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Understanding Obesity

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Understanding Obesity Fundamentals of Obesity Treatment: Understanding Obesity 5 Objectives • Recognize why obesity is a disease • Understand the different definitions of obesity • Learn the basic regulators of hunger and satiety • Identify adiposity-related diseases • Facilitate appropriate discussion of obesity with patients • Recognize the essential history and physical exam components of an obesity evaluation • Learn the essential diagnostic tests used in evaluation the patient with obesity 11 Prevalence¶ of Self-Reported Obesity Among U.S. Adults by State and Territory, BRFSS, 2017 ¶ 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%. 12 Centers for Disease Control and Prevention. 2017 Obesity Prevalence Maps Prevalence of Self-Reported Obesity Among Non-Hispanic White Adults, by State and Territory, BRFSS, 2015-2017 *Sample size <50 or the relative standard error (dividing the standard error by the prevalence) ≥ 30%. 13 Centers for Disease Control and Prevention. 2017 Obesity Prevalence Maps Prevalence of Self-Reported Obesity Among Hispanic Adults, by State and Territory, BRFSS, 2015-2017 *Sample size <50 or the relative standard error (dividing the standard error by the prevalence) ≥ 30%. 14 Centers for Disease Control and Prevention. 2017 Obesity Prevalence Maps Prevalence of Self-Reported Obesity Among Non-Hispanic Black Adults, by State and Territory, BRFSS, 2015-2017 *Sample size <50 or the relative standard error (dividing the standard error by the prevalence) ≥ 30%. 15 Centers for Disease Control and Prevention. 2017 Obesity Prevalence Maps Obesity bias among health care professionals • In a survey of US primary care physicians, genetic factors ranked below physical inactivity, overeating • A survey of US-based cardiologists, endocrinologists, and primary care providers showed that about half agreed that obesity is a due to a lack of self-control • More than 30% viewed patients with obesity as weak-willed, sloppy, or lazy • Over 50% viewed patients with obesity as awkward, unattractive, ugly, and noncompliant • Medical students reported that patients with obesity are a common target of negative attitudes and derogatory humor by peers (63%), health-care providers (65%), and instructors (40%). Hollman BMC Medical Education (2019) 19:16 16 Puhl, et al Obesity (Silver Spring). 2014 Consequences of obesity bias Weight stigma has been shown to increase eating, decrease self-regulation, increase resistance to exercise, and raise cortisol levels. Provider negative attitudes toward patients about obesity may result in: • Avoidance of medical care • Mistrust of the medical care provider • Decreased adherence to recommendations • Poor communication in patient/provider communication “Believing that obesity is caused by factors outside a person’s control was positively correlated with proficiency in obesity counseling skills.” Phalen, SM Obes Rev. 2015 Apr; 16(4): 319–326 Fang, V et al BMC Obes. 2019; 6: 5 17 Tomayama, AJ et al BMC Med. 2018; 16: 123 Definition of Obesity Obesity is defined as a chronic, relapsing, multi- factorial, neurobehavioral disease, wherein an increase in body fat promotes adipose tissue dysfunction and abnormal fat mass physical forces, resulting in adverse metabolic, biomechanical, and psychosocial health consequences. 18 Adapted from Obesity Algorithm®, Obesity Medicine Association® Obesity is a Multi-Factorial Disease Neurobehavioral Medical Genetics / Epigenetics Endocrine Environment Immune 19 Adapted from Obesity Algorithm®, Obesity Medicine Association® Severity of Obesity – as defined by Body Mass Index Body Mass Index (BMI) Body weight in kilograms (Height in meters)² Normal weight (18.5 – 24.9) Overweight and Obesity Overweight (25.0 – 29.9) Classification: Body Mass Index Class I obesity (30.0 – 34.9) Class II obesity (35.0 – 39.9) (BMI) in kg/* Class III obesity (≥ 40) Adapted from Obesity Algorithm®, Obesity Medicine Association® * Different BMI cut-off points may be more appropriate for women versus men, among those of different races, and among individuals 20 Defining Patients with Obesity Percent Category Female Male Body Essential 10-13% 2-5% Fat Athletic 14-20% 6-13% Fitness 21-24% 14-17% Acceptable 25-31% 18-24% Obese >31% >25% 21 Defining Patients with Obesity • Waist Circumference Race Males Females Caucasian 40” 35” African 37” 31.5” American Latino 35.5” 31.5” Asian 33.5” 31.5” 22 Adults with Overweight and/or Obesity Is there clinical evidence that the increase in body fat is pathogenic? Yes No Sick fat disease or Fat mass Metabolically healthy (adiposopathy) disease but with obesity Adapted from Obesity Algorithm®, Obesity Medicine Association® 23 Pathogenic Adiposity Deranged endocrine and Abnormal and pathologic immune responses physical forces Sick fat disease (SFD) Fat mass disease (FMD) (Adiposopathy) Endocrine/Metabolic Biomechanical/Structural 24 Adapted from Obesity Algorithm®, Obesity Medicine Association® 25 26 Derived from Spadano et al, JAMA 1999 Pediatric Weight Assessment Age <2 Age 2-20 BMI BMI Percentile WHO or <5% CDC 5-84% 85-94% Growth 95-99% or Charts BMI>30 >120% of 99th% 27 Adiposopathy “Sick Fat Disease” 28 Metabolic Syndrome (MetS) Metabolic Syndrome Body size Hyperinsulinemia Waist Circumference Insulin Resistance Central adiposity Dyslipidemia: Glucose Uric Acid Hemodynamic: Metabolism: TG Inflammation: Metabolism: SNS activity Uric acid PP lipidemia CRP IFG Na retention Urinary uric acid HDL-C Cytokines IGT Hypertension clearance Small dense LDL Fibrinogen Information from Reaven G. Syndrome X: 10 years after. Drugs. 1999;58(suppl 1):19-20. Coronary Heart Disease 29 Unified Definition of Metabolic Syndrome (MetS) MetS identified by three or more of the following criteria: • Abdominal circumference – >40 inches men, >35 inches women (Caucasian data) – Population and country specific • Triglycerides ≥150mg/dL* • HDL low* – <40mg/dL men, <50mg/dL women • Elevated BP – systolic ≥130 and/or diastolic ≥ 85mmHg* (or currently prescribed an anti-hypertensive medication) • Glycemia FBS ≥100mg/dL* *Or on medication Patients may have insulin resistance and not meet the diagnostic criteria for metabolic syndrome (Alberti 2009) 30 Metabolic Syndrome and Risk of CVD • Cardiovascular Disease – 2x increase risk of CV event – 1.5x increase risk of all-cause mortality • Marker for CV disease in addition to LDL – CV risk assessment is primarily focused on LDL – MetS reflects a pro-inflammatory state that also increases risk for CV disease 31 Age-adjusted Prevalence of Obesity and Diagnosed Diabetes Among US Adults Obesity (BMI ≥30 kg/m2) 1994 2000 2015 No Data <14.0% 14.0%–17.9% 18.0%–21.9% 22.0%–25.9% > 26.0% Diabetes 1994 2000 2015 CDC’s Division of Diabetes Translation. United States Surveillance System available at http://www.cdc.gov/diabetes/data 32 Prediabetes & Type 2 Diabetes Mellitus • T2DM is associated with obesity • Obesity causes insulin resistance • To keep glucose normal, the physiologic response to insulin resistance is hyperinsulinemia • Hyperinsulinemia contributes to weight gain • Hyperglycemia occurs due to β-cell failure and relative insulin deficiency • Up to 80% β-cell failure at diagnosis of T2DM (DeFronzo 2009) 33 Prediabetes & Type 2 Diabetes Mellitus ↑ Endogenous Obesity insulin Insulin resistance 34 Developing Diabetes: The Clinical Progression Insulin resistance begins 10 -15 years prior to dx of T2DM Information from Ramlo-Halsted B. Clinical Diabetes. Spring 2000. 35 Diabetes Prevention Data Incidence T2DM Lifestyle ↓ 58% Metformin ↓ 31% Weight Loss 1 kg ↓ risk 16% 10% WL ↓ risk 85% at 3 years DPP Research Group 2002, Hoskin, 2014 36 DPP Research Group 2015 Diabetes Prevention Program Outcome Studies (DPPOS) • Showed continued benefit at 15 years • Early detection and lifestyle intervention is key • Continued weight gain increases risk of T2DM DPP Research Group 2002, Hoskin, 2014 DPP Research Group 2015 37 Managing T2DM • Weight loss reduces insulin resistance and improves glycemic control • Dietary changes and weight loss may require changes in diabetes therapy • Diets with severe restriction in calories or carbohydrates often require pro-active changes in diabetes therapy 38 Biology of Appetite Regulation 39 Purposeful behavior regulates weight versus Biology regulates weight 40 Traditional Thinking Additional Understanding Purposeful behavior Biology regulates weight Regulates weight - (+) - Calories in & Hormonal Response Calories out regulates weight regulates weight 41 CME Polling Questions Instructions: Go to www.pollEv.com/OMA248 Enter your FULL FIRST and LAST NAME for your username The polling question will appear shortly Participation in the polling questions is a requirement to earn ABIM MOC points for this course. 42 What’s the average annual calorie consumption for adult males? • 150,000 kcal • 250,000 kcal • 400,000 kcal • 500,000 kcal • 750,000 kcal • 1,000,000 kcal 43 What is the average annual weight gain for adults? •0.5 lb. •1.0 lb. •2.0 lbs. •3.0 lbs. •5.0 lbs. 46 Daily excess calories intake needed to gain 1 lb./year? • 10 kcal • 20 kcal • 30 kcal • 40 kcal • 50 kcal 49 Weight Gain • Imbalance of energy intake and energy output – Estimated annual caloric requirement in middle-aged adults • Males ~__________ kcal/year • Females ~__________ kcal/year – Average annual weight gain for middle-aged adults • ___ lb(s)/year (variance of
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