Obesity: The Epidemic

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Obesity The Epidemic

• Patrick McBride, MD, MPH
• Professor
• UW Medical School

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Overview

• Obesity The Epidemic
• U.S. Trends Disease of the decade
• Costs, Causes, Consequences
• Obesity 280,000 deaths annually
• Costs 77 billion year U.S. Wisconsin
  1.4 billion / year
• (5 7 of all health care costs)
• Obesity is complex with genetic, behavioral and
  environmental causes

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Obesity - The Epidemic

• Will soon overtake smoking as the leading
  preventable cause of death!
• Obesity greater morbidity than
• Smoking
• Problem drinking
• Poverty
• Public Health 2001115229-235

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Obesity - The Epidemic

• Overweight or obese in U.S.
• 1 in 4 adults in the 1960s
• Overweight 37 of U.S. adults WI 37
• Obese 21 of U.S. adults
• WI 22
• (Doubled 11 only 10 yrs ago!)

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Obesity Trends Among U.S. AdultsBRFSS, 1991
(BMI ? 30, or 30 lbs overweight for 54
person)
Source BRFSS, CDC.
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Obesity Trends Among U.S. AdultsBRFSS, 1992
(BMI ? 30, or 30 lbs overweight for 54
person)
Source BRFSS, CDC.
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Obesity Trends Among U.S. AdultsBRFSS, 1993
(BMI ? 30, or 30 lbs overweight for 54
person)
Source BRFSS, CDC.
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Obesity Trends Among U.S. AdultsBRFSS, 1994
(BMI ? 30, or 30 lbs overweight for 54
person)
Source BRFSS, CDC.
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Obesity Trends Among U.S. AdultsBRFSS, 1995
(BMI ? 30, or 30 lbs overweight for 54
person)
Source BRFSS, CDC.
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Obesity Trends Among U.S. AdultsBRFSS, 1996
(BMI ? 30, or 30 lbs overweight for 54
person)
Source BRFSS, CDC.
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Obesity Trends Among U.S. AdultsBRFSS, 1997
(BMI ? 30, or 30 lbs overweight for 54
person)
Source BRFSS, CDC.
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Obesity Trends Among U.S. AdultsBRFSS, 1998
(BMI ? 30, or 30 lbs overweight for 54
person)
Source BRFSS, CDC.
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Obesity Trends Among U.S. AdultsBRFSS, 1999
(BMI ? 30, or 30 lbs overweight for 54
person)
Source BRFSS, CDC.
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Obesity Trends Among U.S. AdultsBRFSS, 2000
(BMI ? 30, or 30 lbs overweight for 54
person)
Source BRFSS, CDC.
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Obesity - The Epidemic Kids

• 15 of children are overweight
• 5 in 1970 1980 and 11 in 1990
• 22 African-American Hispanic children are now
  overweight
• 27 of AA and Hispanic male children overweight
• Diabetes in kids up 10 X in 10 years

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Obesity Causes and Consequences
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Physical Activity in U.S.

• activity
• Trend unchanged in past 2 decades exception is
  high school females getting less activity in past
  decade
• Physical activity classes decreasing in U.S. high
  schools

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Childrens Television Resource Education Center

68 increase Video Games and Children. ERIC Digest

• is sedentary
• takes away time from other activities
• associated with eating

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3.7 to 4.2 14 increase
32 are fast food 27 sit down restaurants 24
convenience stores (USDA 1995)
USDA statistics show that the average daily
caloric intake of Americans has risen from 1,854
calories to 2,002 calories during the last 20
years. That increase - 148 calories per day -
theoretically works out to an extra 15 pounds per
year.
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The History of French Fries in America
Small
Medium
Large
Super-Size
1950-60
200
calories
1970s
200
320
calories
calories
1980s
320
400
calories
calories
1990s
450
540
calories
calories
2000
450
540
610
calories
calories
calories
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Obesity Health Consequences

• Heart Disease
• Other Vascular Dz
• Stroke
• Dementia
• Cancer (breast, colon, other)
• Type 2 DM
• Sleep Apnea
• Depression

• Osteoarthritis
• Back pain
• Gallstones
• Surgery complications
• Congenital malformations
• Urinary stress incontinence
• Psychological

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Diabetes Mellitus in the US Increasing
Prevalence of Diagnosed Cases
Persons With Diagnosed Diabetes (millions)
Year
Diabetes Overview. October 1995 (updated 1996).
NDDK publication NIH 96-1468. Kenny SJ et al. In
Diabetes in America 2nd ed. 199547-67.
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What to do?

• Individuals
• Families
• Industry
• Schools
• Policymakers
• Government

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National Guidelines

• American Obesity Association www.aoa.org
• National Institute of Health - Obesity
  Research 19986S51-S209
• www.nhlbi.nih.gov/guidelines
• American Heart Association www.americanheart.org
• BMI calculator www.nhlbisupport.com/bmi

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The Metabolic Syndrome

• High Risk Syndrome
• Overweight / central obesity as the primary
  contributor to insulin resistance with genetic
  predisposition
• Multiple metabolic abnormalities
• Target insulin resistance metabolism
• Emphasis on weight reduction physical activit
  y to reverse

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How Common is the Metabolic Syndrome?

• US NHANES survey
• Adults 20 years of age
• 24 all adults, 42 over age 60 yrs
• Similar for men and women!
• Mexican Americans 32
• African American women men
• 47 million adults in the U.S.
• JAMA 2002287356

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Waist Circumference

• Waist circumference, independent of BMI / weight,
  confers additional health risk with
• Glucose intolerance / Diabetes mellitus
• Hypertension
• Dyslipidemia
• Important - WC in any weight category confers
  similar risk
• Arch Intern Med 20021622074

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New Emphasis of ATP IIIThe Metabolic Syndrome

• Risk Factor
• Abdominal Obesity
• Men
• Women
• Triglycerides
• HDL cholesterol
• Men
• Women
• Blood pressure
• Serum glucose

• Defining Level
• Waist Circumference
• 40 inches
• 35 inches
• 150 mg/dL
• 130/ 85 mmHg
• 110-125 mg/dL

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Insulin Resistance and Atherosclerosis
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Obesity Preventionand Management
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Can Lifestyle Change Work?

• Prevention of Type 2 Diabetes Mellitus
• Changes in lifestyle
• NEJM 20013441343-1350
• Changes in lifestyle or metformin NEJM
  2002346393-403

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Metabolic Syndrome Prevention

• 3234 patients with GINT / high FBG
• Randomized for 3 years to
• Placebo
• Metformin
• Lifestyle intervention
• Results in reducing diabetes
• Lifestyle 58 (NNT 7)
• Metformin 31 (NNT 14)
• N Engl J Med 2002346393

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Diabetes Preventionin Metabolic Syndrome

• 522 men women IGT - mean BMI 31
• RCT Individualized counseling vs UC
• RX 4.2 kg weight loss (vs 0.8 kg UC)
• Diabetes incidence 11 vs 23 UC (58 risk
  reduction, p
• Achieving either 5 wt. loss or fitness reduced
  risk of DM by 70
• NEJM 20013441343-50

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Diabetes Therapy Trial

• 160 patients with Type 2 DM PU
• Trial of Intensive Therapy
• Lowfat diet exercise tobacco cslg.
• ACE or ARB HTN treatment
• Multivitamin
• Statin or Fibrate depending on cholesterol
  disorder
• Diabetes treatment if needed metformin,
  gliclazide, insulin
• NEJM 2003348383-93

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Diabetes Therapy Trial

• Intensive Therapy vs. Usual Care
• Outcomes in 8 years (160 patients)
• 85 events in 35 patients Usual Care
• 33 events in 19 patients Intensive RX
• 53 decrease in CVD
• 61 decrease in nephropathy
• 58 decrease in retinopathy
• 63 decrease in autonomic neuropathy
• NEJM 2003348383-93

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Body Weight Management

• Patients BMI 25 or WC increased
• nutrition and physical activity counseling
• Goal IBW - BMI 19 - 25?
• Goal WC
• OR
• Emphasize weight loss to achieve normal BP,
  cholesterol levels, and glucose?

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Achieve Ideal Body Weightor Achieve a 5 loss?

• 200 5 10 loss
• Total cholesterol down 15
• TG down 20
• HDL up 15
• Sys BP / Dias BP down 12/9 mmHg
• Improved hyperglycemia
• Improved life expectancy

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Weight Loss

• Obese adults can lose 1 per week reducing
  kcalories 500-1000 below maintenance for current
  weight
• Exercise is most important to add for sustained
  weight loss
• Combining caloric restriction and exercise leads
  to 5 - 10 weight loss in a 4 - 6 month period
• NEJM 2002346591

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Activity - Vital

• Modest energy balance Wt. Gain
• 10 calories / day excess LB / year
• 100 calories / day excess 10 LB / yr
• Additional activity daily changes calories
  consumed and the Basal Metabolic Rate (BMR)

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Physical Activity

• Minimum goal - 30 minutes, 3 - 4x per week
• Ideal goal 30 - 45 minutes daily
• Encourage moderate intensity aerobic activity
• supplemented by daily lifestyle activities
• Resistance training has positive effects on
• metabolism and visceral obesity
• Medically supervised programs for moderate
• to high-risk patients demonstrate benefits
• JAMA 20022881622-31

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Websites for Patients

• Atkins alert www.atkinsdietalert.org/physician
• Evaluate diets
• www.pcrm.org/new/health010109.html
• www.niddk.nih.gov/health/nutrit/pubs/myths/index.h
  tm
• Good sites
• www.shapeup.org/index.htm
• www.nhlbi.nih.gov/health/public/heart

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Summary

• Obesity and its consequences are an epidemic in
  the U.S.
• Metabolic and medical outcomes are poor, with
  serious morbidity
• Population change is the only reasonable approach
• Medical management is very limited - emphasize
  health benefits and encourage patients with
  lifestyle

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Body Mass Index (kg/m2)

• Dose - Response Risk Relationship
• Underweight
• Normal 18.5 - 25
• Overweight 25 - 30
• Obese 30
• Class I 30 - 34.9
• Class II 35 - 39.9
• Class III 40

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Exercise Intra- Abdominal Body Fat

• RCT of 173 post-menopausal women
• Moderate intensity exercise vs. stretching
  program control group
• 12 month data
• Body weight difference 1.4 kg
• Total body fat - 1
• Intra-abdominal fat - 8.6 g/cm
• Subcutaneous abdominal fat - 29 g/cm
• JAMA 2003289323-330