The Obesity Explosion: How Did We Get Here and Where Are We At?

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The Obesity Explosion:

How Did We Get Here and Where Are We At?

Donald D. Hensrud, M.D., M.P.H.

Chair, Division of Preventive, Occupational, and Aerospace Medicine

Associate Professor of Preventive Medicine and Nutrition

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Disclosure

Relevant financial relationships

• None

Off label usage

• None

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Learning Objective

• Describe background information on obesity including

• Classification

• Prevalence and trends

• Contributing factors

• Health complications

• Treatment

• Diet

• Physical activity

• Behavior change

• Medications

• Surgery

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Obesity

Obesity (def) - an excess of body fat resulting in

adverse health effects

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Obesity,

Risk Assessment and Classification

Adapted from Clinical guidelines on Obesity. National Heart, Lung, and Blood Institute Web site.

Available at: http://www.nhlbi.nih.gov/guidelines/obesity/ob_home.htm

Disease Risk Relative to Normal Weight and Waist Circumference

Men 40 in Men >40in Category BMI, kg/m

²

Women 35 in Women >35 in

Underweight <18.5 – –

Normal* 18.5-24.9 – –

Overweight 25.0-29.99 Increased High

Obesity 30.0-39.9 High Very high

35.0-39.9 Very high Very high Extreme obesity 40 Extremely high Extremely high

* An increased waist circumference can denote increased disease risk even

in persons of normal weight

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Obesity Trends Among U.S. Adults BRFSS, 1990

No Data <10% 10%–14%

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Obesity Trends Among U.S. Adults BRFSS, 2000

No Data <10% 10%–14 15%–19% ≥20%

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Obesity Trends Among U.S. Adults BRFSS, 2010

No Data <10% 10%–14 15%–19% 20%–24% 25%–29% ≥30%

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Global Obesity

• Obesity around the world has doubled since 1980

• Overweight and obesity are linked to more deaths worldwide than underweight

• Overweight and obesity are the fifth leading risk for global deaths

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Prevalence of Overweight and Obesity, NHANES 2009-2010

All (%) Men (%) Women (%)

 Overweight 68.8 73.9 63.7

Obese 35.7 35.5 35.8

Extreme obese 6.3 4.4 8.1

JAMA 2012;307:491

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Prevalence of Overweight and Obesity, NHANES 2009-2010

JAMA 2012;307:491 All White Black Hispanic White Black Hispanic

Overweight

33.1 37.8 31.1 44.7 27.3 23.6 34.3 BMI 25-29.9

Obese

35.7 36.2 38.8 37.0 32.2 58.5 41.4

BMI 30

Extreme obese

6.3 4.2 7.4 4.1 7.1 17.8 6.0 BMI 40

Men Women

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Obesity, Health Complications

• Type 2 Diabetes Mellitus

• Hypertension

• Dyslipidemia

• High triglycerides

• Low HDL cholesterol

• Small, dense LDL cholesterol

• Coronary artery disease

• Stroke

• Overall mortality

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Obesity, Health Complications

• Most cancers

• Respiratory diseases

• Obstructive sleep apnea

• Restrictive lung disease

• Obesity hypoventilation syndrome

• Asthma

• Osteoarthritis

• Cholelithiasis

• Gastroesophageal reflux disease (GERD)

• Nonalcoholic fatty liver disease (NAFLD)

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Obesity, Health Complications

• Gynecologic abnormalities

• Abnormal menses

• Infertility

• Polycystic ovarian syndrome

• Venous stasis

• Skin problems

• Intertrigo

• Cellulitis

• Increased risk of complications during surgery

or pregnancy

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Societal Cost of Overweight and Obesity

Data from Dor A et al:George Wash Univ, 2010 and

1Health Affairs 2009;28:w822; ²Int J Obes 2005;29:334

3Obes 2008;16:2323; ⁴National Bureau of Economic Research, 2010

Study Year Overweight Obesity

Finkelstein ¹ 1998 76.5

Arterburn ² 2000 24.8 55.9

Wang ³ 2000 27.4-29.7 76.6-87.7

Finkelstein ¹ 2008 151.7 (147)

Cawley ⁴ 2010 168.4

Cost in $ billions/yr*

*2009 dollars

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Individual Yearly Costs of Obesity

Men, $ Women, $

Overweight 432 524

Obese 2,646 4,879

Obese + VLL 6,518 8,365

(value of life lost)

Dor A et al: George Wash Univ, 2010

• Direct and indirect costs (disability, decreased productivity, absenteeism, etc.)

• Direct medical costs largest % for overweight

• Lost wages largest % for obese women

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Obesity Costs, Who Pays?

• Medicare and Medicaid pay about half of all costs ¹

• Business paid an estimated $12.7 billion in 1994 (5% of total medical care costs) ²

• Cost of obesity among full-time employees estimated to be $73 billion in 2006-2008 in a recent study ³

1Health Affairs 2009;28:w822; ²Am J Health Prom 1998;13:120

3J Occup Environ Med 2010;52:971

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Pathogenesis of Obesity

• Genetics vs. environment

• 30% - 40% of variance related to genetics

• Environment

• Diet/energy intake

• Physical activity

• Exercise

• Daily activities

• Individual factors

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Management Plan

• Diet

• Physical activity

• Exercise

• Daily activities

• Behavior change

• Medications

• Surgery

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*Use the assessment and history to tailor the plan

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Individualized Weight Loss

• Hundreds of different influences

• Diet

• Physical activity

• Behavior

• Everyone has different obstacles

• Everyone’s plan should have tailored strategies

• Mayo Clinic Diet – Action Guide

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Weight Loss, Diet

• Diet

• There is no one best diet

• Tailor the dietary program to the individual

• Minimum dietary standards

• Sound scientific rationale

• Safe and nutritionally adequate

• Practical and effective long-term

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Dietary Therapy, AHA/ACC/TOS Recommendations

• Calorie deficit of 500 - 750 kcal/day

• Promotes weight loss of 1 - 2 pounds/week

• Low CD

• 1,200 - 1,500 kcal/day for women

• 1,500 - 1,800 kcal/day for men

• Choose a diet based on patient preferences

• 3-5% weight loss leads to clinical benefit

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Weight Loss, Different Macronutrient Composition

• 811 overweight adults, 2 years

• Group and individual instructions

• 4 reduced calorie diets:

NEJM 2009;360:859

Fat Protein Carbohydrates

20 15 65

20 25 55

40 15 45

40 25 35

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Weight Loss, Different Macronutrient Composition

-7 -6 -5 -4 -3 -2 -1 0

0 6 12 18 24

W ei ght lo ss (k g)

Months

NEJM 2009;360:859

65/15/20%

55/25/20%

45/15/40%

35/25/40%

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Weight Loss, Different Macronutrient Composition

• 80% completed 2 years

• Most weight loss occurred by 6 months (6 kg)

• No significant differences among groups in weight loss or cardiovascular risk factors

• Mean weight loss among all participants 4 kg at 2 years

• Attendance at group sessions was strongly associated with weight loss

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Methods of Calorie Restriction

• Counting calories

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Discrepancy Between Reported and Actual Energy Intake and Expenditure

0 500 1,000 1,500 2,000 2,500 3,000

Reported Actual Reported Actual

*

Lichtman et al: N Engl J Med 1992;327:1893

kc al /d

Energy Intake Energy Expenditure

*P<0.05 vs reported

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Methods of Calorie Restriction

• Counting calories

• Counting fat grams

• Point system

• Exchange system

• Moderation of portion size, types of foods, etc.

• Very-low calorie diets

• Liquid meal replacements

• Energy density

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Fruits & Vegetables and Weight Gain

• 74,000 females followed for 12 years in the Nurses’ Health Study

• Those with the largest increase in intake of

fruits and vegetables had a 24% decreased risk of becoming obese

Int J Obes 2004;28:269

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Dietary Changes and Weight Changes

Dietary Change Weight Change, lb

Potato chips 1.69

Potatoes 1.28

Sugar-sweetened drinks 1.00

Unprocessed red meat 0.95

Processed meat 0.93

Vegetables -0.22

Whole grains -0.37

Fruits -0.49

Nuts -0.57

Yogurt -0.82

NEJM 2011;364:25

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Mayo Clinic Healthy Weight Pyramid

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Determinants of What We Eat

Objective

• Evidence from scientific studies

Subjective

• Cost

• Convenience

• Time

• Food availability

• What we grew up eating

• Taste preferences

• Marketing

• Ethnicity

• Social influences

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Healthful Dietary Change

• Attitude

• People underestimate their ability to change

• Eating healthy vs. eating well

• Lifestyle

• Practical

• Palatable

• Promote satiety

• Low in calories

• Healthy

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Physical Activity, Recommendations

• 150 min/week of moderate-intensity physical activity (e.g., brisk walking)

• 75 min/week of vigorous intensity physical activity (e.g., jogging or running)

• To effectively lose or maintain weight, may need 300 min/week of moderate-intensity physical

activity

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http://www.cdc.gov/physicalactivity/everyone/guidelines/adults.html

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Exercise

• Exercise vs daily activities

• Pick an exercise that:

• Is enjoyable

• Can be performed regularly

• Can be continued indefinitely

• Frequency, duration, intensity

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Obesity, Fitness, and Mortality

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Lee CD: AM J Clin Nutr 1999; 69:373 0.0

0.5 1.0 1.5 2.0 2.5

Lean Normal Obese

Adj us ted RR

Body Fat (%)

Fit Unfit

(<16.7) (>25)

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Daily Activities

• Human nature - conserve energy and decrease activity

• Years ago – survival advantage

• Now – shortens survival

• Different mindset – look for opportunities to obtain increased activity

• Burn calories

• Feel better

• Improve health

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Daily Activities

• Take the long way around

• Choose outdoor vacations/activities

• Avoid using children to do tasks (don’t let them get all the benefits)

• Walk whenever you can

• Stairs, park farther away

• Around the office

• Airports (don’t use the moving walkway)

• Consider a pedometer

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Television Time and Health

• Each 2 hours of TV time increases the risk of:

• Type 2 diabetes by 20%

• Cardiovascular disease by 15%

• All-cause mortality by 13%

• Studies reported similar results after controlling for exercise

JAMA 2011;305:2448

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Weight Loss Strategies

• Determine general goals (health, weight, etc.)

• Determine obstacles and tailor the approach to address obstacles

• Have specific plans, and plan ahead

• Provide suggestions and motivation

• Provide educational information (online, print, etc.)

• Consider commercial programs for

partnering/follow-up (weight, coaching)

• Individualize the plan

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Weight Loss Strategies

• Diet tracking (e.g., sparkpeople.com, myfitnesspal.com, Livestrong.com)

• Physical activity tracking (e.g., Fitbit, Omron, Gruve)

• Focus on the process (lifestyle change) and health, not the outcome (pounds)

• Use process goals - SMART

• The process can be enjoyable!

• Expect lapses – problem solving

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Weight Loss, Systematic Strategies

• Stepped-care approach

• Lifestyle counseling in primary care

• Remote treatment

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Stepped-Care Approach for Obesity

• 363 overweight and obese adults

• 18 months

• 72% follow-up

• Randomized to standard behavior therapy vs.

stepped-care

• Counseling frequency, type, and weight loss strategies modified every 3 months with

increasing intensity if goals are not made

• Weight loss: -7.5 kg std. vs. -6.3 kg stepped-care

• Cost: $1,357 std. vs. $785 stepped-care

JAMA 2012:307:2617

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Lifestyle Counseling in Primary Care Treatment of Obesity

• 390 obese adults

• 2 years

• 86% follow-up

• Randomized to:

• Usual care – quarterly visits and education

• Brief lifestyle counseling with coaches

• Enhanced lifestyle counseling (meal replacements or medications)

• Weight loss: -1.7 kg, -2.9 kg, -4.6 kg, respectively

NEJM 2011;365:1969

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In-Person vs Remote Treatment of Obesity

• 415 obese adults

• 2 years, 95% follow-up

• Randomized to in-person vs. remote intervention vs. control

• Intervention

• Coaches (in-person vs telephone)

• Web-based support

• Weight loss: -0.8 kg control, -4.6 kg remote, -5.1 in-person

NEJM 2011;365:1959

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Weight Loss Medications

• Orlistat

• Phentermine

• Qsymia (phentermine/topiramate)

• Belviq (lorcaserin)

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