Why Obesity is a Chronic Disease Dr. Sean Wharton, MD, FRCPC, PharmD Wharton Medical Clinic Adjunct Professor – McMaster University Diplomate American Board of Obesity Medicine sean.wharton@utoronto.ca

Global Obesity Map 2014 The Lancet, 2016

Prevalence and current landscape X2 6 million Worldwide obesity has more than DOUBLED since 19801 Canadians are living with obesity3,4 >50% of the world’s adult population was living with overweight/obesity in 20142 Note to facilitator: This slide is animated. Upon first click, the Canadian obesity prevalence rates appear. Upon second click, the adult and children obesity prevalence rates appear. Obesity has reached epidemic proportions globally, with at least 2.8 million people dying each year as a result of being overweight or obese.1 Worldwide obesity rates have more than doubled since 1980 and in 2014, more than 1.9 billion adults (18 years of age and older, were overweight. Of these, over 600 million were obese. 39% of adults aged 18 years and over were overweight in 2014, and 13% were obese. Most of the world's population live in countries where overweight and obesity kills more people than underweight. 42 million children under the age of 5 were overweight or obese in 2013.2 In Canada, over 1 in 4 Canadian adults (estimates range from 24.3%-25.4%) are obese, according to measured height and weight data from 2007-2009. Of children and youth aged 6 to 17, 8.6% are obese. Generally actual measurements of height and weight result in higher estimates of obesity than data obtained from self-reports.3 References: WHO. 2014. 10 facts on obesity. Available at: http://www.who.int/features/factfiles/obesity/en/# 10 facts on obesity. WHO. 2015. Obesity and overweight fact sheet. Available at: http://www.who.int/mediacentre/factsheets/fs311/en/. Public Health Agency of Canada. 2011. Obesity in Canada. A joint report from the Public Health Agency of Canada and the Canadian Institute for Health Information. Available at: http://www.phac-aspc.gc.ca/hp-ps/hl-mvs/oic-oac/assets/pdf/oic-oac-eng.pdf. 1 in 4 Canadian adults 2.8 million people die/year from overweight or obesity2 1 in 10 Canadian children 1. WHO. 2015. Obesity and overweight fact sheet. Available at: http://www.who.int/mediacentre/factsheets/fs311/en/. 2. WHO. 2014. 10 facts on obesity. Available at: http://www.who.int/features/factfiles/obesity/en/# 10 facts on obesity. 3. Canadian Obesity Network. 2015. Obesity in Canada. Available at: http://www.obesitynetwork.ca/obesity-in-Canada CON. 4. Public Health Agency of Canada. 2011. Obesity in Canada. A joint report from the Public Health Agency of Canada and the Canadian Institute for Health Information. Available at: http://www.phac-aspc.gc.ca/hp-ps/hl-mvs/oic-oac/assets/pdf/oic-oac-eng.pdf.

Twells, LK., CMAJ Open, 2014;2(1), E18-E26.

The Jamie Bogart Story Behavioral modification and December 2005 527lbs, BMI 72.1 “Feel more normal and not have Children staring at me” PMHX Chronic renal failure Sleep Apnea Arthritis – Hip Behavioral modification and Meal Replacement – Jan 2006 Surgery – in the US

Jamie Bogart Meal Replacement 527lbs to 400lbs Surgery - Waited & Waited & Waited Cellulitis – Hospital - ICU Died of Sepsis and Renal Failure – Age 42 (2006) Approval for surgery – 3 days after his death

Obesity is a Chronic, Progressive, Relapsing Medical Disease (pathological condition) 2011 National Obesity Summit Workshop

Medical Complications of Increased Weight Pulmonary disease abnormal function obstructive sleep apnea hypoventilation syndrome Stroke Cataracts Nonalcoholic fatty liver disease steatosis steatohepatitis cirrhosis Coronary heart disease Diabetes Dyslipidemia Hypertension Gall bladder disease Severe pancreatitis Gynecologic abnormalities abnormal menses infertility polycystic ovarian syndrome urinary incontinence Cancer breast, uterus, cervix colon, esophagus, pancreas kidney, prostate Medical complication of obesity Osteoarthritis Phlebitis/DVT (Blood Clots) venous stasis Skin fungal/bacterial infections Gout

Weight Gain is Natural Weight Loss is Unnatural

Hyperphagia contributes to elevated obesity rates: Humans are eating more, portion size effects 80 70 60 50 40 30 10 20 Breakfast Lunch Dinner Snacks Day 1 Day 2 Day 3 Day 4 Study day and meals Mean cumulative EI (MJ/d) Men increase energy intake by 17%, women by 10% when presented with large portions versus standard portion meals; no compensation observed for increased intake over 4 days CDC, Centre for Disease Control; EI, energy intake Kelly MT et al. Br J Nutr 2009;102:470–477; CDC. The new (Ab)normal. available at: http://makinghealtheasier.org/newabnormal

BIOLOGY DEFEND YOUR SET POINT (highest weight)

Scar Tissue (Gliosis) in the Hypothalamus – leading to chronic obesity Thaler et al. Diabetes Vol 62, 2013

Short Term Weight Changes May Not Lead To Long Term Hypothalamic Changes

Defended Fat Mass Lifestyle Interventions Years of Exposure Weight stabilizing alternatives Healthy Diet Physical Activity Stable eating patterns More and better sleep Stress reduction Abnormal dietary constituents Disturbed Circadian rhythm Weight gaining medications Unhealthy muscle Sleep deprivation Stress Years of Exposure

Treatment time (months) Differences in pattern of weight loss Weight loss trajectories of 7,121 patients over 7.5 years 50 40 30 20 10 -10 -20 -30 -40 15 45 60 75 90 Treatment time (months) % WL Weight gain (0.8%) Weight stable (33.3%) Minimal WL (36.9%) WL regain (6.8%) Large WL (2.3%) Slow WL (15.9%) Moderate WL (4.0%) –21% WL –2.3% WL Patients who attended a physician-lead multi-disciplinary clinical lifestyle weight management that predominantly focused on education and diet counselling management. WL, weight loss Kuk J, Wharton S. Obes Sci Pract 2016;2:215–23