The Obesity Explosion: How Did We Get Here and Where Are We At?

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1 The Obesity Explosion: How Did We Get Here and Where Are We At? Donald D. Hensrud, M.D., M.P.H. Chair, Division of Preventive, Occupational, and Aerospace Medicine Associate Professor of Preventive Medicine and Nutrition 2012 MFMER slide-1

2 Disclosure Relevant financial relationships None Off label usage None 2012 MFMER slide-2

3 Learning Objective Describe background information on obesity including Classification Prevalence and trends Contributing factors Health complications Treatment Diet Physical activity Behavior change Medications Surgery 2012 MFMER slide-3

4 2012 MFMER slide-4

5 Obesity Obesity (def) - an excess of body fat resulting in adverse health effects 2011 MFMER MFMER slide-5

6 Obesity, Risk Assessment and Classification Disease Risk Relative to Normal Weight and Waist Circumference Men 40 in Men >40in Category BMI, kg/m 2 Women 35 in Women >35 in Underweight <18.5 Normal* Overweight Increased High Obesity High Very high Very high Very high Extreme obesity 40 Extremely high Extremely high * An increased waist circumference can denote increased disease risk even in persons of normal weight Adapted from Clinical guidelines on Obesity. National Heart, Lung, and Blood Institute Web site. Available at: MFMER MFMER slide-6

7 Obesity Trends Among U.S. Adults BRFSS, 1990 No Data <10% 10% 14% 2012 MFMER slide-7

8 Obesity Trends Among U.S. Adults BRFSS, 2000 No Data <10% 10% 14 15% 19% 20% 2012 MFMER slide-8

9 Obesity Trends Among U.S. Adults BRFSS, 2010 No Data <10% 10% 14 15% 19% 20% 24% 25% 29% 30% 2012 MFMER slide-9

10 Global Obesity Obesity around the world has doubled since 1980 Overweight and obesity are linked to more deaths worldwide than underweight Overweight and obesity are the fifth leading risk for global deaths MFMER slide-10

11 MFMER slide-11

12 Prevalence of Overweight and Obesity, NHANES All (%) Men (%) Women (%) Overweight Obese Extreme obese JAMA 2012;307: MFMER MFMER slide-12

13 Prevalence of Overweight and Obesity, NHANES Men Women All White Black Hispanic White Black Hispanic Overweight BMI Obese BMI 30 Extreme obese BMI 40 JAMA 2012;307: MFMER MFMER slide-13

14 Obesity, Health Complications Type 2 Diabetes Mellitus Hypertension Dyslipidemia High triglycerides Low HDL cholesterol Small, dense LDL cholesterol Coronary artery disease Stroke Overall mortality 2011 MFMER MFMER slide-14

15 Most cancers Obesity, Health Complications Respiratory diseases Obstructive sleep apnea Restrictive lung disease Obesity hypoventilation syndrome Asthma Osteoarthritis Cholelithiasis Gastroesophageal reflux disease (GERD) Nonalcoholic fatty liver disease (NAFLD) 2011 MFMER MFMER slide-15

16 Obesity, Health Complications Gynecologic abnormalities Abnormal menses Infertility Polycystic ovarian syndrome Venous stasis Skin problems Intertrigo Cellulitis Increased risk of complications during surgery or pregnancy 2011 MFMER MFMER slide-16

17 Societal Cost of Overweight and Obesity Cost in $ billions/yr* Study Year Overweight Obesity Finkelstein Arterburn Wang Finkelstein (147) Cawley *2009 dollars Data from Dor A et al:george Wash Univ, 2010 and 1 Health Affairs 2009;28:w822; 2 Int J Obes 2005;29:334 3 Obes 2008;16:2323; 4 National Bureau of Economic Research, MFMER MFMER slide-17

18 Individual Yearly Costs of Obesity Men, $ Women, $ Overweight Obese 2,646 4,879 Obese + VLL 6,518 8,365 (value of life lost) Direct and indirect costs (disability, decreased productivity, absenteeism, etc.) Direct medical costs largest % for overweight Lost wages largest % for obese women Dor A et al: George Wash Univ, MFMER MFMER slide-18

19 Obesity Costs, Who Pays? Medicare and Medicaid pay about half of all costs 1 Business paid an estimated $12.7 billion in 1994 (5% of total medical care costs) 2 Cost of obesity among full-time employees estimated to be $73 billion in in a recent study 3 1 Health Affairs 2009;28:w822; 2 Am J Health Prom 1998;13:120 3 J Occup Environ Med 2010;52: MFMER MFMER slide-19

20 Pathogenesis of Obesity Genetics vs. environment 30% - 40% of variance related to genetics Environment Diet/energy intake Physical activity Exercise Daily activities Individual factors 2012 MFMER slide-20

21 2011 MFMER MFMER slide-21

22 2011 MFMER MFMER slide-22

23 Management Plan Diet Physical activity Exercise Daily activities Behavior change Medications Surgery *Use the assessment and history to tailor the plan MFMER slide-23

24 Individualized Weight Loss Hundreds of different influences Diet Physical activity Behavior Everyone has different obstacles Everyone s plan should have tailored strategies Mayo Clinic Diet Action Guide MFMER slide-24

25 MFMER slide-25

26 Weight Loss, Diet Diet There is no one best diet Tailor the dietary program to the individual Minimum dietary standards Sound scientific rationale Safe and nutritionally adequate Practical and effective long-term 2012 MFMER slide-26

27 MFMER slide-27

28 Dietary Therapy, AHA/ACC/TOS Recommendations Calorie deficit of kcal/day Promotes weight loss of 1-2 pounds/week Low CD 1,200-1,500 kcal/day for women 1,500-1,800 kcal/day for men Choose a diet based on patient preferences 3-5% weight loss leads to clinical benefit 2012 MFMER slide-28

29 Weight Loss, Different Macronutrient Composition 811 overweight adults, 2 years Group and individual instructions 4 reduced calorie diets: Fat Protein Carbohydrates NEJM 2009;360: MFMER slide-29

30 Weight loss (kg) Weight Loss, Different Macronutrient Composition /15/20% 55/25/20% 45/15/40% 35/25/40% Months NEJM 2009;360: MFMER slide-30

31 Weight Loss, Different Macronutrient Composition 80% completed 2 years Most weight loss occurred by 6 months (6 kg) No significant differences among groups in weight loss or cardiovascular risk factors Mean weight loss among all participants 4 kg at 2 years Attendance at group sessions was strongly associated with weight loss MFMER slide-31

32 Methods of Calorie Restriction Counting calories 2012 MFMER slide-32

33 kcal/d Discrepancy Between Reported and Actual Energy Intake and Expenditure 3,000 2,500 2,000 Energy Intake * Energy Expenditure 1,500 1,000 * Reported Actual Reported Actual *P<0.05 vs reported Lichtman et al: N Engl J Med 1992;327: MFMER slide-33

34 Methods of Calorie Restriction Counting calories Counting fat grams Point system Exchange system Moderation of portion size, types of foods, etc. Very-low calorie diets Liquid meal replacements Energy density 2012 MFMER slide-34

35 2012 MFMER slide-35

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38 2012 MFMER slide-38

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42 2012 MFMER slide-42

43 Fruits & Vegetables and Weight Gain 74,000 females followed for 12 years in the Nurses Health Study Those with the largest increase in intake of fruits and vegetables had a 24% decreased risk of becoming obese Int J Obes 2004;28: MFMER slide-43

44 Dietary Changes and Weight Changes Dietary Change Weight Change, lb Potato chips 1.69 Potatoes 1.28 Sugar-sweetened drinks 1.00 Unprocessed red meat 0.95 Processed meat 0.93 Vegetables Whole grains Fruits Nuts Yogurt NEJM 2011;364: MFMER slide-44

45 Mayo Clinic Healthy Weight Pyramid

46 Determinants of What We Eat Objective Evidence from scientific studies Subjective Cost Convenience Time Food availability What we grew up eating Taste preferences Marketing Ethnicity Social influences 2012 MFMER slide-46

47 Attitude Healthful Dietary Change People underestimate their ability to change Eating healthy vs. eating well Lifestyle Practical Palatable Promote satiety Low in calories Healthy MFMER slide-47

48 2012 MFMER slide-48

49

50 Physical Activity, Recommendations 150 min/week of moderate-intensity physical activity (e.g., brisk walking) 75 min/week of vigorous intensity physical activity (e.g., jogging or running) To effectively lose or maintain weight, may need 300 min/week of moderate-intensity physical activity MFMER slide-50

51 Exercise Exercise vs daily activities Pick an exercise that: Is enjoyable Can be performed regularly Can be continued indefinitely Frequency, duration, intensity MFMER slide-51

52 Adjusted RR Obesity, Fitness, and Mortality Fit Unfit Lean Normal Obese (<16.7) (>25) Body Fat (%) Lee CD: AM J Clin Nutr 1999; 69: MFMER slide-52

53 Daily Activities Human nature - conserve energy and decrease activity Years ago survival advantage Now shortens survival Different mindset look for opportunities to obtain increased activity Burn calories Feel better Improve health MFMER slide-53

54 Daily Activities Take the long way around Choose outdoor vacations/activities Avoid using children to do tasks (don t let them get all the benefits) Walk whenever you can Stairs, park farther away Around the office Airports (don t use the moving walkway) Consider a pedometer MFMER slide-54

55 Television Time and Health Each 2 hours of TV time increases the risk of: Type 2 diabetes by 20% Cardiovascular disease by 15% All-cause mortality by 13% Studies reported similar results after controlling for exercise JAMA 2011;305: MFMER 2012 MFMER slide-55

56 2012 MFMER slide-56

57 Weight Loss Strategies Determine general goals (health, weight, etc.) Determine obstacles and tailor the approach to address obstacles Have specific plans, and plan ahead Provide suggestions and motivation Provide educational information (online, print, etc.) Consider commercial programs for partnering/follow-up (weight, coaching) Individualize the plan 2012 MFMER slide-57

58 Weight Loss Strategies Diet tracking (e.g., sparkpeople.com, myfitnesspal.com, Livestrong.com) Physical activity tracking (e.g., Fitbit, Omron, Gruve) Focus on the process (lifestyle change) and health, not the outcome (pounds) Use process goals - SMART The process can be enjoyable! Expect lapses problem solving 2012 MFMER slide-58

59 Weight Loss, Systematic Strategies Stepped-care approach Lifestyle counseling in primary care Remote treatment 2012 MFMER slide-59

60 Stepped-Care Approach for Obesity 363 overweight and obese adults 18 months 72% follow-up Randomized to standard behavior therapy vs. stepped-care Counseling frequency, type, and weight loss strategies modified every 3 months with increasing intensity if goals are not made Weight loss: -7.5 kg std. vs kg stepped-care Cost: $1,357 std. vs. $785 stepped-care JAMA 2012:307: MFMER slide-60

61 Lifestyle Counseling in Primary Care Treatment of Obesity 390 obese adults 2 years 86% follow-up Randomized to: Usual care quarterly visits and education Brief lifestyle counseling with coaches Enhanced lifestyle counseling (meal replacements or medications) Weight loss: -1.7 kg, -2.9 kg, -4.6 kg, respectively NEJM 2011;365: MFMER slide-61

62 In-Person vs Remote Treatment of Obesity 415 obese adults 2 years, 95% follow-up Randomized to in-person vs. remote intervention vs. control Intervention Coaches (in-person vs telephone) Web-based support Weight loss: -0.8 kg control, -4.6 kg remote, -5.1 in-person NEJM 2011;365: MFMER slide-62

63 2012 MFMER slide-63

64 2012 MFMER slide-64

65 Weight Loss Medications Orlistat Phentermine Qsymia (phentermine/topiramate) Belviq (lorcaserin) MFMER slide-65

66 Obesity, Bariatric Surgery Indications BMI >40 BMI >35 when complications present Roux-en-Y gastric bypass procedure of choice over vertical banded gastroplasty Efficacy - >50% excess weight lost after one year (usually >100 lb) and most weight loss maintained 2012 MFMER slide-66

67 Bariatric Surgery Standard Roux-en-Y Gastric Bypass 2012 MFMER slide-67

68 Obesity, Bariatric Surgery Complications dumping syndrome staple line disruption headaches small bowel obstruction stomal ulcer dehydration iron deficiency vomiting vitamin B12 deficiency diarrhea > constipation hair loss (temporary) stenosis of gastrojejunal anastomosis 2012 MFMER slide-68

69 Treatment of Obesity, Success Weight Weight loss Long-term weight maintenance Prevention of weight gain Inches lost Improvement in body composition Health Improvement in comorbidities of obesity Improved health habits Improvement in quality of life 2012 MFMER slide-69

70 2012 MFMER slide-70

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