Kidney Disease and Its Kidney Disease and Its Leading Causes: Leading Causes:

Diabetes and Diabetes and HypertensionHypertension

A Brown-Bag Presentation byA Brown-Bag Presentation byRobert Beallo, M.D.Robert Beallo, M.D.

Sponsored bySponsored byLBNL Health Care Facilitator ProgramLBNL Health Care Facilitator Program

March 31, 2005March 31, 2005Perseverance HallPerseverance Hall

The Real Epidemics in Our Community: The Real Epidemics in Our Community: Hypertension, Diabetes, and ObesityHypertension, Diabetes, and Obesity

► Epidemic: a disease or condition which is Epidemic: a disease or condition which is highly prevalent in a community or large highly prevalent in a community or large geographical area.geographical area. High blood pressureHigh blood pressure: affects approximately : affects approximately

25%25% of people in the United States. of people in the United States. ObesityObesity: affects approximately : affects approximately 30%30% of people in of people in

the United States.the United States. DiabetesDiabetes: affects approximately : affects approximately 8%8% of people in of people in

the United States.the United States.

High Blood Pressure/HypertensionHigh Blood Pressure/Hypertension

► What is hypertension (HTN):What is hypertension (HTN): a blood pressure reading more than 140/90a blood pressure reading more than 140/90 about 25% of U.S. residents are affectedabout 25% of U.S. residents are affected once it develops, it usually lasts a lifetimeonce it develops, it usually lasts a lifetime it can be treated and controlled very wellit can be treated and controlled very well

► Hypertension is a “silent killer”:Hypertension is a “silent killer”: may be present for years without symptomsmay be present for years without symptoms if not diagnosed at an early stage, peopleif not diagnosed at an early stage, people will not will not

find out it is present until they experience find out it is present until they experience trouble with their heart, brain, kidney, or blood trouble with their heart, brain, kidney, or blood vesselsvessels

Consequences of untreated or Consequences of untreated or inadequately treated hypertensioninadequately treated hypertension

► Enlargement of the heart leading to heart failure.Enlargement of the heart leading to heart failure.► Bulges in large blood vessels (aneurysms) of the Bulges in large blood vessels (aneurysms) of the

brain, intestine, legs, and aorta (main artery in brain, intestine, legs, and aorta (main artery in the chest and abdomen) can develop. These the chest and abdomen) can develop. These bulges can rupture leading to severe bulges can rupture leading to severe consequences including death.consequences including death.

► Arteries throughout the body can become Arteries throughout the body can become narrowed (arteriosclerosis) leading to reduced narrowed (arteriosclerosis) leading to reduced blood supply to the heart (heart attack),blood supply to the heart (heart attack),or the brain (stroke),or the brain (stroke),

or the kidney (dialysis), or the kidney (dialysis), or the legs (gangrene and or the legs (gangrene and amputation.amputation.

What is blood pressure ?What is blood pressure ?

► Blood pressure is recorded as these 2 numbers: Blood pressure is recorded as these 2 numbers: systolic and diastolic, e.g. 120/80.systolic and diastolic, e.g. 120/80.

► When the heart beats, blood is propelled out of When the heart beats, blood is propelled out of the heart into blood vessels called arteries.the heart into blood vessels called arteries.

► Blood pressure is the force of blood pushing Blood pressure is the force of blood pushing against the wall of arteries.against the wall of arteries.

► Systolic pressure: blood pressure is highest when Systolic pressure: blood pressure is highest when the heart beats and blood is pumped out of the the heart beats and blood is pumped out of the heart into the arteries.heart into the arteries.

► Diastolic pressure: blood pressure is lowest in-Diastolic pressure: blood pressure is lowest in-between heart beats when the heart is at rest.between heart beats when the heart is at rest.

Variations in blood pressureVariations in blood pressure

►Normal variations blood pressureNormal variations blood pressure lowest when sleepinglowest when sleeping slightly higher early in the dayslightly higher early in the day increases with vigorous exerciseincreases with vigorous exercise increases with sudden events that provoke increases with sudden events that provoke

anxiety or angeranxiety or anger►High blood pressure / HTNHigh blood pressure / HTN

normal: 120/80normal: 120/80 prehypertension: 120-130/80-90prehypertension: 120-130/80-90 HTN: greater than 130/90HTN: greater than 130/90

What causes hypertension?What causes hypertension?

► Essential hypertension:Essential hypertension: most people with HTN are in this categorymost people with HTN are in this category an identifiable cause cannot be foundan identifiable cause cannot be found the exact scientific explanation for this category the exact scientific explanation for this category

remains unknownremains unknown► Secondary hypertension:Secondary hypertension:

when HTN is caused by another medical when HTN is caused by another medical condition or drugcondition or drug

screening for a secondary cause is done routinely screening for a secondary cause is done routinely by most physiciansby most physicians

Risk factors for developing Risk factors for developing hypertensionhypertension

► ObesityObesity► Family historyFamily history► Excess dietary salt and alcohol intakeExcess dietary salt and alcohol intake► Older age: over 50% of Americans over 60 have Older age: over 50% of Americans over 60 have

HTNHTN► African Americans:African Americans:

develop HTN at an earlier age develop HTN at an earlier age have more severe HTNhave more severe HTN increased risk of heart attack, stroke, and increased risk of heart attack, stroke, and

kidney failurekidney failure► Tobacco useTobacco use► DiabetesDiabetes

Prevention of high blood pressure: life Prevention of high blood pressure: life style modificationsstyle modifications

► Exercise regularly: e.g. walk briskly for 40 Exercise regularly: e.g. walk briskly for 40 minutes, 5 times a week.minutes, 5 times a week.

► Maintain a healthy body weight.Maintain a healthy body weight.► Avoid excess dietary salt: see a dietician, Avoid excess dietary salt: see a dietician,

NIH web site, or one of many diet manuals.NIH web site, or one of many diet manuals.► Avoid excess alcohol: less than 2 drinks / Avoid excess alcohol: less than 2 drinks /

day, e.g. 24 oz. of beer, 10 oz. of wine, 3 day, e.g. 24 oz. of beer, 10 oz. of wine, 3 oz. of whiskey in most men and less in oz. of whiskey in most men and less in women.women.

► Stop tobacco use.Stop tobacco use.

Recent important clinical studies on Recent important clinical studies on drug treatment of HTN: ALLHATdrug treatment of HTN: ALLHAT

► Published in 2002 in JAMAPublished in 2002 in JAMA► ALLHAT: Antihypertensive and Lipid – Lowering ALLHAT: Antihypertensive and Lipid – Lowering

Treatment to Prevent Heart Attack TrialTreatment to Prevent Heart Attack Trial► 8 year study of 33,000 pts. With HTN randomly 8 year study of 33,000 pts. With HTN randomly

selected to receive a diuretic or ace inhibitor or selected to receive a diuretic or ace inhibitor or calcium channel blockercalcium channel blocker

► The incidence of stroke, CHF, heart attack and all The incidence of stroke, CHF, heart attack and all cause mortality was measured for each group.cause mortality was measured for each group.

► Diuretic drug treatment was equal or superior to Diuretic drug treatment was equal or superior to the other drug types.the other drug types.

Seventh report of the Joint National Seventh report of the Joint National Commission of Hypertension TreatmentCommission of Hypertension Treatment

► Commonly referred to as JNC 7Commonly referred to as JNC 7► Systolic BP is a more important indicator of risk Systolic BP is a more important indicator of risk

than diastolic.than diastolic.► Risk of CV disease doubles with each 20mm/Hg Risk of CV disease doubles with each 20mm/Hg

increase in systolic pressure starting at 115.increase in systolic pressure starting at 115.► Thiazide diuretics should be used alone or in Thiazide diuretics should be used alone or in

combination with other drugs to reach target combination with other drugs to reach target BP.BP.

► Most pts. will require 2 or more drugs to achieve Most pts. will require 2 or more drugs to achieve target BP of < 140/90 or 130/80 if diabetes or target BP of < 140/90 or 130/80 if diabetes or kidney disease is present.kidney disease is present.

How many different blood pressure How many different blood pressure lowering drugs are required to reach lowering drugs are required to reach

target goal ?target goal ?

Increasing Prevalence of Diabetes from Increasing Prevalence of Diabetes from 1990 to 20001990 to 2000

Diabetes: what is it?Diabetes: what is it?

► A disease in which blood glucose levels are A disease in which blood glucose levels are higher than normal.higher than normal.

► After a meal, some of the food is broken After a meal, some of the food is broken down into a sugar called glucose.down into a sugar called glucose.

►Glucose is carried by the blood to cells in Glucose is carried by the blood to cells in the body.the body.

► The amount of glucose entering the cells is The amount of glucose entering the cells is controlled by insulin, a hormone secreted controlled by insulin, a hormone secreted by the pancreas. When more insulin is by the pancreas. When more insulin is secreted, cells take up more glucose and secreted, cells take up more glucose and blood sugar levels decrease.blood sugar levels decrease.

Diabetes: how blood glucose levels Diabetes: how blood glucose levels become abnormally highbecome abnormally high

►Diabetes develops when cells do not Diabetes develops when cells do not take up glucose normally and blood take up glucose normally and blood glucose levels rise.glucose levels rise.

► Inadequate secretion of insulin by the Inadequate secretion of insulin by the pancreas will cause elevation of blood pancreas will cause elevation of blood glucose levels. glucose levels.

► Cells of the body become less Cells of the body become less responsive to usually adequate levels of responsive to usually adequate levels of insulin. This situation is called insulin insulin. This situation is called insulin resistance. resistance.

Types of diabetes: modern terminologyTypes of diabetes: modern terminology

► Type 1 diabetes:Type 1 diabetes: formally called juvenile diabetesformally called juvenile diabetes develops in children and young adultsdevelops in children and young adults insulin producing cells in the pancreas insulin producing cells in the pancreas

become damaged by the body’s become damaged by the body’s immuneimmune system so insulin production is system so insulin production is impairedimpaired

affects almost I million people in the U.S. affects almost I million people in the U.S.

Types of diabetes: modern terminologyTypes of diabetes: modern terminology

► Type 2 diabetes:Type 2 diabetes: formally called adult onset diabetesformally called adult onset diabetes most common form: affects 8 to 9 million most common form: affects 8 to 9 million

people in the U.S.people in the U.S. develops at any age including childhooddevelops at any age including childhood begins with insulin resistance: muscle, liver, begins with insulin resistance: muscle, liver,

and fat cells do not use insulin properlyand fat cells do not use insulin properly at first the pancreas responds by making at first the pancreas responds by making

more insulin, but eventually its ability to more insulin, but eventually its ability to keep up is also impaired and blood glucose keep up is also impaired and blood glucose levels become poorly controlled.levels become poorly controlled.

Types of diabetes: modern terminologyTypes of diabetes: modern terminology

► Pre-diabetesPre-diabetes- blood glucose levels are higher than - blood glucose levels are higher than

normalnormal but not high enough to be but not high enough to be characterized as characterized as diabetes. diabetes.

- many people with pre-- many people with pre-diabetes develop diabetes develop diabetes within 10 diabetes within 10 years.years. - an increased risk - an increased risk of stroke and heart of stroke and heart disease has been disease has been noted.noted. - life style changes - life style changes e.g., exercise and weighte.g., exercise and weight loss can delay or loss can delay or prevent full blownprevent full blown

diabetes.diabetes.

Diabetes: diagnosisDiabetes: diagnosis

► Fasting blood glucose:Fasting blood glucose:- measures your blood glucose levels - measures your blood glucose levels

after after not eating for 8 hours. not eating for 8 hours.- a positive test should be - a positive test should be

confirmed by a confirmed by a repeat fasting glucose repeat fasting glucose on another dayon another day

►How to interpret the fasting glucose result:How to interpret the fasting glucose result:- less than 100: normal- less than 100: normal

- 100 to 125: pre-diabetes- 100 to 125: pre-diabetes- more than 125: - more than 125:

diabetesdiabetes

Risk factors for developing diabetesRisk factors for developing diabetes

► Age: 45 years or olderAge: 45 years or older►Obesity: body mass index greater than 25Obesity: body mass index greater than 25► Family history: parent or sibling with diabetesFamily history: parent or sibling with diabetes► Physical inactivityPhysical inactivity► Abnormal values for blood lipid levelsAbnormal values for blood lipid levels

- low HDL cholesterol: less than 35- low HDL cholesterol: less than 35 - - high triglyceride levels: more than 250high triglyceride levels: more than 250

► Family background: African American, Hispanic,Family background: African American, Hispanic,American Indian, or Asian AmericanAmerican Indian, or Asian American

► Presence of high blood pressurePresence of high blood pressure

Complications of diabetesComplications of diabetes

►Hypertension: 25% of diabetics have HTNHypertension: 25% of diabetics have HTN►Heart disease:Heart disease:

leading cause of deathleading cause of death accounts for 65% of deathsaccounts for 65% of deaths risk is 2x higher than those without diabetesrisk is 2x higher than those without diabetes

► Blindness:Blindness: leading cause of severe visual lossleading cause of severe visual loss approximately 12,000 new cases per year approximately 12,000 new cases per year

► Stroke: 2 to 4x the risk compared to non-Stroke: 2 to 4x the risk compared to non-diabeticdiabetic

Complications of diabetesComplications of diabetes

► Kidney disease: approximately 45% of Kidney disease: approximately 45% of people starting dialysis are diabetics.people starting dialysis are diabetics.

►Nerve injury:Nerve injury: referred to as neuropathyreferred to as neuropathy about 60% of diabetics are affectedabout 60% of diabetics are affected slow digestion of foodslow digestion of food reduced sensation or pain in arms and legsreduced sensation or pain in arms and legs foot infection from reduced sensation and foot infection from reduced sensation and

reduced immune response. This can lead reduced immune response. This can lead toto amputation.amputation.

Complications of diabetesComplications of diabetes

► Ketoacidosis and hyperosmolar states:Ketoacidosis and hyperosmolar states: when blood levels become very highwhen blood levels become very high occurs when glucose levels are poorlyoccurs when glucose levels are poorly

controlled or another stressful illness occurscontrolled or another stressful illness occurs

►Dental problems: increased risk of Dental problems: increased risk of periodontal disease.periodontal disease.

► Cost estimates of all the above Cost estimates of all the above complicationscomplications direct medical care costs $82 billion / yeardirect medical care costs $82 billion / year loss of work/early retirement costs $40 billion / loss of work/early retirement costs $40 billion /

yearyear

Causes of death associated with Causes of death associated with diabetesdiabetes

Treatment of diabetes: life style Treatment of diabetes: life style modificationsmodifications

► Regular exercise: 40 to 60 minutes at least Regular exercise: 40 to 60 minutes at least 5 times per week5 times per week unless contraindicated unless contraindicated by some other medical condition.by some other medical condition.

►Maintenance of proper weight: even small Maintenance of proper weight: even small amounts of weight loss can markedly amounts of weight loss can markedly improve glucose control.improve glucose control.

► Stop smoking to reduce risk of Stop smoking to reduce risk of cardiovascular events.cardiovascular events.

► Follow a proper diet: ask your doctor and Follow a proper diet: ask your doctor and dietician what is most appropriate for you.dietician what is most appropriate for you.

Drug treatment of diabetesDrug treatment of diabetes

► Type I: insulin is requiredType I: insulin is required short acting insulins: given before mealsshort acting insulins: given before meals long acting insulins: given once or twice a day. long acting insulins: given once or twice a day.

Glargine (Lantus), a new long acting insulin Glargine (Lantus), a new long acting insulin reduces the incidence of hypoglycemic (low reduces the incidence of hypoglycemic (low blood sugar) reactions.blood sugar) reactions.

► Type 2: try oral medications firstType 2: try oral medications first start with metformin or glyburidestart with metformin or glyburide add a thizolidinedione, e.g. rosiglitazone-Actosadd a thizolidinedione, e.g. rosiglitazone-Actos add insulin to the above if neededadd insulin to the above if needed

Measuring adequacy of diabetic control: Measuring adequacy of diabetic control: Hemoglobin A1C (hgb A1C)Hemoglobin A1C (hgb A1C)

► Hgb A1C measures the amount of glucose Hgb A1C measures the amount of glucose attached to red blood cells and reflects the attached to red blood cells and reflects the overall blood glucose control over the overall blood glucose control over the preceding 2-3 months. Normal value is less preceding 2-3 months. Normal value is less than 6.than 6.

► United Kingdom Prospective Diabetes Study United Kingdom Prospective Diabetes Study (UKPDS): a ten year study of 3,867 people (UKPDS): a ten year study of 3,867 people with newly diagnosed diabetes randomly with newly diagnosed diabetes randomly assigned to diet plus drugs to maintain either assigned to diet plus drugs to maintain either conventional or tight control of blood glucose.conventional or tight control of blood glucose.

Results of UKPDSResults of UKPDS

► Each 1% decrease in HGB A1c led to a decline Each 1% decrease in HGB A1c led to a decline of:of: 21% in any diabetic end point21% in any diabetic end point 21% in diabetes related death21% in diabetes related death 14 % in heart attack14 % in heart attack 37% in retinopathy and neuropathy37% in retinopathy and neuropathy

► Effect of blood pressure control:Effect of blood pressure control: tight control -145/80 vs. less intense control -tight control -145/80 vs. less intense control -

156/85156/85► Tight control resulted in a decrease of:Tight control resulted in a decrease of:

24% in any diabetic death24% in any diabetic death 15% in heart attack15% in heart attack 34% in retinopathy and neuropathy34% in retinopathy and neuropathy

Diabetes Prevention Study:NEJM.2002Diabetes Prevention Study:NEJM.2002

► A randomized study of 3,234 non-diabetic A randomized study of 3,234 non-diabetic people who had mild elevations in blood people who had mild elevations in blood glucose.glucose.

► They were randomly assigned to receive a They were randomly assigned to receive a placebo or metformin or life style placebo or metformin or life style modifications, i.e.,7% weight loss plus 150 modifications, i.e.,7% weight loss plus 150 minutes of exercise per week.minutes of exercise per week.

► After a 3-year average follow up:After a 3-year average follow up: placebo: 11% developed diabetesplacebo: 11% developed diabetes metformin: 31% reduction in diabetesmetformin: 31% reduction in diabetes life style modification: 58% reduction in life style modification: 58% reduction in

diabetesdiabetes

Target blood pressure and initial Target blood pressure and initial antihypertensive agent in diabetesantihypertensive agent in diabetes

Kidney Disease: Basic Functions of the Kidney Disease: Basic Functions of the KidneyKidney

► Two kidneys are normally present.Two kidneys are normally present.► Urinary excretion of waste products resulting from Urinary excretion of waste products resulting from

normal tissue breakdown and metabolism of food normal tissue breakdown and metabolism of food stuffs.stuffs.

► Maintenance of fluid balance by urinary excretion Maintenance of fluid balance by urinary excretion of water, salt, and other ingested substances of water, salt, and other ingested substances according amount ingested and environmental according amount ingested and environmental conditions.conditions.

► Endocrine functions including secretion of Endocrine functions including secretion of hormones which prevent anemia (erythropoietin), hormones which prevent anemia (erythropoietin), maintain bone integrity (vitamin D), and regulate maintain bone integrity (vitamin D), and regulate blood pressure (renin-angiotensin).blood pressure (renin-angiotensin).

Kidney Disease: Risk FactorsKidney Disease: Risk Factors

Clinical:Clinical: hypertensionhypertension diabetesdiabetes severe arteriosclerosissevere arteriosclerosis urinary tract obstructionurinary tract obstruction family historyfamily history autoimmune diseases: Lupus, polyarteritisautoimmune diseases: Lupus, polyarteritis infection: hepatitis B and C, AIDSinfection: hepatitis B and C, AIDS nephrotoxin exposure: NSAIDS, Chinese herbsnephrotoxin exposure: NSAIDS, Chinese herbs

Kidney Disease: Risk FactorsKidney Disease: Risk Factors

► Age > 60Age > 60► African Americans, American Indians, African Americans, American Indians,

Hispanic, AsianHispanic, Asian► Low income/educationLow income/education► Illicit drug use: cocaine, heroineIllicit drug use: cocaine, heroine

Clinical Assessment of Kidney InjuryClinical Assessment of Kidney Injury

► Symptoms:Symptoms: do not occur unless kidney is do not occur unless kidney is mechanically obstructed or infected; or until mechanically obstructed or infected; or until greater than 70% of kidney function has been greater than 70% of kidney function has been lost.lost.

► Serum creatinine and blood urea Serum creatinine and blood urea nitrogen (BUN)nitrogen (BUN) commonly measured with routine blood testscommonly measured with routine blood tests asses overall ability of the kidney to excrete asses overall ability of the kidney to excrete

waste productswaste products become abnormally elevated when kidneys become abnormally elevated when kidneys

are damagedare damaged

Clinical Assessment of Kidney InjuryClinical Assessment of Kidney Injury

►Proteinuria: Proteinuria: the appearance of the appearance of abnormally large amounts of protein in abnormally large amounts of protein in the urine may indicate kidney injury. the urine may indicate kidney injury. Methods of assessment include:Methods of assessment include: dipstick test of urinedipstick test of urine ratio of urinary albumin to urinary ratio of urinary albumin to urinary

creatinine ratio in spot specimen creatinine ratio in spot specimen (<3.0 is normal)(<3.0 is normal)

24-hr protein excretion (< 24-hr protein excretion (< 150mg./day is normal)150mg./day is normal)

Chronic Kidney Disease: Slowing the Chronic Kidney Disease: Slowing the Rate of ProgressionRate of Progression

► Control of hypertension:Control of hypertension: numerous large clinical studies have numerous large clinical studies have

documented a protective effect of good HTN documented a protective effect of good HTN control on slowing decline of kidney functioncontrol on slowing decline of kidney function

two related classes of drugs are recommended two related classes of drugs are recommended for initial therapy: angiotensin converting for initial therapy: angiotensin converting enzyme inhibitors (ACE) and angiotensin enzyme inhibitors (ACE) and angiotensin receptor blockers (ARB) receptor blockers (ARB)

► statins may also be effectivestatins may also be effective► Diabetes: good control of blood glucose levelDiabetes: good control of blood glucose level► Stop smokingStop smoking► Life style modifications: diet, weight controlLife style modifications: diet, weight control

Control of Hypertension in Kidney Control of Hypertension in Kidney Disease: Menon AJKD 2005Disease: Menon AJKD 2005

Kidney Disease: Cardiovascular Risk Kidney Disease: Cardiovascular Risk Menon AJKD 2005Menon AJKD 2005

What is obesity ?What is obesity ?

► A life log, progressive, life threatening, A life log, progressive, life threatening, costly, multifactorial disease of excess costly, multifactorial disease of excess fat storage.fat storage.

► Prevalence has increased dramatically Prevalence has increased dramatically in the past 10-15 years.in the past 10-15 years.

►Has contributed markedly to the Has contributed markedly to the increase in diabetes and high blood increase in diabetes and high blood pressure.pressure.

Increasing Prevalence of Obesity from Increasing Prevalence of Obesity from 1990 to 20001990 to 2000

The Thrifty Gene HypothesisThe Thrifty Gene Hypothesis

► Evolutionary pressure has selected people who Evolutionary pressure has selected people who can survive caloric deprivation.can survive caloric deprivation.

► In the past, people have been subjected to In the past, people have been subjected to circumstances in which periods of poor circumstances in which periods of poor nutritional intake were likely. Starvation was a nutritional intake were likely. Starvation was a real threat to individual and species survival.real threat to individual and species survival.

► Metabolic compensation for excess caloric Metabolic compensation for excess caloric intake apparently did not develop in humans.intake apparently did not develop in humans.

► Increase in obesity: no recent genetic changes Increase in obesity: no recent genetic changes but rather increase in caloric intake and less but rather increase in caloric intake and less compensatory physical activity.compensatory physical activity.

Basic principles in caloric balanceBasic principles in caloric balance

► If more calories are consumed than If more calories are consumed than expended, body weight will increase.expended, body weight will increase.

► If less calories are consumed than If less calories are consumed than expended, body weight will decrease.expended, body weight will decrease.

► If caloric intake equals caloric expenditure, If caloric intake equals caloric expenditure, body weight stays the same.body weight stays the same.

► Total caloric intake determines weight Total caloric intake determines weight gain or loss, not the relative amounts of gain or loss, not the relative amounts of protein, fat, and carbohydrates in a diet.protein, fat, and carbohydrates in a diet.

What are the numbers?What are the numbers?

► Energy expenditure to maintain ideal Energy expenditure to maintain ideal body weight ( average values ):body weight ( average values ): 62 62 calories/ lb.calories/ lb. men: 2100 – 2400 cal/daymen: 2100 – 2400 cal/day women: 1600-1800 cal/daywomen: 1600-1800 cal/day

► Energy expenditure with exercise:Energy expenditure with exercise: walking 1 mile: 100 calorieswalking 1 mile: 100 calories running 1 mile: 100 caloriesrunning 1 mile: 100 calories

► An expenditure of 3500 calories is An expenditure of 3500 calories is required to lose a pound of body weight.required to lose a pound of body weight.

► We are very thrifty in terms of calories!We are very thrifty in terms of calories!

Caloric content of common foodsCaloric content of common foods

► 20 oz. bottle of coke: 240 cal.20 oz. bottle of coke: 240 cal.► Slice of cheese pizza: 250 cal.Slice of cheese pizza: 250 cal.► Big mac, large fries, large coke: 1,450 Big mac, large fries, large coke: 1,450

cal.cal.► Sausage and cheese bisquet sandwich: Sausage and cheese bisquet sandwich:

450 cal.450 cal.► Turkey breast sandwich, bag of chips, Turkey breast sandwich, bag of chips,

and water: 460 cal.and water: 460 cal.► 1 dozen buffalo wings: 850 cal.1 dozen buffalo wings: 850 cal.► 1 cup of Haggen Dazs ice cream: 560 1 cup of Haggen Dazs ice cream: 560

cal.cal.► Krispy Kreme donut: 300 cal.Krispy Kreme donut: 300 cal.

Health risk associated with obesityHealth risk associated with obesity

Body Mass Index TableBody Mass Index Table

Strategies for treatment of obesityStrategies for treatment of obesity

►Dietary control of total caloric intake:Dietary control of total caloric intake: self awareness about eating habitsself awareness about eating habits failure to change may indicate latent failure to change may indicate latent

emotional or psychological issuesemotional or psychological issues

► Regular exercise: concrete strategiesRegular exercise: concrete strategies►Drugs used for obesity:Drugs used for obesity:

sibutramine (Meridia)sibutramine (Meridia) orlistat (Xenical)orlistat (Xenical)

Low-Carbohydrate versus Conventional Low-Carbohydrate versus Conventional Weight Loss Diets in Severely Obese AdultsWeight Loss Diets in Severely Obese Adults

[Annals of Internal Med. May, 2004] [Annals of Internal Med. May, 2004]

► A one year study of 132 patients randomly A one year study of 132 patients randomly assigned to either a low carbohydrate or assigned to either a low carbohydrate or conventional diet.conventional diet.

►Weight loss was similar in both groups.Weight loss was similar in both groups.►More patients in the low carb. diet lost More patients in the low carb. diet lost

weight because the drop out rate was weight because the drop out rate was higher in the conventional group.higher in the conventional group.

► Lipid changes were more favorable in Lipid changes were more favorable in conventional group.conventional group.

►HGB AiC declined more in the low carb. HGB AiC declined more in the low carb. group.group.

Obesity treatmentObesity treatment

►SurgerySurgery►Consider if obesity is severe and not Consider if obesity is severe and not

responsive to other treatmentresponsive to other treatment►Morbid obesity: when other severe Morbid obesity: when other severe

medical problems occur as a direct medical problems occur as a direct result of obesity. When one is > 100 result of obesity. When one is > 100 lb. overweight or BMI is > 40.lb. overweight or BMI is > 40.

►May be done by open technique or May be done by open technique or laprascopically.laprascopically.

Present nomenclature for obesity Present nomenclature for obesity according to Body Mass Index (BMI)according to Body Mass Index (BMI)