Obesity Epidemic 2004

The Obesity Epidemic:This is Your Life : 

The Obesity Epidemic: This is Your Life Introduction to Clinical Medicine November 16, 2004 Arlo Kahn, M.D. UAMS Dept. of Family and Preventive Medicine Arkansas Center for Health Improvement UAMS College of Public Health

Slide2: 

Objectives: 

Objectives Describe how the obesity epidemic is changing health and healthcare Review current trends in how patients are managing obesity Discuss the role of the physician in addressing the epidemics of childhood and adult obesity

Obesity Trends Among U.S. AdultsBRFSS, 1990: 

Obesity Trends Among U.S. Adults BRFSS, 1990

Obesity Trends Among U.S. AdultsBRFSS, 1997: 

Obesity Trends Among U.S. Adults BRFSS, 1997

Obesity Trends Among U.S. AdultsBRFSS, 2002: 

Obesity Trends Among U.S. Adults BRFSS, 2002 Source: Mokdad A H, et al. JAMA 2003;289:1 Source: Mokdad A H, et al. JAMA 1999;282:16;2003;289:1

Obesity in Arkansas: 

77 percent increase in the number of Arkansans who were obese from 1991 to 2000 60% of adult Arkansans were overweight or obese in 2000 21 percent increase in the number of Arkansans who have diabetes from 1993 – 2000 Obesity in Arkansas

All Cause Mortality: 

              2.5 2.0 1.5 1.0 0 20 25 30 35 40 BMI Mortality Ratio Moderate Very Low Low Moderate High Very High Men Women   Gray DS. Med Clin North Am. 1989;73(1):1–13. All Cause Mortality

Actual Causes of Death in the United States, 1990: 

Actual Causes of Death in the United States, 1990 Source: McGinnis JM, Foege WH. JAMA 1993;270:2207-12.

2002 RAND Research: 

2002 RAND Research Obesity is linked to rates of chronic illnesses higher than living in poverty, and much higher than smoking or drinking. Sturm R. The Effects of Obesity, Smoking, and Problem Drinking on Chronic Medical Problems and Health Care Costs. Health Affairs. 2002;21(2):245-253. Sturm R, Wells KB. Does Obesity Contribute As Much to Morbidity As Poverty or Smoking? Public Health. 2001;115:229-295

The Costs: 2000: 

The Costs: 2000 Cost of obesity in U.S. : $117 Billion Cost of obesity in Arkansas: ~$1.2 Billion 9.4 percent of the national health care expenditures in the United States are directly related to obesity and physical inactivity

The Risks of Overweight: 

The Risks of Overweight coronary heart disease breast cancer, prostate cancer, colon cancer, uterine cancer stroke arthritis gallbladder disease sleep apnea, respiratory problems Metabolic syndrome: hypertension, diabetes mellitus, high cholesterol

Slide13: 

Percentage of U.S. Children and Adolescents Who Were Overweight*: 

Percentage of U.S. Children and Adolescents Who Were Overweight* Ages 12-19 Ages 6-11 1963-70 data are from 1963-65 for children 6-11 years of age and from 1966-70 for adolescents 12-17 years of age * andgt;95th percentile for BMI by age and sex based on 2000 CDC BMI-for-age growth charts Source: National Center for Health Statistics

Percentage of U.S. Children and Adolescents Who Were Overweight*: 

Percentage of U.S. Children and Adolescents Who Were Overweight* Ages 12-19 Ages 6-11 5 4 14 13 * andgt;95th percentile for BMI by age and sex based on 2000 CDC BMI-for-age growth charts **Data are from 1963-65 for children 6-11 years of age and from 1966-70 for adolescents 12-17 years of age Source: National Center for Health Statistics

Type 2 diabetes at ACH: 

Type 2 diabetes at ACH 2 cases in mid 90’s andgt;100 cases last year

Slide17: 

Overweight school-age children have a 50% probability of becoming obese adults Overweight adolescents have a 70-80% probability of becoming obese adults

Slide18: 

Slide19: 

Slide20: 

The Toxic Environment 880 calories for $2

Beverage Intake Among Adolescents Aged 11-18, 1965-1996: 

Beverage Intake Among Adolescents Aged 11-18, 1965-1996 SOURCE: Cavadini C et al. Arch Dis Child 2000;83:18-24 (based on USDA surveys)

Slide22: 

Slide23: 

Adult BMI Chart: 

Adult BMI Chart 5'4' Height Weight (lbs) 5'2' 5'0' 5'10' 5'8' 5'6' 6'0' 6'2' 120 130 150 160 170 180 190 200 210 220 230 240 250 140 260 270 280 290 300 6'4'

BMI in Adults and Children:Definitions: 

BMI in Adults and Children: Definitions To be sensitive to the issue of a child’s self-esteem, the term 'obesity' is no longer used in children and adolescents

Slide26: 

Slide27: 

Girls: 2 to 20 years

BMI in Children and Adolescents:Limitations: 

BMI in Children and Adolescents: Limitations Weight and height do not directly measure body fatness Additional criteria are necessary to determine whether someone with BMIandgt;95th percentile is overfat as opposed to overweight because of increased muscle or bone mass Changes in BMI over time may be as important as single reading

The Arkansas BMI Initiative: 

The Arkansas BMI Initiative Act 1220 : Beginning in the 2003-2004 school year, each school district shall annually Measure the BMI of each K-12th grade student and report it to parents Explain to parents the possible health effects of body mass index, nutrition and physical activity

Rationale for the BMI Initiative: 

Rationale for the BMI Initiative Treatment of adult obesity has had less than satisfactory outcomes; prevention is most promising Many children do not make regular doctor visits, and when they do, BMI is not routinely checked (2002 study found that less than 20% of pediatricians were checking BMI) While parents often recognize when their children are extremely overweight, many parents do not recognize less extreme overweight that still poses health and emotional risks to their kids Many parents do not know the risks of overweight

Slide31: 

Slide32: 

Slide33: 

Over- Weight 21% Under- Weight 2% At Risk 17% Normal 60% Statewide BMI Classifications For Arkansas Children

Slide34: 

Statewide Arkansas BMI Results - Ethnicity 20% 24% 26% 17% 17% 20% 0% 10% 20% 30% 40% 50% 60% Caucasian African American Hispanic Percentage At Risk Overweight June 29, 2004

Slide35: 

Slide36: 

14% 17% 17% 17% 16% 17% 18% 18% 17% 16% 16% 16% 15% 18% 20% 22% 23% 23% 23% 23% 22% 21% 19% 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% K 1 2 3 4 5 6 7 8 9 10 11 12 Grade Percentage Overweight At Risk June 29, 2004 18% 18% 23% Statewide BMI Classifications for Arkansas by Grade

Slide37: 

Slide38: 

http://www.ubalt.edu/experts/obesity/index.html

What are your adult patients doing about obesity?: 

What are your adult patients doing about obesity? 29% of men and 44% of women trying to lose weight About 20% report restricting calories or increasing physical activity

Slide40: 

Slide41: 

Slide42: 

Slide43: 

Slide44: 

Slide45: 

Slide46: 

AHA Guidelines for Healthy Diets: 

AHA Guidelines for Healthy Diets Carbohydrates: ~55% of calories Fat: ~30% of calories, andlt;10% sat fat Protein: 15-20% of calories Diet: provide adequate nutrients and support dietary compliance St. Jeor ST, etal. Circulation 104:1869-74, 2001.

Categorization of Diets by CHO and Fat: 

Categorization of Diets by CHO and Fat Riley RE. Clinics in Sports Medicine. 18(3):691-701, 1999.

Slide49: 

Atkins Diet Revolution: 

Atkins Diet Revolution Riley RE. Clinics in Sports Medicine. 18(3):691-701, 1999. Rap

High Protein Diets:Possible Adverse Effects : 

High Protein Diets: Possible Adverse Effects Increases in serum uric acid Kidney stones Osteoporosis Chronic renal insufficiency Ketosis High Saturated Fat Low Fruits, Vegetables and Grains

Long Term Weight Losses:AHA vs Low Carb : 

Long Term Weight Losses: AHA vs Low Carb Weight Loss (% initial weight) *pandlt;.001 *pandlt;.02 NS N= 63 (32% male / 76%Caucasian) BMI= 34; 41% drop out at 12 months baseline carried forward analyses Foster et al NEJM 2003 348:2082-90

Long Term Weight Losses among Significantly Obese Individuals: 

Long Term Weight Losses among Significantly Obese Individuals Weight Loss (kg) N=132 (58% Black / 17% female) mean BMI=43 39% diabetic; 34% drop out p=.002 Samaha et al NEJM 2003;348:2074-81 andamp; Stern et al Ann Intern Med 2004;140:778-85 NS

Slide54: 

Structure: 

Structure Reduces the effort required for adherence Eliminates much of the decision making, temptation, and guesswork involved in making healthy food choices Improves weight loss in the behavioral treatment of obesity

Weight Watchers : 

Weight Watchers Practical advice Group techniques Food variety Moderate protein, low fat Limits refined sugars and EtOH Stresses activity Groups Very structured Weekly fees

Meals VS. Meal Plans:weight loss at 6 months: 

Meals VS. Meal Plans: weight loss at 6 months Providing patients with structured meal plans and grocery lists: 13.7% Portion-controlled servings of food: 13.5% Specifying what foods and what amounts patients should eat improves weight loss Providing the food has no additional effect

South Beach Diet: 

South Beach Diet Phase 1: two weeks. Most should see a rapid weight loss of between 8 – 13 pounds. Most restrictive. Phase 2: until reach goal weight. Weight loss 1-2 pounds per week. Foods that were restricted in re-introduced into the diet. Phase 3: for life. Restrictions: avoid highly processed food that contains ‘bad’ carbs and ‘bad’ fats and try and stick to the food that contains the ‘good’ ones.

Slide59: 

Slide60: 

The Importance of Exercise for Weight Maintenance

Slide61: 

Slide62: 

Weight Control Diets: Key Points from Einstein to PT Barnum: 

Weight Control Diets: Key Points from Einstein to PT Barnum E=mc2; m=E/c2 Time matters Commitment is required Structure helps P.T. Barnum was right Healthy weight is only a part of good nutrition

What Can Physicians Do?: 

What Can Physicians Do? Counsel Drugs Surgery Advocacy

Evidence:USPSTF Conclusions: 

Evidence: USPSTF Conclusions Counseling and pharmacotherapy can promote modest sustained weight loss, improving clinical outcomes. Pharmacotherapy appears safe in the short term; long-term safety is less established. In selected patients, surgery promotes large amounts of weight loss with rare but sometimes severe complications

High-Intensity Counseling: Diet, Exercise, or Both: 

High-Intensity Counseling: Diet, Exercise, or Both Includes behavioral interventions aimed at skill development, motivation, and support strategies Produces modest, sustained weight loss (typically 3-5 kg for 1 year or more) in adults who are obese

How Much Weight?: 

How Much Weight? Regardless of whether overweight or normal weight, those who gain are more likely to have adverse heart disease risks than those who don’t Coronary Artery Risk Development in Young Adults Study (2004): 5000 men and women age 18-30 15 year follow-up 3.6 percent of those who maintained their weight developed metabolic syndrome 18 percent of those whose weight had increased developed metabolic syndrome

Obesity Drugs: 

Obesity Drugs Appetite suppressants Noradrenergic (Schedule IV) Phentermine (Adipex, Fastin) Diethylpropion (Tenuate) Noradrenergic (Schedule III) Benzphetamine (Didrex) Phendimetrazine (Bontril) Serotonergic Fenfluramine, dexfenfluramine Mixed Noradrenergic andamp; Serotonergic Sibutramine (Meridia) Nutrient absorption reducers Lipase inhibitor Orlistat (Xenical)

Sibutramine (Meridia): 

Sibutramine (Meridia) Contraindicated: CAD, CHF, cardiac arrhythmias or stroke Side Effects: hypertension, arrhythmia, tachycardia, headache, dry mouth, constipation, insomnia

Orlistat: 

Orlistat Lipase inhibitor: reduces fat absorption by ~30% resulting in reduction in energy intake Inhibits digestion of dietary triglycerides, decreases absorption of cholesterol and lipid-soluble vitamins

Side Effects: 

Side Effects GI side effects due to inhibition of fat absorption pain, fecal urgency, liquid stools, flatulence with discharge, oily spotting

Summary: Meta-analysis: 

Summary: Meta-analysis Placebo subtracted weight losses for single drugs never exceeded 4.0 kg No drug or class of drug exhibits clear superiority Increasing length of drug treatment does not lead to more weight loss Haddock CK, et al. Int J Obesity. 26:262-73, 2002.

Surgery: 

Surgery 2001 47,000 2002 63,000 2003 98,000 NIH Criteria: Well informed and motivated patient BMIandgt;40 or BMIandgt;35 with co-morbidities Mortality: 1-2% Effectiveness: andgt;50% excess weight loss at 14 years

Advocacy: 

Advocacy The epidemic of overweight cannot be addressed in the office setting alone A provider’s role should also involve the community

Slide75: