Obesity is an epidemic world wide. It is a disease ..

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Putting the Obesity Epidemic in Perspective What
Physicians Can Do

• Vivian M. Dickerson, MD, FACOG
• Associate Professor
• Director General OB/GYN
• University of California Irvine
• President, American College of Obstetricians
• and Gynecologists

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Learning Objectives

• As a participant you will
• Gain an understanding of how the obesity epidemic
  directly impacts womens health and well-being
• Describe the role and influence of women
  physicians in their patients nutritional and
  physical activity choices

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Does obesity discriminate???
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No.but we do!!!
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Sometimes, we empathize with the effort..
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Sometimes we make jokes.
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Sometimes, we cant help but stare
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Sometimes we laugh
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And sometimes, we just want to cry
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CLASSIFICATION OF OBESITY
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Classification of ObesityNIH Guidelines
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Classification of Obesity

• Number one nutritional disorder in the developed
  world
• Not an adult only problem
• WHO (2000)
• Obesity is an epidemic world wide
• It is a disease
• Projections for the next decade warrant urgent
  public health action

WHO Tech Rep Ser 2000894i-xii, 1-253
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The Problem

• 1996 Third National Health and Nutrition
  Examination Survey (NHANES III)
• 36 of women are overweight or obese
• 33 of men are overweight or obese
• 1998 NIH re-classification
• 24.7 of women are overweight
• 39.4 of men are overweight
• 24.7 of women are obese
• 19 of men are obese
• Above 75ile, median BMI of women exceeds that of
  men!

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Obesity Trends Among U.S. Adults BMI gt 30-
BRFSS, 1985
Source Mokdad A H, et al. J Am Med Assoc
200128610
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Obesity Trends Among U.S. Adults BMI gt 30-
BRFSS, 1990
Source Mokdad A H, et al. J Am Med Assoc
200128610
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Obesity Trends Among U.S. Adults BMI gt 30-
BRFSS, 1995
Source Mokdad A H, et al. J Am Med Assoc
200128610
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Obesity Trends Among U.S. Adults BMI gt 30-
BRFSS, 2000
Source Mokdad A H, et al. J Am Med Assoc
200128610
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Economics

• 5-10 of the health care dollar is spent on
  obesity and obesity related problems in the U.S.
• Over 100 billion in direct expenditures per year

Jakicic JM et al. Med Sci Sports Exerc
2001332145
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Demographics

• Vulnerable periods for weight gain in women
• Adolescence
• Pregnancy
• Menopause
• Old age

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Etiology of Obesity
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Etiology

• Genetics
• Cultural values and constraints
• Eating out
• Lack of knowledge
• Medications
• Sedentary Lifestyle (lack of motivation)
• Underlying disease

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Dieting to Lose Weight
Women 50
High School Students 40
Men 25
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The Role of Supersizing
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Fantasy and DietEat More Lose More
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Sedentary Life Style
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A Pictures Worth A Thousand Words
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Health Consequences of Obesity
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Health Consequences of Obesity

• Infertility
• Diabetes
• CAD
• Hyperlipidemia
• Hypertension
• Osteoarthritis
• Increased surgical risks

• Endometrial Cancer
• VTEs
• Stroke
• CHF
• Gout
• Gallstones
• Sleep apnea
• GERD

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Health Consequences of Obesity
Increased MORTALITY

• Approximately 280,000 deaths per year in US are
  directly attributable to obesity in adults

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NHLBI and NIH Category A Recommendations

• Weight loss is recommended to
• Lower blood pressure in hypertensive obese
  patients
• Lower cholesterol and trigylcerides in obese and
  overweight persons
• Raise HDL cholesterol in obese and overweight
  people
• Lower blood glucose in overweight and obese
  patients with Type II diabetes

Clinical Guidelines NIH 1998 Publ no. 98-4083
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Resources
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Resources

• Online Resources
• www.nhlbi.nih.gov/about/oei/index/htm
• www.Mayo/Clinic/Health/Letter.com
• www.usda.gov/FoodandNutrition
• www.ama-assn.org
• www.diet-reviews-zone.com/Fad-Diets.htm
• www.obesity.org
• www.shapeup.org
• www.healtheirus.gov/dietaryguidelines

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Resources

• Do not go it alone
• registered dieticians
• exercise clubs and trainers
• psychologists
• health educators
• self-help groups
• FAMILY FRIENDS

Slow and steady wins the race
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ASSESSMENTS AND INTERVENTIONS
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Assessment

• Calculate BMI and measure waist circumference
• If BMI gt 25 or waist gt 35 inches, assess other
  risk factors
• If BMI gt 25 with three or more risk factors or if
  BMI gt 30 assess motivation to change
• Risk factors Type II DM, GB disease, CHD,
• HTN, Osteoarthritis, hyperlipidemia
• Modified from the NIH Practical Guide 1998

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Assessment

• Determine if patient is receptive to intervention
• If not outline potential risks of weight,
  interventions available, willingness to help
• If yes Stress the chronicity of the illness and
  the need for a multi-faceted approach
• No matter what the answer, do not make weight
  loss the basis of the relationship with the
  patient

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Assessment

• Create appropriate goals
• Dream weight
• choice if could weigh whatever you wanted
• Happy weight
• not ideal, but happy to achieve
• Acceptable weight
• not particularly happy, but accept since less
  than current
• Disappointed weight
• not viewed as successful, although less than
  current
• Foster et al J Consult Clin Psychol
  1997

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Assessment

• Create realistic goals
• Weight loss of 10-15 in one year
• Increased energy and fitness
• Enhanced well-being and self-esteem
• Positive mood and appearance
• Improved functional and recreational activities
• Wadden 1998

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Interventions

• Evaluation of the Obese Patient
• Weight at 18 y.o. and pattern of gain/loss
• Family history of obesity
• Medications
• Review of systems for co-morbidities
• Current diet and exercise patterns
• Current and prior attempt(s) to lose weight
• Psychological assessment to rule out depression,
  history of abuse
• Physical exam

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Therapeutic Interventions

• Diet individual or in commercial programs
• Exercise
• Behavior Modification
• Medications
• Surgery

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Diet
Fats, oils 40g
Milk, yogurt cheese 2-3 servings
Meat, poultry, fish, beans and nuts 2-3 servings
Vegetables and Legumes 4 servings
Fruits 3 servings
Grains 8 servings
USDA Food Pyramid 2005
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Diet

• Current recommendations focus on low fat and low
  calories
• Vegetarian
• Ornish
• Pritikin
• Alternatives include
• Low CHO diets (Atkins, Zone, Sugar Busters)
• Only one study has found ? risk of CAD
• Single food diets (NOT recommended!)
• Very low calorie diets (400 800 kcal per day)
• Efficacious over the short term

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Diet

• Adherence to diets even after one month is highly
  variable
• Insufficient knowledge about recidivism in
  obesity
• Challenges to the weight reduced state
• Increased appetite for energy dense foods
• Decreased BMR and physical activity
• Increased insulin sensitivity
• Decreased tissue specific lipase
• The diet must match the patient

Dansinger ML et al JAMA 200529343-53
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Exercise

• Adults
• 60 not regularly active
• 25 not active at all
• Women lt men
• Blacks/Hispanics lt white
• Older lt younger
• Less affluent lt more affluent
• Less educated lt more educated
• 15 vigorously exercise 3x/wk gt 20 min
• 22 regularly exercise 5x/wk gt 30 min

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Exercise

• Average daily expenditure of 150 kcal of moderate
  activity sufficient to derive benefit
• Walking briskly for 30 min daily
• Running for 15 min _at_ 6 mph daily
• Running for 35 min _at_ 6 mph 3x/wk
• Dose response
• Benefits increase with increased duration,
  frequency, exertion
• Recommendation 30 minutes of vigorous activity 5
  6 days per week

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Exercise

• Role of the physician
• Physical activity prescriptions
• Move 4 Life
• 8 week program www.Move4Life.org
• Dartmouth-Hitchcock program
• Specific directions Walk this trail near your
  house twice a day
• Capitalize on exercise forms the patient enjoys
• 10,000 steps Americans in Motion 2000

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Behavior Modification
Behavior Change
Education(5) Perspiration(10)
Motivation(85)
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Overall Treatment Strategy
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Follow Up

• Schedule regular visits
• Follow up on line
• Be caring, Be encouraging, Be aggressive
• Big changes are easier than little ones
• Dean Ornish
• Know the steps in behavior change
• Precontemplation, contemplation, planning,
  action, maintenance
• Dont let partial success discourage you

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Interventions

• Physician Barriers
• Feeling of powerlessness
• Viewed as a self indulgent bad habit
• Viewed as a purely emotional disorder
• Impatience with slow progress
• Intolerance for recidivism
• Ignorance of therapeutic modalities
• Skepticism of motivation

Arthur Frank, MD
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Conclusion

• The role of the practitioner is probably crucial
  to patient success
• Prevention is preferable to treatment
• Starts at birth for some patients
• Obesity is a disease for which we currently have
  a minimal cure rate