1. Assessment of the Obesity Epidemic

2. More than 60% of US Adults Are Overweight
Obese (BMI ≥ 30)
Overweight (BMI )
Flegal K, et al. JAMA 2002;288: Hedley AA, et al. JAMA 2004;291:

3. Assessing Obesity: What Is BMI?
Calculated as weight(kg)/height(m2)
Evaluates weight relative to height
Replaced % ideal body weight as the primary criterion for assessing obesity
Correlates significantly with body fat, morbidity, and mortality
Category
BMI
Underweight
< 18.5
Normal*
18.5 – 24.9
Overweight
25.0 – 29.9
Obesity
≥ 30.0
Class I
30.0 – 34.9
Class II
35.0 – 39.9
Class III
≥ 40.0
The BMI, easily calculated by office staff, should be an essential part of the
patient work-up
BMI
Is calculated as weight divided by height squared
Evaluates weight relative to height
Has replaced % ideal body weight as the primary criterion for assessing obesity
Correlates significantly with % of total body fat, morbidity, and mortality
Conversion tables are available so calculations are done for you
Today, calculating the BMI in all patients is considered to be state-of-the-art medicine
Today, there are successful, proven approaches for controlling obesity
Knowing the BMI is the first step to categorizing the patient’s overweight and obese status
Repeated calculations lead to understanding the patient’s trends for risks associated with obesity
Waist circumference is an additional measure of the level of risk associated with obesity
Classification for BMI - see file 1
NIH Natl Heart, Lung, and Blood Inst. Obes Res. 1998;6(suppl 2):51S.
Willett WC et al. N Engl J Med. 1999;341:427.

4. Prevalence of Obesity by Age
Men
Women
Flegal et al. JAMA 2002;288:

5. Obesity Trends by Gender and Ethnicity
Men
Women
Flegal K, et al. JAMA 2002;288:

6. Prevalence of Obesity by Education and Income
23.00
23.50
24.00
24.50
25.00
25.50
26.00
26.50
27.00
27.50
Average BMI
1986
1988
1990
1992
1994
1996
1998
2000
2002
Year
Lowest
Highest
Average BMI 22 23 24 25 26 27 28
1986
1988
1990
1992
1994
1996
1998
2000
2002
Year
No High School
High School
Some College
College
Flegal et al. JAMA 2002;288:

7. Prevalence of Extreme Obesity (BMI ≥ 40) by Gender and Ethnicity
Men
Women
Hedley AA, et al. JAMA 2004;291:

8. Prevalence of Overweight in Children and Adolescents
Flegal K, et al. JAMA 2002;288: Hedley AA, et al. JAMA 2004;291:

9. Obesity and Coronary Heart Disease (CHD)
Morbidity mortality
Morbidity mortality
Morbidity mortality
Hypertension
Diabetes
Dyslipidemia
40% are obese
80% are obese
50% – 70% are obese
OBESITY

10. Trends in Cardiovascular Risk Factors in Obese Individuals (BMI ≥ 30 kg/m2 )
High Blood Pressure
Smoking
High Cholesterol
Diabetes
Gregg EW, et al. JAMA 2005;293:

11. Obesity Is Caused by Long-Term Positive Energy Balance
Fat
stores
Energy
expenditure
Energy
intake

12. Regulation of Body Weight
Genes confer the potential for obesity
Environment determines whether and to what extent the potential is realized

13. Weight Classification of Adoptees
Relationship Between Adoptee Weight and Weight of Biological or Adoptive Parents 27 21 26 25 24 23 22
Biological Parents
Adoptive Parents
BMI of Parents (kg/m2)
Fathers
Mothers
Thin Median Overweight Obese
Thin Median Overweight Obese
Weight Classification of Adoptees
Stunkard et al. N Engl J Med 1986;314:193.

14. Heritability of Body Weight

15. Components of Daily Energy Expenditure
Thermic effect of feeding
Resting energy expenditure
Energy expenditure of physical activity 8%
17% 8%
32%
75%
60%
Sedentary person
(1800 kcal/d)
Physically active person
(2200 kcal/d)

16. Decreased Energy Expenditures
and Weight Gain
Low RMR
Middle RMR
High RMR 1 2 3 4 5 10 15 20 25 30
Cumulative Incidence of a
10-kg Body Weigh Gain (%)
Time (years)
RMR = resting metabolic rate
Ravussin E, et al. N Engl J Med. 1988;318:

17. Barsh GS, Schwartz MW. Nat Rev Genet. 2002;3:589-600.

18. Gene-Environment Interaction in the Pathogenesis of Obesity
Body Mass Index (kg/m2) 10 20 30 40 50
p <
Pima Indians in
Maycoba, Mexico
Pima Indians in
Arizona
Ravussin E et. al. Diabetes Care 17:1067, 1994.

19. The Toxic Environment Food is… Highly accessible Inexpensive
Advertised heavily
High fat, high sugar
Delicious

20. 16 oz
32 oz
44 oz
52 oz
64 oz
1 oz ≈ 12 calories

21. Food Portion Size Trends5 10 15 20
Salty
Snacks
Desserts
Soft
Drinks
Fruit
French
Fries
Ham-
burgers
Cheese-burgers
Pizza
Mexican
Food
Food Intake per Eating Occasion, oz
Nielsen & Popkin, JAMA 2003.

22. Prevalence of Obesity by Hours of TV per Day
NHES Youth Aged 12 to 17 in and
NLSY Youth Aged 10 to 15 in 1990 5 10 15 20 25 30 35 40
TV hours per day (youth report)
Prevalence (%)
NHES
NLSY 1990
0 - 1
1 - 2
2 - 3
3 - 4
4 - 5
> 5

23. Daily Physical Education
% of Children with
Daily Physical Education
American Academy of Pediatrics.

24. Responding To The Obesity Epidemic
• Create a child-healthy environment
• Banish junk food from schools
• Reduce food ads directed at children
• Increase opportunities for physical activity

25. Psychological Factors and Obesity
• Moral problem?
• Psychological problem?
• Aesthetic problem?
• Social and medical problem?

26. Psychosocial Status of Obese Individuals
Most obese individuals have normal psychological status
Persons who seek weight loss report greater distress
Patients at greatest risk of depression:
Women
Extreme obesity (BMI ≥ 40 kg/m2)
Binge eating disorder (BED)
Friedman & Brownell. Psych Bull 1995;117:3-20.

27. Risk of Major Depression with Extreme Obesity
Onyike, et al. Amer J Epidemiology 2003;158:

28. Bodily Pain and Depression in Obese Individuals (N = 306)
BDI-II Score
Fabricatore AF. Obes Surg 2005; 15:

29. Prejudice Against the Obese
Six-year old children labeled silhouettes
of an overweight child as:
Lazy
Dirty
Stupid
Ugly
Cheats
Lies
Staffieri. J Per Social Psychol 1967;7:101.

30. Prejudice Against the Obese
1961
2001 1
Healthy* 2
Healthy
Crutches
Face*
Mean Rank 3
Wheelchair
Crutches*
Hand
Hand 4
Face
Wheelchair*
Obese 5
Obese* 6
Latner, JD, Stunkard, AJ. Obes Res 2003;11:454.

31. Discrimination Against the Obese
Discrimination has been reported in:
Student Selection
Employee Selection
Employee Pay and Promotion
Tenant Selection
Marriage
Roehling MV. Personnel Psychology 1999; 52:

32. Discrimination in the Workplace
Discrimination against obese does not violate federal law in the US
Title VII in US protects people from discrimination based on race, color, religion, sex, or national origin
Obesity is not a protected characteristic

33. Social Stigma and Obesity:
“I’d Rather Go Blind”
Patients who lost 45 kg or more
Preferred to be normal weight with a major handicap (deaf, dyslexic, diabetic, legally blind, bad acne, heart disease, leg amputated) than to be morbidly obese
Rather be normal weight than a morbidly obese multi-millionaire
Rand CS. Macgregor AM. Int J Obesity 1991; 15:577.

34. Conclusion
The epidemic of obesity is the result of a complex interplay of genetic, environment, cultural, and economic factors
Greater efforts are needed to change the environment that lies at the heart of the epidemic
Obese individuals should not be blamed for their condition, but instead be treated with respect, fairness, and compassion