1. The Obesity/Diabetes Epidemic: Adiposopathy & Obesity- The New Disease! Dx & (Rx) of Insulin Resistance & early DM Part 3 Stan Schwartz MD, FACP, FACE Private Practice, Ardmore Obesity Program Cardiometabolic Diabetes Center and Affiliate,

2. Increasing Caloric Intake Over time in USA Energy Intake (kcal) NHANES 1 (1971-74) NHANES 2 (1976-80) NHANES 3 (1988-94) NHANES 4 (1999-2002) All 1968 ± 201942 ± 162172 ± 182205 ± 16 Men 2420 ± 302409 ± 262627 ± 272616 ± 22 Women 1537 ± 171503 ± 131741 ± 141820 ± 20 Kant AK. Am J Clin Nutr. 2006:84:1215-23.

3. Health Benefits of Modest Weight Loss (5-10%)  Decreased cardiovascular risk  Decreased blood glucose and insulin levels  Decreased blood pressure  Decreased LDL and triglycerides, increased HDL  Decrease in severity of sleep apnea  Reduced symptoms of degenerative joint disease  Improvement in gynecologic conditions  Multiple cardiovascular risk factors and other complications can be improved. Source: The Practical Guide to the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults..

5. The “Toxic Environment” Physical Activity is… –To be avoided –Nearly unnecessary –Limited by infrastructure Brownell KD & Horgen KB. Food Fight. New York: McGraw-Hill; 2003.

6. Burning a lot less energy (per half hour) in 2004 vs 1984 Calories Burned 2004Calories Burned 1984 Lift (2 mins) 3Take Stairs 19 Order take away 1Cook Meal 70 Load Dishwasher 23Wash Up 80 Watch TV 35Play Cards 52 Go to car wash 35Wash Car 104 Play Video Game 53Play Basketball 280 Ride Lawn Mower 88Mow Lawn 193

7. Outline Epidemiology and Economics of obesity/diabetes Perspectives on Obesity Consequences of Obesity, Prediabetes, Obesity Obesity/ Diabetes Risk Factors Obesity/ Diabetes Onset can be Prevented or Delayed – Early Risk Identification and Intervention. Medical Benefits to Weight Loss Treatment-CDC’s diabetes prevention program and other Evidence-Based Interventions- –Basics, –Next Lecture in Series

8. Medical Complications of Obesity Phlebitis venous stasis

9. Obesity and Metabolic Syndrome: A Cluster of Coronary Heart Disease Risk Factors Adapted from Grundy SM. J Clin Endocrinol Metab. 2005;89:2595-2600. Raised Blood Pressure Autonomic Dysfunction Proinflammatory State Obesity Insulin Resistance Genetic Susceptibility Diet,Physical Inactivity and Stress All potentiate the genetic susceptibility to obesity Prothrombotic State  Small Low-Density Lipoprotein Particles  High-Density Lipoprotein Cholesterol  Triglycerides Atherogenic Dyslipidemia Slide Source: Obesityonline.org

10. Overweight Overweight and Obesity Increase the Risk of CV Disease Mortality Data are from 1 million men and women (average age, 57 years) followed for 16 years who never smoked and had no history of disease at enrollment. Calle EE, et al. N Engl J Med. 1999;341:1097-1105. Normal weightObese Relative Risk of Cardiovascular Disease Mortality 0.6 3.0 2.6 2.2 1.8 1.4 1.0 >18 25 30 >40 BMI, kg/m 2 Women Men

11. Folsom et al. Arch Intern Med 2000;160:2117. Body Mass Index Tertile 32 3 1 1 2 Relative Risk Waist-Hip Ratio Tertile Abdominal Fat Distribution Increases the Risk of Coronary Heart Disease The Iowa Women ’ s Health Study

12. Elevated Visceral Fat Metabolically more active Greater effect on visceral organs –Greater Insulin Resistance hyperinsulinemia impaired glucose tolerance Type 2 diabetes –Hyperlipidemia Hypertriglyceridemia Hypercholesterolemia –Hypertension NORMAL Diabetic

13. The Adipocytokine Syndrome: A New Model for Insulin Resistance and ß-Cell Dysfunction Muscle Pancreas Liver Brain Visceral fat cells FFA, TNF  Leptin Leptin Sns FFA, TNF  IL-6 Angiotensinogen, PAI-1 Adiponectin CRP, PAI-1 Atherothrombosis FFA, TNF  Adiponectin Artery FFA Resistin, TNF  ObesityIRDiabetesASVD