overview of the obesity epidemic
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Speaker notes included in notes section below. Overview of the Obesity Epidemic. Obese (BMI ≥ 30) Overweight (BMI 25 - 29.9). More than 60% of US Adults Are Overweight or Obese. - PowerPoint PPT PresentationTRANSCRIPT
Overview of the Obesity Epidemic
Speaker notes included in notes section below
More than 60% of US Adults Are Overweight or Obese
Flegal K, et al. JAMA. 2002;288:1723-1727. Hedley AA, et al. JAMA. 2004;291:2847-2850.
Obese (BMI ≥ 30)
Overweight (BMI 25 - 29.9)
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. 1998;6(suppl 2):51S.Willett WC et al. N Engl J Med. 1999;341:427.
Category BMI
Underweight < 18.5
Normal* 18.5 – 24.9
Overweight 25.0 – 29.9
Obesity ≥ 30.0
Class I 30.0 – 34.9
Class II 35.0 – 39.9
Class III ≥ 40.0
Obesity Trends by Gender and Ethnicity
28 29 29
0
10
20
30
40
50
60
White Men Black Men Mexican Men
Pre
vale
nce
of O
besi
ty
.
31
51
40
0
10
20
30
40
50
60
WhiteWomen
Black Women MexicanWomen
Pre
vale
nce
of O
besi
ty
.
Men Women
Flegal K, et al. JAMA 2002;288:1723-1727.
0
2
4
6
8
10
12
14
16
18
NHES II &III1963-70
NHANES I1971-74
NHANES II1976-80
NHANES III1988-94
NHANES1999-2002
Pre
vale
nce
of O
verw
eig
ht
.
Aged 6-11 years Aged 12-19 years
Prevalence of Overweight in Children and Adolescents
Flegal K, et al. JAMA 2002;288:1723-1727. Hedley AA, et al. JAMA 2004;291:2847-2850.
BMI-for-Age Cutoffs for Children and Adolescents
≥ 95th percentile Overweight
85th to < 95th percentile Risk of overweight
< 5th percentile Underweight
Example: 95th Percentile Tracking
Age BMI
2 yrs 19.3 4 yrs 17.8 9 yrs 21.013 yrs 25.1
For Children, BMI Changes with Age
Boys: 2 to 20 years
BMI BMI
BMI BMI
Obesity is Caused by Long-Term Positive Energy Balance
Fatstores
Energyintake
Energyexpenditure
Heritability of Body Weight
Obesity Genetics vs Environment
Restrictiveenvironment
Resistant Prone
“Obesigenic”environment
Obesity Predisposition
BM
I
Ravussin E, Bouchard C. Eur J Pharmacol. 2000;410:131-145.
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
16 oz 32 oz 44 oz 52 oz 64 oz
1 oz ≈ 12 calories
20%
43%
70%
80%
0
10
20
30
40
50
60
70
80
90
1969 1979 1989 1999
American Academy of Pediatrics.
% of Children withDaily Physical Education
0
5
10
15
20
25
30
35
40
TV hours per day (youth report)
Pre
vale
nce
(%)
NHES 1967-1970
NLSY 1990
0 - 1 1 - 2 2 - 3 3 - 4 4 - 5 > 5
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
Medical Complications of Obesity
Pulmonary diseaseabnormal functionobstructive sleep apneahypoventilation syndrome
Nonalcoholic fatty liver diseasesteatosissteatohepatitiscirrhosis
Coronary heart disease Diabetes Dyslipidemia Hypertension
Gynecologic abnormalitiesabnormal mensesinfertilitypolycystic ovarian syndrome
Osteoarthritis
Skin
Gall bladder disease
Cancerbreast, uterus, cervixcolon, esophagus, pancreaskidney, prostate
Phlebitisvenous stasis
Gout
Medical Complications of ObesityIdiopathic intracranial hypertension
Stroke
Cataracts
Severe pancreatitis
Excess fat stores
GenesEnvironment
Activity Food Intake
Diseases due to increased fat cellsize & visceral fat
Stigma
Sleep apnea
OsteoarthritisDiabetes
GB Disease
NAFLD CVD
Cancer
Diseases due to increased fat
mass
Pathogenesis of Health Problems Associated with Obesity
0
0.5
1
1.5
2
2.5
3
< 1
8.5
18.5
- 2
0.4
20.5
- 2
1.9
22.0
- 2
3.4
23.5
- 2
4.9
25.0
- 2
6.4
26.5
- 2
7.9
28.0
- 2
9.9
30.0
- 3
1.9
32.0
- 3
4.9
35.0
- 3
9.9
> 4
0.0
Body Mass Index Interval
Re
lative
Ris
k o
f D
ea
th
White Men
White Women
BMI and Mortality by Ethnic Group The American Cancer Society Study
Calle NEJM 1999;341:1097.
Relative Risk of Death by BMI Levels from the NHANES I, II, & III Surveys
BMI Level Relative Risk by Age Category
25-59 60-69 ≥ 70
< 18.5 1.38 2.30 1.69
18.5 to < 25 1.00 1.00 1.00
25 to < 30 0.83 0.95 0.91
30 to < 35 1.20 1.13 1.03
≥ 35 1.83 1.63 1.17
Flegal et al JAMA;2005:1861
Range of Estimates of Mortality Associated with Overweight
Author YearEstimated excess
deaths
Foege & McGinnis 1993 300,000
Fontaine et al 1999275,000 to
325,000
Mokdad et al 2004 365,000
Flegal et al NHANES I
2005 112,000
Overweight*(BMI 25 - 29.9)
Obese*(BMI > 30)
Female (non-smoker, 40 years of age) 3.29 y 7.08 y
Male (non-smoker, 40 year of age) 3.05 y 5.82 y
Obesity Decreases Life Expectancy:The Framingham Study
Peeters Ann Int Med 2003;138:24-32.
* Compared to a BMI 18.5-24.9 kg/m2
Proportion of Disease Prevalence Attributable to Obesity
Type 2 Diabetes 57%
Gall bladder disease 30%
Hypertension 17%
Cardiovascular disease 17%
Osteoarthritis 14%
Breast Cancer 11%
Uterine Cancer 11%
Colon Cancer 11%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).
Relationship Between BMI and Risk of Type 2 Diabetes Mellitus
Chan J et al. Diabetes Care 1994;17:961.Colditz G et al. Ann Intern Med 1995;122:481.
Age
-Adj
uste
d R
elat
ive
Ris
k
Body Mass Index (kg/m2)
< 23 24 - 24.9
25 - 26.9
27 -28.9
33 -34.9
0
25
50
75
100
1.02.9 4.3 5.0
8.1 15.8
27.6
40.3
54.0
93.2
< 22 23 - 23.9
29 -30.9
31 -32.9
35 +
1.0 1.52.2
4.46.7
11.6
21.3
42.1
1.0
Men
Women
Waist Circumference Relative Risk of Type 2 DM
< 28 inches 1.0
28 - 29 1.2
30 - 31 2.8
32 - 33 4.0
34 - 35 4.8
36 - 37 5.5
> 38 6.2
*Controlled for age, family history of diabetes, exercise, smoking, saturated fat intake, calcium, potassium, magnesium, and glycemic index.
Nurses’ Health Study: Waist Circumference Directly Related to Risk for Type 2 Diabetes
Carey et al. Am J Epidemiol. 1997;145:614.
Characteristics of the Metabolic Syndrome
• 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
Full members Wannabes
Abdominal Obesity
Abdominal Adiposity
Courtesy of Steven Smith, M.D.
Visceral Subcutaneous
Subcutaneous Fat
Abdominal Muscle Layer
Intra-abdominal Fat
Visceral Adiposity:The Critical Adipose Depot
Metabolic Syndrome: NCEP ATP III compared to IDF
* requires presence of 3 or more criteria** requires central adiposity and presence of 2 more criteria
Risk Factor ATP III * IDF**
Central Adiposity (defined by waist circumference)
M (waist) > 40 in (> 102 cm) ≥ 37 in (≥ 94 cm)
F > 35 in (> 88 cm) ≥ 31.5 in (≥ 80 cm)
Triglycerides ≥ 150 mg/dL (≥ 1.7 mmol/L)
≥ 150 mg/dL (≥ 1.7 mmol/L)
HDL-C M < 40 mg/dL
(< 1.03 mmol/L)< 40 mg/dL (< 1.03 mmol/L)
F < 50 mg/dL (< 1.0 mmol/L)
< 50 mg/dL (< 1.0 mmol/L)
Blood Pressure ≥ 130/≥ 85 mm Hg ≥ 130/≥ 85 mm Hg
Fasting Glucose ≥ 110 mg/dL (≥ 6.1 mmol/L)
≥ 100 mg/dL (≥ 5.6 mmol/L)
Age-Adjusted Prevalence of the Metabolic Syndrome
Ford JAMA 2002;287:356-9.
Among 8814 Adults Age > 20
Mortality from Cancer in American Men and Women
Calle NEJM 2003;348:1625.
Men Women
• Liver• Pancreas• Stomach/Esophagus• Colon/Rectum• Gallbladder• Multiple Myeloma• Kidney• Non-Hodgkin’s• Prostate
• Uterus• Kidney• Cervix• Pancreas/Esophagus• Gallbladder• Breast• Non-Hodgkin’s• Liver• Ovary• Colon/Rectum
Other Increased Risks
• Kidney stones• Complications of pregnancy• Sleep disorders• Osteoarthritis• Stigmatization
The Interheart Study: Risk of MI
FactorOdds Ratio
Population Attributable Risk
Abdominal Obesity (WHR)+ 2.24 33.7
Diabetes+ 3.08 12.3
Hypertension+ 2.48 23.4
ApoB/ApoA1+ 3.87 54.2
Smoking* 2.27 36.4
Psychosocial+ 2.51 28.8* Adj for Age, Sex & Geography+ Adj Age, Sex & Smoking
Yusuf et al Lancet 2004;364-352.
BMI and Physical Functioning (SF-36)The Nurses Health Study
BMI Categories Relative Risk
< 21.9 0.94
22 - 23.9 1.00
24 - 24.9 1.05
25 - 27.9 1.23
28 - 29.9 1.49
30 - 34.9 1.66
35 - 39.9 2.08
> 40 3.08
Coakley et al IJO 1998;22:958-963.
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 1995;117:3-20.
Risk of Major Depression with Extreme Obesity
Onyike, et al. Amer J Epidemiology 2003;158:1139-1147.
1.13 1 0.961.33
1.9
4.63
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
< 18.5 18.5 - 24.9 25 - 29.9 30 - 34.9 35 - 39.9 > 40
Body Mass Index (kg/m2)
Odd
s R
atio
Bodily Pain and Depression in Obese Individuals (N = 306)
0
2
4
6
8
10
12
14
16
18
20
40 - 49.9 50 - 59.9 60 +
Body Mass Index
Not Impaired
Impaired
Fabricatore AF. Obes Surg 2005; 15:304-309.
BD
I-II
Sco
re
Bodily Pain:
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
Diabetes Prevention Program Research Group. N Engl J Med. 2002;346,393-403.
Diabetes Prevention Program
40
30
20
10
00 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0
Placebo
Metformin
Lifestyle
Cum
ulat
ive
Inci
denc
eof
Dia
bete
s (%
)
Year
Small Weight Losses Are BeneficialThe Diabetes Prevention Program
-8
-7
-6
-5
-4
-3
-2
-1
0
1
Wei
ght C
hang
e in
DP
P (
Kg)
0 6 12 18 24 30 36 42 48
Months in study
Lifestyle
+
Placebo
Reduces Risk of Diabetes by 58%
DPP NEJM 2002;346:393-402
Plasma Lipids Improve With Weight Loss
Meta-analysis of 70 Clinical Trials
*P0.05.LDL-C=low density lipoprotein cholesterol; HDL-C=high-density lipoprotein cholesterol; TG=triglycerides.
Dattilo et al. Am J Clin Nutr 1992;56:320.
-0.06
-0.04
-0.02
0.00
0.02
TotalCholesterol LDL-C TG
HDL-C(weight stable)
HDL-C (actively losing)
m
mol
/L p
er k
g of
Wei
ght
Loss
-2.5
-2.0
-1.5
-1.0
-0.5
0.0
0.5 m
g/dL per kg of Weight Loss*
**
*
*
Peppard et al. JAMA 2000;284:3015.
Change in Body Weight (%)
-20 to < -10(n = 22)
-10 to < -5(n = 39)
-5 to < +5(n = 371)
+5 to < +10(n = 179)
+10 to +20(n = 79)
6
4
2
0
-2
-4
Mea
n C
hang
e in
AH
I (E
vent
s/h)
Effect of Weight Change on Apnea-Hypopnea Index (AHI)
The Economics of Obesity
Economic Burden of Obesity Similar to Other Chronic Diseases
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 2004;12 4Hodgson TA et al. Med Care 2001;39:599 2 ADA Diabetes Care, 2003;26:917 5 Yelin & Callahan. Arthritis Rheum 1995;38:13513 Hodgeson TA et al. Medical Care 1999:37:994. 6Brown ML, et al. Medical Care; 2002;40(suppl): IV-
104Courtesy of Anne Wolf, MS, RD
Direct cost of chronic diseases in the U.S. ($2003)
Cost Difference
• 2.3% - Cost increase for each higher BMI unit
• 52.9% - Cost increase for each major associated co-morbidity
Raebel, M. et al. Health Services Use and Health Care Costs of Obese and Non-obese Individuals. Arch Intern Med 2004; No.19. Vol.164: 2135-2140. Oct.25,2004
Obesity Effect on Expected Lifetime Medical Care Costs in Women
0
10,000
20,000
30,000
40,000
Co
sts
($)
37.5 32.5 27.5 22.5
35 - 4445 - 54
55 - 64
BMI (kg/m2)
Age
*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 1999;2177-2183.
Expected Lifetime Medical Care* Savings of Sustained 10% Weight Loss by
Age and Initial BMI (Women)
0
1000
2000
3000
4000
5000
6000
Co
sts
($)
37.5 32.5 27.5
35 - 44
45 - 54
55 - 64
BMI (kg/m2)
Age
*Total cost of 5 diseases: CHD, type 2 DM, hypertension, hypercholesterolemia, and stroke. Adapted from Oster G, et al. Am J Public Health 1999;89:1536-1542.
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.
• 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.
Obesity Medications
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