Women, Weight, and Health

1
Women, Weight, and Health
Caroline M. Apovian, MD, FACP Director, Nutrition
and Weight Management Center Co-director,
Nutrition Support and Metabolic Services Boston
Medical Center Associate Professor of
Medicine Boston University School of Medicine
2
Serdula, JAMA, 282, 1353-1358, 1999
Percent of US Population Trying to Lose Weight

70 of Women
3
Classification of Obesity

• Body Mass Index (BMI)
• Measure of weight in relation to height
• BMI chart in all exam rooms

• Classification BMI
• Healthy Weight 18.5 24.9
• Overweight 25.0 29.9
• Obesity (I) 30.0 34.9
• Obesity (II) 35.0 39.9
• Obesity (III) 40.0 or more

4
Prevalence of Overweight and Obesityin U.S.
Women BMI 25 Ages 20

• 61.9 All women
• 57.3 White, non-Hispanic
• 77.3 Black, non-Hispanic 71.9 Mexican
  American

JAMA. 20022881723-1727,NHANES 1999-2000
5
Minority Women at Greatest Risk for Severe Obesity
Prevalence of BMI40 in the US
Increase from 7.9 to 15.1 in the last decade
NHANES 1999-2000
JAMA 20022881723-7
6
Obesity Affects Low-income Women
Disproportionately
7
Causes of Obesity

• Genetics
• 70 loci, genes or markers may be involved w/
  obesity
• Environment
• Fast-food, portion sizes, sedentary lifestyle
• Physical Environment
• Unsafe, no sidewalks, bike paths
• Family/Nurturing
• Mothers obesity is 1 predictor of childhood
  obesity1
• Medications
• e.g., antidepressants, steroids, contraceptives

1. Srauss RS, Knight J. Pediatrics.1999103(6)e85
8
.
Medical Complications of Obesity
Phlebitis venous stasis
9
Association Between BMI and Comorbidities
Women 30-55 yrs
Relative Risk
Body Mass Index (kg/m2)
Type 2 diabetes Cholelithiasis
Hypertension Coronary heart disease
Willett WC, et al. N Engl J Med. 1999341427-34.
10
.
Medical Complications of Obesityin Women

• Cancers endometrial and breast
• Psychological depression, discrimination,
  self-denigration
• Infertility
• Pregnancy Obesity is most common nutritional
  problem complicating pregnancy risks for fetus
  and woman

11
(No Transcript)
12
Women and Weight
Benefits of Weight Loss for Women
13
Test Your Knowledge

• Obese individuals can achieve significant
  reductions in medical risk factors with a weight
  loss of
• a. 5-10 of initial body weight
• b. 15-25 of initial body weight
• c. 30-40 of initial body weight
• d. 50 of initial body weight

Obese individuals can achieve significant
reductions in medical risk factors with a weight
loss of a. 5-10 of initial body weight b.
15-25 of initial body weight c. 30-40 of
initial body weight d. 50 of initial body weight
14

• Losing 5-10 of initial body weight can
  significantly decrease the severity of
  obesity-related risk factors.
• Benefits include lowering total cholesterol,
  triglycerides, LDL "bad cholesterol", blood
  pressure, blood glucose in type II diabetics and
  improving HDL "good" cholesterol, lower back
  pain, reflux, lower extremity arthralgias, and
  obstructive sleep apnea. Moderate weight loss can
  also often decrease medications for
  obesity-related conditions.

Source Clinical Guidelines on the
Identification, Evaluation, and Treatment of
Overweight and Obesity in Adults-The Evidence
Report. National Institutes of Health. Obes Res.
19986 (suppl)251S-209S.
15
Benefits of Moderate (5-10) Weight Loss Across
the Lifespan

• Increases life expectancy1
• Improves glycemic control2
• Lowers BP3
• Improves serum lipid profile4
• May decrease cancer risk5
• Improves lower back pain, reflux, lower extremity
  arthralgias, sleep apnea6
• Can ? meds for obesity-related conditions6

• Lean et al. Diabet Med. 19897228-233.
• Wing et al. Arch Intern Med. 19871471749-1753.
• Schotte et al. Arch Intern Med.
  19901501701-1704.
• Dattilo et al. Am J Clin Nutr. 199256320-328.
• Bianchini F et al. Obesity Reviews 200235-8
• NHLBI Guidelines, June 1998

16
Women and Weight
Strategies Tools for Weight Management
17
Healthy Eating Quiz 1

• 2. Your diet should contain no more than what
  percentage of fat a day?
• A. 15 percent
• B. 30 percent
• C. 35 percent

https//www.healthforums.com/library/1,1258,articl
e6976,00.html
18
Answer 1
A. 15 percent B. 30 percent   C. 35 percent
The American Heart Association recommends that no
more than 30 percent of daily calories come from
fat. Increased dietary fat puts women at risk of
heart disease -- the leading cause of death for
postmenopausal women -- and other health
conditions as well. But quality trumps quantity -
if you are eating a lot of mono and unsaturated
fats and omega-3s, you can get closer to 35 fat.
https//www.healthforums.com/library/1,1258,articl
e6976,00.html
19
Healthy Eating Quiz 2

• 3. How many grams of fiber should your daily diet
  include?
•   A. 5 to 15 gramsB. 15 to 20 gramsC. 20 to 35
  grams

https//www.healthforums.com/library/1,1258,articl
e6976,00.html
20
Answer 2
A. 5 to 15 gramsB. 15 to 20 gramsC. 20 to 35
grams
The National Cancer Institute and the American
Dietetic Association suggest 20 to 35 grams of
daily dietary fiber. Insoluble fiber may decrease
the risk of breast cancer, while soluble fiber
may help prevent heart disease.
https//www.healthforums.com/library/1,1258,articl
e6976,00.html
21
Healthy Eating Quiz 3

• 4. You should limit your daily sodium intake to
  how many milligrams?
• A. 2,325 milligrams
• B. 2,800 milligrams
• C. 3,000 milligrams

https//www.healthforums.com/library/1,1258,articl
e6976,00.html
22
Answer 3
A. 2,325 milligrams B. 2,800 milligrams C. 3,000
milligrams
Although there is no recommended daily allowance
for sodium, limiting yourself to 2,325 milligrams
a day is wise. Too much dietary sodium may
increase the risk of hypertension and
osteoporosis.
https//www.healthforums.com/library/1,1258,articl
e6976,00.html
23
Calories Count
Energy Expenditure
Energy Intake

• To lose weight, reduce energy intake
• One pound of body fat 3500 kcal
• To lose 1 pound / week
• Decrease caloric intake by 500 kcal / day
• To lose 2 pounds / week
• Decrease caloric intake by 1000 kcal / day

24
Which Diet is Best?

• Randomized trial comparing dietary interventions
  
• Atkins Very low carb, high fat
• Zone Moderate carb, moderate fat
• Weight Watchers High carb, moderate fat
• Ornish High carb, very low fat

• Study Question
• How well do these very different popular diets
  work under realistic clinical conditions over a
  one-year period?

Dansinger ML, et al. JAMA Jan 200545-53
25
Which Diet is Best?

• Answer
• All diets had similar effect 20-25 of subjects
  sustained modest weight loss beyond 1 year

What an individual will ADHERE to is the key to
successful dieting - not the macronutrient
combination
Dansinger ML, et al. JAMA Jan 200545-53
26
Recommendations for Physical Activity

• 30 minutes most days
  moderate intensity in
  addition to usual daily
  activity  
• 60 minutes/day moderate physical activity to
  prevent weight gain
• 60 to 90 minutes/day to
  maintain weight loss

Children and teenagers should be physically
active for at least 60 minutes/day most days
http//www.mypyramid.gov/pyramid/physical_activity
_amount.html
27
Cardinal Behaviors of Successful Long-term Weight
Management

• 1. Self-monitoring
• Record food intake daily
• Check body weight ?1 x/wk
• 2. Low-calorie, low-fat diet
• Total energy intake 1300 1400 kcal/day
• Energy intake from fat 2025
• 3. Eat breakfast daily
• 4. Regular physical activity
• 25003000 kcal/wk (eg walk 4 miles/day)

Klem et al. Am J Clin Nutr 199766239, McGuire
et al. Int J Obes 199822572.
28
BMCNutrition and Weight Management
ProgramOutcomes Data
29
BMC Clinic Data

• Review of clinic records for two-year period Jan
  02 Dec 03
• To evaluate obesity treatment outcomes (wt loss,
  of wt loss, and changes in BMI) and to compare
  the outcomes among ethnicities, sexes, types of
  treatment, and other factors
• N 427 overweight and obese patients (BMI 25),
  ages 16-75

30
BMC Clinic Data

• 336 (78.7) women (66 premenopausal) and 91
  (21.3) men (total n427)
• Ethnicities
• 251 (58.8) Caucasian
• 121 (28.3) African American
• 41 (9.6) Hispanic
• 10 others and 4 unknown (3.3)
• 14.8 smokers and 31.5 drinkers
• 55.3 did no exercise, 24.7 light exercisers,
  19.5 moderate exercisers, 5 heavy exercisers

31
Types of Treatment

• 217 (50.8) diet lifestyle modification
• 143 (33.5) diet with 1-2 medications1
• 36 (8.43) very low calorie deficit diets2
• 31 (7.3) combinations3
• Medications phentermine, sibutramine and
  orlistat
• VLCD Protein sparing modified fast, liquid diet
  (HMR) or 1-2 meal replacements with HMR or Slim
  Fast
• Combinations more than one treatment (? 2 month
  duration each or ? 33 of the entire period of
  treatment for each patient)

32
Weight Loss Data Follow-up Group (n315)

• Mean duration of treatment 4.85 ? 4.52 months
  (0.25-24.7 months)
• Net weight change 10.27 ? 15.91 lbs (-89.5 to
  67.5 lbs)
• Percent of net weight change 3.68 ?
  5.25 (-25.2 to 16.7)
• Mean BMI change 1.67 ? 3.51 kg/m2

No difference in types of treatment among
ethnicities, between GBS and Non-GBS groups or
between sexes
33
Did Patients Meet Goal for Modest Weight Loss?

• Benefits of Modest Weight Loss
• Losing 5-10 of initial body weight can
  significantly decrease the severity of
  obesity-related risk factors.
• Benefits include lowering total cholesterol,
  triglycerides, LDL "bad cholesterol", blood
  pressure, blood glucose in type II diabetics and
  improving HDL "good" cholesterol, lower back
  pain, reflux, lower extremity arthralgias, and
  obstructive sleep apnea. Moderate weight loss can
  also often decrease medications for
  obesity-related conditions.

Source Clinical Guidelines on the
Identification, Evaluation, and Treatment of
Overweight and Obesity in Adults-The Evidence
Report. National Institutes of Health. Obes Res.
19986 (suppl)251S-209S.
34
Weight Loss Data Follow-up Group (n315)

• ? 5 wt loss 99/315 (31.4)
• ? 10 wt loss 32/315 (10.16)
• ? 15 wt loss 13/315 (4.13)
• 0 wt gain/loss 72/315 (22.86)

No difference in success, high success, very high
success rate as well as weight gain or weight
maintenance between sexes or between GBS and
Non-GBS groups or among classes of obesity
35
Summary

• 61.9 of all women are overweight/ obese
• 70 of women are trying to lose weight
• Life phases for weight gain
• Pregnancy, menopause/post-menopause hormones
  play a key role
• Older/elderly muscle loss plays key role
• Goal of weight loss 510 body weight
• Reduces associated co-morbidities

36
Recommendations for Healthy Eating National
Academies' Institute of MedicineDietary
Reference Intakes (DRI)
Calcium 1200 mg/d Vitamin D 1000
IU2,3 Phosphorus 4 g/d Folate 1000
ug/d Magnesium 350 mg/d Potassium 2000 mg
(bananas, apricots, salmon) Omega 3 .5 1.8
g/d4 (fatty fish or supplements)

• http//fnic.nal.usda.gov/nal_display/index.php?inf
  o_center4tax_level3tax_subject256topic_id13
  42level3_id5140
• Holick MF. The role of vitamin D for bone health
  and fracture prevention. Curr Osteoporos Rep.
  2006 Sep4(3)96-102. Review.
• Holick MF. Vitamin D importance in the
  prevention of cancers, type 1 diabetes, heart
  disease, and osteoporosis. Am J Clin Nutr. 2004
  Mar79(3)362-71. Review. Erratum in Am J Clin
  Nutr. 2004 May79(5)890.
• http//circ.ahajournals.org/cgi/reprint/106/21/274
  7