Disease X in 1985 No Data <10% 10%–14%
Disease X in 1985
No Data <10% 10%–14%
Disease X in 1986
No Data <10% 10%–14%
Disease X in 1987
No Data <10% 10%–14%
Disease X in 1988
No Data <10% 10%–14%
Disease X in 1989
No Data <10% 10%–14%
Disease X in 1990
No Data <10% 10%–14%
Disease X in 1991
No Data <10% 10%–14% 15%–19%
Disease X in 1992
No Data <10% 10%–14% 15%–19%
Disease X in 1993
No Data <10% 10%–14% 15%–19%
Disease X in 1994
No Data <10% 10%–14% 15%–19%
Disease X in 1995
No Data <10% 10%–14% 15%–19%
Disease X in 1996
No Data <10% 10%–14% 15%–19%
Disease X in 1997
No Data <10% 10%–14 15%–19% ≥20%
Disease X in 1998
No Data <10% 10%–14 15%–19% ≥20%
Disease X in 1999
No Data <10% 10%–14 15%–19% ≥20%
Disease X in 2000
No Data <10% 10%–14 15%–19% ≥20%
Disease X in 2001
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%
Disease X in 2002
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%
Disease X in 2003
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%
Disease X in 2004
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%
Disease X in 2005
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
Alcohol Medical Scholars ProgramSource: Behavioral Risk Factor Surveillance System, CDC.
Obesity* Among U.S. Adults, 2006
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
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OBESITY: AN EXPANDING EPIDEMIC
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Obesity
• Major public health concern
• Related to high calorie intake
• Influenced by
– Physiology
– Environment
– Genes
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Covered Topics
Obesity
– Definition and epidemiology
– Comorbid illness
– Mechanism of disease
– Treatment
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Obesity
Body mass index (BMI)=kg/m2
BMI Weight in lbs for 5’8”
Normal 18.5-24.9 122-164
Overweight 25.0-29.9 164-197
Obese ≥30.0 ≥ 197
Class I 30.0-34.9 197-230
Class II 35.0-39.9 230-262
Class III ≥40.0 ≥262
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Who is obese?
• 66% in United States overweight or obese
– 32% obese
– 5% extreme obesity
• Mexican American 76%
• Non-Hispanic Black 76%
• Non-Hispanic White 64%
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Covered Topics
Obesity
– Definition and epidemiology
– Comorbid illness
– Mechanism of disease
– Treatment
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So what?
• 300,000 obesity-related deaths/year in US
• 5x risk for diabetes
• 5x risk for gallbladder disease
• More depression and bipolar disorder
• More deaths from heart disease
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Covered Topics
Obesity
– Definition and epidemiology
– Comorbid illness
– Mechanism of disease
– Treatment
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Mechanisms of Obesity
• Environment
– Types of food available
– Increased portion size
– Sedentary lifestyle
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Mechanisms of Obesity
• 50% of risk is genetic
– Concordance: 60% dizygotic 75% monozygotic
– Adoptee weight more like biological parents
– Gene mutations
• Leptin
• Proopiomelanocortin (POMC)
– Bred in or out of mice
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Mechanisms of Obesity: Feeding
• Dopamine with food
• Opioids will feeding
Leptin Ghrelin
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Stress Eating and Opioids
• Stress consumption of comfort food
• Opiates sugar intake
POMCβ-endorphin
α-MSH
ACTH RewardStress
Feeding
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Extrinsic factors
food-related cue & availability
Emotional factors
Stress, boredom
Intrinsic factorsLeptinGhrelin
Dopamine
Hypothalamus
Signals that Control Feeding
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Dopamine and Reward
• Dopamine critical to reward
– Pleasure dopamine
• Drugs
• Sex
• Food
– Too much pleasure dopamine
• Drugs
• Food
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p < 0.002
Dopamine and Obesity
Control Obese
Dopamine D2 receptor imaging
BM
I
Dopamine Receptor Concentration
• Obese
o Control
p = 0.3
Wang et al, Lancet 2001
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Food Craving
• When do we crave?
– Chronic stress
– Food deprivation
• What do we crave?
– Sweets
– Carbohydrates
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Carbohydrates (mmmm…)
• Dopamine
• Opiates
• Serotonin
• Alcohol is carbohydrate rich
– Is food
– Is drug
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From Chocolate to Morphine
• Sugar preferring rats
– Increased cocaine
– Increased morphine
– Increased alcohol
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Drug Withdrawal and Sweets
• Increased sweets consumption after
– Smoking cessation
– Alcohol abstinence
– Opiate withdrawal
– Cocaine withdrawal
• No impairment in taste
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Weight Loss and Alcohol
• Calorie restricted body wants calories
– Prefers carbohydrates
– Calorie deprived rats drink alcohol
• Surgically treated obesity
– Decreased calorie intake
– Overcome size restriction by liquid calories
• Standard drink = 100 calories
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Covered Topics
Obesity
– Definition and epidemiology
– Comorbid illness
– Mechanism of disease
– Treatment
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Weight Loss Strategies
• Improve health
• Address behavioral change
• Address neurobiological change?
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Treatment: Surgery
• Roux-en-Y– Restrict stomach size /
decrease absorption
– 25% in body weight
• Vertical banded gastroplasty– Restrict stomach size
– 15% in body weight
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Treatment: Behavioral
• Brief Intervention
– Medical consequences
– Impact of dietary change
– Impact of exercise
• Diet and exercise 5% in body weight
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Treatment: Behavioral
• Overeaters Anonymous
– Get peer network
– Change attitudes
• Cognitive behavioral therapy
– Help patient change view of eating
– Help change behavior to weight loss
– Help recognize and avoid risk situations
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Treatment: Behavioral
• Motivational interviewing
– Emphasize change
– Discuss resistance
– Encourage acceptable change
• Behavioral therapy alone 5% weight
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Treatment: Medications
• Decrease appetite / increase metabolism
– Sibutramine: inhibits monoamine reuptake
– Rimonabant: cannabinoid receptor antagonist
• Decrease absorption
– Orlistat: fat absorption in gut
• Decrease appetite
– Naltrexone?: opioid antagonist
• Medications 5% in body weight
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Conclusions
• Obesity morbidity and mortality
• Overlapping neuropathways with
addiction
• Treatments
– Surgical
– Behavioral
– Pharmacological
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Future Studies Needed
• Is eating behavior replaced?
• Elucidate common neuropathways
• Elucidate common genetics
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In the Meantime
• Screen for overweight and obesity (BMI)
• Counsel about healthy eating
• Treat or refer to treatment
– Behavioral
– Pharmacological
– Surgical
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