Overview of the Obesity Epidemic

1
Speaker notes included in notes section below
Overview of the Obesity Epidemic
2
More than 60 of US Adults Are Overweight or
Obese
Flegal K, et al. JAMA. 20022881723-1727.
Hedley AA, et al.
JAMA. 20042912847-2850.
3
Assessing Obesity What Is BMI?

• BMI
• Calculated as weight(kg)/height(m2)
• Evaluates weight relative to height
• Replaced ideal body weight as the primary
  criterion for assessing obesity
• Correlates significantly with body fat,
  morbidity, and mortality

NIH Natl Heart, Lung, and Blood Inst. Obes Res.
19986(suppl 2)51S. Willett WC et al. N Engl J
Med. 1999341427.
4
Obesity Trends by Gender and Ethnicity
Men
Women
Flegal K, et al. JAMA 20022881723-1727.
5
Prevalence of Overweight in Children and
Adolescents
Flegal K, et al. JAMA 20022881723-1727.
Hedley AA, et al.
JAMA 20042912847-2850.
6
BMI-for-Age Cutoffs for Children and Adolescents
7
For Children, BMI Changes with Age
Boys 2 to 20 years
Example 95th Percentile Tracking Age
BMI 2 yrs 19.3 4 yrs 17.8 9 yrs
21.0 13 yrs 25.1
8
Obesity is Caused by Long-Term Positive Energy
Balance

• Fat
• stores

Energy expenditure

Energy intake
9
Heritability of Body Weight
10
Obesity Genetics vs Environment
Obesigenicenvironment
Restrictiveenvironment
Resistant Prone
Ravussin E, Bouchard C. Eur J Pharmacol.
2000410131-145.
11
Responding to the Obesity Epidemic

• Create a child-healthy environment
• Banish junk food from schools
• Reduce food ads directed at children
• Increase opportunities for physical activity

12
16 oz
32 oz
44 oz
52 oz
64 oz
1 oz 12 calories
13
of Children with Daily Physical Education
American Academy of Pediatrics.
14
Prevalence of Obesity by Hours of TV per Day
NHES Youth Aged 12 to 17 in 1967-1970 and NLSY
Youth Aged 10 to 15 in 1990
15
Medical Complications of Obesity
16
Medical Complications of Obesity
Idiopathic intracranial hypertension
Pulmonary disease abnormal function obstructive
sleep apnea hypoventilation syndrome
Stroke
Cataracts
Nonalcoholic fatty liver disease steatosis steatoh
epatitis cirrhosis
Coronary heart disease Diabetes
Dyslipidemia Hypertension
Severe pancreatitis
Gall bladder disease
Cancer breast, uterus, cervix colon, esophagus,
pancreas kidney, prostate
Gynecologic abnormalities abnormal
menses infertility polycystic ovarian syndrome
Osteoarthritis
Phlebitis venous stasis
Skin
Gout
17
Pathogenesis of Health Problems Associated with
Obesity
Genes
Environment
Activity
Food Intake
Excess fat stores
Diseases due to increased fat cell size
visceral fat
Diseases due to increased fat mass
Diabetes
CVD
Stigma
Osteoarthritis
NAFLD
Sleep apnea
GB Disease
Cancer
18
BMI and Mortality by Ethnic Group The American
Cancer Society Study
Calle NEJM 19993411097.
19
Relative Risk of Death by BMI Levels from the
NHANES I, II, III Surveys
Flegal et al JAMA20051861
20
Range of Estimates of Mortality Associated with
Overweight
21
Obesity Decreases Life ExpectancyThe Framingham
Study
Compared to a BMI 18.5-24.9 kg/m2
Peeters Ann Int Med 200313824-32.
22
Proportion of Disease Prevalence Attributable to
Obesity
Diet, Nutrition and the Prevention of Chronic
Diseases. Report of a Joint WHO/FAO Expert
Consultation. Geneva, World Health Organization
(WHO Technical Report Series, No. 916).
23
Relationship Between BMI and Risk of Type 2
Diabetes Mellitus
100
75
Age-Adjusted Relative Risk
50
25
0
23 - 23.9
24 - 24.9
25 - 26.9
27 - 28.9
33 - 34.9
29 - 30.9
31 - 32.9
35
Body Mass Index (kg/m2)
Chan J et al. Diabetes Care 199417961. Colditz
G et al. Ann Intern Med 1995122481.
24
Nurses Health Study Waist Circumference
Directly Related to Risk for Type 2 Diabetes
Controlled for age, family history of diabetes,
exercise, smoking, saturated fat intake,
calcium, potassium, magnesium, and glycemic
index.
Carey et al. Am J Epidemiol. 1997145614.
25
Characteristics of the Metabolic Syndrome
Full members
Wannabes

• Abdominal obesity
• Glucose intolerance
• High triglycerides
• Low HDL-cholesterol
• High blood pressure
• Insulin resistance

• Microalbuminuria
• Small dense LDL
• Inflammatory markers
• Thrombotic factors
• Endothelial dysfunction
• Hyperuricemia

26
Abdominal Adiposity
Abdominal Obesity
Visceral
Subcutaneous
Courtesy of Steven Smith, M.D.
27
Visceral AdiposityThe Critical Adipose Depot
28
Metabolic Syndrome NCEP ATP III compared to IDF
requires presence of 3 or more criteria
requires central adiposity and presence of 2 more
criteria
29
Age-Adjusted Prevalence of the Metabolic Syndrome
Among 8814 Adults Age 20
Ford JAMA 2002287356-9.
30
Mortality from Cancer in American Men and Women
Calle NEJM 20033481625.
31
Other Increased Risks

• Kidney stones
• Complications of pregnancy
• Sleep disorders
• Osteoarthritis
• Stigmatization

32
The Interheart Study Risk of MI
Adj for Age, Sex Geography Adj Age, Sex
Smoking
Yusuf et al Lancet 2004364-352.
33
BMI and Physical Functioning (SF-36)The Nurses
Health Study
Coakley et al IJO 199822958-963.
34
Psychosocial Status of Obese Individuals

• Most obese individuals have normal psychological
  status
• Persons who seek weight loss report greater
  distress
• Patients at greatest risk of depression
• Women
• Extreme obesity (BMI 40 kg/m2)
• Binge eating disorder (BED)

Friedman Brownell. Psych Bull 19951173-20.
35
Risk of Major Depression with Extreme Obesity
Onyike, et al. Amer J Epidemiology
20031581139-1147.
36
Bodily Pain and Depression in Obese Individuals
(N 306)
Bodily Pain
BDI-II Score
Fabricatore AF. Obes Surg 2005 15304-309.
37
Medical Benefits of Modest Weight Loss

• Reduces mortality
• Lowers conversion rate to diabetes
• Improves blood pressure
• Reduces risk factors for CHD
• Lowers lipids
• Improves sleep apnea

38
Diabetes Prevention Program
Placebo
Metformin
Lifestyle
Cumulative Incidence of Diabetes ()
Year
Diabetes Prevention Program Research Group. N
Engl J Med. 2002346,393-403.
39
Small Weight Losses Are Beneficial The Diabetes
Prevention Program

Placebo
Reduces Risk of Diabetes by 58
Lifestyle
0 6 12 18 24 30 36
42 48
Months in study
DPP NEJM 2002346393-402
40
Plasma Lipids Improve With Weight Loss
Meta-analysis of 70 Clinical Trials
HDL-C (weight stable)
HDL-C (actively losing)
Total Cholesterol
LDL-C
TG



D mmol/L per kg of Weight Loss

D mg/dL per kg of Weight Loss

P?0.05. LDL-Clow density lipoprotein
cholesterol HDL-Chigh-density lipoprotein
cholesterol TGtriglycerides. Dattilo et al. Am
J Clin Nutr 199256320.
41
Effect of Weight Change on Apnea-Hypopnea Index
(AHI)
6
4
2
Mean Change in AHI (Events/h)
0
-2
-4
10 to 20 (n 79)
-20 to -10 to -5 to 5 to Change in Body Weight ()
Peppard et al. JAMA 20002843015.
42
The Economics of Obesity
43
Economic Burden of Obesity Similar to Other
Chronic Diseases
Direct cost of chronic diseases in the U.S.
(2003)

• 
  Billions,
• Obesity 1 75.0
• Type 2 Diabetes 2 73.7
• Coronary heart disease 3 52.4
• Hypertension 4 28.2
• Arthritis 5 23.9
• Breast Cancer 6 7.1

1 Finkelstein EA, Obes Res 200412 4Hodgson TA
et al. Med Care 200139599 2 ADA Diabetes Care,
200326917 5 Yelin Callahan.
Arthritis Rheum 1995381351 3 Hodgeson TA et al.
Medical Care 199937994. 6Brown ML, et al.
Medical Care 200240(suppl) IV- 104 Courtesy
of Anne Wolf, MS, RD
44
Cost Difference

• 2.3 - Cost increase for each higher BMI unit
• 52.9 - Cost increase for each major associated
  co-morbidity

Raebel, M. et al. Health Services Use and Health
Care Costs of Obese and Non-obese Individuals.
Arch Intern Med 2004 No.19. Vol.164
2135-2140. Oct.25,2004
45
Obesity Effect on Expected Lifetime Medical Care
Costs in Women
40,000
30,000
Costs ()
20,000
55 - 64
10,000
45 - 54
Age
35 - 44
0
37.5
32.5
27.5
22.5
BMI (kg/m2)
Total cost of 8 diseases CHD, type 2 DM,
hypertension, hypercholesterolemia, stroke,
gallbladder disease, osteoarthritis of knee,
endometrial cancer.
Adapted from Thompson D et al. Arch Intern Med
19992177-2183.
46
Expected Lifetime Medical Care Savings of
Sustained 10 Weight Loss by Age and Initial BMI
(Women)
6000
5000
4000
Costs ()
3000
55 - 64
2000
45 - 54
1000
Age
35 - 44
0
37.5
32.5
27.5
BMI (kg/m2)
Total cost of 5 diseases CHD, type 2 DM,
hypertension, hypercholesterolemia, and stroke.
Adapted from Oster G, et al. Am J Public Health
1999891536-1542.
47
Childhood/Adolescent Health Costs

• 9 20 Cost of a single day of absenteeism
  for a student
• 9 days Median sick days away from school for
  the most overweight students
• Obesity associated annual hospital costs for
  children and youth more than tripled over the
  last two decades
• 35 million in1979 1981
• 127 million in 1997 1999

Action for Healthy Kids- The Learning Connection-
Value of Improving Nutrition and Physical
Activity in Our Schools. Preventing Childhood
Obesity Health in the Balance. 2005. Institute
of Medicine. Childhood Obesity Prevention Study.
48
Obesity Medications

• Obesity medications produced substantial weight
  loss
• Drug cost savings for obesity co-morbid
  conditions
• Subjects were taking medications for
• Diabetes
• Hyperlipidemia
• Hypertension
• Pharmaceutical cost computed for
• Weight loss
• Cardiac risk reduction
• Lipid reduction
• Glucose reduction

Greenway, FL.. Ryan, DH. Bray, GA.
Pharmaceutical Cost Savings of Treating Obesity
with Weight Loss Medications. Obesity Research.
1999 7 523-531.
49
Conclusions

• Obesity is a growing epidemic in the United
  States and worldwide
• The prevalence of type 2 diabetes and obesity in
  children/adolescents has dramatically increased
• The risk of comorbid conditions increases as
  obesity increases.
• The economic burden of obesity is great, and
  increases as obesity increases