Obesity Womb to Tomb Kathleen K. Davis MD, FACP Yakima

1
ObesityWomb to Tomb

• Kathleen K. Davis MD, FACP
• Yakima Valley Farm Workers Clinic
• Board Member
• Foundation for Care Management
• Whidbey General Hospital
• June 16, 2009

2
Objectives

• 1. Discuss the obesity epidemic in the United
  States.
• 2. Describe the role of obesity as a risk factor
  at each stage of life
• 3. Review current and future therapeutic
  approaches for weight loss.
• 4. Identify and implement the most effective
  evidence based interventions to aid patients in
  obesity related risk factors for other diseases
  to achieve better patient health.

3
JaneQuestion 1

• 45 year old female with a BMI of 35, diabetes,
  and hypertension.
• How many calories does she have to decrease to
  lose a pound?
• 1000
• 2500
• 3500
• 5000

4
Question 2

• You are advising her on food choices.
• Which has the most calories?
• 1. Starbucks oatmeal cookie
• 2. Starbucks blueberry scone
• 3. Reduced fat turkey bacon, cholesterol free
  egg, reduced fat cheese breakfast sandwich from
  McDonalds
• 4. 2 grande white chocolate mocha, hold the whip

5
Question 3

• She has joined a weight loss program. In the last
  6 months she has dropped from 250 to 240. She
  would like you to help her with medications.
• Which is best for her?
• 1. Sibutramine
• 2. Orlistat
• 3. Phentermine
• 4. None, she is doing well.

6
Obesity

• Ideal body weight
• Minimum morbidity and mortality
• Age, sex, height
• Determined by Metropolitan Life 1983
• BMI
• 19-25 normal
• 26-30 overweight
• 30-40 obese
• lt40 or twice ideal weight morbidly obese
• Waist menlt40 inches, womenlt35 inches
• Waist/hip menlt1, womenlt.85

Pischon, T.et al.General and Abdominal Adiposity
and Risk of Death in Europe NEJM, Nov. 13,
2008Vol 359, 20
7
Sarah

• 25 years old. Married for 2 years.
• Was overweight as teen
• Has gained 20 lbs since marriage, now obese, 220
  lbs, BMI 35.5
• Wants to stop BCP and get pregnant
• What increased risks does she have with pregnancy
  from her weight gain?

8
Obesity and pregnancy

• gt200 lbs at first prenatal visit
• 1980 7
• 1999 24 obese, 37 overweight
• 2003 40 overweight

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Planning for Pregnancy

• Obesity related to
• Infertility including with in vitro fertilization
• Polycystic ovarian disease
• Ovulatory infertility
• Improves with weight loss
• Increased spontaneous abortions
• May or may not improve with weight loss

10
Gestational Diabetes Risk

• With increased weight gain
• Between pregnancies
• Between 18 y.o. and first pregnancy
• With actual weight
• gt 200 lbs risk 6-12
• lt200 lbs 2-4
• Double risk of diabetes compared to normal weight
  ladies

Francis S Nuthalapaty, Dwight J Rouse. Impact of
Obesity on Fertility and Pregnancy. UpToDate Jan
2009 17.1
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Weight gain between pregnancies(even if BMI
normal)

• 200,000 women with pregnanciesgt2 yrs apart
• -.9 - 1 BMI gain vs 3 units BMI (9 kg)
• Preeclampsia
• Gestational diabetes
• C-section
• Longer labor
• Large for gestational age baby
• Still birth
• Post term birth

Villamor E Cnattingius S Interpregnancy weight
change and risk of adverse pregnancy outcomes a
population-based study. Lancet. 2006 Sep
30368(9542)
12
Obesity and fetal outcome

• Increased neural tube defects
• Resistant to folate prophylaxis
• Overweight OR 1.22
• Obese OR 1.7
• Morbid obesity OR 3.1
• OSA precipitated/exacerbated
• Small for gestational age baby
• Failure of lactation

Francis S Nuthalapaty, Dwight J Rouse. Impact of
Obesity on Fertility and Pregnancy. UpToDate Jan
2009 17.1
13
Obesity Post Partum

• Increased hospital stay for complications
• Vaginal deliveries
• C sections
• Increased wound complications
• Increased hemorrhage

Francis S Nuthalapaty, Dwight J Rouse. Impact of
Obesity on Fertility and Pregnancy. UpToDate Jan
2009 17.1
14
Obesity and pregnancy

• Counsel ladies to lose weight before pregnancy
• Work with pregnant ladies to not gain more than
  recommended weight
• Warn against gaining weight between pregnancies
• Gestational diabetes high risk for nongravid
  diabetes

15
Recommended weight gain in pregnancy
Institute of Medicine recommendations
16
The first three months

• Longitudinal retrospective study Netherlands
• 87 18-24 y.o. assessed for Cardiovascular risks
• Rate of weight gain age 0-1 y.o.
• Rapid increase in weight first 3 mos
• Increased insulin resistance
• Decreased HDL
• Increased TC/HDL, TG, central adiposity
• Than gradual weight gain over the year

Leunissen, Ralph. Timing and Tempo of First Year
Rapid Growth in Relation to Cardiovascular and
Metabolic Risk Profile in Early Adulthood. JAMA,
June 3, 2009 Vol 301 No 21
17
Early childhood

• Multiple studies show early traumatic or
  stressors in early childhood related to
• Depression, drug use, smoking, alcoholism
• Cardiovascular disease, obesity
• when they become adults

Shonkoff, Jack et al. Neuroscience, Molecular
Biology and the Childhood Roots of Health
Disparities. JAMA June 3, 2009, Vol 301, no 21
18
Obesity 2 years old - 20

• Underweight BMI lt5th percentile for age and
  sex.
• Normal weight BMI between the 5th and 85th
  percentile for age and sex.
• Overweight BMI between the 85th and 95th
  percentile for age and sex. "at risk for
  overweight (CDC)
• Obese BMI 95th percentile for age and sex.
  "overweight". (CDC)

19
What about school age kids?
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1977 - 1996, portion sizes for key food groups
grew markedly in the United States, not only at
fast-food outlets but also in homes and at
conventional restaurants.

• One study of portion sizes for typical items
  showed that
• Salty snacks increased from 132 calories to 225
  calories.
• Soft drinks increased from 144 calories to 193
  calories.
• French fries increased from 188 calories to 256
  calories.
• Hamburgers increased from 389 calories to 486
  calories.

(Nielsen SJ, Popkin BM. Patterns and trends in
food portion sizes, 1977-1998. JAMA
2003289450-3)
From the statistical sourcebook A Nation at
Risk Obesity in the United States. To order,
call 1-800-AHA-USA1 or email inquiries_at_heart.org
21
Children eat nearly twice as many calories (770)
at restaurants as they do during a meal at home
(420). (Zoumas-Morse C, Rock CL, Sobo EJ,
Neuhouser ML. Childrens patterns of
macronutrient intake and associations with
restaurant and home eating. J Am Diet Assoc
2001101-923-5)
From the statistical sourcebook A Nation at
Risk Obesity in the United States. To order,
call 1-800-AHA-USA1 or email inquiries_at_heart.org
22
Between 1977-78 and 2000-01, milk consumption
decreased by 39 percent in children ages
6-11, consumption of fruit drink consumption rose
69 percent consumption of carbonated soda rose
137 percent. (Cleveland L. U.S. Department of
Agriculture National Food Consumption Survey,
1977-78 What We Eat in America, NHANES 2001-02)
What are the problems with not drinking milk?
From the statistical sourcebook A Nation at
Risk Obesity in the United States. AHA
23
No milk

• Replaced with higher calorie sodas
• Not meeting RDA of calcium for growing bones
• No protein in replacement drinks
• Vitamin D deficiency

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Vitamin D Deficiency
. 3,577 adolescents, 12 to 19 years old
National Health and Nutrition Examination Survey
(NHANES) 20012004. Adolescents with the lowest
levels of vitamin D were 2.36 times more
likely to have high blood pressure 2.54 times
more likely to have high blood sugar and 3.99
times more likely to have metabolic
syndrome. Adjusted for age, sex, race/ethnicity,
body mass index, socioeconomic status and
physical activity The highest levels of vitamin
D were found in whites, the lowest levels in
blacks and intermediate levels in
Mexican-Americans
Denise von Muhlen, M.D., Ph.D. Edgar R. Miller
III, M.D., Ph.D. Erin D. Michos, M.D., M.H.S.
and Lawrence J. Appel, M.D., M.P.H. AHA Annual
Conference March 2009
25
92 percent of elementary schools no daily
physical education classes for all students
throughout the school year. (School Health
Policies and Programs Study. Journal of School
Health 2001717)
From the statistical sourcebook A Nation at
Risk Obesity in the United States. To order,
call 1-800-AHA-USA1 or email inquiries_at_heart.org
26
The typical American child spends about 44.5
hours per week using media outside of school.
(Generation M Media in the Lives of 8-18 Year
Olds. Menlo Park, Calif. Kaiser Family
Foundation, 2005)
From the statistical sourcebook A Nation at
Risk Obesity in the United States. To order,
call 1-800-AHA-USA1 or email inquiries_at_heart.org
27
gt22 percent of children and nearly 40 percent of
adults get no free-time physical activity at all.
(Physical activity levels among children aged
9-13 years United States, 2002. MMWR
20035233785-8) and (National Center for
Health Statistics. National Health Interview
Survey, 1999-2001)
From the statistical sourcebook A Nation at
Risk Obesity in the United States. To order,
call 1-800-AHA-USA1 or email inquiries_at_heart.org
28
Adult Obesity

• How big is the problem?

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Obesity Trends Among U.S. AdultsBRFSS, 1985
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
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Obesity Trends Among U.S. AdultsBRFSS, 1990
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
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Obesity Trends Among U.S. AdultsBRFSS, 1998
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014 1519
20
32
Obesity Trends Among U.S. AdultsBRFSS, 2000
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014 1519
20
33
Obesity Trends Among U.S. AdultsBRFSS, 2005
(BMI 30, or 30 lbs. overweight for 5 4
person)
lt10 1014
1519 2024 2529
30
34
Obesity Trends Among U.S. AdultsBRFSS, 2007
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014 1519
2024 2529 30
http//www.cdc.gov/obesity/downloads/obesity_trend
s_2007.ppt1
35
Obesity Trends Among U.S. AdultsBRFSS, 1990,
1998, 2007
(BMI ?30, or about 30 lbs. overweight for 54
person)
1998
1990
2007
No Data lt10 1014
1519 2024 2529
30
http//www.cdc.gov/obesity/downloads/obesity_trend
s_2007.ppt1
36
Obesity is Costly

• In 2000, obesity-related health care costs
• totaled an estimated 117 billion. 
• Between 1987 and 2001, diseases associated with
  obesity account for 27 of the increases in
  medical costs. 
• Medical expenditures for obese workers, depending
  on severity of obesity and sex, are between
  29117 greater than expenditures for workers
  with normal weight. 
• From 19791981 to 19971999, annual hospital
  costs related to obesity among children and
  adolescents increased, rising from 35 million to
  127 million.

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People who are obese or overweight also have a
lower life expectancy
A 40-year-old nonsmoking male who is overweight
will lose 3.1 years of life expectancy one who
is obese will lose 5.8 years. A 40-year-old
overweight nonsmoking female will lose 3.3 years
of life expectancy one who is obese will lose
7.1 years. (Peeters A, Barendregt JJ, Willekens
F, Mackenbach JP, Al Mamun A, Bonneux L.
Overweight and obesity by middle age are
associated with a shortened lifespan. Ann Intern
Med 2003 13824-32)
From the statistical sourcebook A Nation at
Risk Obesity in the United States. To order,
call 1-800-AHA-USA1 or email inquiries_at_heart.org
38
Why are we so big???

• Genetics
• Endocrine factors
• Carbohydrate addiction
• Risks start in utero and early development
• Upsizing, advertising and profits
• Farms to desks
• Faster paced life, less time for physical
  activity
• Changing habits

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Is it my parents fault?

• "Despite obesity having strong genetic
  determinants, the genetic composition of the
  population does not change rapidly. Therefore,
  the large increase in . . . obesity must
  reflect major changes in non-genetic factors."
• Hill, James O., and Trowbridge, Frederick L.
  Childhood obesity future directions and research
  priorities. Pediatrics. 1998 Supplement 571.

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Neurohormonal causes

• Leptin a peptide
• Prevents starvation
• Made in fat cells and placenta
• Feedback to brain regarding fat stores
• Increases appetite, decreases satiety
• Decreases metabolic rate
• Patients with deficiency are obese and can be
  treated with Leptin
• But most obese people have high levels of Leptin

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Ghrelin

• Made in stomach
• Activates neuropeptide Y and growth hormone
• Potent stimulator of appetite
• Increases premeal and decreases after meal to
  decrease satiety
• Increased in fasting, starvation and anorexia
• Lower levels with bypass surgery

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Public Health Approach

• Involve entire community
• Involve government, grocery stores, community
  groups, schools, medical community, farmers
• Develop infrastructure for data collection and
  sharing results
• Like cholera, obesity may be a problem that
  cannot be solved by individual persons but
  requires community action.

Sacks, FM et al. Comparison of Weight Loss Diets
with Different Compositions of Fat, Protein or
Carbohydrates NEJM Feb 26, 2009 vol 360 9
43
What can we do?

• Public health approach
• Finland
• France
• New York

44
FranceChildhood obesity Initiative

• Pilot 1992-1997 2 towns 80 involvement
• Goal to change children's eating habits
• 5-10 y.o screened parents given specific advice
• Special lessons at schools, colleges,
• School breakfasts
• Food factory visits
• Dietary knowledge in school curriculum and games

Westly, Hannah. Thin Living, Childhood Obesity.
British Medical Journal Dec15 2007 vol 335
45
France Results1992-2000

• Children more knowledgeable
• Changed eating habits
• Chips once/week decreased 56-39
• No increase obesity, but doubled elsewhere
• Mothers gained less than elsewhere
• Now in 113 communities
• More comprehensive
• Community led
• Support from Government, Corporations,
  Foundations
• Results expected this year

46

• Banned trans fats in restaurants
• Calorie labeling on menu chain restaurants
• 1/3 who eat in chain restaurants mealgt1000 cal
• People underestimate calories
• 10 restaurants in NYC are chains
• 83 people wanted nutritional info on menu
• Result
• 84 surprised at calorie count
• 73 information changed what they bought

Mello, Michelle. New York Citys War on Fat. NEJM
May 7, 2009 Vol 360 no 19
47
Individual approach

• Eating for health
• Medical treatment
• Surgical treatment
• Changing unhealthy habits into healthy lifestyle
  one step at a time
• Make it hobby!
• Local community resources

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The Food

• Low, hi carbs?
• Low, high fats?
• Calories restricted, low or very low
• Others
• Which do you believe in?
• What is the evidence?

49
Weight loss diets

• NEJM study diets high or low in carbohydrates,
  protein or fats
• 6 KG lost at 6 months
• 3-4 kg lost at 2 years, regaining weight
• Higher weight loss
• Better adherence to prescribed diet
• Attended more counseling sessions

Sacks, FM et al. Comparison of Weight Loss Diets
with Different Compositions of Fat, Protein or
Carbohydrates NEJM Feb 26, 2009 vol 360 9
50
NEJM Editorial

• Best circumstances for adherence
• Volunteers didnt achieve weight loss needed to
  reverse obesity epidemic
• powerless against an environment that offers so
  many high calorie foods and labor saving devices

Katan, Martijan. Weight loss Diets for the
Prevention and Treatment of Obesity NEJM vol 360
9 Feb. 26 2009
51
How many calories to lose a pound?

• 3500
• Assess calories to maintain weight
• Decrease 500 calories a day, lose a pound a week
• Augment by increased physical activity and for
  maintenance

52
Estimate how many calories in

• 1. Starbucks oatmeal cookie
• 2. Starbucks blueberry scone
• 3. Reduced fat turkey bacon, cholesterol free
  egg, reduced fat cheese breakfast sandwich from
  McDonalds
• 4. 2 grande white chocolate mocha, hold the whip
• 5. Bag of Fritos

53
Estimate how many calories in each?

• 1. Starbucks oatmeal cookie 370 calories, 9g fat
• 2. Starbucks blueberry scone 460 cal 12 g fat
• 3. Reduced fat turkey bacon, cholesterol free
  egg, reduced fat cheese breakfast sandwich from
  McDonalds 390 cal 4.5g fat
• 4. 2 grande white chocolate mocha, hold the
  whip 400 cal 11g fat
• 5. Bag of Fritos 800 cal 50 g fat!

54
Carbohydrate addictiongt33 obesity

• Chemical, control, compulsion3 Cs
• Carbohydrates increase serotonin
• Food for celebration, suffering etc.,etc.
• Binging, cant stop
• Deceiving self and others
• Surrogating to and involving others
• Overeaters Anonymous

55
Web sites

• http//www.fruitsandveggiesmatter.gov/
• CDC type in ingredients and get healthy recipe
  with nutritional info
• www.AHA.org many multimedia tools
• BMI calculators- many-google
• www.mayoclinic.com/health/exercise/SM00109
  Exercise chart with calories burned and other
  tools

56
How to drop 500 calories a day

• Decrease portions
• Eat slowly-stomach fills, satiety lags (15-20
  min)
• Make routine meals healthier
• Changes for long term

57
The work

• Fun, convenient, measurable
• Build up to 30 minutes most days/ week
• No excuses!
• TV exercise, rainy day, improve daily activity
• How many calories does a normal weight man burn
  jogging 1 mile at 6 miles an hour?

58
130 calories

• 1 oz chips (small bag)
• 1 beer 12 oz
• 1 glass medium wine
• 1 grande nonfat latte
• normal weight man jogging 1 mile at 6 miles an
  hour
• Or 4 times around a high school track!

59
How to drop 500 calories a day

• One less beer 130 calories
• One less coke 150 calories
• 2 less bread slices 200 calories
• 2 mile/hour walk 30 minutes 80 calories

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The drugs

• What medicines are FDA approved for weight loss?
• When are they indicated?

61
The drugs

• FDA approved
• Orlistat
• Sibutramine
• Phentermine
• Diethylpropion
• Guidelines
• May recommend FDA approved pharmacotherapy
• after 6 mos. weight loss program with out gt5
  loss.

62
Pharmacotherapy FDA ApprovedDiet and exercise
not working

• 2A Weak recommendation, good evidence
• Orlistat -2.75 kg in 1 year approved lt4 years,
• Increased fecal fat gt30g fat ingested
• Diarrhea, flatulence
• Best for patients with heart disease, high BP
• Sibutramine -4.45 kg loss, 1 year, approved lt2
  years
• NSRI, sympathomimetic
• Increased BP, HR, dont use in heart disease
• Phentermine -3.6 kg in 2-24 weeks, approvedlt12
  weeks
• Increases norepinephrine
• Related to amphetamines, schedule 4 abuse
  potential
• Diethylpropion Similar to Phentermine, Schedule 4
• Weight regained after stopping medicines
• No increased gain with Orlistatsibutramine
  combination

63
Orlistat better than Placebo
Data from Sjostrom, L, Rissanen, A, Anderson, T,
et al, Lancet 1998 352167.
64
FutureNeurohormonal therapy

• Recombinant Leptin
• 47 obese pts, restricted calorie diet
• High dose leptin
• Decreased weight by 5.8 kilos gt placebo at 24
  weeks
• May prevent weight associated decreased metabolism

65
FutureNeurohormonal Therapy

• Ghrelin
• Blocker or receptor antagonist
• Decrease hunger, increase satiety
• Gut hormone peptide PYY
• Supresses appetite IV
• Not sustained intranasally over 12 weeks
• High dose, not tolerated
• Tesofensine
• Supresses appetite like Sibutramine
• Sympathomimetic
• Hypertension, tachycardia

66
The Knife Bariatric Surgery

• Restrictive
• Laproscoptic adjustable gastric band
• Malabsorptive
• Jeujunoileal bypass
• Combination
• Roux-en-Y gastric bypass

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Who can have Bariatric Surgery?NIH guidelines

• Well informed and motivated
• Failed weight loss therapy, medical mgt
• Acceptable surgical risk
• BMIgt40
• BMIgt35 with DM, severe DJD, sleep apnea, obesity
  related cardiomyopathy

68
Roux-en-Y gastric bypass
Bariatric surgery. UpToDate Jan 2009
69
Roux-en-Y gastric bypass

• Most effective long term
• Gold standard
• Gastric restriction 30ml drains food to intestine
• Gastric remnant, biliopancreatic limb supplies
  digestive enzymes to intestine
• Can also be done laparoscopicaly

70
Roux-en-Y Gastric Bypass

• 62-68 weight loss in 1 year
• Plateau at 50-75 at two years-16 years
• Resolution of diabetes
• Resolution/improvement sleep apnea
• Improvement
• Hypertension
• Dyslipidemia (HDL, not TC)
• Improvement quality of life
• More post op morbidity, more long term success

71
Laparoscopic Adjustable Gastric Band
72
Laparoscopic Adjustable Gastric Band

• Weight loss
• 15-20 at 3 months
• 40-53 1 year
• 45-75 2 year
• Band adjustable and removable
• Less post op morbidity and mortality than
  roux-en-y

73
Morbidity mortality

• Post op mortality
• Restrictive procedures 0.1
• Gastric bypass 0.5
• Complication 20 with roux-en-y mostly
• Better with laparoscopic surgery
• Compared to medical management 29 reduction risk
  of death at 10 years

74
Overall success of surgery

• Overall weight loss 61
• DM
• Resolved 77
• Resolved or improved 86
• Hyperlipidemia improved gt70
• Hypertension
• resolved 62
• Resolved or improved 79
• Sleep apnea resolved 86
• Improved quality of life

75
Wellness Programs

• Hospitals, community, schools WEB
• Focus on healthy lifestyle changes
• Goals
• Specific, realistic, forgiving
• Record keeping
• Group support
• Follow up
• Change habits for long term

76
Bottom line

• All interventions require intentional persistent
  attention to healthy lifestyle habit
• Decreasing obesity and its comorbidities takes a
  whole community
• Adult obesity risk starts in utero and with first
  months of life.
• The more support long term, the more success
• Success breed success.

77
North Karelia Project

• 1960s Finland highest mortality from MIs
• 1972 Project Started in worst area
• Diet with high diary fat (farming community)
• Low consumption fruit and vegetable
• High rate smoking (men, throughout Finland)
• High blood pressure and salt in diet
• /- inactivity

Allin, Sara. Public Health Good Practice-The
Case of Finland. Public Health and Health
Care 5/2005. www.euro.who.int/observatory
78
North Karelia Projectand beyond

• Interventions
• Health Clinics increased screening CV risks
• Grocery stores increase healthy foods
• Planted berries
• Lay leaders trained to discuss health issues
• Cholesterol lowering competitions BTW towns
• Smoking restrictions, taxes, and ad bans
• Farm subsidies for lower fat foods

79
Finland 1972-2002

• CVD mortality decreased by
• 82 North Karelia
• 75 Nationwide
• Lowered saturated fat in diet
• Replaced butter, cream, whole milk with low fat
• Lowered cholesterol levels
• Lowered salt intake lowered blood pressure
• Better medications