Disease X in 1985 No Data

Disease X in 1985

No Data <10% 10%–14%

Disease X in 1986

No Data <10% 10%–14%

Disease X in 1987

No Data <10% 10%–14%

Disease X in 1988

No Data <10% 10%–14%

Disease X in 1989

No Data <10% 10%–14%

Disease X in 1990

No Data <10% 10%–14%

Disease X in 1991

No Data <10% 10%–14% 15%–19%

Disease X in 1992

No Data <10% 10%–14% 15%–19%

Disease X in 1993

No Data <10% 10%–14% 15%–19%

Disease X in 1994

No Data <10% 10%–14% 15%–19%

Disease X in 1995

No Data <10% 10%–14% 15%–19%

Disease X in 1996

No Data <10% 10%–14% 15%–19%

Disease X in 1997

No Data <10% 10%–14 15%–19% ≥20%

Disease X in 1998

No Data <10% 10%–14 15%–19% ≥20%

Disease X in 1999

No Data <10% 10%–14 15%–19% ≥20%

Disease X in 2000

No Data <10% 10%–14 15%–19% ≥20%

Disease X in 2001

No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

Disease X in 2002

No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

Disease X in 2003

No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

Disease X in 2004

No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

Disease X in 2005

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Alcohol Medical Scholars ProgramSource: Behavioral Risk Factor Surveillance System, CDC.

Obesity* Among U.S. Adults, 2006

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Alcohol Medical Scholars Program 23

OBESITY: AN EXPANDING EPIDEMIC


Obesity

• Major public health concern

• Related to high calorie intake

• Influenced by

– Physiology

– Environment

– Genes


Covered Topics

Obesity

– Definition and epidemiology

– Comorbid illness

– Mechanism of disease

– Treatment


Obesity

Body mass index (BMI)=kg/m2

BMI Weight in lbs for 5’8”

Normal 18.5-24.9 122-164

Overweight 25.0-29.9 164-197

Obese ≥30.0 ≥ 197

Class I 30.0-34.9 197-230

Class II 35.0-39.9 230-262

Class III ≥40.0 ≥262


Who is obese?

• 66% in United States overweight or obese

– 32% obese

– 5% extreme obesity

• Mexican American 76%

• Non-Hispanic Black 76%

• Non-Hispanic White 64%


Covered Topics

Obesity




– Treatment


So what?

• 300,000 obesity-related deaths/year in US

• 5x risk for diabetes

• 5x risk for gallbladder disease

• More depression and bipolar disorder

• More deaths from heart disease


Covered Topics

Obesity




– Treatment


Mechanisms of Obesity

• Environment

– Types of food available

– Increased portion size

– Sedentary lifestyle


Mechanisms of Obesity

• 50% of risk is genetic

– Concordance: 60% dizygotic 75% monozygotic

– Adoptee weight more like biological parents

– Gene mutations

• Leptin

• Proopiomelanocortin (POMC)

– Bred in or out of mice


Mechanisms of Obesity: Feeding

• Dopamine with food

• Opioids will feeding

Leptin Ghrelin


Stress Eating and Opioids

• Stress consumption of comfort food

• Opiates sugar intake

POMCβ-endorphin

α-MSH

ACTH RewardStress

Feeding


Extrinsic factors

food-related cue & availability

Emotional factors

Stress, boredom

Intrinsic factorsLeptinGhrelin

Dopamine

Hypothalamus

Signals that Control Feeding


Dopamine and Reward

• Dopamine critical to reward

– Pleasure dopamine

• Drugs

• Sex

• Food

– Too much pleasure dopamine

• Drugs

• Food


p < 0.002

Dopamine and Obesity

Control Obese

Dopamine D2 receptor imaging

BM

I

Dopamine Receptor Concentration

• Obese

o Control

p = 0.3

Wang et al, Lancet 2001


Food Craving

• When do we crave?

– Chronic stress

– Food deprivation

• What do we crave?

– Sweets

– Carbohydrates


Carbohydrates (mmmm…)

• Dopamine

• Opiates

• Serotonin

• Alcohol is carbohydrate rich

– Is food

– Is drug


From Chocolate to Morphine

• Sugar preferring rats

– Increased cocaine

– Increased morphine

– Increased alcohol


Drug Withdrawal and Sweets

• Increased sweets consumption after

– Smoking cessation

– Alcohol abstinence

– Opiate withdrawal

– Cocaine withdrawal

• No impairment in taste


Weight Loss and Alcohol

• Calorie restricted body wants calories

– Prefers carbohydrates

– Calorie deprived rats drink alcohol

• Surgically treated obesity

– Decreased calorie intake

– Overcome size restriction by liquid calories

• Standard drink = 100 calories


Covered Topics

Obesity




– Treatment


Weight Loss Strategies

• Improve health

• Address behavioral change

• Address neurobiological change?


Treatment: Surgery

• Roux-en-Y– Restrict stomach size /

decrease absorption

– 25% in body weight

• Vertical banded gastroplasty– Restrict stomach size

– 15% in body weight


Treatment: Behavioral

• Brief Intervention

– Medical consequences

– Impact of dietary change

– Impact of exercise

• Diet and exercise 5% in body weight



• Overeaters Anonymous

– Get peer network

– Change attitudes

• Cognitive behavioral therapy

– Help patient change view of eating

– Help change behavior to weight loss

– Help recognize and avoid risk situations



• Motivational interviewing

– Emphasize change

– Discuss resistance

– Encourage acceptable change

• Behavioral therapy alone 5% weight


Treatment: Medications

• Decrease appetite / increase metabolism

– Sibutramine: inhibits monoamine reuptake

– Rimonabant: cannabinoid receptor antagonist

• Decrease absorption

– Orlistat: fat absorption in gut

• Decrease appetite

– Naltrexone?: opioid antagonist

• Medications 5% in body weight


Conclusions

• Obesity morbidity and mortality

• Overlapping neuropathways with

addiction

• Treatments

– Surgical

– Behavioral

– Pharmacological


Future Studies Needed

• Is eating behavior replaced?

• Elucidate common neuropathways

• Elucidate common genetics


In the Meantime

• Screen for overweight and obesity (BMI)

• Counsel about healthy eating

• Treat or refer to treatment

– Behavioral

– Pharmacological

– Surgical

Disease X in 1985 No Data

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