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

Obesity: The Epidemic

Patrick McBride, MD, MPH

Professor

UW Medical School

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

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

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!)

Obesity* Trends Among U.S. AdultsBRFSS, 1991

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

No Data <10% 10%-14% 15-19% 20%

Source: BRFSS, CDC.



Source: BRFSS, CDC.

No Data <10% 10%-14% 15-19% 20%



No Data <10% 10%-14% 15-19% 20%

Source: BRFSS, CDC.



Source: BRFSS, CDC.

No Data <10% 10%-14% 15-19% 20%



No Data <10% 10%-14% 15-19% 20%

Source: BRFSS, CDC.



Source: BRFSS, CDC.

No Data <10% 10%-14% 15-19% 20%



No Data <10% 10%-14% 15-19% 20%

Source: BRFSS, CDC.



Source: BRFSS, CDC.

No Data <10% 10%-14% 15-19% 20%

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

C hildhood obesity predicts adult obesity*C hildhood obesity predicts adult obesity*

1519

12

36

11

55

10

75

9

67

0

20

40

60

80

Percent obese as young

adult (at age 21 to 29 yrs)

1-2 yr 3-5 yr 6-9 yr 10-14 yr 15-17 yr

Age

Not obese

Obese

Obesity: Causes and Consequences

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

0

1

2

3

4

5

1967 1983

Hoursperday

• is sedentary• takes away time from other activities• associated with eating

68% increaseVideo Games and Children. ERIC Digest

Children’s Television Resource & Education Center

0

1

2

3

4

5

1981 2000

Mealsoutperweek

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 food27% sit down restaurants24% convenience stores(USDA 1995)

SmallSmall MediumMedium LargeLarge Super-SizeSuper-Size

1950-601950-60 200200caloriescalories

1970’s1970’s 200200caloriescalories

320320caloriescalories





20002000 450450caloriescalories



The History of French Fries in AmericaThe History of French Fries in America

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

Diabetes Mellitus in the US:Increasing Prevalence of Diagnosed Cases

Pe

rso

ns

Wit

h D

iag

no

sed

D

iab

ete

s (

mill

ion

s)

8

7

6

5

4

3

2

1

0

1958 1963 1968 1979 1984 1989 1994

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

What to do?

• Individuals

• Families

• Industry

• Schools

• Policymakers

• Government

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

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 & physical activity to reverse

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

Waist CircumferenceWaist 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

New Emphasis of ATP III:The Metabolic Syndrome

Risk FactorAbdominal Obesity

MenWomen

TriglyceridesHDL cholesterol

MenWomen

Blood pressureSerum glucose

Defining LevelWaist Circumference

> 40 inches > 35 inches

> 150 mg/dL

< 40 mg/dL< 50 mg/dL> 130/ 85 mmHg> 110-125 mg/dL

Accelerated atherosclerosis

Clinical diabetes

Hyperinsulinemia Impairedglucose

tolerance

HypertriglyceridemiaDecreased HDL-C

Essentialhypertension

Insulin resistance

Insulin Resistance and Atherosclerosis

Obesity Preventionand

Management

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

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

Diabetes Preventionin 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

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, insulinNEJM 2003;348:383-

93

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

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?

Achieve Ideal Body Weightor

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

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

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)

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

Websites for PatientsAtkins 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

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

Body Mass Index (kg/m2)

Dose - Response Risk Relationship

Underweight < 18.5

Normal 18.5 - 25

Overweight 25 - 30

Obese > 30 – Class I 30 - 34.9– Class II 35 - 39.9– Class III >40

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

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

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