The Obesity Epidemic: This is Your Life

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The Obesity EpidemicThis 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

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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

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Obesity Trends Among U.S. AdultsBRFSS, 1990
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Obesity Trends Among U.S. AdultsBRFSS, 1997
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Obesity Trends Among U.S. AdultsBRFSS, 2002
Source Mokdad A H, et al. JAMA 20032891
Source Mokdad A H, et al. JAMA
19992821620032891
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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

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All Cause Mortality
2.5
2.0
?
?
MortalityRatio
1.5
?
?
?
?
?
?
?
?
1.0
?
?
?
?
VeryLow
VeryHigh
Moderate
Low
Moderate
High
0
MenWomen
20
25
30
35
40
?
?
BMI
Gray DS. Med Clin North Am. 198973(1)113.
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Actual Causes of Death in the United States, 1990
Source McGinnis JM, Foege WH. JAMA
19932702207-12.
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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.
  200221(2)245-253.
• Sturm R, Wells KB. Does Obesity Contribute As
  Much to Morbidity As Poverty or Smoking? Public
  Health. 2001115229-295

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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

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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

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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 95th percentile for BMI by
age and sex based on 2000 CDC BMI-for-age growth
charts Source National Center for Health
Statistics
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Percentage of U.S. Children and Adolescents Who
Were Overweight
14
13
Ages 12-19
5
4
Ages 6-11
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
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Type 2 diabetes at ACH

• 2 cases in mid 90s
• 100 cases last year

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

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The Toxic Environment
880 calories for 2
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Beverage Intake Among Adolescents Aged 11-18,
1965-1996
SOURCE Cavadini C et al. Arch Dis Child
20008318-24 (based on USDA surveys)
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Adult BMI Chart
Weight (lbs)
260
270
280
290
300
190
200
210
220
230
240
250
120
130
150
160
170
180
140
5'0"
5'2"
5'4"
5'6"
Height
5'8"
5'10"
6'0"
6'2"
6'4"
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BMI in Adults and ChildrenDefinitions
To be sensitive to the issue of a childs
self-esteem, the term obesity is no longer used
in children and adolescents
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Girls 2 to 20 years
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BMI in Children and AdolescentsLimitations

• Weight and height do not directly measure body
  fatness
• Additional criteria are necessary to determine
  whether someone with BMI95th 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

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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

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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

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Statewide BMI Classifications For Arkansas
Children
Under- Weight 2
Over- Weight 21
Normal 60
At Risk 17
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Statewide Arkansas BMI Results - Ethnicity
60
50
40
26
24
20
Percentage
30
Overweight
20
At Risk
17
20
10
17
0
Caucasian
African
Hispanic
American
June 29, 2004
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Statewide BMI Classifications for Arkansas by
Grade
50
45
40
35
23
23
23
23
22
23
30
22
21
20
18
19
16
15
25
Percentage
20
15
10
14
18
18
18
18
17
17
17
16
17
17
16
16
5
0
K
1
2
3
4
5
6
7
8
9
10
11
12
Grade
Overweight
At Risk
June 29, 2004
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http//www.ubalt.edu/experts/obesity/index.html
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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

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AHA Guidelines for Healthy Diets

• Carbohydrates 55 of calories
• Fat 30 of calories,
• Protein 15-20 of calories
• Diet provide adequate nutrients and
• support dietary compliance

St. Jeor ST, etal. Circulation 1041869-74, 2001.
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Categorization of Diets by CHO and Fat
Riley RE. Clinics in Sports Medicine.
18(3)691-701, 1999.
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Atkins Diet Revolution
Rap
Riley RE. Clinics in Sports Medicine.
18(3)691-701, 1999.
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High Protein DietsPossible Adverse Effects

• Increases in serum uric acid
• Kidney stones
• Osteoporosis
• Chronic renal insufficiency
• Ketosis
• High Saturated Fat
• Low Fruits, Vegetables and Grains

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Long Term Weight LossesAHA vs Low Carb

pNS
Weight Loss ( initial weight)
pN 63 (32 male / 76Caucasian) BMI 34 41 drop
out at 12 months baseline carried forward analyses
Foster et al NEJM 2003 3482082-90
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Long Term Weight Losses among Significantly Obese
Individuals

NS
p.002
Weight Loss (kg)
N132 (58 Black / 17 female) mean BMI43 39
diabetic 34 drop out
Samaha et al NEJM 20033482074-81 Stern et al
Ann Intern Med 2004140778-85
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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

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Weight Watchers

• Practical advice
• Group techniques
• Food variety
• Moderate protein, low fat
• Limits refined sugars and EtOH
• Stresses activity

• Groups
• Very structured
• Weekly fees

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Meals VS. Meal Plansweight 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

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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.

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The Importance of Exercise for Weight Maintenance
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Weight Control Diets Key Points from Einstein
to PT Barnum

• Emc2 mE/c2
• Time matters
• Commitment is required
• Structure helps
• P.T. Barnum was right
• Healthy weight is only a part of good nutrition

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What Can Physicians Do?

• Counsel
• Drugs
• Surgery
• Advocacy

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EvidenceUSPSTF 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

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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

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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 dont
• 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

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Obesity Drugs

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

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Sibutramine (Meridia)

• Contraindicated CAD, CHF, cardiac arrhythmias or
  stroke
• Side Effects hypertension, arrhythmia,
  tachycardia, headache, dry mouth, constipation,
  insomnia

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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

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Side Effects

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

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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. 26262-73, 2002.
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Surgery

• 2001 47,000
• 2002 63,000
• 2003 98,000
• NIH Criteria
• Well informed and motivated patient
• BMI40 or
• BMI35 with co-morbidities
• Mortality 1-2
• Effectiveness 50 excess weight loss at 14
  years

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Advocacy

• The epidemic of overweight cannot be addressed in
  the office setting alone
• A providers role should also involve the
  community

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