OBESITY

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					  OBESITY
  IRA KEITH ELLIS
UT FAMILY MEDICINE
    JACKSON TN
        GOALS/OBJECTIVES
   TO APPRECIATE THE GROWING RATE OF
    OBESITY IN THE POPULATION
   TO UNDERSTAND THE COMPLICATIONS OF
    OBESITY
   TO REVIEW METHODS TO REDUCE BODY
    WEIGHT
   TO UNDERSTAND A FAMILY PHYSICIAN’S ROLE
    IN WEIGHT LOSS
   REVIEW THE EVIDENCE BASED MEDICINE
    GUIDELINES FOR OBESITY
        CLINICAL PRACTICE GUIDELINE

   PRACTICE RECOMMENDATION: Physicians should screen all
    adult patients for obesity and offer counseling and intensive
    behavioral interventions to promote sustained weight loss.

   EVIDENCE BASED SOURCE: U.S. Preventative Services Task
    Force

   WEB SITE OF SUPPORT: www.ahrq.gov/clinic/uspstf/uspsobes.html
   STRENGTH OF EVIDENCE: B
         OBESITY DEFINITIONS
   ADULTS
       OVERWEIGHT IS BMI 25-29.9
       OBESE IS BMI 30 OR GREATER
         OBESE GRADE I 30-34.9
         OBESE GRADE II 35-39.9

         OBESE GRADE III 40 OR GREATER
               ALSO CALLED MORBID OR SEVERE OBESITY
         OBESITY DEFINITIONS
   CHILDREN
       RISK OF OVERWEIGHT
           85TH-95TH PERCENTILE OF WEIGHT(BMI) BASED
            ON AGE
       OVERWEIGHT
           GREATER THAN THE 95TH PERCENTILE OF
            WEIGHT(BMI) BASED ON AGE
         OBESITY DEFINITIONS
   METABOLIC SYNDROME
       W.H.O DEFINITION IS THE PRESENCE OF IMPAIRED
        GLUCOSE TOLERANCE (OR DIAGNOSED DIABETES)
        PLUS ANY TWO OF THE FOLLOWING:
            WAIST/HIP RATIO >.90 MEN/>.85 WOMEN or BMI > 30
            TRIGLYCERIDES > 150MG/DL
            HDL < 35MG/DL MEN/<39 MG/DL WOMEN
            BP >140/90 OR TREATED
            URINARY ALBUMIN >20MG/MINUTE
                 ALBUMIN/CREATININE RATIO OF 30MG/G
HOW MUCH OF A PROBLEM?
   JAMA JUNE 16, 2004
   PREVALENCE OF OVERWEIGHT AND
    OBESITY IN US CHILDREN, ADOLESCENT,
    AND ADULTS
       ADULTS
         OVERWEIGHT OR OBESE 65%
         OBESE 30.5%

         EXTREME OBESITY 4.7%
HOW MUCH OF A PROBLEM?
   MORE CONCERNING, IT’S NOT JUST IN ADULTS
       NEW ENGLAND JOURNAL OF MEDICINE
       JUNE 3, 2004
       METABOLIC SYNDROME IN CHILDREN AND
        ADOLESCENCE
           APPROXIMATELY 50% OF OBESE CHILDREN AND
            ADOLESCENCE MEET DIAGNOSTIC CRITERIA FOR
            METABOLIC SYNDROME
           RISK OF DEVELOPMENT OF METABOLIC SYNDROME
            INCREASES AS BMI AND INSULIN RESISTANCE INCREASE
    HOW MUCH OF A PROBLEM?
   ―TIME FOR ACTION‖
       AAFP JUNE 15, 2004
       METABOLIC SYNDROME: A TIME FOR ACTION
            OVER 50% OF US ADULTS ARE OVERWEIGHT
            APPROXIMATELY 20% OF US MALES AND 25% OF US
             FEMALES HAVE METABOLIC SYNDROME
            METABOLIC SYNDROME (AS A REFLECTION OF OBESITY)
             WILL SOON OVERTAKE CIGARETTE USE AS THE NUMBER
             ONE MODIFIABLE CAUSE OF DEATH IN THE USA
HOW MUCH OF A PROBLEM?
   JAMA DECEMBER 15, 2004
   OBESITY IN US IMMIGRANTS
       16% OF IMMIGRANTS ARE OBESE
       19% OF IMMIGRANTS WHO HAVE BEEN IN
        THE US AT LEAST 15 YEARS ARE OBESE
Leading Causes of Percentage          Actual Causes of      Percentage
Death*              (of all deaths)   Death†                (of all deaths)
United States, 2000                   United States,
                                      2000


Heart Disease              30%        Tobacco                    18.1%
Cancer                     23%        Poor Diet/Physical         16.6%
                                      Inactivity

Stroke                                Alcohol consumption
                            7%                                    3.5%
Chronic lower               5%        Microbial agents            3.1%
respiratory disease                   (e.g., influenza,
                                      pneumonia)

Unintentional               4%        Toxic agents                2.3%
Injuries                              (e.g., pollutants,
                                      asbestos)

Diabetes                    3%        Motor-vehicles              1.8%
Pneumonia/influenza                   Firearms
                            3%                                    1.2%
Alzheimer's disease         2%        Sexual behavior             0.8%
Kidney disease               2%       Illicit drug use              0.7%
    HEALTH COMPLICATIONS
   MORTALITY
       OVERALL OUTCOMES
            CARDIOVASCULAR
   MORBITY (THINK METABOLIC SYNDROME)
       HYPERTENSION
       DIABETES MELLITUS
       HYPERINSULINEMIA
       DYSLIPIDEMIA
            HYPERTRIGLYCERIDEMIA
            LOW HDL
                 ATHEROGENIC DYSLIPIDEMIA
            HYPERCHOLESTEROLEMIA (LDL)
    HEALTH COMPLICATIONS
   MORTALITY
       OVERALL EARLY MORTALITY INCREASES
        WITH BMI ESPECIALLY EXTREME OBESITY
         EXCESSIVE DEATHS 110,000 TO 365,000
         OVER 50 YEARS OF AGE THAT DON’T SMOKE
               OVERWEIGHT = 30-50% INCREASE RISK
               OBESE = 200-300% INCREASE RISK
       RISK OF PREMATURE DEATH AS ADULT
        RELATED TO BMI AS ADOLESCENT
Estimated Hazard Ratios for Death from Any Cause According to Body-Mass Index for All
           Study Participants and for Healthy Subjects Who Never Smoked




                       Berrington de Gonzalez A et al. N Engl J Med
                       2010;363:2211-2219
    Adjusted Relative Risk of Death among Men and Women in the European Prospective
Investigation into Cancer and Nutrition, According to BMI, Waist Circumference, and Waist-to-
                                           Hip Ratio




   Pischon T et al. N Engl J Med 2008;359:2105-2120
Adjusted Relative Risk of Death among Men and Women, According to Waist Circumference
                      and Waist-to-Hip Ratio after Adjustment for BMI




             Pischon T et al. N Engl J Med 2008;359:2105-2120
    HEALTH COMPLICATIONS
   MORTALITY
       HYPERTENSION
         TRENDING DOWN
         25-30% ATTRIBUTABLE TO OBESITY

       DIABETES MELLITUS
         TRENDING UP
         80% ATTRIBUTABLE TO OBESITY

       HYPERCHOLESTEROLEMIA
           TRENDING DOWN
    HEALTH COMPLICATIONS
   MORBIDITY
       DYSLIPIDEMIA
            ATHROGENIC DYSLIPIDEMIAS
                 HIGH LDL, HIGH TRIGLYCERIDES, LOW HDL
            TOTAL CHOLESTEROL AND LDL TRENDING DOWN
       VENOUS THROMBOSIS
       CHOLELITHIASIS
            CHOLESTEROL PRODUCTION INCREASES WITH BODY
             WEIGHT
       DEMENTIA
       STROKE
            THROMBOEMBOLIC
     HEALTH COMPLICATIONS
   ATRIAL FIBRILLATION/FLUTTER
       LIKELY TO BE IRREVERSIBLE
   GERD/ESOPHAGEAL CANCER
   OSTEOARTHRITIS
       ONE OF THE GREATEST ―DIRECT‖ ECONOMICAL BURDENS
        RELATED TO OBESITY
       AFFECTS NON-WEIGHT BEARING JOINTS SUGGESTING
        ABNORMAL BONE/CARTILAGE METABOLISM
   SKIN CHANGES
       STRETCH MARKS
       ACANTHOSIS NIGRICANS
       HIRSUITISM
    HEALTH COMPLICATIONS
   HEART DISEASE/CHF/CORONARY DISEASE
       RISK OF EACH INCREASE WITH INCREASING BMI
       LIKELY RELATED TO MULTIPLE FACTORS
            METABOLIC SYNDROME
       PARADOXICAL OUTCOMES WITH MI
            HIGHER BMI TRENDS TOWARDS BETTER OUTCOMES
            MAY BE RELATED TO ―MORE AGGRESSIVE‖ TREATMENT
   OBSTRUCTIVE SLEEP APNEA
    HEALTH COMPLICATIONS
   WOMEN’S HEALTH
       THINK POLYCYSTIC OVARIAN SYNDROME
         MENSTRAL IRREGULARITIES
         ANOVULATORY CYCLES

       GYN CANCER RISKS INCREASE
   KIDNEY DISEASE
       HIGHER INCIDENCE
           MULTI-FACTORAL
       MORE KIDNEY STONES
    HEALTH COMPLICATIONS
   INCREASED RISK OF CANCERS
   INCREASED DEATH RATES FROM CANCERS
   SPECIFIC CANCERS
       ESOPHAGUS
       COLON/RECTUM
       LIVER/GALLBLADDER
       PANCREAS
       KIDNEY
       NON HODGKIN’S LYMPHOMA
       MULTIPLE MYELOMA
    PSYCHOSOCIAL ASPECTS
   PEOPLE WHO ARE OBESE
       LESS LIKELY TO MARRY
       COMPLETE FEWER YEARS OF SCHOOL
       HAVE LOWER INCOMES
       HIGHER RATE OF POVERTY
       HAVE MORE DEPRESSION
       USE 2 TIMES AS MANY SICK DAYS
       2 – 3 TIMES MORE LIKELY TO DRAW
        DISABILITY
  ECONOMICAL BURDEN
DISEASE          COST (BIL)
DIABETES         32.4
CHD              7
OA               4.3
HTN              3.2
GALLBLADDER      2.6
COLON CA         1
BREAST CA        .84
ENDOMETRIAL CA   .29
TOTAL            51.6
            ECONOMIC BURDEN
   http://articles.moneycentral.msn.com/Insurance
    /Advice/WhatIfNoOneWereFat.aspx
       WWW.MSN.COM April 30, 2008


   What if nobody in America were fat?
   Add up the savings up on health, food, clothing and
    efficiencies, and you could buy a professional home gym
    for every U.S. household -- or hand each $4,270 in cash.

 $487          billion in gas, sweat and stretch
    pants
       That's almost 3.5% of gross domestic product.
     TREATMENT OF OBESITY
   IS IT JUST IN MY GENES?
   ROLE OF EXERCISE?
   MEDICATIONS?
       NON PHARMACOLOGICAL?
   SURGERY?
    IT RUNS IN THE FAMILY
   GENETICS
       RESEARCH SHOWS TWO SIGNIFICANT FINDINGS
           BETA 3 ADRENERGIC RECEPTOR ABNORMALITIES
                RECEPTORS FOUND IN VISCERAL FAT AND MAY INFLUENCE
                 LIPOLYSIS AND TRIGLYCERIDE RELEASE
                SPECIFIC MUTATION TRP64ARG MUTATION RELATED TO
                 INSULIN RESISTANCE AND OBESITY
           MELANOCORTIN 4 RECEPTOR MUTATIONS
                NEJM MARCH 20, 2003
                500 CHILDREN WITH SEVERE OBESITY
                    6% WITH MUTATIONS (23 HETEROZYGOTES/6
                      HOMOZYGOTES)
                    ALL HAD SEVERE OBESITY, INCREASED LINEAR GROWTH,
                      HYPERPHAGIA, HYPERINSULINEMIA
                25 SEVERELY OBESE CHILDREN WITH MC4R MUTATION
                    ALL HAD SIGNIFICANT REPORTS OF BINGE EATING AS
                      COMPARED TO OTHER GROUPS
     TREATMENT OF OBESITY
   CALORIC IMBALANCE
       CALORIES IN GREATER THAN CALORIES OUT
            DIET
            EXERCISE
         CALORIE REDUCTION
   3500 KCAL REDUCTION LEADS TO
    APPROXIMATELY 1 POUND OF WEIGHT
    LOSS
   MAXIMUM LOSS NOTED AT 1200 KCAL
    PER DAY DIETS
       EVERYONE LOSES WEIGHT IF TRULY
        CONSUMING LESS THAN 1200 KCAL PER DAY
            CALORIE REDUCTION
   5 COMMON/POPULAR DIETS
       WEIGHT WATCHERS
           WWW.WEIGHTWATCHERS.COM
       LEARN
           LIFE, EXERCISE, ATTITUDE, RELATIONSHIPS, NUTRITION
           WWW.THELIFESTYLECOMPANY.COM
       ORNISH
           WWW.ORNISH.COM
       ZONE
           WWW.ZONEDIET.COM
       ATKINS
           WWW.ATKINS.COM
         CALORIE REDUCTION
   COMPARISON STUDIES
       LOW CARB DIETS VS CONVENTIONAL
           MORE RAPID WEIGHT LOSS FIRST 6 TO 12
            WEEKS
       OVERALL
         POOR ADHERENCE LONG TERM
         HIGH ATTRITION LONG TERM

         MINIMAL DIFFERENCE IN OVERALL WEIGHT LOSS
          AT ONE YEAR IF DIETS MAINTAINED
         CALORIE REDUCTION
   REAL WORLD IDEAS
       START WITH LIQUID CALORIES
           1 CAN COKE = APPROX 240 CALORIES
       THINK ABOUT PORTION SIZE
       EAT SLOW/SAVOR THE FOODS
       STOP EATING WHEN NOT HUNGRY
           DON’T KEEP GOING TIL ―FULL‖
       SMALLER MORE FREQUENT MEALS
RECOMMENDED EXERCISE
   To reduce the risk of chronic disease in adulthood: Engage in at
    least 30 minutes of moderate-intensity physical activity, above
    usual activity, at work or home on most days of the week.
        For most people, greater health benefits can be obtained by
         engaging in physical activity of more vigorous intensity or longer
         duration.
   To help manage body weight and prevent gradual, unhealthy
    body weight gain in adulthood: Engage in approximately 60
    minutes of moderate- to vigorous-intensity activity on most days
    of the week while not exceeding caloric intake requirements.
   To sustain weight loss in adulthood: Participate in at least 60 to
    90 minutes of daily moderate-intensity physical activity while not
    exceeding caloric intake requirements. Some people may need
    to consult with a healthcare provider before participating in this
    level of activity.
       RECOMMEND EXERCISE
   Children and adolescents. Engage in at least 60 minutes of physical
    activity on most, preferably all, days of the week.
   Pregnant women. In the absence of medical or obstetric
    complications, incorporate 30 minutes or more of moderate-
    intensity physical activity on most, if not all, days of the week. Avoid
    activities with a high risk of falling or abdominal trauma.
   Breastfeeding women. Be aware that neither acute nor regular
    exercise adversely affects the mother's ability to successfully
    breastfeed.
   Older adults. Participate in regular physical activity to reduce
    functional declines associated with aging and to achieve the other
    benefits of physical activity identified for all adults.
    TREATMENT OF OBESITY
   MEDICATIONS
       BMI GREATER THAN 30
       BMI 27 TO 30 WITH CO MORBIDITIES
   SURGERY
       BMI GREATER THAN 40
           GREATER THAN 35 WITH COMORBIDITIES
       MOTIVATED
       FAILED NON SURGICAL WEIGHT LOSS
       BENEFIT GREATER THAN RISK
     OBESITY MEDICATIONS
   OVER 30 BILLION DOLLARS PER YEAR
    SPENT IN USA FOR WEIGHT LOSS
   AT ANY GIVEN TIME 50% OF WOMEN
    AND 25% OF MEN ATTEMPTING WEIGHT
    LOSS
        OBESITY MEDICATIONS
   DRUGS/DRUG CLASSES APPROVED FOR
    TREATMENT OF OBESITY
       APPETITE SUPRESSANTS
       THERMOGENIC AGENTS
       DIGESTIVE INHIBITORS
    APPETITE SUPRESSANTS
   NORADRENERGIC (APPETITE CENTER)
       PHENTERMINE (ADIPEX) (FDA APPROVED)
         LABELED ONLY FOR SHORT TERM USE (2WEEKS)
          IN COMBINATION WITH DIET AND EXERCISE
         ALTERNATING PERIODS OF ACTIVE MEDICATION
          WITH PLACEBO INCREASES SUSTAINED WEIGHT
          LOSS
         SIDE EFFECTS: PALPITATIONS, TACHYCARDIA,
          ELEVATED BP
        OBESITY MEDICATIONS
   SEROTONERGIC (ACT ON HYPOTHALAMUS)
       ADRENERGIC/SEROTONERGIC
           SIBUTRAMINE (MERIDIA) (FDA APPROVED)
                SIMILAR TO PROZAC, BUT ALSO BLOCKS MONOAMINE
                 UPTAKE SO BE CAREFUL OF SEROTONIN SYDROME
                MAY STIMULATE BETA 3 ADRENERGIC THERMOGENESIS IN
                 BROWN ADIPOSE
                STUDIES SHOW 1-2 KG LOSS THAT IS STABLE
                    UP TO 4KG AT ONE YEAR

                LABELED FOR USE IN THOSE WITH BMI >30 OR >27 WITH
                 COMORBIDITIES
                SIDE EFFECTS: DRY MOUTH, ANOREXIA, CONSTIPATION,
                 INSOMNIA
        OBESITY MEDICATIONS
   DIGESTIVE INHIBITORS
       ORLISTAT (XENICAL) FDA APPROVED
         INHIBITS PANCREATIC/GASTRIC LIPASES
         STATISTICALLY SIGNIFICANT WIEGHT LOSS OF
          3-4KG
               ALSO IMPROVED BP, CHOLESTEROL, GLUCOSE
                TOLERANCE
         FAT SOLUBLE VITAMINES SHOULD BE TAKEN 2
          HOURS BEFORE OR 1 HOUR AFTER
         SIDE EFFECTS: 10% OF PATIENTS STOP BECAUSE
          OF GI SIDE EFFECTS
               ANAL LEAKAGE, URGENCY, ABDOMINAL PAIN
        OBESITY MEDICATIONS
   USED OUTSIDE FDA APPROVAL:
       METFORMIN
            2.1KG VS .1KG
       PRAMLINTIDE
            1.4KG LOST VS. .7KG GAINED
       EXENATIDE
            1.6 TO 2.8KG 30 WEEKS
       TOPIRAMATE
            6.3% VS 2.6%
       ZONISAMIDE
            5.9KG VS. .9 KG
       FLUOXETINE
       BUPROPION
            7 TO 10% LOST VS 5%
        OBESITY MEDICATIONS
   EXPERIMENTAL
       RIMONABANT
           CANNABINOID RECEPTOR BLOCKER
                ―PLEASURE REDUCER‖
           APPROVED IN EUROPE
        CLINICAL PRACTICE GUIDELINE
   PRACTICE RECOMMENDATION: Pharmacologic therapy can be offered to
    obese patients who have failed to reach weight loss goals through diet and
    exercise alone. Drug choices for adjunctive treatment of obesity include
    sibutramine, orlistat, phentermine, diethylpropion, fluoxetine, and
    bupropion. The choice of drug depends on each individual patients co-
    morbidities and requires a doctor-patient discussion of side effects, safety
    data and temporary nature of weight loss

   EVIDENCE BASED SOURCE: Annals of Internal Medicine

   WEB SITE OF SUPPORT: www.annals.org/cgi/content/full/142/7/525

   STRENGTH OF EVIDENCE: Major Recommendation per guidelines based on
    review of randomized controlled trials and meta analysis.
PSYCHOLOGICAL ASSISTANCE
   IS OVER-EATING THE EQUIVALENT OF
    FOOD ADDICTION?
       OVER EATERS ANONYMOUS
       http://www.oa.org/
       12 STEP PROGRAM DERIVED FROM AA
           the Twelve Steps of Over-eaters Anonymous
                1. We admitted we were powerless over food — that our
                 lives had become unmanageable.
                  SURGERY
   ROUX-EN-Y GASTRIC BYPASS
       65-70% EXCESSIVE WEIGHT IS LOST
       RESOLUTION/IMPROVEMENT RATES:
         DIABETES 90%
         HYPERTENSION 90%

         HYPERLIPIDEMIA 95%

       COMPLICATIONS
         MALABSORPTION
         PULMONARY EMBOLISM

         HYPERINSULINEMIC HYPOGLYCEMIA
                          SURGERY
   ADJUSTABLE GASTRIC BANDING
       50-65% EXCESSIVE WEIGHT IS LOST
       RESOLUTION/IMPROVEMENT RATES:
            DIABETES 80%
            HYPERTENSION 70%
            HYPERLIPIDEMIA 60%
       COMPLICATIONS
            NO MALABSORPTION
            PERI OPERATIVE MORTALITY .1%
                 LOWEST FOR ANY BARIATRIC PROCEDURE
            SLIPPAGE, BAND EROSION, VOMITING
                 MAY REQUIRE REVISION
CLINICAL PRACTICE GUIDELINE
   PRACTICE RECOMMENDATION: Surgery should be considered as a treatment
    option for patients with a BMI of 40kg/m2 or greater who failed adequate
    exercise and diet program (with or without pharmacologic therapy) and
    who present with obesity-related co-morbid conditions

   EVIDENCE BASED SOURCE: Annals of Internal Medicine

   WEB SITE OF SUPPORT: www.annals.org/cgi/content/full/142/7/525

   STRENGTH OF EVIDENCE: Major Recommendation per guidelines based on
    review of randomized controlled trials and meta analysis.
        GOALS
BMI      URGENCY          REC
                        HEALTHY
20-25     NONE          LIFESTYLE
                     5-10KG LOSS OVER
25-30     MILD       6 MONTHS
                     5-10% LOSS, MEDS
30-35      MOD       IF NEEDED IN 3
                     MONTHS
35-40                >10% LOSS, USE
        AGGRESSIVE   MEDS AT START

                        SPECIALIST,
        VERY
>40     AGGRESSIVE
                        CONSIDER
                        SURGERY
AMERICAN BOARD OF
BARIATRIC MEDICINE
              WHAT IS MY ROLE?
   IDENTIFY OVERWEIGHT AND OBESE
   PROVIDE INFORMATION
       HEALTH CONSEQUENCES
       NUTRITIONAL INFORMATION
       EXERCISE PRESCRIPTIONS
   PHARMACOLOGICAL THERAPY
       DRUGS DO NOT CURE OBESITY
       MAXIMUM TIME OF STUDY IS 2 YEARS
            SIBUTRAMINE (WITHDRAWN)
   REFERAL TO SPECIALIST/SURGEON
            PATIENT HANDOUTS
   HTTP://FAMILYDOCTOR.ORG/NURTITION
       NUTRITION
           HOW TO READ LABELS
           DETERMINE YOUR CALORIE NEEDS
           MAKE HEALTHIER FOOD CHOICES
           KEEPING A FOOD DIARY
       WEIGHT LOSS
           IS A LOW CARB DIET RIGHT FOR ME?
           FAD DIETS
           WHAT IT TAKES TO LOSE WEIGHT
           CHOOSING THE RIGHT DIET
BE A ROLE MODEL

“The most important thing family
physicians can do is to model
healthy behaviors for their patients.”
— AAFP Panel on Obesity
         IDEAS TO REMEMBER
   NOTHING GOOD COMES FROM BEING OBESE
   CALORIES IN VERSUS CALORIES OUT
       DECREASE INTAKE
       INCREASE EXPENDITURE
   USE OF MEDICATIONS BASED ON:
       BMI
       COMORBIDITIES
   CONSIDER PSYCHOLOGICAL ASSISTANCE
       OVER-EATERS ANONYMOUS
       GROUP MEETINGS
         IDEAS TO REMEMBER
   BE A ROLE MODEL FOR GOOD HEALTH
       YOU ARE A ROLE MODEL REGARDLESS
                    SOURCES
   AMERICAN BOARD OF BARIATRIC MEDICINE AS
    ACCESSED FEBRUARY 7, 2011.
    http://abbmcertification.org/bariatric_physicians.php
   Berrington de Gonzalez A et al. Body-Mass Index and
    Mortality among 1.46 Million White Adults. N Engl J Med
    2010;363:2211-2219
   BRAY, GEORGE. OVERVIEW OF THERAPY FOR OBESITY
    IN ADULTS. WWW.UPTODATE.COM AS ACCESSED
    APRIL 1, 2008.
   BRAY, GEORGE. HEALTH HAZARDS ASSOCIATED WITH
    OBESITY IN ADULTS. WWW.UPTODATE.COM AS
    ACCESSED APRIL 1, 2008.
                   SOURCES
   BRAY, GEORGE. DRUG THERAPY OF
    OBESITY. WWW.UPTODATE.COM AS
    ACCESSED APRIL 1, 2008.
   Dietary Guidelines for Americans,
    2005.USDA. As accessed April 8, 2008
       http://www.health.gov/dietaryguidelines/dga2
        005/document/pdf/DGA2005.pdf
              SOURCES
   DEEN, DARWIN. METABOLIC SYNDROME:
    TIME FOR ACTION. AAFP. 69(12): 2731-
    2942. JUNE 15, 2004.
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