1. A.P.J. Houdijk Euro Weight Loss-2015 Frankfurt, Germany August 18 – 20, 2015

2. Weight loss what is the best outcome measure ? A.P.J. Houdijk MD PhD Medical Center Alkmaar Free University Hospital Amsterdam

3. The worldwide weight problem

4. Overweight worldwide WHO facts  Overweight and obesity: abnormal or excessive fat accumulation that may impair health.  Overweight expressed as BMI ≥ 25; Obese ≥ 30 kg/m 2  1.9 billion overweight,13 % of world population  600 million obese  Doubled since 1980  35 years of lifestyle (non) change how is this possible ?

5. Weight component of BMI  Weight = fat + lean body mass (LBM) + water  Fat = subcutaneous + intraabdominal + intracellular  LBM = organs +bone + muscle BMI = LBM + subcut. fat + intraabd. fat + water per M 2 Waist circumf. = organs + subcut fat + intraabd fat + air

6. Weight loss  Water dehydration  LBM; bone, muscle, organsprotein wasting  Fat; subcut fat, intraabd fatwasting or health benefit BMI reduction measures more than loss of metabolic risky fat BMI as a sole measure of health monitoring is questionable But there may be hope for another role for BMI

7. Body fat depots Total adipose tissue subcutaneous peripheral abdominal Internal Abdominal (visceral) intra/inter muscular Pericardial Hepatic Pancreatic

8. Overweight related metabolic disease visceral obesity is the motor

9. Visceral obesity induces inflammation and insulin resistance

10. Loss of visceral fat reverses inflammation and insulin resistance i Kovácˇiková, M. et al. Dietary intervention-induced weight loss decreases macrophage content in adipose tissue of obese women. Int. J. Obes. 2011

11. Surrogate marker waist circumference cardiovascular events Dagenais GR et al, 2005 Adjusted relative risk 111 1.17 1.16 1.14 1.29 1.27 1.35 0.8 1 1.2 1.4 CVD deathMIAll-cause deaths Tertile 1 Tertile 2 Tertile 3 MenWomen <95 95–103 >103 <87 87–98 >98 Waist circumference (cm): The HOPE study Adjusted for BMI, age, smoking, sex, CVD disease, DM, HDL-cholesterol, total-C; CVD: cardiovascular disease; MI: myocardial infarction ; BMI: body mass index; DM: diabetes mellitus; HDL: high-density lipoprotein cholesterol

12. IAAT= 0.53 l IAAT= 1.11 l IAAT= 1.31 lIAAT= 4.2 l IAAT= 1.15 lIAAT= 4.26 l Visceral fat and waist circumference ? waist circumference = 84 cm Courtesy: Prof J. Bell University of Westminster

13. IAAT= 0.53 l IAAT= 1.11 l IAAT= 1.31 lIAAT= 4.2 l IAAT= 1.15 l IAAT= 4.26 l Visceral fat and waist circumference ? waist circumference = 84 cm Courtesy: Prof J. Bell University of Westminster

14. TAT = 13.2 L, IAAT = 1.07 TAT = 21.8 L, IAAT = 3.56 L TAT = 17.3 L, IAAT = 1.8 LTAT = 21.4 L, IAAT = 2.9 L TAT = 16.8 L, IAAT = 2.2 L TAT = 24.1 L, IAAT = 3.7 L TAT = 14.3 L, IAAT= 1.2 L TAT = 12.4 L, IAAT = 0.63 L TAT = 26.2 L, IAAT = 3.6 L Visceral fat and BMI ? Umbilical images from subjects with BMI 24 kg/m2 Courtesy: Prof J. Bell University of Westminster

15. TAT = 13.2 L, IAAT = 1.07 TAT = 21.8 L, IAAT = 3.56 L TAT = 17.3 L, IAAT = 1.8 LTAT = 21.4 L, IAAT = 2.9 LTAT = 16.8 L, IAAT = 2.2 L TAT = 24.1 L, IAAT = 3.7 L TAT = 14.3 L, IAAT= 1.2 L TAT = 12.4 L, IAAT = 0.63 L TAT = 26.2 L, IAAT = 3.6 L Visceral fat and BMI ? Umbilical images from subjects with BMI 24 kg/m2 Courtesy: Prof J. Bell University of Westminster

16. Ct scan image for visceral fat Visceral fat area (cm 2 ) at L3 – L4 level Threshold for metabolic disease = 100 cm 2

17. Visceral obesity and BMI in colon cancer 46 %83 % Cakir et al. Visceral obesity, BMI and risk of complications after colon cancer resection: a retrospective cohort study. Surgery 2015

18. Visceral obesity and BMI in colon cancer CVD, hypertension and diabetes Cakir et al. Visceral obesity, BMI and risk of complications after colon cancer resection: a retrospective cohort study. Surgery 2015

19. Visceral obesity and BMI in colon cancer CVD, hypertension and diabetes Cakir et al. Visceral obesity, BMI and risk of complications after colon cancer resection: a retrospective cohort study. Surgery 2015

20. Visceral obesity and BMI in colon cancer Postoperative complications Cakir et al. Visceral obesity, BMI and risk of complications after colon cancer resection: a retrospective cohort study. Surgery 2015

21. Visceral obesity and BMI in colon cancer Postoperative complications Cakir et al. Visceral obesity, BMI and risk of complications after colon cancer resection: a retrospective cohort study. Surgery 2015

22. Visceral obesity, BMI and complications 29 % Cakir et al. Visceral obesity, BMI and risk of complications after colon cancer resection: a retrospective cohort study. Surgery 2015 38 % 17 % 14 %

23. Visceral obesity – BMI phenotypes Cakir et al. Visceral obesity, BMI and risk of complications after colon cancer resection: a retrospective cohort study. Surgery 2015 Slim unfit Slim fit Fat unfit Fat fit

24. Slim fit Slim unfit Fat fit Fat unfit O'Donovan et al Fit versus unfit phenotypes

25. Visceral obesity in relation to BMI A new marker for risk phenotyping ?  Visceral fat in oncological patients CT MRI  Visceral fat measurement in the general population DEXA

26. Summary and conclusions  Visceral fat measurement in relation to BMI identifies risk phenotypes for metabolic syndrome and postoperative complications  Visceral obesity in BMI 25 kg/m 2 ??  A larger study n=3500 colon cancer patients is including  BMI has a new role  Visceral fat and BMI risk phenotypes may focus lifestyle programs to the highest risk phenotypes

27. Summary and conclusions  Stop weighing people measure visceral fat and BMI  Further research needed on the effects of lifestyle programs in the different phenotypes Thank you

28. Questions

29. Fat-Fit: Sumo Wrestling Sumo wrestlers bulk (>20,000 kcal/day) (as the heavier the fighter, the lower his centre of gravity) Yokozuna have large BMI: - Taiho: 43.8 –Konishki: 58.2 –Akibono: 56.8 Elevated % body fat, but low insulin resistance: –low TG –low T-chol and LDL-chol –low Fasting glucose

30. Euro Weight Loss – 2016 Website: http://weightloss.global-summit.com/europe/ Meet the eminent gathering once again at Euro Weight Loss-2016 Vienna, Austria September 19-20, 2016