The Obesity Epidemic: This 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
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
Obesity Trends Among U.S. Adults BRFSS, 1990
No Data
<10%
10%-14%
15-19%
20-24%
25%
Obesity Trends Among U.S. Adults BRFSS, 1997
No Data
<10%
10%-14%
15-19%
20-24%
25%
Obesity Trends Among U.S. Adults BRFSS, 2002
No Data
<10%
10%-14%
15-19%
20-24%
25%
1999;282:16;2003;289:1 Source: Mokdad A H, et al. JAMA 2003;289:1
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
All Cause Mortality
2.5 2.0
Mortality Ratio 1.5
1.0 0
Moderate
Men Women
Very Low
Low
Moderate
High
Very High
20
25
30 BMI
35
40
Gray DS. Med Clin North Am. 1989;73(1):1–13.
Actual Causes of Death in the United States, 1990
400,000
300,000
100,000
90,000
30,000
Tobacco Diet/Activity Alcohol Microbial agents Sexual behavior
20,000
Illicit use of drugs
Source: McGinnis JM, Foege WH. JAMA 1993;270:2207-12.
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. 2002;21(2):245-253. Sturm R, Wells KB. Does Obesity Contribute As Much to Morbidity As Poverty or Smoking? Public Health. 2001;115:229-295
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
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
Percentage of U.S. Children and Adolescents Who Were Overweight*
16 14 12 10 8 6 4 2 0 1963-70 1971-74 1976-80 1988-94 1999
1963-70 data are from 1963-65 for children 6-11 years of age and from 1966-70 for adolescents 1217 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
Ages 12-19 Ages 6-11
Percentage of U.S. Children and Adolescents Who Were Overweight*
16 14 12 10 8 6 4 2 0 1963-70** 1971-74 1976-80 1988-94 1999
* >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
14
13
5 4
Ages 12-19 Ages 6-11
Type 2 diabetes at ACH
2 cases in mid 90‟s >100 cases last year
Overweight school-age children have a 50% probability of becoming obese adults Overweight adolescents have a 7080% probability of becoming obese adults
The Toxic Environment
880 calories for $2
Beverage Intake Among Adolescents Aged 11-18, 1965-1996
Boys 1600 1400 1200 1000 800 600 400 200 (Soft drinks, diet soft drinks, and fruit drinks) 0 1965 1977 1989 1996 Girls
SOURCE: Cavadini C et al. Arch Dis Child 2000;83:18-24 (based on USDA surveys)
Per capita grams consumed per day
Generation
XXL
Adult BMI Chart
Weight (lbs)
120 130 140 150 160 170 180 190 200 210 220 230 240 250 260 270 280 290 300 5'0" 5'2" 5'4"
Height
5'6"
5'8" 5'10" 6'0" 6'2" 6'4"
BMI in Adults and Children: Definitions
To be sensitive to the issue of a child’s self-esteem, the term “obesity” is no longer used in children and adolescents
Percentile
Adults
Kids
> 95th percentile 85th -94th percentile
Obese (BMI>30) Overweight (BMI>25)
Overweight
At Risk of Overweight
BMI
BMI
Boys: 2 to 20 years
BMI
BMI
Girls: 2 to 20 years
BMI in Children and Adolescents: Limitations
Weight and height do not directly measure body fatness Additional criteria are necessary to determine whether someone with BMI>95th 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
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
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
UnderWeight 2%
Statewide BMI Classifications For Arkansas Children
OverWeight 21%
Normal 60% At Risk 17%
Overweight At Risk Normal Underweight
Statewide Arkansas BMI Results - Ethnicity
60%
50% Percentage
40% 26%
24% 30% 20%
10% 20% Overweight
At Risk 17%
17% 20%
0%
Caucasian African American Hispanic
June 29, 2004
Statewide BMI Classifications for Arkansas by Grade
50% 45% 40%
35%
Percentage 30% 25% 20% 15% 10% 5% 14% 17% 17% 17% 16% 16% 15% 18% 20% 22% 23% 23% 23% 23% 23% 22%
21%
19%
17%
18%
18%
18%
18%
17%
16%
16%
0%
K 1 2 3 4 5 6 Grade Overweight At Risk 7 8 9 10 11 12
June 29, 2004
http://www.ubalt.edu/experts/obesity/index.html
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
Diets
Atkin‟s Diet The Zone Sugar Busters Protein Power Carbohydrate Addict‟s diet
Jenny Craig Weight Watchers Slim Fast Richard Simmons Right for your type Beverly Hills Fit for Life Grapefruit Diet Cabbage diet
Description
Limit carbohydrates; increase protein and sometimes fat.
Low calorie, generally levels of 1200 or less.
A particular food or nutrient causes weight loss. Usually low in calories. May lead to protein calorie malnutrition leading to breakdown of lean muscle mass.
AHA Guidelines for Healthy Diets
Carbohydrates: ~55% of calories Fat: ~30% of calories, <10% sat fat Protein: 15-20% of calories
Diet: provide adequate nutrients and support dietary compliance
St. Jeor ST, etal. Circulation 104:1869-74, 2001.
Categorization of Diets by CHO and Fat
< 20% CHO < 30% CHO Atkins (20-60g CHO), Protein Power (<60g CHO), VLCD-protein sparing modified fast Carbohydrate Addicts Diet
40% CHO 30% Fat
The Zone Diet
55-60% CHO Weight Watchers, Jenny Craig, DASH diet, <30% Fat Food Guide Pyramid <15% Fat <10% Fat Pritikin Diet Dean Ornish Diet
Riley RE. Clinics in Sports Medicine. 18(3):691-701, 1999.
Atkins Diet Revolution
Protein
14 days = 125g/d (36%) Ongoing = 161g/d (35%) Maintenance = 110g/d (24%) 14 days = 28g/d (5%) Ongoing = 33g/d Maintenance = 128g/d 14 days = 53% fat/d, 23% sat fat/d Strict limits on carbs enable body to burn fat. Insulin is “single most significant determinant of weight.” High protein, fat and saturated fat. Ketotic Limited food choices. Low in fiber, vit D, Ca, K, Mg, Mn.
Riley RE. Clinics in Sports Medicine. 18(3):691-701, 1999.
Carbs
Fat
Rap
Safety?
High Protein Diets: Possible Adverse Effects
Increases in serum uric acid Kidney stones Osteoporosis Chronic renal insufficiency Ketosis High Saturated Fat Low Fruits, Vegetables and Grains
Long Term Weight Losses: AHA vs Low Carb
Weight Loss (% initial weight)
3 6 Months months 0
*p<.001 NS
12 Months
-2 -4
*p<.02
-6 -8 Low Fat Low Carb
N= 63 (32% male / 76%Caucasian) BMI= 34; 41% drop out at 12 months baseline carried forward analyses
Foster et al NEJM 2003 348:2082-90
Long Term Weight Losses among Significantly Obese Individuals
6 Mo 0
Weight Loss (kg) NS
12 Mo
-2 -4 -6 -8 -10 Low Fat Low Carb
p=.002
N=132 (58% Black / 17% female) mean BMI=43 39% diabetic; 34% drop out
Samaha et al NEJM 2003;348:2074-81 & Stern et al Ann Intern Med 2004;140:778-85
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
Weight Watchers
Practical advice Group techniques Food variety Moderate protein, low fat Limits refined sugars and EtOH Stresses activity Groups Very structured Weekly fees
Meals VS. Meal Plans: weight 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
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.
The Importance of Exercise for Weight Maintenance
Weight Control Diets: Key Points from Einstein to PT Barnum
E=mc2; m=E/c2 Time matters Commitment is required Structure helps P.T. Barnum was right Healthy weight is only a part of good nutrition
What Can Physicians Do?
Counsel Drugs Surgery Advocacy
Evidence: USPSTF 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
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
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 don‟t 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
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)
Sibutramine (Meridia)
Contraindicated: CAD, CHF, cardiac arrhythmias or stroke Side Effects: hypertension, arrhythmia, tachycardia, headache, dry mouth, constipation, insomnia
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
Side Effects
GI side effects due to inhibition of fat absorption
pain, fecal urgency, liquid stools, flatulence with discharge, oily spotting
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. 26:262-73, 2002.
Surgery
2001 47,000 2002 63,000 2003 98,000 NIH Criteria: Well informed and motivated patient BMI>40 or BMI>35 with co-morbidities Mortality: 1-2% Effectiveness: >50% excess weight loss at 14 years
Advocacy
The epidemic of overweight cannot be addressed in the office setting alone A provider‟s role should also involve the community