OBESITY: TRENDS AND IMPLICATIONS

Mark Skillan, M.D. ACSW – SEAC November 18, 2011

“ Obesity: Time bomb or dud? ”

USA Today

“ Obesity as an over-hyped crisis ”

Boston News

“ The supposed detrimental effects of obesity are actually exaggerated…”

Spektrum der Wissenschaft

“ The rising prevalence and severity of obesity are capable of offsetting the positive influences on longevity ”

New England Journal of Medicine

“ Obese children may have a lower life expectancy than their parents ”

New York Times

“ Obesity may stall trend of increasing longevity ”

Washington Post

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Obesity in the media

Obesity – A growing concern

Obesity Defined

Prevalence

Etiology

Health Consequences

Morbidity and Mortality Implications

Interventions & Challenges

The Future

OBESITY: AN INSURER’S CONCERN

Relation between mortality and body mass index

5

At a body mass index below 20 kg/m2 and above 25 kg/m2 there is an increase in relative mortality for men and women. Data from Lew, EA. Ann Intern Med 1985; 103:1024

OBESITY DEFINED

Overweight and obesity defined

Overweight: having extra body weight, for a particular height, from fat, muscle, bone, or water.

Obesity: having a high amount of excess body fat.

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Methods of detecting overweight and obesity

Scale

Skin-fold thickness

Waist circumference

Waist-to-hip circumference ratios

Body Mass Index (BMI)

- BMI = weight (in kgs) / height squared (in meters)

- Practical measure

- Accepted internationally (NHLBI, CDC, WHO, etc)

- Does not differentiate between lean mass and adiposity

- Based on statistical norms

Imaging techniques

Classification of weight - adult

BMI Description Class of obesity Example 1.74 m

18.5 or less Underweight - less than 56 kg

18.5 – 24.9 Normal weight - 56 kg - 75 kg

25.0 – 29.9 Overweight 0 75 kg - 90 kg

30.0 – 34.9 Obesity I 90 kg - 106 kg

35.0 – 39.9 Obesity II 106 kg - 121 kg

40 or higher Extreme obesity III more than 121 kg

Body Mass Index (BMI) Weight (kg) Height (m2)

Classification of weight - child and adolescent

Category Youth (2-20 yrs) Underweight BMI <5th percentile for age Normal weight BMI 5th to <85th percentile Overweight BMI 85th to <95th percentile Obesity BMI ≥ 95th percentile Class III obesity (super obesity) Not used*

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Source: AAP: American Academy of Pediatrics; IOM: Institute of Medicine; ES: Endocrine society; CDC: Centers for Disease Control; IOTF: International obesity task force. * In children, a proposed definition of severe obesity is BMI > 120 percent of the 95th percentile.

PREVALENCE

Past and projected prevalence of overweight by country

Source: The Lancet 2011; 378:815-825 (DOI:10.1016/S0140-6736(11)60814-3)

2000

*BMI ≥30, or about 30 lbs. overweight for 5’4” person

2010

1990

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

Obesity trends* among U.S. adults BRFSS, 1990, 2000, 2011

Source: Behavioral Risk Factor Surveillance System, CDC.

Obesity & overweight prevalence 2010

Obesity

- Adults (BMI > 30): 33.8% (32.2% men, 35.5 % women)

- Children & Adolescents (ages 2-19) – 16.4%

Overweight and Obesity

- Adults (BMI > 25): 68 % (72.3% men, 64.1% women)

- Children & Adolescents (ages 2-19): 34.6%

Increasing percentage of those with BMI > 40

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Smoothed frequency distributions of body mass index for men and women aged 40 to 59 years in 1999-2000 and 2007-2008

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Source: Flegal, K. M. et al. JAMA 2010;303:235-241

Obesity – not only an adult concern…

Conditions now more commonly seen in children

High cholesterol

Type 2 Diabetes/Impaired Glucose Tolerance

High blood pressure

Social problems and poor self-esteem

Sleep disturbances

Orthopaedic problems

A major concern -

Obese children and adolescents are at increased risk to become overweight or obese adults

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Rising prevalence of overweight children (5-11)

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For this figure, the prevalence of overweight children is defined as the percent of children aged 5 to 11 with BMI > 85 percentile, using IOTF standards. IOT: International Obesity Task Force. Reproduced with permission from: Lobstein, T, Rigby, N, Leach, R. International Obesity Task Force. EU platform diet, physical activity, and health. International Obesity Task Force EU Platform Briefing Paper. Brussels 2005. Copyright © 2005 European Association for the Study of Obesity.

Percentage of overweight children, ages 5 – 11

Source: International Obesity Task Force (IOTF), London, March 2005

0

5

10

15

20

25

30

1950 1960 1970 1980 1990 2000 2010

Netherlands Germany USA England Poland France

Percentage of U.S. children and adolescents classified as obese, 1963-2008*

0

5

10

15

20

1963-70** 1971-74 1976-80 1988-94 1999-2000 2001-02 2003-06 2007-08

Ages 6-11 Ages 12-19

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*>95th percentile for BMI by age and sex based on 2000 CDC BMI-for-age growth charts. ** 1963-1970 data are from 1963-1965 for children 6-11 years of age and from 1966-1970 for adolescents 12-17 years of age. Source: NCHS. Health, United States, 2010:With Special Feature on Death and Dying. Hyattsville, MD.2011

Global prevalence of overweight in boys 2000-2006

% Overweight < 5%

5 – 9.9% 10 – 14.9% 15 – 19.9% 20 – 24.9% 25 – 29.9%

≥30%

Source: IASO/IATF

ETIOLOGY

Causes of obesity

Calories Ingested

Calories Burned

Factors contributing to obesity

Genetics

Environment

Unhealthy diet

Sedentary lifestyle

Lack of physical activity

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Etiology of overweight and obesity

Weight Gain Follows Caloric Imbalance

- Calories Ingested (food + beverage) >

- Calories Expended (bodily functions + physical activity)

Determinants of Body Weight

- Genes and pre-natal factors

- Metabolism

- Behavior – food choices, eating habits, activity choices, sleep habits

- Environment – advertising

- Culture – ethnic differences

- Socioeconomic status – educational level

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HEALTH CONSEQUENCES

Health consequences of obesity

Coronary Heart Disease

Type 2 Diabetes

Cancers

Hypertension

Lipid Disorders

Stroke

Liver and Gall Bladder Disease

Sleep apnea

Osteoarthritis

Infertility

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Obesity affects longevity via associated diseases

Stroke

Coronary heart disease

Left ventricular hyper-

trophy

Diabetes mellitus

Gyn abnormalities

Fatty liver

Cholelithiasis

Hypertension

Pulmonary disease

Sleep apnea

Depression

Arthroses

Pancreatitis

Malignant tumors

Back pain

Musculoskeletal

Dyslipidemia

Prevalence of cardiovascular disease risk factors* in adults, USA 1961-2000

0

10

20

30

40

50

60

70

1960 1965 1970 1975 1980 1985 1990 1992 1995 2000

Year

Perc

ent o

f Pop

ulat

ion

Overweight Hypertension Smoking High Cholesterol

Source: NIH, NHLBI, Fact Book Fiscal Year 2003. Feb. 04

(*age adjusted)

MORBIDITY AND MORTALITY IMPLICATIONS

0

10

20

30

40

50

60

70

<22 22-22,9 23-23,9 24-24,9 25-26,9 27-28,9 29-30,9 31-32,9 33-34,9 >=35

BMI

Relative risk

Nurses Health Study: n=100,000 16 yr follow=up

Relationship between BMI and Risk of Type 2 Diabetes

Prevalence of diabetes worldwide Percentage of people aged ≥ 20 with diabetes in 2000

15% and above 10% - 14.9% 5% - 9.9% below 5% no data

Source: WHO, 2007

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Relative Risk, All-Cause Mortality for A 1 C Levels

From Khaw, K, et al, Annals of Internal Medicine. 2004; 141(6):413

0.5

1

1.5

2

2.5

3

3.5

4

< 5 % 5 - 5.4 % 5.5 - 5.9 % 6.0 - 6.4 % 6.5 - 7.0 %

Women

Men

Risk

Ratio

Diabetes

Relative Risk, All-Cause Mortality for A 1 C Levels

From Khaw, K, et al, Annals of Internal Medicine. 2004; 141(6):413

0.5

1

1.5

2

2.5

3

3.5

4

< 5 % 5 - 5.4 % 5.5 - 5.9 % 6.0 - 6.4 % 6.5 - 7.0 %

Women

Men

Risk

Ratio

Diabetes

Relation between age and rates of CHD with and without diabetes

20 0

40

60

80

100

120

140

160

180

200

220

240

Age (years)

Source: The Lancet, Vol. 368, July 1, 06 retrospective cohort, n=9MM

Num

ber o

f eve

nts

per 1

000

pers

on-y

ear

Diabetes, recent AMI No diabetes, recent AMI

Increase in diseases attributable to rising obesity levels

0

10

20

30

40

50

60

70

80

2005 2010 2015 2020 2025 2030 2035

Time (years)

Incr

ease

%

Coronary heart disease Stroke Diabetes

Source: Foresight 2007, K. McPherson, University of Oxford; adjusted for age and gender

Obesity and cancer risk

Women Men

Endometrium RR=5.42 Prostate RR=1.29

Cervix RR=2.39 Colorectal RR=1.73

Breast RR=1.53

Gall bladder RR=3.58

Possible causes:

1. Hormonal changes

Gynecological tumors, prostate

2. Dietary intake (e.g. high fat content)

Intestinal tract, gall bladder

Relative risk of death in relation to BMI, age 50

0

0.5

1

1.5

2

2.5

3

3.5

18.5 20.9 23.4 24.9 26.4 27.9 29.9 34.9 39.9 >40

Rel

ativ

e R

isk

BMI

Men Women

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Source: Adams KF, et al, NEJM 2006 355;8:763-778.

Relative risk of death in relation to BMI, ages 50 to 71

0

0.5

1

1.5

2

2.5

18.5 20.9 23.4 24.9 26.4 27.9 29.9 34.9 39.9 >40

Rel

ativ

e R

isk

BMI

Men Women

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Source: Adams KF, et al, NEJM 2006 355;8:763-778.

COSTS

Obese and overweight: 9.1 % of total annual US medical expenditures

Obese (BMI > 30) annual medical expenditures 36% higher than BMI 18.5-25

Grade III obesity – 3% workforce, 21% of obesity costs

Estimated annual employer cost of obesity per 1000 employees $285,000Associated medical care costs: $147 Billion (Finklestein, 2009)

Excess third party costs vs. normal weight: $1,429/yr.

Obesity costs

Obesity costs

Indirect Costs: Absenteeism, Disability, Premature mortality, “Presenteeism”, Workmen’s Comp…

BMI > 40: 11.65 WC claims/100 FTE’s (vs. 5.8 for “normal” weight)

- 184 lost work days/100 FTE’s (vs. 14)

- Medical claims $51,000/100FTE’s (vs. $7500)

- Indemnity claims $59,000/100 FTE’s (vs. $5400)

Commonest claims: limbs, back / pain, sprain / falls, lifting

(Duke Health & Safety Surveillance System)

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INTERVENTIONS AND CHALLENGES

Therapeutic goals

Weight loss

Normalize blood sugar

Improve lipids

Slow or halt progression of coronary heart disease

Reduce or resolve obstructive sleep apnea

Improve sense of well-being

Reduce cancer risk

Reduce liver and gall bladder disease risk

Improve fertility

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Interventions and challenges

Treatment goals – reduce or prevent complications associated with obesity

Interventions

Dietary modification

Exercise

Behavior modification

Drug therapy

Surgery

- Liposuction

- Bariatric Surgery

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Weight loss-induced reduction in blood pressure

0

2

4

6

8

10

>-9.5 -4.5 to -9.5 -2 to -4.5 +1 to -2 >+1

Fall

in d

iast

olic

BP,

mm

Hg

Weight change, kg

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Relationship between the quantity of weight lost and the fall in diastolic blood pressure in 308 moderately obese patients given a weight reduction regimen for 18 months. The patients began with a diastolic pressure between 80 and 89 mmHg; those who lost the most weight had the largest reduction in diastolic pressure. The decreases in the systolic pressure were similar. Source: Data from Stevens, VJ, Corrigan, SA, Obarzanek, E, et al, Arch Intern Med 1993; 153:849.

Importance of body weight and exercise on development of type 2 diabetes

0

20

40

60

<24 24-25.9 >26

Rat

e of

type

2 d

iabe

tes

per 1

0,00

0 pa

tient

-yea

rs

Body mass index, kg/m2

<500 kcal/wk 500-1999 kcal/wk >2000 kcal/wk

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Adjusted incidence of type 2 diabetes mellitus in 5990 men in relation to body mass index (BMI, in kg/m2) and the level of physical activity (in kcal/wk). The risk of type 2 diabetes was directly related to BMI, while regular exercise was protective except for men with a BMI below 24. Source: Data from Helmrich, SP, Ragland, DR, Leung, RW, Paffenbarger, PS, N Engl J Med 1991; 325:147.

THE FUTURE

100 million obese now –> 165 million by 2030

50% American Men Obese by 2030

US healthcare spending will rise by $66 Billion a year

Potential decline in US Life expectancy?

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Projections for 2030 if historical trend continues

Measures to be considered

1. Tax on unhealthy food and beverages

2. Promote good nutrition

3. Promote physical activity

4. Limit or ban junk food advertising

Conclusions

Explosion of obesity is a global problem

Obesity related disorders a growing problem for the foreseeable future

Childhood obesity is a special concern for both the intermediate and long term

Life: Trend reversal on longevity in the intermediate term cannot be excluded

Living benefits: increasing morbidity in the intermediate term appears assured

Without concerted interventions, outlook challenging

Continuous monitoring of epidemiologic trends necessary

References

1. Prevalence and Trends in Obesity Among US Adults, 1999-2008 - Flegal, KM, et al, Journal of the American Medical Association. 2010; 303(3):235-241

2. Body Mass Index in a Prospective Cohort of U.S. Adults, Calle, EE, et al, New England Journal of Medicine. 1999; 341(15): 1097-1105

3. Mortality and Morbidity Liaison Committee – ISCS Body Mass Index Study – Roudebush, B, et al, Journal of Insurance Medicine. 2006; 38:167-180

4. Mortality and Weight: Insured Lives and the American Cancer Society Studies. Lew, E A, Annals of Internal Medicine. 1985; 103(6): 1024-1029

5. Overweight, Obesity and Mortality in a Large Prospective Cohort of Persons 50-71 Years Old - Adams, KF, et al, New England Journal of Medicine. 2006; 355(8): 763-778

References (continued)

7. Excess Deaths Associated With Underweight, Overweight and Obesity – Flegal, KM, et al, JAMA. 2005; 293(15): 1861-1867

8. Cause-Specific Excess Deaths Associated with Underweight, Over weight and Obesity – Flegal, KM, et al, JAMA. 2007; 298(17): 2028-2037

9. Body Mass Index and Mortality in an Insured Population – Niverthi, M., et al, Journal of Insurance Medicine. 2001; 33: 321-328

10. Body Mass Index and Mortality Among 1.46 Million White Adults – Berrington deGonzalez, A., et al, New England Journal of Medicine 2010; 363(23): 2211-2219

11. Obesity and Mortality – Calle, E, et al, New England Journal of Medicine. 2005; 353(20):2197-99

12. Adolescent BMI Trajectory and Risk of Diabetes Versus Coronary Artery Disease – Tirosh, A., et al, New England Journal of Medicine. 2011; 364(14): 1315-1325

10/11/2011 51 Title of presentation and name of speaker

References (continued)

13. Childhood Obesity, Other Cardiovascular Risk Factors and Premature death – Franks, P., et al New England Journal of Medicine. 2010; 326(6): 485-493

14. A Potential Decline in Life Expectancy in the United States in the 21st Century – Olshansky, SJ, et al, New England Journal of Medicine. 2005; 325(11): 1138-1145

15. Deadweight ? – The Influence of Obesity on Longevity – Preston, SH, New England Journal Of Medicine. 2005; 352(11): 1135-1137

16. Obesity and Its Relation to Mortality and Morbidity Costs – Behan, D, et al, Society of Actuaries. December 2010

17. Obesity and Workers’ Compensation - Ostbye, T, et al, Archives of Internal Medicine. 2007; 167(8):766-773

18. Indirect Costs of Obesity: a review of the current literature - Trogdon, JG, et al; Obesity Reviews. 2008; 9: 489-500

References (continued)

19. Occupation-Specific Absenteeism Costs Associated with Obesity and Morbid Obesity – Crawley, J, et al, Journal of Occupational and Environmental Medicine. 2007; 49:1317-1324

20. Annual Medical Spending Attributable to Obesity: Payer- and Service-Specific Estimates - Finklestein, EA, et al, Heath Affairs 2009; 28(5): w822-w831

21. The Cost of Obesity Among Full-time Employees – Finklestein, E, et al, American Journal of Health Promotion. 2005; 20(1): 45-50

22. Medical Disability Advisor – 6th edition, Reed, P, et al

23. Health and Economic Burden of the Projected Obesity Trends in the U.S. and U.K. – Yang, Y, et al, The Lancet. 2011; 378(9793): 815-825

Calculation of BMI

English formula for BMI: [ Weight in pounds ÷ Height in inches ÷ Height in inches ] × 703 Metric formula for BMI: Weight in Kilograms ÷ Height in meters ÷ Height in meters

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