1. Obesity: The Epidemic Patrick McBride, MD, MPH Professor UW Medical School

2. Overview Obesity: The Epidemic U.S. Trends: Disease of the decade Costs, Causes, Consequences –Obesity = 280,000 deaths annually –Costs: $77 billion year U.S. Wisconsin = $1.4 billion / year (5 – 7% of all health care costs) –Obesity is complex with genetic, behavioral and environmental causes

3. Obesity - The Epidemic Will soon overtake smoking as the leading preventable cause of death!* *Obesity greater morbidity than: –Smoking –Problem drinking –Poverty * Public Health 2001;115:229-235

4. Obesity - The Epidemic Overweight or obese in U.S. –1 in 4 adults in the 1960’s Overweight: 37% of U.S. adults WI = 37% Obese: 21% of U.S. adults WI = 22% (Doubled: 11% only 10 yrs ago!)

5. Obesity* Trends Among U.S. Adults BRFSS, 1991 (*BMI  30, or ~ 30 lbs overweight for 5’4” person) No Data <10% 10%-14% 15-19%  20% Source: BRFSS, CDC.

6. Obesity* Trends Among U.S. Adults BRFSS, 1992 (*BMI  30, or ~ 30 lbs overweight for 5’4” person) Source: BRFSS, CDC. No Data <10% 10%-14% 15-19%  20%

7. Obesity* Trends Among U.S. Adults BRFSS, 1993 (*BMI  30, or ~ 30 lbs overweight for 5’4” person) No Data <10% 10%-14% 15-19%  20% Source: BRFSS, CDC.

8. Obesity* Trends Among U.S. Adults BRFSS, 1994 (*BMI  30, or ~ 30 lbs overweight for 5’4” person) Source: BRFSS, CDC. No Data <10% 10%-14% 15-19%  20%

9. Obesity* Trends Among U.S. Adults BRFSS, 1995 (*BMI  30, or ~ 30 lbs overweight for 5’4” person) No Data <10% 10%-14% 15-19%  20% Source: BRFSS, CDC.

10. Obesity* Trends Among U.S. Adults BRFSS, 1996 (*BMI  30, or ~ 30 lbs overweight for 5’4” person) Source: BRFSS, CDC. No Data <10% 10%-14% 15-19%  20%

11. Obesity* Trends Among U.S. Adults BRFSS, 1997 (*BMI  30, or ~ 30 lbs overweight for 5’4” person) Source: BRFSS, CDC. No Data <10% 10%-14% 15-19%  20%

12. Obesity* Trends Among U.S. Adults BRFSS, 1998 (*BMI  30, or ~ 30 lbs overweight for 5’4” person) No Data <10% 10%-14% 15-19%  20% Source: BRFSS, CDC.

13. Obesity* Trends Among U.S. Adults BRFSS, 1999 (*BMI  30, or ~ 30 lbs overweight for 5’4” person) Source: BRFSS, CDC. No Data <10% 10%-14% 15-19%  20%

14. Obesity* Trends Among U.S. Adults BRFSS, 2000 (*BMI  30, or ~ 30 lbs overweight for 5’4” person) Source: BRFSS, CDC. No Data <10% 10%-14% 15-19%  20%

15. Obesity - The Epidemic: Kids 15% of children are overweight 5% in 1970 – 1980 and 11% in 1990 22% African-American & Hispanic children are now overweight 27% of AA and Hispanic male children overweight Diabetes in kids: up 10 X in 10 years < 25% children active regularly

18. Obesity: Causes and Consequences

19. Physical Activity in U.S. < 20% Adults and Children get regular physical activity Trend unchanged in past 2 decades; exception is high school females getting less activity in past decade Physical activity classes decreasing in U.S. high schools

21. is sedentary takes away time from other activities associated with eating 68% increase Video Games and Children. ERIC Digest Children’s Television Resource & Education Center

23. 3.7 to 4.2 14% increase USDA statistics show that the average daily caloric intake of Americans has risen from 1,854 calories to 2,002 calories during the last 20 years. That increase - 148 calories per day - theoretically works out to an extra 15 pounds per year. 32% are fast food 27% sit down restaurants 24% convenience stores (USDA 1995)

24. SmallMediumLargeSuper-Size 1950-60200 calories 1970’s200 calories 320 calories 1980’s320 calories 400 calories 1990’s450 calories 540 calories 2000450 calories 540 calories 610 calories The History of French Fries in America

25. Obesity Health Consequences Heart Disease Other Vascular Dz Stroke Dementia Cancer (breast, colon, other) Type 2 DM Sleep Apnea Depression Osteoarthritis Back pain Gallstones Surgery complications Congenital malformations Urinary stress incontinence Psychological

26. Diabetes Mellitus in the US: Increasing Prevalence of Diagnosed Cases Persons With Diagnosed Diabetes (millions) 8 7 6 5 4 3 2 1 0 1958196319681979198419891994 Diabetes Overview. October 1995 (updated 1996). NDDK publication NIH 96-1468. Kenny SJ et al. In: Diabetes in America 2nd ed. 1995:47-67. Year

28. What to do? Individuals Families Industry Schools Policymakers Government

29. National Guidelines American Obesity Association www.aoa.org National Institute of Health - Obesity Research 1998;6:S51-S209 www.nhlbi.nih.gov/guidelines American Heart Association www.americanheart.org BMI calculator: www.nhlbisupport.com/bmi

30. The Metabolic Syndrome High Risk Syndrome: Overweight / central obesity as the primary contributor to insulin resistance with genetic predisposition Multiple metabolic abnormalities Target: insulin resistance & metabolism Emphasis on weight reduction & physicalactivity to reverse

31. How Common is the Metabolic Syndrome? US NHANES survey Adults > 20 years of age 24% all adults, 42% over age 60 yrs Similar for men and women! Mexican Americans 32% African American women >> men 47 million adults in the U.S. JAMA 2002;287:356

32. Waist Circumference Waist circumference, independent of BMI / weight, confers additional health risk with: –Glucose intolerance / Diabetes mellitus –Hypertension –Dyslipidemia Important - WC in any weight category confers similar risk Arch Intern Med 2002;162:2074

34. New Emphasis of ATP III: The Metabolic Syndrome Risk Factor Abdominal Obesity Men Women Triglycerides HDL cholesterol Men Women Blood pressure Serum glucose Defining Level Waist Circumference > 40 inches > 35 inches > 150 mg/dL < 40 mg/dL < 50 mg/dL > 130/ 85 mmHg > 110-125 mg/dL

35. Accelerated atherosclerosis Clinical diabetes HyperinsulinemiaImpaired glucose tolerance Hypertriglyceridemia Decreased HDL-C Essential hypertension Insulin resistance Insulin Resistance and Atherosclerosis

36. Obesity Prevention and Management

37. Can Lifestyle Change Work? Prevention of Type 2 Diabetes Mellitus Changes in lifestyle: NEJM 2001;344:1343-1350 Changes in lifestyle or metformin NEJM 2002;346:393-403

38. Metabolic Syndrome Prevention 3234 patients with GINT / high FBG Randomized for 3 years to: –Placebo –Metformin –Lifestyle intervention Results in reducing diabetes: –Lifestyle 58% (NNT = 7) –Metformin 31% (NNT = 14) N Engl J Med 2002;346:393

39. Diabetes Prevention in Metabolic Syndrome 522 men & women IGT - mean BMI 31 RCT Individualized counseling vs UC RX 4.2 kg weight loss (vs 0.8 kg UC)* Diabetes incidence 11% vs 23% UC* (58% risk reduction, p< 0.001*) 3 yrs. Achieving either 5% wt. loss or fitness reduced risk of DM by 70% NEJM 2001;344:1343-50

40. Diabetes Therapy Trial* 160 patients with Type 2 DM + PU Trial of “Intensive Therapy”: –Lowfat diet + exercise + tobacco cslg. –ACE or ARB + HTN treatment –Multivitamin –Statin or Fibrate depending on cholesterol disorder –Diabetes treatment if needed: metformin, gliclazide, insulin NEJM 2003;348:383-93

42. Diabetes Therapy Trial* Intensive Therapy vs. Usual Care Outcomes in 8 years (160 patients): 85 events in 35 patients Usual Care 33 events in 19 patients Intensive RX –53% decrease in CVD –61% decrease in nephropathy –58% decrease in retinopathy –63% decrease in autonomic neuropathy NEJM 2003;348:383-93

43. Body Weight Management Patients BMI > 25 or WC increased: nutrition and physical activity counseling Goal: IBW - BMI 19 - 25? Goal: WC < 35” women, 40” male? OR Emphasize weight loss to achieve normal BP, cholesterol levels, and glucose?

44. Achieve Ideal Body Weight or Achieve a 5% loss? 200# 5% = 10 loss Total cholesterol down 15% TG down 20% HDL up 15% Sys BP / Dias BP down 12/9 mmHg Improved hyperglycemia Improved life expectancy

45. Weight Loss Obese adults can lose 1# per week reducing kcalories 500-1000 below maintenance for current weight Exercise is most important to add for sustained weight loss Combining caloric restriction and exercise leads to 5 - 10% weight loss in a 4 - 6 month period NEJM 2002;346:591

46. Activity - Vital Modest energy balance = Wt. Gain 10 calories / day excess = LB / year 100 calories / day excess = 10 LB / yr Additional activity daily changes calories consumed and the Basal Metabolic Rate (BMR)

47. Physical Activity Minimum goal - 30 minutes, 3 - 4x per week Ideal goal: 30 - 45 minutes daily Encourage moderate intensity aerobic activity supplemented by daily lifestyle activities Resistance training has positive effects on metabolism and visceral obesity Medically supervised programs for moderate to high-risk patients demonstrate benefits JAMA 2002;288:1622-31

48. Websites for Patients Atkins alert: www.atkinsdietalert.org/physician Evaluate diets: www.pcrm.org/new/health010109.html www.niddk.nih.gov/health/nutrit/pubs/ myths/index.htm Good sites www.shapeup.org/index.htm www.nhlbi.nih.gov/health/public/heart

49. Summary Obesity and it’s consequences are an epidemic in the U.S. Metabolic and medical outcomes are poor, with serious morbidity Population change is the only reasonable approach Medical management is very limited - emphasize health benefits and encourage patients with lifestyle

50. Body Mass Index (kg/m 2 ) Dose - Response Risk Relationship Underweight< 18.5 Normal18.5 - 25 Overweight25 - 30 Obese> 30 –Class I30 - 34.9 –Class II35 - 39.9 –Class III>40

51. Exercise & Intra- Abdominal Body Fat RCT of 173 post-menopausal women Moderate intensity exercise vs. stretching program control group 12 month data: –Body weight difference 1.4 kg –Total body fat - 1% –Intra-abdominal fat - 8.6 g/cm –Subcutaneous abdominal fat - 29 g/cm JAMA 2003;289:323-330