > 35 with comorbid conditions) when less invasive methods of weight loss have failed and the patient is at high risk for obesity-associated morbidity and mortality 2. Can result in substantial weight loss, and therefore is an available weight loss option for well-informed and motivated patients with clinically severe obesity, who have comorbid conditions and acceptable operative risks 3. Evidence Category B 4. Gastric restriction [vertical gastric banding] or gastric bypass [Roux-en Y] recommended

Etiology of Obesity

1. Genetics 2. Differences in resting metabolic expenditure (RME) 3. Differences in thermic effect of food 4. Environmental factors, e.g., "built environment" 5. Decreased physical activity 6. Food choices 7. Medical illness, e.g., Cushing Disease 8. Mental illness 9. Major depression 10. Medications 11. Smoking cessation

Prevalence of Obesity

1. Global Health concern 2. Data Collected in U.S. a. Behavioral Risk Factor Surveillance System (BRFSS) b. National Health & Nutrition Exam Surveys (NHANES) 3. Obesity is a chronic disease 4. Approx. 34.5% of adult Americans are obese 5. Approx. 35% of adult Americans overweight 6. Approx. 17% children in U.S. overweight or obese

Steps of Behavioral Therapy

1. Goal-setting a. Realistic b. quantifiable 2. Self-monitoring a. Food & beverage intake (food journals on a daily basis have been found to be very helpful for people) b. Physical activity 3. Stimulus control a. Identify desired & undesired cues b. Stress reduction 4. Cognitive skills a. Problem-solving b. Cognitive restructuring

Exercise Daily!

1. Goals should be set with the person and evaluated on a regular basis- every office visit 2. 2008 Physical Activity Guidelines for Americans: 3. http://www.health.gov/paguidelines/guidelines/ 4. Adults gain health benefits when they carry out the equivalent of at least 150 minutes of moderate intensity aerobic physical activity (2 hours/30 minutes) each weektell your patients to move 30 mins a day for 5 days a week 5. Weight loss requires 30-60 minutes of activity per day with sustained tachycardia at 70-80% or maximum predicted heart rate

Consequences of Childhood Obesity

1. High blood pressure and high cholesterol, which are risk factors for cardiovascular disease (CVD). 2. Increased risk of impaired glucose tolerance, insulin resistance and type 2 diabetes. 3. Breathing problems, such as sleep apnea, and asthma. 4. Joint problems and musculoskeletal discomfort. 5. Fatty liver disease, gallstones, and gastro-esophageal reflux (i.e., heartburn). 6. Obese children and adolescents have a greater risk of social and psychological problems, such as discrimination and poor self-esteem, which can continue into adulthood.

Teach Self-Help

1. If the patient needs to lose weight & the risk assessment finds the patient mentally and physically ready - a weight-loss treatment plan can be developed 2. The patient should begin practicing self-help activities: a. Self-monitoring is a crucial component of any weight-loss regimen b. Two key tools for addressing lifestyle habits and making small adjustments in healthy eating and physical activity are a food and activity journal as well as a bathroom scale

Obesity Prevalence Across States— midwest and the south

1. In 1990, among states participating in the Behavioral Risk Factor Surveillance System, 10 states had a prevalence of obesity less than 10% and no state had prevalence equal to or greater than 15%. 2. By 2000, no state had a prevalence of obesity less than 10%, 23 states had a prevalence between 20-24%, and no state had prevalence equal to or greater than 25%. 3. In 2010, no state had a prevalence of obesity less than 20%. Thirty-six states had a prevalence equal to or greater than 25%; 12 of these states (Alabama, Arkansas, Kentucky, Louisiana, Michigan, Mississippi, Missouri, Oklahoma, South Carolina, Tennessee, Texas, and West Virginia) had a prevalence equal to or greater than 30%.

Obesity Prevalence Across States

1. In 2012, no state had a prevalence of obesity less than 20% 2. Nine states had prevalence between 20-25% 3. Thirteen states had a prevalence equal to or greater than 30% 4. Higher prevalence of adult obesity was in the Midwest (29.5%) & the South (29.4%) 5. Lower prevalence in Northeast (25.3%) & the West (25.1%)

Tools to Help Build an Individualized Program: Calculating energy requirements

1. Intentional weight loss generally results from a negative energy balance: a decrease in caloric intake and/or an increase in energy expenditure achieved through physical activity 2. Recommending healthy eating that produces an energy deficit must calculate patient's energy requirements 3. For a quick approximation of energy needs, APNs can use dietary guidelines estimated calorie requirements table 4. When the person achieves a "moderately active" physical activity level, another simple way to estimate caloric needs is to multiply body weight by 15 calories/lb a. For example, a moderately active 130-lb woman would require 1950 calories/day 5. There are different charts for men and women to diagnose your client as overweight

USPSTF on Physical Activity

1. Is recommended as part of a comprehensive weight loss therapy and weight maintenance program because it: a. Modestly contributes to weight loss in overweight and obese adults (Evidence Category A) b. may decrease abdominal fat (Category B) c. Increases cardio-respiratory fitness (Category A) d. May help with maintenance of weight loss (Category C)

Barriers to Treatment -Health Professionals

1. Lack of training/knowledge in weight treatment 2. Perception that no treatment works 3. Perceived patient non-adherence or interest 4. Lack of time in clinic settings 5. Ineffective treatment materials and methods 6. Inadequate reimbursement

Behavior Modification- Suggestions

1. Leave 10% of your meal behind 2. Place a few forkfuls on a side salad plate before eating 3. Eventually, try starting with smaller helpings 4. Take at least 20 minutes to eat each meal 5. Use a timer to monitor your eating pace and set your fork down between bites 6. Avoid second and third helpings at the dinner table by moving away from family-style meals; instead, serve each plate individually in the kitchen 7. Skip dessert or opt for fruit in place of baked goods 8. Make calorie-cutting substitutions

Motivational Interviewing

1. Motivational interviewing is patient-oriented and geared to enhancing intrinsic motivation by exploring and resolving the patient's ambivalence about lifestyle change 2. A key goal for a motivational interviewer is to help an individual reframe the change in positive terms (for example, what is gained versus what is lost) and to identify a source or motivation that can sustain these behavior changes

Multidisciplinary Approach

1. Multidisciplinary approach, dietitians, psychologists, and other healthcare professionals can offer comprehensive behavior therapy for the obese patient 2. These professionals may also be a regular adjunct to PCP visits in order to address diet, exercise, and behavior therapy 3. May be dictated by the patients insurance plan 4. Registered dietitians certified in the weight Management Dietetic Practice Group of the American Dietetic Association are especially equipped to provide structured meal planning

Childhood obesity:

1. Overweight or obese (BMI >85th %) a. 22.8% preschool children (2-5 years) b. 34.2% school-aged children (6-11 years) c. 34.5% adolescents (12-19 years) 2. Obese (BMI >95th%) a. 8.4% preschool children b. 17.7% school-aged children c. 20.5% adolescents 3. Severe obesity (BMI >97th%) a. 1.7% preschool children b. 6.8% school-aged children c. 7.7% adolescent girls/6.8% adolescent boys d. (uptodate 2014)

As APN's We are... Motivational Agents of Change

1. Patients solicit and respect advice from their PCP's, and other evidence indicates that PCP's advice can motivate patients to make healthy lifestyle changes 2. Clinicians can take steps to intervene, such as setting realistic expectations and using the prescription pad to write specific recommendations for physical activity and diet 3. APN's can become effective agents of change by modifying their traditional roles as authoritative figures and using motivational interviewing techniques

Additional Behavioral Techniques

1. Practice stopping before you are stuffed 2. Be selective in your food choices 3. Keep track of the calories in your food 4. Spoil your appetite, ie, eat a small snack before dinner to avoid overeating at dinner 5. Minimize temptation: Don't stock your pantry with tempting, unhealthy options 6. Keep it simple 7. Split an entrée when dining out or ask for half of the meal to be put in a doggie bag before eating 8. Train yourself to avoid scenarios where overeating is inevitable

USPSTF Recommendations on Weight Loss Medications

1. Recommendation: may only be used as part of a comprehensive weight loss program including diet and physical activity for patients with: a. BMI of >30 with no concomitant obesity-related risk factors or diseases, or b. BMI of >27 with concomitant obesity-related risk factors or diseases 2. Weight loss drugs should never be used without concomitant lifestyle modifications. Continual assessment of drug therapy for efficacy and safety is necessary. If the drug is efficacious in helping the patient lose and/or maintain weight loss and there are no serious adverse effects, it can be continued. If not, it should be discontinued. 3. Evidence Category B

Is Overweight- Obesity Contagious?

1. Social networks appear to be a factor in the obesity epidemic 2. 57% chance of becoming obese if friend is obese - even if living across the country 3. Especially same sex friend; more than family or spouse 4. Associated in close manner with anyone, their level has an influence on your level of obesity, but friends have greater influence (WE NEED TO STOP EATING PIZZA) 5. Exchange an emotional reality with your friend 6. Your psychological behavior is influenced by others around you

Predictors of Obesity- Genetics

1. Studies involving twins, adoption, and family have demonstrated that obesity is highly heritable 2. Twin studies suggest fat mass is 40-70% in monozygotic (identical) twins & 30-40% in dizygotic (fraternal) twins 3. Risk of obesity is increased when individual has relatives who are obese 4. "Polygenetic" pattern

2ND Phase.. Maintenance

1. The 2nd should last a lifetime - All of the portion control and calorie-cutting tools from the first phase must continue 2. if physical activity has not reached a moderately active level, additional motivation is required 3. The good news is that the number of calories calculated to achieve the weight loss will be enough to maintain the weight loss 4. Sustaining smaller portion sizes should be a long-term strategy! 5. Because the outcome will be 5% to 10% change in body weight, the process may be repeated again the following year with an added emphasis on weight maintenance. Average successful weight maintenance involves 4 years of active intervention! 6. Statement: After 6 months of weight loss treatment, efforts to maintain weight loss through diet, physical activity, and behavior therapy are important. Evidence Category B.

Weight-Loss Maintenance

1. Weight-loss maintenance can be challenging 2. Maintain diet and exercise efforts a. 30 to 60 minutes of daily physical activity are also crucial for preventing patients from regaining 3. Portion-controlled meals, including liquid meal replacements, can help maintain weight loss 4. People who adhere to behavior strategies, maintain the most substantial weight losses 5. Weight-loss maintenance becomes easier over time

Economic Costs of Obesity

2010 statistics: o 168 billion U.S. dollars o 17% of all medical costs o $2,800 added for individual medical costs

How to Address Weight Issues

a. Ask... i. "How do you feel about your weight?" ii. "Are you thinking about losing weight?" iii. "Have you ever tried to lose weight in the past?" b. Follow with active, empathetic listening i. Takes 2 minutes to adequately express concerns c. Validate feelings i. Leads to patient empowerment

Prevalence of obesity*

among children and teenagers, by age group and selected period--United States, 1963-2010* *Children with body mass index (BMI) values at or above the 95th percentile of the sex-specific body mass index (BMI) growth charts released by the Centers for Disease Control (CDC) in 2000.

Age Differences in Obesity

o 20-39 years= 32.3% o 40-59 years (middle age)= 40.2% o ≥ 60 years (elders)= 37.0%

Dietary Guidelines 2015

o Balance calories with physical activity to manage weight o Consume more of certain foods and nutrients such as fruits, vegetables, whole grains, fat-free and low-fat dairy products, and seafood o Consume fewer foods with sodium (salt), saturated fats, trans fats, cholesterol, added sugars, and refined grains

USPSTF Screening & Interventions to Prevent Obesity in Adults

o Clinicians screen all adult patients for obesity. Offer or refer patients with a BMI of 30 kg/m2 or higher to intensive, multicomponent behavioral interventions. o Rating: B Recommendation

BMI

o Describes relative weight for height o Significantly correlated with total body fat content o Used to assess overweight and obesity and risk for co-morbidities o Weight (kg)/ height (m2)

Limitations of BMI

o Does not correlate well with fat mass in both over-muscled (athletic) and under-muscled (sarcopenic) patients o Does not reveal differences in fat distribution (visceral vs. subcutaneous) o Does not measure fat directly but correlates with body fat over thousands of average patients o At any given BMI, women have more fat than men (post pregnancy and menopause)

RELATED FACTS

o Fundamentally: an energy imbalance between calories consumed and calories (energy) expended: o shift in diet towards increased intake of energy-dense foods that are high in fat and sugars but low in vitamins, minerals and other micronutrients o trend towards decreased physical activity due to the increasingly sedentary nature of many forms of work, changing modes of transportation, and increasing urbanization

Ethnic Differences in Obesity

o Non-Hispanic blacks have the highest age-adjusted rates of obesity (48.1%) compared to o All Hispanics (42.5%), o Non-Hispanic whites (34.5%), and o Non-Hispanic Asians (11.7%)

Definition of Obesity

o Obesity is defined as excess body fat (not simply excess weight) o Definitions: o BMI 25 kg/m2 = Overweight o BMI 30 kg/m2 = Obesity

BURDEN OF DISEASE-2

o Obesity-related conditions include heart disease, stroke, type 2 diabetes and cancer o Annual medical cost of obesity in the U.S. was $147 billion in 2008 U.S. dollars; o Medical costs for obese persons were $1,429 higher than those of normal weight in 2008

Benefits of BMI

o Permits population-based studies of trends in obesity and is used for clinical guidelines o As a measure of relative weight...easy to obtain o An acceptable proxy for thinness and fatness o Directly related to health risks and death rates o BMI classifications based upon risk of CVD o Adopted by NIH and WHO for Caucasian, Hispanic, and Black individuals

The Role of the APN

o Recognize the unique opportunity that exists to formulate and implement an effective strategy to substantially reduce disease burden (and possible death) by improving nutrition and promoting physical activity with our patients and their families o Invest in personal, community or public action (UCLA focuses on health of their students. Example: elevators will have signs that say "walk for a healthier life") o Help individuals appreciate the health consequences, the loss of QOL, and the disability that is associated with excess weight o An APN equipped with motivational interviewing skills can be remarkably effective in helping individuals manage their weight o The APN can monitor patient progress, treat co-morbidities, provide additional resources, and act as an agent of change with motivational interviewing skills and tools to create an individualized program for patients

Studies To Assess Providers Attitudes

o Reported that many biases do not differ from those traditionally held by society, that is, providers attribute overweight and obesity to behavioral, self-control issues o In fact, research shows that obese patients infrequently receive weight-loss counseling during office visits

Commercial Weight-Loss Clinics, Support Groups

o Such as Weight Watchers and Jenny Craig, can intensify self-help efforts and offer support, education, and structure o Success varies o Important for APN in supporting their patient's participation in ethical commercial or organized self-help programs

BURDEN OF DISEASE-1

o The prevalence of obesity exceeds 36% in most age-and sex-specific groups of adults o Approx. 1 in 20 Americans have a BMI > 40kg/m2 (7.7% from 2013-2014) o Depending on age & race, obesity is a/w a 6- to 20 year decrease in life expectancy

How do we measure waist circumference?

o To measure locate the top of the right iliac crest o Place a measuring tape in a horizontal plane around the abdomen at level of iliac crest o Before reading tape measure, ensure that tape is snug but does not compress the skin and is parallel to floor o Measurement is made at end of normal expiration

FACING A "DOUBLE BURDEN"

o While many continue to deal with the problems of under-nutrition, at the same time they are experiencing a rapid upsurge in chronic disease risk factors such as obesity and overweight, particularly in urban settings o It is not uncommon to find under-nutrition and obesity existing side-by-side within the same community and even within the same household o This double burden is caused by inadequate pre-natal, infant and young child nutrition followed by exposure to high-fat, energy-dense, micronutrient-poor foods and lack of physical activity