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Ob itObesity: Causes, Consequencess & Treatments & …Gout ations of Obesity Idiopathic intracranial...
Transcript of Ob itObesity: Causes, Consequencess & Treatments & …Gout ations of Obesity Idiopathic intracranial...
Ob itObesity: ConsequencesConsequences
Gary D. Foy
Center for ObesEduc
Temple University
C Causes, s & Treatments & Treatment
oster, Ph.D.
ity Research and cationSchool of Medicine
OvervOverv
1. Discriminat2 P l2. Prevalence3. Consequenq4. Treatment5 Expectation5. Expectation
viewview
tionences
nsns
Obesity Trends* ABRFSSBRFSS
(*BMI ≥30, or ~ 30 lbs. ov
No Data <10% 10%–14%
Among U.S. AdultsS 1985S, 1985
erweight for 5’ 4” person)
Obesity Trends* ABRFSSBRFSS
(*BMI ≥30, or ~ 30 lbs. ov
No Data <10% 10%–14%
Among U.S. AdultsS 1986S, 1986
erweight for 5’ 4” person)
Obesity Trends* ABRFSSBRFSS
(*BMI ≥30, or ~ 30 lbs. ov
No Data <10% 10%–14%
Among U.S. AdultsS 1987S, 1987
erweight for 5’ 4” person)
Obesity Trends* ABRFSSBRFSS
(*BMI ≥30, or ~ 30 lbs. ov
No Data <10% 10%–14%
Among U.S. AdultsS 1988S, 1988
erweight for 5’ 4” person)
Obesity Trends* ABRFSSBRFSS
(*BMI ≥30, or ~ 30 lbs. ov
No Data <10% 10%–14%
Among U.S. AdultsS 1989S, 1989
erweight for 5’ 4” person)
Obesity Trends* ABRFSSBRFSS
(*BMI ≥30, or ~ 30 lbs. ov
No Data <10% 10%–14%
Among U.S. AdultsS 1990S, 1990
erweight for 5’ 4” person)
Obesity Trends* ABRFSSBRFSS
(*BMI ≥30, or ~ 30 lbs. ov
No Data <10% 10%–14% 15%–19%
Among U.S. AdultsS 1991S, 1991
erweight for 5’ 4” person)
Obesity Trends* ABRFSSBRFSS
(*BMI ≥30, or ~ 30 lbs. ov
No Data <10% 10%–14% 15%–19%
Among U.S. AdultsS 1992S, 1992
erweight for 5’ 4” person)
Obesity Trends* ABRFSSBRFSS
(*BMI ≥30, or ~ 30 lbs. ov
No Data <10% 10%–14% 15%–19%
Among U.S. AdultsS 1993S, 1993
erweight for 5’ 4” person)
Obesity Trends* ABRFSSBRFSS
(*BMI ≥30, or ~ 30 lbs. ov
No Data <10% 10%–14% 15%–19%
Among U.S. AdultsS 1994S, 1994
erweight for 5’ 4” person)
Obesity Trends* ABRFSSBRFSS
(*BMI ≥30, or ~ 30 lbs. ov
No Data <10% 10%–14% 15%–19%
Among U.S. AdultsS 1995S, 1995
erweight for 5’ 4” person)
Obesity Trends* ABRFSSBRFSS
(*BMI ≥30, or ~ 30 lbs. ov
No Data <10% 10%–14% 15%–19%
Among U.S. AdultsS 1996S, 1996
erweight for 5’ 4” person)
Obesity Trends* ABRFSSBRFSS
(*BMI ≥30, or ~ 30 lbs. ov
No Data <10% 10%–14% 15%–19% ≥20%
Among U.S. AdultsS 1997S, 1997
erweight for 5’ 4” person)
%
Obesity Trends* ABRFSSBRFSS
(*BMI ≥30, or ~ 30 lbs. ov
No Data <10% 10%–14% 15%–19% ≥20%
Among U.S. AdultsS 1998S, 1998
erweight for 5’ 4” person)
%
Obesity Trends* ABRFSSBRFSS
(*BMI ≥30, or ~ 30 lbs. ov
No Data <10% 10%–14% 15%–19% ≥20%
Among U.S. AdultsS 1999S, 1999
erweight for 5’ 4” person)
%
Obesity Trends* ABRFSSBRFSS
(*BMI ≥30, or ~ 30 lbs. ov
No Data <10% 10%–14% 15%–19% ≥20%
Among U.S. AdultsS 2000S, 2000
erweight for 5’ 4” person)
%
Obesity Trends* ABRFSSBRFSS
(*BMI ≥30, or ~ 30 lbs. ov
No Data <10% 10%–14% 15%–19% 20%
Among U.S. AdultsS 2001S, 2001
erweight for 5’ 4” person)
–24% ≥25%
Obesity Trends* ABRFSS
(*BMI ≥30, or ~ 30 lbs. ov
BRFSS
No Data <10% 10%–14% 15%–19% 20%
Among U.S. AdultsS 2002
erweight for 5’ 4” person)
S, 2002
–24% ≥25%
Obesity Trends* ABRFSSBRFSS
(*BMI ≥30, or ~ 30 lbs. ov
No Data <10% 10%–14% 15%–19% 20%
Among U.S. AdultsS 2003S, 2003
erweight for 5’ 4” person)
–24% ≥25%
Obesity Trends* ABRFSSBRFSS
(*BMI ≥30, or ~ 30 lbs. ov
No Data <10% 10%–14% 15%–19% 20%
Among U.S. AdultsS 2004S, 2004
erweight for 5’ 4” person)
–24% ≥25%
Obesity Trends* ABRFSSBRFSS
(*BMI ≥30, or ~ 30 lbs. ov
No Data <10% 10%–14% 15%–19% 20%
Among U.S. AdultsS 2005S, 2005
erweight for 5’ 4” person)
–24% 25%–29% ≥30%
Obesity Trends* ABRFSSBRFSS
(*BMI ≥30, or ~ 30 lbs. ov
No Data <10% 10%–14% 15%–19% 20%
Among U.S. AdultsS 2006S, 2006
erweight for 5’ 4” person)
–24% 25%–29% ≥30%
Medical ComplicPulmonary diseasePulmonary diseaseabnormal functionabnormal functionobstructive sleep apneaobstructive sleep apneahypoventilation syndromehypoventilation syndrome
p
hypoventilation syndromehypoventilation syndrome
Nonalcoholic fatty liver Nonalcoholic fatty liver diseasediseasesteatosissteatosissteatosissteatosissteatohepatitissteatohepatitiscirrhosiscirrhosis
G ll bl dd diG ll bl dd di
Gynecologic abnormalitiesGynecologic abnormalitiesabnormal mensesabnormal mensesinfertilityinfertility
Gall bladder diseaseGall bladder disease
infertilityinfertilitypolycystic ovarian syndromepolycystic ovarian syndrome
OsteoarthritisOsteoarthritis
SkinSkin
GoutGout
cations of ObesityyIdiopathic intracranial Idiopathic intracranial hypertensionhypertension
StrokeStroke
Coronary heart diseaseCoronary heart diseaseDiabetesDiabetes
CataractsCataracts
DyslipidemiaDyslipidemiaHypertensionHypertension
Severe pancreatitisSevere pancreatitis
CancerCancerbreast, uterus, cervixbreast, uterus, cervixcolon esophagus pancreascolon esophagus pancreas
Severe pancreatitisSevere pancreatitis
colon, esophagus, pancreascolon, esophagus, pancreaskidney, prostatekidney, prostate
PhlebitisPhlebitisvenous stasisvenous stasis
Direct Cost* of Chthe United Sthe United S
80$71.4$83.3
60
70
ns $
)*
$
50
Cos
t (B
illio
n
30
40
Dire
ct C
Type 2 Diabetes
Obesity CHe
11 ADA Diabetes Care, 2003;26:917 ADA Diabetes Care, 2003;26:917 44. . Hodgson TA Hodgson TA 22 Finkelstein EA, Obes Res 2004;12Finkelstein EA, Obes Res 2004;12 55 Yelin & CallahYelin & Callah33 Hodgeson TA et al.Hodgeson TA et al. Medical Care 1999:37:994.Medical Care 1999:37:994.
hronic Diseases in States (2006)States (2006)
$59.2
$31.9 $27.0
Coronaryart Disease
Hypertension Arthritis
A et al. Med Care 2001;39:599A et al. Med Care 2001;39:599han. Arthritis Rheum 1995;38:1351han. Arthritis Rheum 1995;38:1351
Who is Paying and Paid for OverweiPaid for Overwei
•Annua•Ovwt
•Insurance Category
8
•7•Ovwt
P i t
•Out-of-Pocket
•8
•8
•Medicaid
•Private
•1•Medicare
•9•Total
How Much is being ight and Obesity?ight and Obesity?al Cost (%) & Obesity
•Amount ($ billions) Ovwt
8 2%
7.3%& Obesity
$19 8
•$7.1($,billions) Ovwt
& Obesity
8.8%
8.2%
•$3.7
•$19.8
1.1% •$20.9
9.1% •$51.5
Finkelstein et al. Health Affairs.May 2003:219
Obesity’s Growing Prevaare Impacting Private Heare Impacting Private He
••Percent of Obese Adults•Spending Attributable to
• Spending per member (dollar
Spending Attributable to Obesity
• Private insurance spending (billions, USD)
• % of private insurance spendin
Thorpe, KE et al. Health Affairs, 2005;W5-317-325:
alence & Treatment Costs ealth Insurance Spendingealth Insurance Spending
•2002•1987•23.83•12.6120021987
•1,244•272s)
•36.5•3.6
•11.6•2.0ng
–Major Cost Dri–PrevalenceS i–Severity
–AgingAging–Each Unit IncrAssociated witin Health Carein Health Care
1. Raebel MA, et al. Arch Intern Med 2004;164:2135-2140
ivers of Obesity are:
rease in BMI is th a 2.3% Increase
e Costs 1e Costs.1
Obesity is Ass
Mean Annual WGreater Loss in
Men
5.355.18 5.5
Healthy Weight OvHealthy Weight Ov
sociated with a
Work Days Lostn Productivity
8.82Women
5.856.22
verweight Obese
Thompson, D.et al. Am J Health Promot 1998;12:120-127
verweight Obese
Percent UnabAnd, Greater Ra
Men
5.65.9
4 7 5.64.7
Healthy Weight OvHealthy Weight Ov
le to Workates of Disability
9.612.6
Women
7.9
verweight Obese
Thompson, D.et al. Am J Health Promot 1998;12:120-127
verweight Obese
Behaviora
•Dietary iny•Physical y
al Factors
ntakeactivityy
Environmen• MarketingMarketing
–Bigger packages, muquantity limitsquantity limits
–Bigger equals cheap»“Supersize”»22 oz soda for $2.$$3.00
–All-you-can-eat buffeAll you can eat buffe
ntal Factors
ultiple unit pricing,
per
50 versus 44 oz for
etsets
EnergyEnergy personal computersp pcellular phonesshopping by phones opp g by p o ephone extensionsescalators/elevatorsescalators/elevatorsdrive-thru windowsintercomsintercomsremote controls
SaversSaverstele-commutingge-mail/Internet food delivery servicesood de ve y se v cesdishwasherscable moviescable moviescomputer gamesmoving sidewalksmoving sidewalksgarage door openers
Obesity TryGuidel
The Practical GuideThe Practical Guidecan be found at:can be found at:can be found at:can be found at:
NHLBI web site:www.nhlbi.nih.gov
The Obesity Society y yweb site:www.obesity.org
reatment lines
Guide for Selecting
BMI CBMI C
Treatment 25-26.9 27-29.9
Diet, Exercise, B h i T + +Behavior Tx + +Pharmaco-th
With cobidittherapy morbidit
SurgerySurgery
The Practical Guide: Identification, Evaluation, andObesity in Adults. October 2000, NIH Pub. No.00-4
g Obesity Treatment
Category (kg/mCategory (kg/m22))
9 30-34.9 35-39.9 >40
+ + ++ + +o-i + + +ies + + +
With co-biditi +morbidities +
Treatment of Overweight and 4084
Self-Monitorin
• Types of foodsyp• Portion sizes• Calories (redu• Times places• Times, places• Thoughts and g
ng Food Intakeg
s
ce by 500 kcal/d)and activities, and activities
moods
Changes in BChanges in B4
0
2
t (kg
)
4
-2
n W
eigh
t
-6
-4
Cha
nge
in
-80 0.5 1 1.5 2
C
YeaDiabetes Preventio
Body WeightBody Weight
PlaceboPlacebo
Metformin
Lif lLifestyle
2.5 3 3.5 4
aron Program Research Group. N Engl J Med 2002;346,393-403
Diabetes Preve40
30
denc
e%
)
20
ativ
e In
cid
iabe
tes
(%
10Cum
ula
of D
i
00 0.5 1.0 1.5 2.0
Diabetes Prevention Program Research Group. N E
Ye
ention ProgramgPlacebo
MetforminMetformin
Lifestyle
2.5 3.0 3.5 4.0
Engl J Med. 2002;346,393-403.
ar
Portion-ContPortion Cont
• Provide fixed-portion• Reduce choices and c
f dfoods• Are convenient to us• Satisfy appetite (mon
ifi i )specific satiety)• Facilitate dietary adhFacilitate dietary adh
trolled Mealstrolled Meals
n and calorie amountscontact with problem
senotony and sensory
herenceherence
Meal Replacements Long term WLong-term W
Phase 1*
0
Phase 1
t Los
s CF
5
MR-2age
Wei
ght
15
10
Perc
enta
*1200–1500 kcal/d diet prescription.CF=conventional foods.
15
T0 2 4 6 8 10
MR-2=replacements for 2 meals, 2 snacks daily.MR-1=replacements for 1 meal, 1 snack daily.
Enhance Initial and Weight LossWeight Loss
Phase 2Phase 2
MR-1
Time (mo)12 18 24 30 36 45 51
Ditschuneit et al. Am J Clin Nutr 1999;69:198.Fletchner-Mors et al. Obes Res 2000;8:399.
The Dieter’s Dilemma
Calories oCalories o• N: 43
W k 6 (i ti• Weeks: 6 (inpati• Diets: Isocalori
(15% vs.• Weight Loss: 8 9 + 0• Weight Loss: 8.9 + 0.
or Carbs?or Carbs?
t)ent) ic (1000 kcal/d) ( ). 45% CHO) 6 kg 7 5 + 0 5 kg6 kg 7.5 + 0.5 kg
Golay. IJO, 1996.
Weight Loss –g
1
-3-1
e
9-7-5
Cha
nge
*
-13-11-9%
C
**
-15
hm ster
aha
*
Breh
Foste
Samah
Y
*
– 6 Months
LowLow-CarbohydrateLow-Calorie
ncy
*
Yanc
Weigh1 Y
0
3-2-10
6-5-4-3
hang
e
9-8-7-6
% C
h
-11-10-9
-12Foster Stern Dan
ht LossYear
Low-CarbLow-Cal
Foster et al. NEJM, 2003.,
Stern et al Ann Intern Med, 2004,
nsingerDansinger et al. JAMA 2005
Lip1 Year C1 Year C
1520 *
05
10
-15-10-5
Cha
nge
-30-25-20%
Choles
terol
LDL
HDL
Total
Ch
pidsChangesChanges
Low-Carb FosterLow-Cal FosterLow Carb-SternLow Cal-Stern
*
*
*
*
iglyc
eride
s *
Trig
Foster et al. NEJM, 2003., Stern et al Ann Intern Med, 2004
Antiobesity AgenWorkWork
ReleasingAgent
5-HT NE DA
Agents
Dexamphetamine
Phentermine
5-HT NE DA
+++
+++
++
++Sibutramine
Orlistat
1Bray GA Ann Intern Med 1993;119(7 pt 2):707 2Beales PL Kopelma
5-HT = serotonin; NE = noradrenaline; DA
1Bray GA. Ann Intern Med. 1993;119(7 pt 2):707. 2Beales PL, Kopelma3Buckett WR et al. Prog Neuropsychopharmacol Biol Psychiatry. 1988;14Drent ML et al. Int J Obes Relat Metab Disord. 1995;19:221. 5Heal DJ
nts: How They kk
Selective
A
ReuptakeInhibitor
5-HT NE DA
SelectiveLipase
Inhibitor
A
++
++
5-HT NE DA
+++
+++
+++ +
an PG PharmacoEconomics 1994;5(suppl 1):18
A = dopamine
an PG. PharmacoEconomics. 1994;5(suppl 1):18. 12:575. J et al. Psychopharmacology (Berl). 1992;107:303.
Drugs ApproveTreatingTreating
Status Gene
Rx Sibu
Status Gene
Rx OrlRx Orl
OTC OrOTC Or
(Approved 2/07)
Approved in Europe Ri
but not U.S.
ed by FDA for ObesityObesity
eric Name Trade Name
utramine Meridia
eric Name Trade Name
istat Xenicalistat Xenical
rlistat 60mg allirlistat 60mg alli
imonabant Acomplia/Zimulti
STORM
230 Weight Loss230
(lb)
225
220
210y W
eigh
t ( 220
215
Bod
y
205
200
1950 2 4 6 8 10
Adapted with permission from James WPT et al. Lancet. 2000;356:2
*Same diet, exercise for sibutramine, placebo;P 0.001, sibutramine vs placebo for weight mainten
M Trial
Weight Maintenance
Placebo
Sib t i
12 14 16 18 20 22 24Month
Sibutramine
2119.
nance
STORM: ChangeBaseline to 24 MonBaseline to 24 Mon
Treatmen
SibBP, mm Hg
SystolicDiastolic
Pulse rate (bpm)
James WPT et al. Lancet. 2000;356:2119.
e in Vital Signs—nths in Sibutraminenths in Sibutramine nt Group
Mean Changebutramine Placebo
0.1 –4.72.3 –1.64.1 –1.9
STORM: Safety % f P ti t R% of Patients R
Weight Loss Phas(n=605)
Infection 14Flu syndrome 7Headache 23Increased appetite 4Pharyngitis 7Dry mouth 39Constipation 19Asthenia 6Insomnia 12
*Frequency of 10% in any treatment group; reporteJames WPT et al. Lancet. 2000;356:2119.
and Tolerability—R ti AE *Reporting AEs*
Weight Maintenance PhaseWeight Maintenance Phasese Placebo Sibutramine
(n=115) (n=352)22 2210 1418 1412 1413 133 94 911 73 8
ed as therapy-related
Orlistat: Weight LosO 2 YOver 2 Y
0–1 Placeb
Orlista–2–3–4–5ei
ght (
%)
P<0.001 vs
Orlista
5–6–7–8–9in
Bod
y W
e
–9–10–11–12C
hang
e
SB DB
–10 0 10 20 30 40
W
Adapted with permission from Sjöström L et al. Lancet. 1998;352:167
Slightlyhypocaloric diet
SB = single blind; DB = double blind
s and Maintenance YYearsboat
s placebo at 1 and 2 years
at
DB
50 60 70 80 90 110100
Week
7.
Weightmaintenance
(eucaloric) diet
Orlistat: Safety—Aat 1at 1
40Pla
30Orl
Pla
31%
20%
20%
105%
7%
0Fatty/Oily
StoolIncreasedDefecation
Sjöström L et al. Lancet. 1998;352:167.
• There is concern about fat-soluble vitamin absorp
Adverse Events (AEs) YearYear
acebo n=340
listat, n=343
acebo, n 340
18%
1%3%
10%7%
OilySpotting
FecalUrgency
FecalIncontinence
1% 0%
ption
Use OTC
alli vs. XUse OTC
Dosage 60 mg
Target Pop Overweight
Indication Weight Loss
A R 18Age Range 18+
GI AEs(withdrawal rates) 3 2(withdrawal rates) 3.2
Behavioral myalliplan.com S t PSupport Program
Rx
XenicalRx
120 mg
BMI > 27 kg/m2 or > 30kg/m2
(w/ co-morbidities) or (without)
Weight Loss & Maintenance
1212+
5 45.4
Xenicare
Goals for WGoals for W
“The initial goal of weoverweight patients isoverweight patients isweight of about 10%…of this magnitude canof this magnitude canthe severity of obesity-as
Weight LossWeight Loss
eight loss therapy fora reduction in bodya reduction in body
…moderate weight losssignificantly decreasesignificantly decreasessociated risk factors.”
NHLBI, 1998
Subject Chaj
60 obese women160 obese women1
40.0 + 8.7 years
99.1 + 12.3 kg
BMI = 36.3 + 4.3 kg/m2
aracteristics
397 obese individuals2397 obese individuals354 women43 men
43.1 + 10.9 years
109.0 + 28.9 kg
BMI = 39.3 + 9.5 kg/m2
1Foster et al. JCCP 65(1) 79-85 19972Foster et al Arch Int Med. 161 2133-2139 2001
Goal WGoal W• Averaged 32% reductig• Three times greater th
d d b h Nrecommended by the NScience and Departmep
• Greatly exceeds weightreatments
WeightsWeightsion in body weighty g
han the goals N i l A d fNational Academy of ent of Agricultureght losses of nonsurgical
Defined W
Dream WeightA weight you would choose if
wanted.
Happy WeightThis weight is not as ideal as
however, that you would be happy to
Acceptable WeightA weight that you would not b
that you could accept, since it is less
Disappointed WeightA weight that is less than you
could not view as successful in any wcould not view as successful in any wthis were your final weight after the p
Fo
Weights
you could weigh whatever you
the first one. It is a weight, o achieve.
be particularly happy with, but one s than your current weight.
r current weight, but one that you way. You would be disappointed ifway. You would be disappointed if program.
oster et al, J Consult Clin Psychol, 1997
Defined W
19971997% Reduc
Dream 38%Dream 38%Happy 31%Acceptable 25Acceptable 25Disappointed 17%
1Foster et al. JCCP 65(1) 79-85 19972Foster et al Arch Int Med. 161 2133-2
Weights
7 20017 2001ction1 % Reduction2
% 38 4%% 38.4%% 30.9%% 24 9%% 24.9%% 15.7%
2139 2001
% Achieving Defined WW i ht lWeight loss:
Acceptable
24%24%
420%Disappointed 4
F
Weights at Week 48 (N=45)16 3 + 7 2 k: 16.3 + 7.2 kg
HappyHappy
D 0%9%
Dream = 0%
Did not reach47% Did not reach Disappointed Weight
47%
Foster et al, J Consult Clin Psychol, 1997.
Principles anp• Simplicityp y
– EngagementE ll– Enrollment
– Implementation p• Structure
– Duration – IntakeIntake–Activity
nd Practices
Principles anp• Accountabilityy
EmployeesE lEmployers
• IncentivesEnrollmentParticipation/SuccessParticipation/Success
nd Practices
Principles anp• Expectationsp
– Weight– Non-weightNon weight– Fees
nd Practices