1. The Obesity/Diabetes Epidemic: Adiposopathy & Obesity- The New Disease! Dx & (Rx) of Insulin Resistance & Early DM (Part 1) Stan Schwartz MD, FACP, FACE Private Practice, Ardmore Obesity Program Cardiometabolic Diabetes Center and Affiliate, Main Line Health System Emeritus, Clinical Associate Professor University of Pennsylvania

2. Disclosures Advisor Takeda, Amylin, A-Z, BMS, Novo. Merck, Santarus Speaker Lilly, Amylin, Takeda, Novo, BMS, Santarus Merck, Astra-Zeneca

3. Duggal, Evidence-Based Medicine in Practice,, Int’l j. Clinical Practice,65:639-644,2011 Lecture Based on Evidence -Based PRACTICE = = EBM=Evidence Based Medicine Has Led to Students/MDs who don’t Think =Evidence Based Practice = = EBM=Eviden ce Based Medicine Research Evidence Randomized, Prospective Publication Trials Critical Appraisal Patient-Based Experience Clinical expertise Expert Opinions Guidelines +

4. Body Mass Index –Evaluates weight relative to height (kg/m 2 ) –Correlates highly with body fat, morbidity, and mortalit y Categories –Underweight (< 18.5 kg/m 2) –Normal weight (18.5-24.9 kg/m 2 ) –Overweight (25.0-29.9 kg/m 2 ) –Class I Obesity (30.0-34.9 kg/m 2 ) –Class II Obesity (35.0-39.9 kg/m 2 ) –Class III Obesity (> 40 kg/m 2 ) NIH National Heart, Lung, and Blood Institute. Obes Res. 1998;6(suppl 2):51S Defining Obesity- A Disease, ADA 6/2013

5. Waist Circumference correlates with BMI- but BMI not closely correlated with IR- Leads to…. Even some HIGH BMI FOLK have normal IR

6. Leads to Concept- Metabolically Healthy Obese

8. Date of download: 12/14/2013 Copyright © American College of Physicians. All rights reserved. Are Metabolically Healthy Overweight and Obesity Benign Conditions?: NO!! THUS= OXYMORON Ann Intern Med. 2013;159(11):758-769. doi:10.7326/0003-4819-159-11-201312030-00008 Meta-analyses of various clinical characteristics, by metabolic–body mass index categories. Data shown as weighted mean difference compared with metabolically healthy normal- weight persons (reference). To convert cholesterol, triglyceride, and glucose values to traditional units (mg/dL), divide by 0.0259, 0.0113, and 0.0555, respectively. HOMA-IR = Homeostasis Model Assessment of Insulin Resistance.* P < 0.05.

10. Obesity Paradox some long-term studies have shown that weight loss in overweight and obesity is associated with increased mortality coupled with many CV studies showing a better prognosis with a higher BMI suggested that purposeful weight loss may not be beneficial and may even be detrimental in patients with CV diseases In contrast, other studies assessing mortality based on body fat and lean mass suggested that subjects losing body fat rather than lean mass have a lower mortality Potential adverse effects of weight loss may be explained by wrong methods of wt. loss. eg: starvation, very-low-calorie diets, liquid protein diets, and obesity surgeries have been associated with prolongation of the QTc interval and increased risk of malignant dysrhythmias (1), and various pharmacologic agents have either limited efficacy or considerable toxicity (70-72).17072 Overwhelming evidence supports the importance of obesity in the pathogenesis and progression of CV disease. Although an obesity paradox exists,, the constellation of data still support purposeful weight reduction in the prevention and treatment of CV diseases Carl J. Lavie, MD; Richard V. Milani, MD; Hector O. Ventura, MDJ Am Coll Cardiol. 2009;53(21):1925-1932. CHF outcomes better if Obese

11. Obesity Paradox :Metabolically Healthy Obese Patients still has Increased CV rates and All Cause mortality And have other adverse outcomes related to DJD and Sleep Apnea, for example

12. 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

13. Overweight and Obesity Prevalence Increasing Among U.S. Adults Flegal KM et al. JAMA 2002;288:1723-27 Hedley AA et al. JAMA 2004;291:2847-50 Ogden CL et al. JAMA 2006;295:1549-55

14. Leads to Diabetes Epidemic

15. An Expensive Epidemic 56 million Americans have a BMI of 30-40 –Had healthcare costs 36 percent greater than normal-weight individuals –Had pharmacy costs 77 percent greater than normal-weight individuals Nearly 10% of annual medical spending was for overweight and obese patients Total medical cost for obesity in 2003 was $75 billion. Finkelstein,Jan/2004Obesity Research Sturm, Ph.D. Archives of Medicine

16. Direct Cost* of Chronic Diseases in the United States *Adjusted to 1995 dollars. Wolf and Colditz. Obes Res 1998;6:97. Hodgson and Cohen. Med Care 1999;37:994. 0 10 20 30 40 50 60 Type 2 Diabetes Obesity Coronary Heart Disease Hypertension Stroke $51.6 Direct Cost (Billions $)* $38.7 $18.4 $18.1 $53.2