Obesity Medicine Epidemiology & Pathophysiology Treatment Options – Efficacy & Safety Benefits of Weight Loss Therapy Maria Collazo-Clavell, MD W. Timothy Garvey, MD, PhD (moderator) Daniel L. Hurley, MD Endocrine University at Mayo Clinic, Rochester, MN 24 March 2015
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Obesity Medicine Epidemiology & Pathophysiology
Treatment Options – Efficacy & Safety Benefits of Weight Loss Therapy
Maria Collazo-Clavell, MD W. Timothy Garvey, MD, PhD (moderator) Daniel L. Hurley, MD
Endocrine University at Mayo Clinic, Rochester, MN 24 March 2015
OBESITY MEDICINE: EPIDEMIOLOGY & PATHOPHYSIOLOGY
Dr. Maria Collazo-Clavell
Learning Objectives
• Understand public health burden and social costs of obesity
• Understand the pathophysiology that protects body weight against weight loss
• Understand the interactions among weight gain, insulin resistance, adipose distribution and inflammation and cardiovascular disease
• Understand why obesity is a disease
Prevalence of Self-Reported Obesity Among
U.S. Adults by State and Territory
Definitions
Obesity: Body Mass Index (BMI) of 30 or higher.
Body Mass Index (BMI): A measure of an adult’s weight in relation to his or her height, calculated by using the adult’s weight in kilograms divided by the square of his or her height in meters.
Prevalence of Self-Reported Obesity Among
U.S. Adults by State and Territory
Source of the Data
The data were collected through the Behavioral Risk Factor Surveillance System (BRFSS), an ongoing, state-based, telephone interview survey conducted by state health departments with assistance from CDC.
Height and weight data used in the BMI calculations were self-reported.
Prevalence of Self-Reported Obesity Among
U.S. Adults by State and Territory
BRFSS Methodological Changes Started in 2011
New sampling frame that included both landline and cell phone households.
New weighting methodology used to provide a closer match between the sample and the population.
Prevalence of Self-Reported Obesity Among U.S. Adults by State and Territory
Exclusion Criteria Used Beginning with 2011 BRFSS Data
Records with the following were excluded:
Height: <3 feet or ≥8 feet
Weight: <50 pounds or ≥650 pounds
BMI: <12 kg/m2 or ≥100 kg/m2
Pregnant women
Prevalence¶ of Self-Reported Obesity Among
U.S. Adults by State and Territory, BRFSS,
2011
¶ Prevalence estimates reflect BRFSS methodological changes started in 2011. These estimates should not be
compared to prevalence estimates before 2011.
*Sample size <50 or the relative standard error (dividing the standard error by the prevalence) ≥ 30%.
Prevalence¶ of Self-Reported Obesity Among
U.S. Adults by State and Territory, BRFSS,
2014
¶ Prevalence estimates reflect BRFSS methodological changes started in 2011. These estimates should not be
compared to prevalence estimates before 2011.
Prevalence* of Self-Reported Obesity Among U.S.
Adults
by State and Territory, BRFSS, 2013 Summary
No state had a prevalence of obesity less than 20%.
7 states and the District of Columbia had a prevalence of obesity between 20% and <25%.
23 states had a prevalence of obesity between 25% and <30%.
18 states had a prevalence of obesity between 30% and <35%.
2 states (Mississippi and West Virginia) had a prevalence of obesity of 35% or greater.
The prevalence of obesity was 27.0% in Guam and 27.9% in Puerto Rico.+
*Prevalence estimates reflect BRFSS methodological changes started in 2011. These estimates should not be compared to prevalence estimates before 2011.
+ Guam and Puerto Rico were the only US territories with obesity data available on the 2013 BRFSS.
Men and women. Adjusted for educational level, marital status, smoking, alcohol, physical activity, and BMI. WC cut
points were <90.0, 90.0 to 94.9, 95.0 to 99.9, 100.0 to 104.9, 105.0 to 109.9, and >110.0 cm for men and <70.0, 70.0 to
74.9, 75.0 to 79.9, 80.0 to 84.9, 85.0 to 89.9, and >90.0 cm for women. Mayo Clin Proc 2014; 89:335-345.
BMI, WC and Mortality HR and 95% CIs for WC (5-cm increments)
and all-cause mortality by BMI category.
Men and women.
Body Fat Distribution
• Gonadal steroids • Adolescent boys : Increased muscle
mass/Decreased fat mass
• Adolescent girls: Increased muscle/fat mass
• Visceral fat • Higher risk for metabolic/cardiovascular
complications
• Waist circumference measurement
• BMI’s 25-35 kg/m2
WHY ARE WE GETTING HEAVIER?
Obesity Medicine
Epidemiology & Pathophysiology
Factors Contributing to Weight Gain
• Genetic
• Physiologic
• Environmental
• Lifestyle
• Socioeconomic
• Cultural
Hard to change your genes
but not your jean size!
Genetic Factors • Single Gene Defects
• Leptin (ob gene)
• Signals the brain about stored body fat
• Decreases energy intake “adipostatic”
• Ob deficient mice: hyperphagia, insulin resistance, hyperinsulinemia, infertility
• Consanguineous families
• Leptin receptor gene
• Db/db mice
• Zucker rats
Genetic Factors
• Prader Willi
• Bardet Biedl
• Common obesity
• “Susceptibility” genes influenced by environmental factors
• Polymorphisms
Hereditary Factors
• BMI highly correlates within families
• Twin, adoptee, family studies
• Metabolic rate
• Thermic response to food
• Spontaneous physical activity
Physiologic Factors
• Metabolic rate
• Correlates with Fat Free Mass
Changes in Fat Free Mass lead to significant variations in energy expenditure
• Food intake
• Activity
Exercise
Non-Exercise Activity thermogenesis
Energy intake
Ingestion of:
Proteins
Fats
Carbohydrates
Energy expenditure
Physical activity
Meal-induced thermogenesis
Basal metabolic rate
Body Weight
Increase
Energy Homeostasis
Decrease Genetics
Environment
Behavior
Here is the Title Physiology Energy requirements
• Determinants of energy requirements
• Age Drops as we age
• Sex Higher for men than women
• Height Taller you are, the higher calorie needs
• Weight Heavier you are, the higher calorie needs
• Components of energy requirements • Basal metabolic rate
• Activity Exercise
NEAT (Non-Exercise Activity Thermogenesis)
(Calorie needs)
Here is the Title Estimated Calorie Requirements
• Harris Benedict Equation • Resting Energy Expenditure (REE) • Basal Metabolic Rate (BMR) • Men = 66 + 13.8 (kg) + 5(cm) – 6.8 (Age in years)
86.7 kg/170 cm/51 years 1766 kcal/d
• Women= 655 +9.5 (kg) + 1.9 (cm) – 4.7(Age in years) 86.7 kg/170cm/51 years 1562 kcal/d
• Activity Factor • 20-50% of estimated REE
Low (sedentary) Intermediate (Some regular exercise) High (Regular physical activity or physically demanding job)
Here is the Title
Estimated Calorie Requirements World Health Organization
• Estimate BMR • Men 18-30 = (0.0630 X (kg) + 2.8957) X 240 kcal/d • Men 31-60 = (0.0484 X (kg) + 3.6534 X 240 kcal/d • Women 18-30 = (0.0621 X (kg) + 2.0357) X 240 kcal/d
25 yrs/86.7 kg 1780 kcal/d
• Women 31-60 = (0.0342 X (kg) + 3.5377) X 240 kcal/d 40 yrs/86.7 kg 1560 kcal/d
• Condition of abnormal vital function involving any structure, part or system of an organism
• Disorder characterized by a recognizable set of signs and symptoms attributable to hereditary, infection, diet or environment
Obesity as A Disease
• American Medical Association
• August 2013 meeting
• Obesity officially recognized as a disease
• Against recommendation by the committee charged to study the subject
• AACE
• October 2012 Position Statement
NHLBI Classification of Weight, Waist Circumference & Disease Risk
Classification
BMI (kg/m2)
Disease Risk*
Men WC ≤40 in Women WC ≤35 in
Men WC >40 in Women WC >35 in
Underweight <18.5
Normal 18.5 – 24.9
Overweight 25.0-29.9 Increased High
Obesity Class I 30.0-34.9 High Very high
Obesity Class II 35.0-39.9 Very high Very high
Obesity Class III ≥40 Extremely high Extremely high
*Type 2 diabetes, hypertension, and cardiovascular disease.
BMI, body mass index; NHLBI, National Heart, Lung, and Blood Institute; WC, waist circumference
NHLBI Obesity Education Initiative. Obesity in adults. Available at: http://www.nhlbi.nih.gov/guidelines/obesity/prctgd_c.pdf.
Summary
• Obesity as defined by BMI of 30 kg/m2 continues to be an increasing health threat • Affects minority groups to a greater extent • Worldwide problem
• Obesity is a major contributor to rising health care costs • Currently in the management of its co-morbidities • There remain biases in coverage for obesity
treatments
• Many factors have contributed to the rising prevalence of obesity • Genetic, Hereditable, Physiologic, Environmental
Summary
• These factors represent obstacles the effective management of obesity
• Obesity meets the criteria for a disease but requires a multifaceted approach to management