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The Global Obesity Pandemic JHI Partners Forum October 2, 2012 Richard R. Rubin, PhD Professor, Medicine and Pediatrics The Johns Hopkins University School of Medicine [email protected] Obesity Pandemic Key Points • • • • Prevalence Causes Medical consequences Financial consequences BMI Chart WHO Fact sheet N°311, September 2006, http://www.who.int/mediacentre/factsheets/fs311/en/index.html Almost 70% of the U.S. population are either overweight or obese Obese Overweight U.S. adult population overweight or obese Percentage, age 20-74 70 65 • Obesity levels in the 60 55 50 45 • 40 35 30 • 25 20 15 10 5 U.S. have more than doubled since 1980, and currently ~1/3 of adults are obese In contrast, the percentage of overweight adults has changed little over the past 40 yrs Just 33% of adults in the U.S. are of normal/under weight, down from 55% which held steady between 1960 and 1980 0 1966 1976 1986 1996 2006 6 Source:CDC/National Center for Health Statistics, National Health Exam Survey Portion Sizes 20 Years Ago to Today Drivers of the Obesity Pandemic Swinburn et al. The Lancet 2011;378:804-814. Obesity Prevalence in U.S Children 2-19 Years 1999-2010 Age-Adjusted Relative Risk Relationship Between BMI and Risk of Type 2 Diabetes 93.2 100 Men Women 75 54.0 50 42.1 40.3 27.6 21.3 25 1.0 2.9 1.0 <22 <23 4.3 1.0 5.0 1.5 8.1 2.2 15.8 4.4 6.7 11.6 0 23-23.9 24-24.9 25-26.9 27-28.9 29-30.9 31-32.9 33-34.9 Body Mass index (kg/m2) Chan J et al. Diabetes Care 1994;17:961. Colditz G et al. Ann Intern Med 1995;122:481. 35+ Sample data suggest that obese adults can incur close to twice the annual health care costs of normal weight adults Normal weight Healthcare costs Obese by BMI* 7,555 $/capita, 2007 6,120 *91% *55% 4,675 3,950 BMI <25 *18% 30-34* *35-39 *40+ Weighted average cost of the obese is $5,500 * For the U.S. adult population (ages 20-64) Source: McKinsey analysis; D2Hawkeye database of ~20,000 people with biometric data, National Bureau of Economic Research, 2007 census data for population by age 1 5 Medical Management of Obesity Kimberly Gudzune, MD, MPH Assistant Professor of Medicine Johns Hopkins Digestive Weight Loss Center Johns Hopkins International Partners Forum October 2, 2012 Objectives • Eligibility for obesity treatment • Description of medical management of obesity • Review of new weight loss medications coming on the market • • • • • Weight is more than about looking good… Heart disease Diabetes Cancer Gall stones Fatty liver • • • • • Lung disease Infertility Arthritis Incontinence Disability Decreased quality of life! Increased risk of early death! Shorter life span! WHO IS ELIGIBLE FOR OBESITY TREATMENT? Estimating Obesity • Measuring body fat requires specialized equipment • Patients typically identified in the clinical setting using body mass index (BMI) Weight (kg) Height (m)2 • NIH and WHO have categorized BMI based on increased risk of cardiovascular (CVD) and other diseases BMI Classification of Obesity Normal weight BMI 18.5-24.9 kg/m2 5’ 11” man @ 5’ 4” woman @ Overweight BMI 25.0-29.9 kg/m2 5’ 11” man @ 179 lbs 5’ 4” woman @ 146 lbs Class I obesity BMI 30.0-34.9 kg/m2 5’ 11” man @ 215 lbs 5’ 4” woman @ 175 lbs Class II obesity BMI 35.0-39.9 kg/m2 5’ 11” man @ 5’ 4” woman @ Class III obesity BMI≥40 kg/m2 5’ 11” man @ 287 lbs 5’ 4” woman @ 233 lbs Fat Distribution • Increased visceral fat in the abdomen is linked with greater CVD disease risk • Assessed by a proxy measure -- waist circumference – >40” in men – >35” in women From http://www.nhlbi.nih.gov/guidelines/obesity/e_txtbk/txgd/4142.htm CVD Risk Assessment Waist Circumference Normal High Overweight Increased High Class I obesity High Very High Class II obesity Very High Very High Class III obesity Extremely High Extremely High Obesity-related Comorbidities • • • • • • Hypertension Heart disease Dyslipidemia Pre-diabetes Diabetes mellitus Gastroesophageal reflux disease • • • • Fatty liver Back pain Arthritis Polycystic ovarian syndrome • Infertility • Incontience WHAT SERVICES ENCOMPASS THE MEDICAL MANAGEMENT OF OBESITY? Integrated Weight Management Model Medical Care Nutrition Exercise Behavioral Care Modified from Kushner & Pendarvis 1999 Medical Care • Weight evaluation and management performed by a physician – Primary care physician – Weight management specialist • Physician counseling can be more effective if the 5A’s or motivational interviewing used Medical Care • Role of the physician includes evaluation and management of: – Goal setting – Secondary causes of obesity – Co-morbidities associated with weight gain – Medications associated with weight gain – Candidacy for use of anti-obesity medications Goal Setting • Initial goal for weight loss is to achieve a “healthier weight” – 5-10% loss of initial body weight • Accomplishable for most people • Typically leads to improvement in blood pressure, blood sugar, and other obesityrelated diseases – Goal rate of 1-2 lbs lost per week • Accomplishable for most people • Safe • Less risk of weight regain Secondary Causes of Obesity Common • Hypothyroidism • Polycystic ovarian syndrome (PCOS) Rare • Cushing syndrome • Hypothalamic obesity syndromes • Melanocortin-4 mutations • Leptin deficiency Co-morbid Conditions Cardiovascular • Hypertension • Coronary heart disease Pulmonary • Asthma • Obstructive Sleep Apnea Metabolic • Diabetes mellitus • Dyslipidemia • Metabolic syndrome • Gout Gastrointestinal • GERD • Gallbladder disease • Fatty liver Co-morbid Conditions Musculoskeletal • Osteoarthritis • Back pain Reproductive/GU • PCOS • Infertility • Incontinence Cancer • Colorectal cancer • Prostate cancer • Endometrial cancer • Cervical cancer • Breast cancer • Ovarian cancer • Pancreatic cancer Medications Associated with Weight Gain Disease Type of Medication How they cause weight gain Examples High Blood Pressure Betablockers1 -Reduced resting energy expenditure & thermogenesis -Increased tiredness -Reduced exercise tolerance -Increased insulin resistance Metoprolol Atenolol Carvedilol Allergies Antihistamines2 -Increased appetite Diphenhydramine -Impaired glucose tolerance -Increased truncal fat Prednisone AntiCorticoinflammatory steroids2-3 From: 1. Sharma et al 2001 2. Malone 2005 3. Cheskin 1999 Medications Associated with Weight Gain Disease Type of Medication How they cause weight gain Examples Diabetes mellitus Sulfonylureas -Anabolic effects -Increased appetite -Fluid retention Glyburide Glipizide Glimepiride Diabetes mellitus Thiazolidinediones (TZDs) -Increased adipogenesis -Fluid retention -Increased appetite Pioglitazone Rosiglitazone Diabetes mellitus Insulin -Anabolic effects -Increased appetite -Fluid retention From Mitri & Hamdy 2009 Medications Associated with Weight Gain Disease Type of Medication How they cause weight gain Examples Depression Selective Serotonin Reuptake Inhibitors (SSRIs) -Increased appetite -Increased food cravings Fluoxetine Sertraline Paroxetine Depression Tricyclic Antidepressants (TCAs) -Increased appetite Amitriptyline Nortriptyline Schizophrenia -Increased appetite and binge eating Olanzipine Quetiapine Risperidone From Malone 2005 Atypical Antipsychotics Nutrition • Nutrition evaluation and diet plan – Trained physician – Registered dietician – Certified nutrition specialist Nutrition • Assessment of dietary habits • Tailor dietary recommendations to individual patient needs • Work with physician to address diet and medication changes as needed given comorbid condition profile • Address patient nutrition education and skill deficiencies One-Year Changes in Body Weight By Diet Group and By Adherence Level Copyright restrictions may apply. Dansinger, M. L. et al. JAMA 2005;293:43-53. Exercise • Physical activity evaluation performed by an exercise physiologist or personal trainer Exercise • Role of the exercise physiologist and/or personal trainer includes: – Assessment of exercise tolerance, metabolic fitness, and cardiovascular risk – Create an individualized exercise prescription WHAT NEW WEIGHT LOSS MEDICATIONS WILL BE AVAILABLE? Criteria for Medication Use Element Criteria Body Mass Index ≥30 kg/m2 ≥27 kg/m2 + an obesity-related condition • High blood pressure • High cholesterol • Pre-diabetes or diabetes Prior attempt at lifestyle change Unable to achieve a goal of 1 lb of weight loss per week during a 6 month period of diet and exercise changes Any medication must be combined with diet and exercise changes to be effective Patient Counseling • Expected weight loss • Potential side effects and risks • Interactions with other medications Medication selected should be tailored to best suit each individual patient QSYMIA • Combination of phentermine and topiramate • Works by suppressing the appetite • Patients lost between 11-24 lbs at 12 months QSYMIA • Common side effects include tingling, dizziness, increased heart rate, and depressed mood. • May not be a good choice if you have heart, liver or kidney disease • Causes birth defects BELVIQ • New medication that targets a special Serotonin neurotransmitter receptor • Works by suppressing the appetite • Patients lost 10-12 lbs at 12 months BELVIQ • Common side effects include headache, dizziness, nausea, drowsiness • May not be a good choice if you have heart, liver, or kidney disease What current medication options do I have? ALLI (orlistat) • Works by blocking absorption of fat • Common side effects include abdominal cramping, bloating, diarrhea • May not be a good choice if you have gastrointestinal issues or liver disease ADIPEX (phentermine) • Works by suppressing the appetite • Common side effects include headache, dizziness, nausea • May not be a good choice if you have heart, liver, or kidney disease Digestive Weight Loss Center 2360 W. Joppa Rd, Suite 200 Lutherville, MD 21093 410-583-LOSE http://www.hopkinsmedicine.org/digestive_weight_loss_center/index.html Behavioral Lifestyle Interventions for Obesity: The Foundation for Change Janelle W. Coughlin, Ph.D. Johns Hopkins School of Medicine Department of Psychiatry and Behavioral Sciences Johns Hopkins Medicine International Partners Forum October 2, 2012 Objectives To describe important components of behavioral lifestyle interventions for obesity To summarize outcomes achieved with behavioral lifestyle interventions for obesity To highlight recent innovative developments in behavioral lifestyle interventions for obesity Obesity Treatment Pyramid Surgery BMI Pharmacotherapy Lifestyle Modification Diet Physical Activity Dietary Approaches to Lifestyle Modification Calorie Deficit ~1200-2000 kcal/d Dietary Approaches: Low-fat Low-carbohydrate Mediterranean Low-glycemic load Portion-controlled diets Increasing Physical Activity > 180 m/wk MVPA for weight loss Must also include caloric restriction Associated with a number of health improvements, independent of weight loss Critical for long-term weight loss maintenance ~ 60 m/d MVPA Can be performed in short bouts Increasing other lifestyle activities is also effective > 2000 steps for weight loss; > 6000 to avoid regain Behavioral Strategies •Self-monitoring Increase self-efficacy and social support •Goal Setting •Stimulus control •Problem solving •Cognitive restructuring •Relapse Prevention Motivational Interviewing Weight Loss Maintenance Patients gain ~ 1/3 of There is significant their lost weight in the year following treatment Nearly half of participants return to their original weight within 5 years 1:6 adults accomplish > 1 yr of maintaining > 10% of IBW evidence that weight loss maintenance interventions can decrease the chance of weight regain Regular ongoing contact following initial weight loss is perhaps the most successful method of preventing weight regain Study Design Phase I N=1685 Behavioral weight loss intervention Phase I 6 months Weight loss ≥4 kg Yes Phase II 30 months No No further contact Phase II Randomization N=1032 Self-directed control group Personal Contact Interactive Technology Data collection prior to Phase I, at randomization, then every 6 months Change from initial weight Weight change, kg 0 -2.9 -2 -3.3 -4.2 -4 -6 -8 -10 -6 0 6 12 18 24 30 Months after Randomization Self-directed Interactive technology Svetkey et al., 2008 Personal Contact Remote/Telephone-delivered Technology-Based PCP-Enhanced or Promoted Design Randomization Control Remote In-Person Baseline 6 Mo 12 Mo = Measured weights and other outcomes 24 Mo Interventions Mode of Delivery Coach Coach support Study website Physician Roles Remote In-Person Telephone only Group meetings Individual meetings Telephone Hopkins Healthways Case management Educational modules Self-monitoring tools Tailored emails Supportive Review weight progress reports Weight change, kg 2 0 -0.8 -2 -4.3* -4.6* -4 -6 -8 0 6 12 24 Months after Randomization Control Appel et al, NEJM 2011;365:1959-68 Remote In-Person *P <0.001 (vs control Does lifestyle modification enhance the effects of weight loss medications and surgery? Surgery BMI Pharmacotherapy Lifestyle Modification Diet Physical Activity Thank You Wadden et al., (March, 2012). Circulation