The Problem: Obesity in America

JacobiAmbulatory Care Service

The Problem: The Problem: Obesity in AmericaObesity in America

Lori A. Lemberg, M.D.Adapted from MCE Conferences March 14-16, 2011

Lecture presented by Frank J. Domino, M.D.Frank J. Domino, M.D.

Barbara Olendzki, RD, MPHBarbara Olendzki, RD, MPH


World Wide Rates of overweight and World Wide Rates of overweight and obesity, 2000-2004obesity, 2000-2004

US 66.3%UK 63.0% Mexico 62.3% Canada 57.5% Greece 57.1% New Zealand 56.2% Germany 49.2%Italy 42.6%


Consequences of ObesityConsequences of Obesity

• 66% of Americans are overweight*66% of Americans are overweight*• 22% of Americans are obese 22% of Americans are obese

• Deaths from Obesity:Deaths from Obesity: • 300,000 premature deaths associated with obesity 300,000 premature deaths associated with obesity

annuallyannually (CDC) (CDC)– 25,000/month, 5,769/week, 821/day, 34/hour.25,000/month, 5,769/week, 821/day, 34/hour.

• 450,000 from tobacco-related disease450,000 from tobacco-related disease• 10.4 million people with type II diabetes10.4 million people with type II diabetes• 4747 million with metabolic syndrome million with metabolic syndrome

**CDC 2006CDC 2006


Is treating obesity a way to save the Is treating obesity a way to save the economy?economy?

•2003: 9.1 % of U.S. health expenditures* •Estimated annual medical spending due to overweight and obesity (BMI >25) to be as much as $92.6 billion in 2002 dollars*

•2006: 10% of U.S. expenditures**•$147 billion in 2006 dollars**•(Afghan war ~ 28 Billion per year over 8 Yrs)

*Finkelstein EA; Health Affairs Web Exclusive. 2003; W3:219-226. **Finkelstein EA; Health Affairs 28, no. 5 (2009): w822-w831


Obesity Trends* Among U.S. AdultsObesity Trends* Among U.S. AdultsBRFSS, 1985BRFSS, 1985

No Data <10% 10%–14%

(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)



(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%



(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%


(*BMI 30)

Hispanic

State-specific Prevalence of Obesity* Among State-specific Prevalence of Obesity* Among U.S. Adults, by Race/Ethnicity, 2006-2008U.S. Adults, by Race/Ethnicity, 2006-2008

White non-Hispanic

Black non-Hispanic


Childhood Obesity


What else has changed?What else has changed?

• Humans have a Humans have a genotypegenotype that permits energy intake > that permits energy intake > expenditureexpenditure

• Political decisions & industrialization of farms Political decisions & industrialization of farms growth growth of grain for livestock, rather than humansof grain for livestock, rather than humans

• 11stst in recorded history cost of in recorded history cost of meat < vegetablesmeat < vegetables. . • ↑↑ portion sizes, portion sizes, ↑ ↑ fat intakes, sweetened beveragesfat intakes, sweetened beverages• Lack of physical activityLack of physical activity: : ↓ Manual Labor, ↓ Manual Labor,

Computer/Screen time, increased automation allows for less Computer/Screen time, increased automation allows for less activity @ homeactivity @ home

• ““What’s for Take Out?” What’s for Take Out?” 1.2 vs > 5.0 per week1.2 vs > 5.0 per week


140 calories 3-inch diameter

Calorie Difference: 210 calories

350 calories 6-inch diameter

BAGELBAGEL

20 Years Ago Today

5 days/wk X 50 weeks=15.6 lb.

If you rake the leaves for 50 minutes you will burn the extra 210 calories.*


Calorie Difference: 257 calories

590 calories

CHEESEBURGER

20 Years Ago Today

333 calories

If you lift weights for 1 hour and 30 minutes,you will burn approximately 257 calories.*


610 Calories6.9 ouncesDifference: 400 Calories

FRENCH FRIES

20 Years Ago Today

210 Calories

2.4 ounces

You need to walk for 1 hour and 10 minutes to burn approximately 400 extra calories



How can WE help our patients?

What are the barriers to providing good nutritional counseling?

TimeKnowledge of current guidelinesEffectiveness of interventions


““Successful Losers”Successful Losers”

The National Weight Control RegistryThe National Weight Control Registry

>5000 successful losers>5000 successful losers

Members lost an average of 66 lbs (range=30-300 Members lost an average of 66 lbs (range=30-300 lbs) x 5.5 years (= 1 lb/month x 5 years)lbs) x 5.5 years (= 1 lb/month x 5 years)

– 78% eat breakfast every day. 78% eat breakfast every day. – 75% weigh them self at least once a week. 75% weigh them self at least once a week. – 62% watch < 10 hours of TV per week. 62% watch < 10 hours of TV per week. – 90% exercise, about 1 hour per day.90% exercise, about 1 hour per day.

http://www.nwcr.wshttp://www.nwcr.ws


What about the average person?What about the average person?Daily PracticesDaily Practices

• Survey 2004 US > 18 Yrs. Survey 2004 US > 18 Yrs. “Successful Weight Loss Maintainers”“Successful Weight Loss Maintainers”

1.1. Eat Fast Food Eat Fast Food < 2/Week< 2/Week

2.2. >> 5 Fruits & Vegetables/day ** AND 5 Fruits & Vegetables/day ** AND

3.3. 150 Minutes physical activity (25 Min/Day)150 Minutes physical activity (25 Min/Day)



Action PlanAction Plan

• Action PlanAction Plan–Based upon patient’s suggestionBased upon patient’s suggestion

–Provide Provide optionsoptions for patient for patient

–Be open to whatever they suggestBe open to whatever they suggest

–ALWAYS schedule Follow up with ALWAYS schedule Follow up with agreed upon agreed upon GoalGoal


First Some Basics TrainingFirst Some Basics Training


CaloriesCalories

• Energy IN vs Energy OUTEnergy IN vs Energy OUT

• 3500 calories= 1 pound3500 calories= 1 pound

• 500 calories/day x 1 Week = 1 lb500 calories/day x 1 Week = 1 lb

• +10 calories/day = 1 lb weight/year+10 calories/day = 1 lb weight/year


Body WeightBody Weight

Ideal Body Weight:Ideal Body Weight:Women:Women: 100 lbs first 5 feet + 5 lbs/inch. 100 lbs first 5 feet + 5 lbs/inch. +/- 10%+/- 10%

Men:Men: 106 lbs for first 5 feet + 6 lbs/inch 106 lbs for first 5 feet + 6 lbs/inch +/- 10%+/- 10%

Calories Needed to Maintain WeightCalories Needed to Maintain Weight

Active male: Lb Active male: Lb x 15 = total calories per day.x 15 = total calories per day.

Active female: LbActive female: Lb x 12 = total calories per day. x 12 = total calories per day.

Inactive male: Lb Inactive male: Lb x 13 = total calories per day. x 13 = total calories per day.

Inactive female: Lb Inactive female: Lb x 10 = total calories per day.x 10 = total calories per day.


Daily RequirementsDaily Requirements

Female adult (5’4”) ~ 1,500 calories/dayFemale adult (5’4”) ~ 1,500 calories/day

Male adult (5’7”) ~ 2,250 calories/dayMale adult (5’7”) ~ 2,250 calories/day

Remember:Remember:• Fat = Fat = 99 Kcal/gm Kcal/gm

• Protein = Protein = 44 Kcal/gm Kcal/gm• CHO = CHO = 44 Kcal/gm Kcal/gm• Alcohol = Alcohol = 7 7 Kcal/gmKcal/gm


What is a Serving Size?What is a Serving Size?

• Meats: 3 oz. (deck of cards)Meats: 3 oz. (deck of cards)• Dairy: 4 oz = ½ cup Dairy: 4 oz = ½ cup • Grains: ½ cup or 1 slice breadGrains: ½ cup or 1 slice bread• Veg: ½ cup cooked or 1 cup Veg: ½ cup cooked or 1 cup

rawraw• Fruit: ½ cup cut up or 1 Fruit: ½ cup cut up or 1

mediummedium


The LabelThe Label

• Look at Look at – serving sizeserving size

– saturated fatsaturated fat

– dietary fiberdietary fiber

– sugarssugars

• Glance at carbohydrateGlance at carbohydrate• Read Read ingredientsingredients (for (for

hydrogenated oils and hydrogenated oils and whole grains)whole grains)


5 Steps to Healthy Diet5 Steps to Healthy Diet

1.1. Increase FiberIncrease Fiber

2.2. Increase Water 16 Oz before mealsIncrease Water 16 Oz before meals

3.3. Prescribe ExercisePrescribe Exercise

4.4. MINDFULLY Eat Calorie “hypodense” MINDFULLY Eat Calorie “hypodense” foodsfoods

5.5. Limit Screen Time to < 10 Hr/weekLimit Screen Time to < 10 Hr/week


24 Hour Dietary Recall


“Tell me everything you ate and drank yesterday, starting with breakfast.”


“Oh no, not yesterday!”


Count Fruit and Vegetable ServingsCount Fruit and Vegetable Servings

• GoalGoal: 10 servings/day : 10 servings/day 25-30 Grams of Fiber25-30 Grams of Fiber

• MinMin: 5 servings/day (15 Grams/Day): 5 servings/day (15 Grams/Day)• Potatoes, Pasta &White Rice do Potatoes, Pasta &White Rice do NOTNOT

countcount


Water Consumption and DietingWater Consumption and Dietingfor Adultsfor Adults

• RCT over 12 weeks of adultsRCT over 12 weeks of adults• Compared Low Calorie Diet vs. Low Compared Low Calorie Diet vs. Low

Calorie Diet + 16 Oz water prior to Calorie Diet + 16 Oz water prior to each mealeach meal

• 44% RRR (~4.5 Lbs) greater weight 44% RRR (~4.5 Lbs) greater weight loss in Water group.loss in Water group.

Obesity. 2010; 18(2): 300-7Obesity. 2010; 18(2): 300-7


Apples to Oranges…Apples to Oranges…

CaloriesCalories

• 1 Orange 1 Orange 4040• 8 Oz OJ 8 Oz OJ 120 120 • 8 Oz Cola8 Oz Cola 100100• Coffee BlackCoffee Black 2 2• Coffee + 2 SugarCoffee + 2 Sugar 3030• Coffee + 1 Oz CreamCoffee + 1 Oz Cream 100100• StarBucks Café MochaStarBucks Café Mocha 400400


Simple ApproachSimple Rule:


3. Prescribe… EXERCISE3. Prescribe… EXERCISE

• 6300 adults Observational Study6300 adults Observational Study• Dx: Sed Lifestyle HTN, DM, OB, M/SkelDx: Sed Lifestyle HTN, DM, OB, M/Skel• ““Inactive” Baseline = Inactive” Baseline = 33% 33%

• At 3 Months= 17%; At 3 Months= 17%; • At 12 Months = 20%At 12 Months = 20%

BMJ 2008: 337:a2084BMJ 2008: 337:a2084Scandinavian Journal of Medicine and Science in SportsScandinavian Journal of Medicine and Science in Sports, doi: , doi:

10.1111/j.1600-0838.2008.00820.x 10.1111/j.1600-0838.2008.00820.x

WALK


How Much and What Kind of Exercise????How Much and What Kind of Exercise????

• No one knows what is ideal for weight loss.No one knows what is ideal for weight loss.

• For CHD: For CHD: 30-50 Min Aerobic exercise 5 days/week.30-50 Min Aerobic exercise 5 days/week.

• For Weight loss:For Weight loss:• Aerobic + Weight training 5 days per weekAerobic + Weight training 5 days per week

• No “after exercise treat”No “after exercise treat”


Why bother?Why bother?

•Weight lossWeight loss

•Reduced cardiovascular and all-cause mortalityReduced cardiovascular and all-cause mortality

•Cognitive benefitsCognitive benefitsAnxiolytic effects of exercise: a meta-analysisAnxiolytic effects of exercise: a meta-analysisJ Sports & Exer Psychol. 2008 Aug; 30(f):392-410J Sports & Exer Psychol. 2008 Aug; 30(f):392-410

•Improved quality of life (RCT)Improved quality of life (RCT)Martin , Exercise dose and quality of life. Arch Int Med. Martin , Exercise dose and quality of life. Arch Int Med. 2009;169(3):269-78.2009;169(3):269-78.

•The cost of NOT exercising: the STRRIDE trialThe cost of NOT exercising: the STRRIDE trial

•We are health role modelsWe are health role modelsWarburton DE Health benefits of physical activity: the evidence. Warburton DE Health benefits of physical activity: the evidence. CMAJ. 2006;174(6):801-9. CMAJ. 2006;174(6):801-9.


STRRIDE Study: STRRIDE Study: Cost of NOT exercisingCost of NOT exercising

• RCT, 4 groupsRCT, 4 groups• INTERVENTION: INTERVENTION: • Low amount/Mod intensity, Low amount/Mod intensity, • Low amount/Vigorous intensity, Low amount/Vigorous intensity, • High amount/VigorousHigh amount/Vigorous• Low/High: 120 min vs 200 minLow/High: 120 min vs 200 min• Intensity: Moderate 40-55% V02 max, High 65-80%Intensity: Moderate 40-55% V02 max, High 65-80%• Non-exercisers: +1% body weight, +8.6% visceral fat Non-exercisers: +1% body weight, +8.6% visceral fat

in 6 months!in 6 months!• Exercisers: -1-2% body weight, no change/-7% visc. Exercisers: -1-2% body weight, no change/-7% visc.

FatFat Slentz CA, STRRIDE; J Appl Physiol. 2005;99:1613-8.Slentz CA, STRRIDE; J Appl Physiol. 2005;99:1613-8.


1. Exercise efficiently1. Exercise efficiently

2. Keep your lifestyle active2. Keep your lifestyle active

3. Incorporate resistance training3. Incorporate resistance training


Exercising efficiently: Interval training and Exercising efficiently: Interval training and “threshold”“threshold”

• HIIT as a health HIIT as a health promotion strategypromotion strategy

Gibala, MJ. High-intensity interval training: Gibala, MJ. High-intensity interval training: a time efficient strategy for health a time efficient strategy for health promotion? Curr Sports Med Reports. promotion? Curr Sports Med Reports. 2007;6:211-3.2007;6:211-3.

• HIIT training HIIT training increases aerobic and increases aerobic and anaerobic capacityanaerobic capacity

Tabata I, Nishimura K, et al. Effects of Tabata I, Nishimura K, et al. Effects of moderate-intensity endurance and moderate-intensity endurance and high-intensity intermittant training on high-intensity intermittant training on anaerobic capacity and V02 max. anaerobic capacity and V02 max. Med Sci Sports Exerc. Med Sci Sports Exerc. 1996;28(10):1327-301996;28(10):1327-30

http://www.xiser.com/store/pdf/Sprint_Interval_Training.pdf


2. Keep lifestyle active 2. Keep lifestyle active


Lifestyle ImportanceLifestyle Importance

DESIGN: 16 week RCT in 40 obese women, both observing DESIGN: 16 week RCT in 40 obese women, both observing similar diet, 16 wk and 1 yr follow upsimilar diet, 16 wk and 1 yr follow up

INTERVENTION: structured aerobic activity or moderate INTERVENTION: structured aerobic activity or moderate lifestyle activitylifestyle activity

OUTCOME MEASURES: body weight and composition OUTCOME MEASURES: body weight and composition changes, cardiovascular risk profile, physical fitnesschanges, cardiovascular risk profile, physical fitness

RESULTS: at 1 year, equivalent reductions in triglycerides, RESULTS: at 1 year, equivalent reductions in triglycerides, LDL, HDL, resting DBP; LDL, HDL, resting DBP; lifestyle group had lifestyle group had significantly greater reductions in total cholesterol, significantly greater reductions in total cholesterol, resting SBP, increased VO2 max, depression scales, resting SBP, increased VO2 max, depression scales, maintained weight lossmaintained weight loss

Anderson RE, Wadden TA, Bartlett SJ, et al. Effects of lifestyle activity vs structured aerobic exercise in obese Anderson RE, Wadden TA, Bartlett SJ, et al. Effects of lifestyle activity vs structured aerobic exercise in obese women. JAMA. 1999;281:335-340women. JAMA. 1999;281:335-340


3. Incorporate resistance training3. Incorporate resistance training


How does resistance training provide How does resistance training provide lasting benefits?lasting benefits?

Muscle mass as a “metabolic sink”Muscle mass as a “metabolic sink”– Increased insulin sensitivityIncreased insulin sensitivity– Decreased HbA1c (0.5%-1.0%)Decreased HbA1c (0.5%-1.0%)

Maintain muscle mass lost with age (1 lb/yr after 50)Maintain muscle mass lost with age (1 lb/yr after 50)Increased strength (falls in the elderly!)Increased strength (falls in the elderly!)Increased basal metabolism beyond expected with Increased basal metabolism beyond expected with

adding muscle (21 kcal/kg vs 28-218 kcal/kg)adding muscle (21 kcal/kg vs 28-218 kcal/kg)Reduced visceral fat on par with aerobic exerciseReduced visceral fat on par with aerobic exerciseIncreased bone mineral densityIncreased bone mineral densityRecommend: single set of 8-10 reps covering major Recommend: single set of 8-10 reps covering major

muscle groups min 2x/weekmuscle groups min 2x/weekBraith RW Circulation. 2006;113:2642-50.Braith RW Circulation. 2006;113:2642-50.


How little is “enough”?How little is “enough”?

• Simple answer: whatever you can fit into your Simple answer: whatever you can fit into your day, anything is better than nothingday, anything is better than nothing

• Better answer: Review of observational cohort Better answer: Review of observational cohort studies of exercise and reduction in all-cause studies of exercise and reduction in all-cause mortalitymortality– 1000 kcal/week associated with 20-30% risk 1000 kcal/week associated with 20-30% risk

reductionreduction

Haennel RG and Lemire F. Physical activity to prevent cardiovascular disease: How much is enough? Can Haennel RG and Lemire F. Physical activity to prevent cardiovascular disease: How much is enough? Can Fam Physician. 2002;48:65-71.Fam Physician. 2002;48:65-71.


Fitness is more important than fatnessFitness is more important than fatness

METHODS: 58 sedentary obese men and women, 12 wk supervised aerobic exercise (500 METHODS: 58 sedentary obese men and women, 12 wk supervised aerobic exercise (500 kcal, 70% max HR, 5 times/wk)kcal, 70% max HR, 5 times/wk)

OUTCOME MEASURES: body composition, aerobic capacity, BP, psychological response OUTCOME MEASURES: body composition, aerobic capacity, BP, psychological response score, measured at weeks 0 and 12score, measured at weeks 0 and 12

RESULTS: 26/58 had less than predicted weight loss, but all had significantly increased RESULTS: 26/58 had less than predicted weight loss, but all had significantly increased aerobic capacity and positive mood, decreased SBP/DBP, waist circumference, resting HRaerobic capacity and positive mood, decreased SBP/DBP, waist circumference, resting HR

– The concept of exercise “nonresponder”The concept of exercise “nonresponder”– No association between weight loss and improvements in health markersNo association between weight loss and improvements in health markers

King NA, Hopkins M, et al. Beneficial effects of exercise: shifting the focus from body weight to King NA, Hopkins M, et al. Beneficial effects of exercise: shifting the focus from body weight to other markers of health. Br J Sports Med. 2009;43:924-7.other markers of health. Br J Sports Med. 2009;43:924-7.

I was short, fat and bald when I started running, but after running nearly I was short, fat and bald when I started running, but after running nearly every day for more than 30 years and covering about 70,000 miles...I am every day for more than 30 years and covering about 70,000 miles...I am still short, fat, and bald. But I suspect I'm in much better shape than I'd be still short, fat, and bald. But I suspect I'm in much better shape than I'd be if I didn't run. – Steve Blairif I didn't run. – Steve Blair


Workout to recommendWorkout to recommend

• Warm-up Warm-up • HIIT HIIT

– 20 seconds on/10 seconds off20 seconds on/10 seconds off– 8 sets8 sets

• Resistance trainingResistance training– Turkish getupTurkish getup– Kettlebell swingKettlebell swing– Squat jumpsSquat jumps(see YouTube for demonstrations)(see YouTube for demonstrations)


Other things to consider…Other things to consider…

• CalciumCalcium: Calcium is needed for fecal : Calcium is needed for fecal fat excretion. Systematic review fat excretion. Systematic review found supplementation of about 1,200 found supplementation of about 1,200 mg of calcium per day leads to an mg of calcium per day leads to an increase in fecal fat excretion. increase in fecal fat excretion. Obes Obes Rev 2009; 10(4): 475-86Rev 2009; 10(4): 475-86


• SleepSleep: : A small pilot study compared a A small pilot study compared a low calorie diet w/either 5.5 hours of low calorie diet w/either 5.5 hours of sleep vs 8.5 hours over 14 days. 8.5 hr sleep vs 8.5 hours over 14 days. 8.5 hr had greater weight loss of body fat, and had greater weight loss of body fat, and less hunger. The authors postulate it less hunger. The authors postulate it was due to the neuroendocrine changes was due to the neuroendocrine changes decreased sleep induces. decreased sleep induces. Ann Intern Ann Intern Med 2010; 153: 435-441Med 2010; 153: 435-441


• Chronic PPIs: Chronic PPIs: Case control study Case control study obesity developed in patients with GERD obesity developed in patients with GERD who were treated chronically with PPIs who were treated chronically with PPIs vs other treatments vs other treatments World J Gastro World J Gastro 2009; 15(38): 4794-47982009; 15(38): 4794-4798

The Problem: Obesity in America

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