ob itobesity: causes, consequencess & treatments & …gout ations of obesity idiopathic...

Ob itObesity: ConsequencesConsequences

Gary D. Foy

Center for ObesEduc

Temple University

C Causes, s & Treatments & Treatment

oster, Ph.D.

ity Research and cationSchool of Medicine

OvervOverv

1. Discriminat2 P l2. Prevalence3. Consequenq4. Treatment5 Expectation5. Expectation

viewview

tionences

nsns

Obesity Trends* ABRFSSBRFSS

(*BMI ≥30, or ~ 30 lbs. ov

No Data <10% 10%–14%

Among U.S. AdultsS 1985S, 1985

erweight for 5’ 4” person)


(*BMI ≥30, or ~ 30 lbs. ov

No Data <10% 10%–14%




(*BMI ≥30, or ~ 30 lbs. ov

No Data <10% 10%–14% 15%–19%




(*BMI ≥30, or ~ 30 lbs. ov

No Data <10% 10%–14% 15%–19% ≥20%



%


(*BMI ≥30, or ~ 30 lbs. ov

No Data <10% 10%–14% 15%–19% 20%



–24% ≥25%

Obesity Trends* ABRFSS

(*BMI ≥30, or ~ 30 lbs. ov

BRFSS

No Data <10% 10%–14% 15%–19% 20%

Among U.S. AdultsS 2002


S, 2002

–24% ≥25%


(*BMI ≥30, or ~ 30 lbs. ov

No Data <10% 10%–14% 15%–19% 20%



–24% ≥25%


(*BMI ≥30, or ~ 30 lbs. ov

No Data <10% 10%–14% 15%–19% 20%



–24% 25%–29% ≥30%

Medical ComplicPulmonary diseasePulmonary diseaseabnormal functionabnormal functionobstructive sleep apneaobstructive sleep apneahypoventilation syndromehypoventilation syndrome

p

hypoventilation syndromehypoventilation syndrome

Nonalcoholic fatty liver Nonalcoholic fatty liver diseasediseasesteatosissteatosissteatosissteatosissteatohepatitissteatohepatitiscirrhosiscirrhosis

G ll bl dd diG ll bl dd di

Gynecologic abnormalitiesGynecologic abnormalitiesabnormal mensesabnormal mensesinfertilityinfertility

Gall bladder diseaseGall bladder disease

infertilityinfertilitypolycystic ovarian syndromepolycystic ovarian syndrome

OsteoarthritisOsteoarthritis

SkinSkin

GoutGout

cations of ObesityyIdiopathic intracranial Idiopathic intracranial hypertensionhypertension

StrokeStroke

Coronary heart diseaseCoronary heart diseaseDiabetesDiabetes

CataractsCataracts

DyslipidemiaDyslipidemiaHypertensionHypertension

Severe pancreatitisSevere pancreatitis

CancerCancerbreast, uterus, cervixbreast, uterus, cervixcolon esophagus pancreascolon esophagus pancreas

Severe pancreatitisSevere pancreatitis

colon, esophagus, pancreascolon, esophagus, pancreaskidney, prostatekidney, prostate

PhlebitisPhlebitisvenous stasisvenous stasis

Direct Cost* of Chthe United Sthe United S

80$71.4$83.3

60

70

ns $

)*

$

50

Cos

t (B

illio

n

30

40

Dire

ct C

Type 2 Diabetes

Obesity CHe

11 ADA Diabetes Care, 2003;26:917 ADA Diabetes Care, 2003;26:917 44. . Hodgson TA Hodgson TA 22 Finkelstein EA, Obes Res 2004;12Finkelstein EA, Obes Res 2004;12 55 Yelin & CallahYelin & Callah33 Hodgeson TA et al.Hodgeson TA et al. Medical Care 1999:37:994.Medical Care 1999:37:994.

hronic Diseases in States (2006)States (2006)

$59.2

$31.9 $27.0

Coronaryart Disease

Hypertension Arthritis

A et al. Med Care 2001;39:599A et al. Med Care 2001;39:599han. Arthritis Rheum 1995;38:1351han. Arthritis Rheum 1995;38:1351

Who is Paying and Paid for OverweiPaid for Overwei

•Annua•Ovwt

•Insurance Category

8

•7•Ovwt

P i t

•Out-of-Pocket

•8

•8

•Medicaid

•Private

•1•Medicare

•9•Total

How Much is being ight and Obesity?ight and Obesity?al Cost (%) & Obesity

•Amount ($ billions) Ovwt

8 2%

7.3%& Obesity

$19 8

•$7.1($,billions) Ovwt

& Obesity

8.8%

8.2%

•$3.7

•$19.8

1.1% •$20.9

9.1% •$51.5

Finkelstein et al. Health Affairs.May 2003:219

Obesity’s Growing Prevaare Impacting Private Heare Impacting Private He

••Percent of Obese Adults•Spending Attributable to

• Spending per member (dollar

Spending Attributable to Obesity

• Private insurance spending (billions, USD)

• % of private insurance spendin

Thorpe, KE et al. Health Affairs, 2005;W5-317-325:

alence & Treatment Costs ealth Insurance Spendingealth Insurance Spending

•2002•1987•23.83•12.6120021987

•1,244•272s)

•36.5•3.6

•11.6•2.0ng

–Major Cost Dri–PrevalenceS i–Severity

–AgingAging–Each Unit IncrAssociated witin Health Carein Health Care

1. Raebel MA, et al. Arch Intern Med 2004;164:2135-2140

ivers of Obesity are:

rease in BMI is th a 2.3% Increase

e Costs 1e Costs.1

Obesity is Ass

Mean Annual WGreater Loss in

Men

5.355.18 5.5

Healthy Weight OvHealthy Weight Ov

sociated with a

Work Days Lostn Productivity

8.82Women

5.856.22

verweight Obese

Thompson, D.et al. Am J Health Promot 1998;12:120-127

verweight Obese

Percent UnabAnd, Greater Ra

Men

5.65.9

4 7 5.64.7

Healthy Weight OvHealthy Weight Ov

le to Workates of Disability

9.612.6

Women

7.9

verweight Obese

Thompson, D.et al. Am J Health Promot 1998;12:120-127

verweight Obese

Behaviora

•Dietary iny•Physical y

al Factors

ntakeactivityy

Environmen• MarketingMarketing

–Bigger packages, muquantity limitsquantity limits

–Bigger equals cheap»“Supersize”»22 oz soda for $2.$$3.00

–All-you-can-eat buffeAll you can eat buffe

ntal Factors

ultiple unit pricing,

per

50 versus 44 oz for

etsets

EnergyEnergy personal computersp pcellular phonesshopping by phones opp g by p o ephone extensionsescalators/elevatorsescalators/elevatorsdrive-thru windowsintercomsintercomsremote controls

SaversSaverstele-commutingge-mail/Internet food delivery servicesood de ve y se v cesdishwasherscable moviescable moviescomputer gamesmoving sidewalksmoving sidewalksgarage door openers

Obesity TryGuidel

The Practical GuideThe Practical Guidecan be found at:can be found at:can be found at:can be found at:

NHLBI web site:www.nhlbi.nih.gov

The Obesity Society y yweb site:www.obesity.org

reatment lines

Guide for Selecting

BMI CBMI C

Treatment 25-26.9 27-29.9

Diet, Exercise, B h i T + +Behavior Tx + +Pharmaco-th

With cobidittherapy morbidit

SurgerySurgery

The Practical Guide: Identification, Evaluation, andObesity in Adults. October 2000, NIH Pub. No.00-4

g Obesity Treatment

Category (kg/mCategory (kg/m22))

9 30-34.9 35-39.9 >40

+ + ++ + +o-i + + +ies + + +

With co-biditi +morbidities +

Treatment of Overweight and 4084

Self-Monitorin

• Types of foodsyp• Portion sizes• Calories (redu• Times places• Times, places• Thoughts and g

ng Food Intakeg

s

ce by 500 kcal/d)and activities, and activities

moods

Changes in BChanges in B4

0

2

t (kg

)

4

-2

n W

eigh

t

-6

-4

Cha

nge

in

-80 0.5 1 1.5 2

C

YeaDiabetes Preventio

Body WeightBody Weight

PlaceboPlacebo

Metformin

Lif lLifestyle

2.5 3 3.5 4

aron Program Research Group. N Engl J Med 2002;346,393-403

Diabetes Preve40

30

denc

e%

)

20

ativ

e In

cid

iabe

tes

(%

10Cum

ula

of D

i

00 0.5 1.0 1.5 2.0

Diabetes Prevention Program Research Group. N E

Ye

ention ProgramgPlacebo

MetforminMetformin

Lifestyle

2.5 3.0 3.5 4.0

Engl J Med. 2002;346,393-403.

ar

Portion-ContPortion Cont

• Provide fixed-portion• Reduce choices and c

f dfoods• Are convenient to us• Satisfy appetite (mon

ifi i )specific satiety)• Facilitate dietary adhFacilitate dietary adh

trolled Mealstrolled Meals

n and calorie amountscontact with problem

senotony and sensory

herenceherence

Meal Replacements Long term WLong-term W

Phase 1*

0

Phase 1

t Los

s CF

5

MR-2age

Wei

ght

15

10

Perc

enta

*1200–1500 kcal/d diet prescription.CF=conventional foods.

15

T0 2 4 6 8 10

MR-2=replacements for 2 meals, 2 snacks daily.MR-1=replacements for 1 meal, 1 snack daily.

Enhance Initial and Weight LossWeight Loss

Phase 2Phase 2

MR-1

Time (mo)12 18 24 30 36 45 51

Ditschuneit et al. Am J Clin Nutr 1999;69:198.Fletchner-Mors et al. Obes Res 2000;8:399.

The Dieter’s Dilemma

Calories oCalories o• N: 43

W k 6 (i ti• Weeks: 6 (inpati• Diets: Isocalori

(15% vs.• Weight Loss: 8 9 + 0• Weight Loss: 8.9 + 0.

or Carbs?or Carbs?

t)ent) ic (1000 kcal/d) ( ). 45% CHO) 6 kg 7 5 + 0 5 kg6 kg 7.5 + 0.5 kg

Golay. IJO, 1996.

Weight Loss –g

1

-3-1

e

9-7-5

Cha

nge

*

-13-11-9%

C

**

-15

hm ster

aha

*

Breh

Foste

Samah

Y

*

– 6 Months

LowLow-CarbohydrateLow-Calorie

ncy

*

Yanc

Weigh1 Y

0

3-2-10

6-5-4-3

hang

e

9-8-7-6

% C

h

-11-10-9

-12Foster Stern Dan

ht LossYear

Low-CarbLow-Cal

Foster et al. NEJM, 2003.,

Stern et al Ann Intern Med, 2004,

nsingerDansinger et al. JAMA 2005

Lip1 Year C1 Year C

1520 *

05

10

-15-10-5

Cha

nge

-30-25-20%

Choles

terol

LDL

HDL

Total

Ch

pidsChangesChanges

Low-Carb FosterLow-Cal FosterLow Carb-SternLow Cal-Stern

*

*

*

*

iglyc

eride

s *

Trig

Foster et al. NEJM, 2003., Stern et al Ann Intern Med, 2004

Antiobesity AgenWorkWork

ReleasingAgent

5-HT NE DA

Agents

Dexamphetamine

Phentermine

5-HT NE DA

+++

+++

++

++Sibutramine

Orlistat

1Bray GA Ann Intern Med 1993;119(7 pt 2):707 2Beales PL Kopelma

5-HT = serotonin; NE = noradrenaline; DA

1Bray GA. Ann Intern Med. 1993;119(7 pt 2):707. 2Beales PL, Kopelma3Buckett WR et al. Prog Neuropsychopharmacol Biol Psychiatry. 1988;14Drent ML et al. Int J Obes Relat Metab Disord. 1995;19:221. 5Heal DJ

nts: How They kk

Selective

A

ReuptakeInhibitor

5-HT NE DA

SelectiveLipase

Inhibitor

A

++

++

5-HT NE DA

+++

+++

+++ +

an PG PharmacoEconomics 1994;5(suppl 1):18

A = dopamine

an PG. PharmacoEconomics. 1994;5(suppl 1):18. 12:575. J et al. Psychopharmacology (Berl). 1992;107:303.

Drugs ApproveTreatingTreating

Status Gene

Rx Sibu

Status Gene

Rx OrlRx Orl

OTC OrOTC Or

(Approved 2/07)

Approved in Europe Ri

but not U.S.

ed by FDA for ObesityObesity

eric Name Trade Name

utramine Meridia

eric Name Trade Name

istat Xenicalistat Xenical

rlistat 60mg allirlistat 60mg alli

imonabant Acomplia/Zimulti

STORM

230 Weight Loss230

(lb)

225

220

210y W

eigh

t ( 220

215

Bod

y

205

200

1950 2 4 6 8 10

Adapted with permission from James WPT et al. Lancet. 2000;356:2

*Same diet, exercise for sibutramine, placebo;P 0.001, sibutramine vs placebo for weight mainten

M Trial

Weight Maintenance

Placebo

Sib t i

12 14 16 18 20 22 24Month

Sibutramine

2119.

nance

STORM: ChangeBaseline to 24 MonBaseline to 24 Mon

Treatmen

SibBP, mm Hg

SystolicDiastolic

Pulse rate (bpm)

James WPT et al. Lancet. 2000;356:2119.

e in Vital Signs—nths in Sibutraminenths in Sibutramine nt Group

Mean Changebutramine Placebo

0.1 –4.72.3 –1.64.1 –1.9

STORM: Safety % f P ti t R% of Patients R

Weight Loss Phas(n=605)

Infection 14Flu syndrome 7Headache 23Increased appetite 4Pharyngitis 7Dry mouth 39Constipation 19Asthenia 6Insomnia 12

*Frequency of 10% in any treatment group; reporteJames WPT et al. Lancet. 2000;356:2119.

and Tolerability—R ti AE *Reporting AEs*

Weight Maintenance PhaseWeight Maintenance Phasese Placebo Sibutramine

(n=115) (n=352)22 2210 1418 1412 1413 133 94 911 73 8

ed as therapy-related

Orlistat: Weight LosO 2 YOver 2 Y

0–1 Placeb

Orlista–2–3–4–5ei

ght (

%)

P<0.001 vs

Orlista

5–6–7–8–9in

Bod

y W

e

–9–10–11–12C

hang

e

SB DB

–10 0 10 20 30 40

W

Adapted with permission from Sjöström L et al. Lancet. 1998;352:167

Slightlyhypocaloric diet

SB = single blind; DB = double blind

s and Maintenance YYearsboat

s placebo at 1 and 2 years

at

DB

50 60 70 80 90 110100

Week

7.

Weightmaintenance

(eucaloric) diet

Orlistat: Safety—Aat 1at 1

40Pla

30Orl

Pla

31%

20%

20%

105%

7%

0Fatty/Oily

StoolIncreasedDefecation

Sjöström L et al. Lancet. 1998;352:167.

• There is concern about fat-soluble vitamin absorp

Adverse Events (AEs) YearYear

acebo n=340

listat, n=343

acebo, n 340

18%

1%3%

10%7%

OilySpotting

FecalUrgency

FecalIncontinence

1% 0%

ption

Use OTC

alli vs. XUse OTC

Dosage 60 mg

Target Pop Overweight

Indication Weight Loss

A R 18Age Range 18+

GI AEs(withdrawal rates) 3 2(withdrawal rates) 3.2

Behavioral myalliplan.com S t PSupport Program

Rx

XenicalRx

120 mg

BMI > 27 kg/m2 or > 30kg/m2

(w/ co-morbidities) or (without)

Weight Loss & Maintenance

1212+

5 45.4

Xenicare

Goals for WGoals for W

“The initial goal of weoverweight patients isoverweight patients isweight of about 10%…of this magnitude canof this magnitude canthe severity of obesity-as

Weight LossWeight Loss

eight loss therapy fora reduction in bodya reduction in body

…moderate weight losssignificantly decreasesignificantly decreasessociated risk factors.”

NHLBI, 1998

Subject Chaj

60 obese women160 obese women1

40.0 + 8.7 years

99.1 + 12.3 kg

BMI = 36.3 + 4.3 kg/m2

aracteristics

397 obese individuals2397 obese individuals354 women43 men

43.1 + 10.9 years

109.0 + 28.9 kg

BMI = 39.3 + 9.5 kg/m2

1Foster et al. JCCP 65(1) 79-85 19972Foster et al Arch Int Med. 161 2133-2139 2001

Goal WGoal W• Averaged 32% reductig• Three times greater th

d d b h Nrecommended by the NScience and Departmep

• Greatly exceeds weightreatments

WeightsWeightsion in body weighty g

han the goals N i l A d fNational Academy of ent of Agricultureght losses of nonsurgical

Defined W

Dream WeightA weight you would choose if

wanted.

Happy WeightThis weight is not as ideal as

however, that you would be happy to

Acceptable WeightA weight that you would not b

that you could accept, since it is less

Disappointed WeightA weight that is less than you

could not view as successful in any wcould not view as successful in any wthis were your final weight after the p

Fo

Weights

you could weigh whatever you

the first one. It is a weight, o achieve.

be particularly happy with, but one s than your current weight.

r current weight, but one that you way. You would be disappointed ifway. You would be disappointed if program.

oster et al, J Consult Clin Psychol, 1997

Defined W

19971997% Reduc

Dream 38%Dream 38%Happy 31%Acceptable 25Acceptable 25Disappointed 17%

1Foster et al. JCCP 65(1) 79-85 19972Foster et al Arch Int Med. 161 2133-2

Weights

7 20017 2001ction1 % Reduction2

% 38 4%% 38.4%% 30.9%% 24 9%% 24.9%% 15.7%

2139 2001

% Achieving Defined WW i ht lWeight loss:

Acceptable

24%24%

420%Disappointed 4

F

Weights at Week 48 (N=45)16 3 + 7 2 k: 16.3 + 7.2 kg

HappyHappy

D 0%9%

Dream = 0%

Did not reach47% Did not reach Disappointed Weight

47%

Foster et al, J Consult Clin Psychol, 1997.

Principles anp• Simplicityp y

– EngagementE ll– Enrollment

– Implementation p• Structure

– Duration – IntakeIntake–Activity

nd Practices

Principles anp• Accountabilityy

EmployeesE lEmployers

• IncentivesEnrollmentParticipation/SuccessParticipation/Success

nd Practices

Principles anp• Expectationsp

– Weight– Non-weightNon weight– Fees

nd Practices

ob itobesity: causes, consequencess & treatments & …gout ations of obesity idiopathic...

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