1. 1 OBESITY

2. 2 Definition A BMI of 25.0 to 29.9 kg per m2 is defined as overweight; a BMI of 30.0 kg per m2 or more is defined as obesity.

3. 3 Historical Perspective Paleolithic Era > 25,000 years ago

4. 4 Obesity - How Big A Problem… 1.7 billion worldwide are overweight or obese The US has the highest percentage of obese people. By 2006, only four states had a prevalence of obesity less than 20%. And the numbers are growing…

5. 5 Epidemiology of Obesity 31.3% of U.S. males 34.7% of U.S. females 30% increase in the last 10 years Health care costs - >$100 billion/year Results in 300,000 preventable deaths each year in the U.S.

6. 6 Obesity and Life Expectancy If current rates of obesity are left unchecked, the current generation of American children will be the first in two centuries to have a shorter life expectancy than their parents. Olshansky SJ, et al. A Potential Decline in Life Expectancy in the United States in the 21 st Century. NEJM, 352(11):1138- 1145, 2005

7. 2000 Obesity Trends* Among U.S. Adults BRFSS, 1990, 2000, 2010 (*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%

8. Obesity Trends* Among U.S. Adults BRFSS, 1985 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

9. Obesity Trends* Among U.S. Adults BRFSS, 1986 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

10. Obesity Trends* Among U.S. Adults BRFSS, 1987 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

11. Obesity Trends* Among U.S. Adults BRFSS, 1988 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

12. Obesity Trends* Among U.S. Adults BRFSS, 1989 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

13. Obesity Trends* Among U.S. Adults BRFSS, 1990 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

14. Obesity Trends* Among U.S. Adults BRFSS, 1991 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

15. Obesity Trends* Among U.S. Adults BRFSS, 1992 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

16. Obesity Trends* Among U.S. Adults BRFSS, 1993 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

17. Obesity Trends* Among U.S. Adults BRFSS, 1994 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

18. Obesity Trends* Among U.S. Adults BRFSS, 1995 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

19. Obesity Trends* Among U.S. Adults BRFSS, 1996 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

20. Obesity Trends* Among U.S. Adults BRFSS, 1997 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%

21. Obesity Trends* Among U.S. Adults BRFSS, 1998 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%

22. Obesity Trends* Among U.S. Adults BRFSS, 1999 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%

23. Obesity Trends* Among U.S. Adults BRFSS, 2000 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%

24. Obesity Trends* Among U.S. Adults BRFSS, 2001 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

25. (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) Obesity Trends* Among U.S. Adults BRFSS, 2002 No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

26. Obesity Trends* Among U.S. Adults BRFSS, 2003 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

27. Obesity Trends* Among U.S. Adults BRFSS, 2004 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

28. Obesity Trends* Among U.S. Adults BRFSS, 2005 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

29. Obesity Trends* Among U.S. Adults BRFSS, 2006 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

30. Obesity Trends* Among U.S. Adults BRFSS, 2007 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

31. Obesity Trends* Among U.S. Adults BRFSS, 2008 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

32. Obesity Trends* Among U.S. Adults BRFSS, 2009 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

33. Obesity Trends* Among U.S. Adults BRFSS, 2010 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

34. 34 Classification of Overweight and Obesity BMI Classification BMI Classification <18.5 Underweight –18.5-24.9 Normal weight –25-29.9Overweight –30-34.9Obesity Class I –35-39.9Obesity Class II –40-49.9Obesity Class III –50 and aboveSuper Obesity

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36. 36 What causes Obesity? Nutrient and Energy model of obesity: Metabolism Appetite regulation Energy expenditure Genetics Behavioral and cultural factors

37. 37 Contributors to weight gain Socio-economic status Smoking cessation Hormonal Inactivity Psychosocial/emotions Medications

38. 38 Nutrient and Energy Model of Obesity Obesity results from increased intake of energy or decreased expenditure of energy, as required by the first law of thermodynamics. Energy Intake Adipose tissue Energy Expenditure

39. 39 Medical Complications of Obesity Pulmonary disease abnormal function obstructive sleep apnea hypoventilation syndrome Nonalcoholic fatty liver disease steatosis steatohepatitis cirrhosis Gall bladder disease Gynecologic abnormalities abnormal menses infertility PCOS Osteoarthritis Gout Phlebitis venous stasis Cancer breast, uterus, cervix colon, esophagus, pancreas kidney, prostate Severe pancreatitis CHD Diabetes Dyslipidemia Hypertension Cataracts Stroke

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41. 41 Consequences of Obesity Hippocrates recognized that : “sudden death is more common in those who are naturally fat than in lean.”

42. 42 Treating Obesity Measure height and weight (BMI) Calculate waist circumference Assess comorbidities What labs does the patient need? Is the patient ready and motivated enough to loose weight? Which diet should you recommend? Discuss a physical activity goal

43. 43 Weight Loss Strategies Diet therapy Increased Physical Activity Pharmacotherapy Behavioral Therapy Surgery Any combination of the above

44. 44 Rate Of Weight Loss A realistic goal is from 5% to 15% from baseline in 6 months of obesity treatment. Weight should be lost at the rate of 1- 2 lbs per week, based on the caloric deficit between 500-1000 Kcal/day.

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46. 46 Dieting Dieting is highly ineffective - 95% long term failure rate Often results in higher weight than before the diet

47. 47 Principles Of Dieting Women should consume atleast 1200 kcal/day, men 1500 kcal/day. Select a diet that has: >75g/day proteins (15% of total calories) > 55% total calories from carbs ▪ Fat should contribute 30% or less of total calories Atleast 3 meals/day. High fiber (20-30g/day), fruits and vegetables. Supplement the diet with multivitamis and minerals. Avoid sugar containing beverages and fat spreads.

48. What about all the diets that are out there? Weight Watchers ($13 registration fee, $15 weekly fee) Jenny Craig (consultation $200-370, $65 meals/week) Tops Club ($20/week) Nutrisystem.com ($50/week) Atkins Diet 48

50. Medications A) Serotonin Nor-epinephrine Reuptake Inhibitor: reduces food intake. Sibutramine: initial dose 10mg/day, max 20mg/day. B) Orlistat: Lipase inhibitor. Alters metabolism, dec absorption of dietary fat. 120mg PO TID 50

52. Surgery Roux-en-Y gastric bypass. Lap band procedure Criteria : a) BMI > 40 or >35 with 2 comorbidities. b) Failure of non surgical methods c) Presence of 2 or more medical conditions that would benefit with weight loss. 52

55. 55 Obesity warning on London buses The United Kingdom Branch of the International Size Acceptance Association is encouraging the public to contact World Cancer Research Fund UK to voice their concerns about this discriminating ad campaign.

56. ICD 9 Codes Obesity: 278 Morbid Obesity: 278.01 Overweight: 278.02 56

57. Questions??