Download Obesity - Jimmy Hall

Obesity in the Veteran
Population
A Growing Problem
Jimmy Hall, RN, MSN
Objectives
•
•
•
•
•
Define Overweight/Obesity
Recognize complications
Identify who is at risk
Identify areas of prevention
Distinguish methods of treatment
Defined
• Overweight and obesity are both labels for ranges
of weight that are greater than what is generally
considered healthy for a given height.
• The terms also identify ranges of weight that
have been shown to increase the likelihood of
certain diseases and other health problems.
Overweight and Obesity. (2010). Centers for Disease Control and Prevention. Retrieved from
http://www.cdc.gov/obesity/defining.html
Overweight vs. Obese
• Overweight - Adults with a body mass index (BMI),
calculated as weight in kilograms divided by height in
meters squared, between 25 and 30 are considered
overweight.
• Obese - Adults with a BMI greater than or equal to
30 are considered obese.
• Morbidly Obese - Anyone who is more than 100
pounds overweight or who has a BMI greater than or
equal to 40.
Obesity. (2010). National Center for Biotechnology Information.
Obesity
• BMI is calculated from a person's weight and height
and provides a reasonable indicator of body fatness
and weight categories that may lead to health
problems.
• In 2009, only Colorado and the District of Columbia
had a prevalence of obesity less than 20%.
• Thirty-three states had a prevalence equal to or greater
than 25%.
– Nine of these states (Alabama, Arkansas, Kentucky,
Louisiana, Mississippi, Missouri, Oklahoma, Tennessee,
and West Virginia) had a prevalence of obesity equal to or
greater than 30%!!
Overweight and Obesity. (2010). Centers for Disease Control and Prevention. Retrieved from
http://www.cdc.gov/obesity/data/trends.html
Body Mass Index (BMI)
• Body Mass Index (BMI)
is a number calculated
from a person's weight
and height.
• Some people question
the validity of BMI
itself as an indicator of
obesity.
– BMI is higher in higher
in highly physically fit
individuals, such as
professional athletes
Percent of Obese (BMI > 30) in U.S. Adults
Overweight and Obesity. (2010). Centers for Disease Control and Prevention. Retrieved from
http://www.cdc.gov/obesity/data/trends.html
Percent of Obese (BMI > 30) in U.S. Adults
Overweight and Obesity. (2010). Centers for Disease Control and Prevention. Retrieved from
http://www.cdc.gov/obesity/data/trends.html
Percent of Obese (BMI > 30) in U.S. Adults
Overweight and Obesity. (2010). Centers for Disease Control and Prevention. Retrieved from
http://www.cdc.gov/obesity/data/trends.html
Percent of Obese (BMI > 30) in U.S. Adults
Overweight and Obesity. (2010). Centers for Disease Control and Prevention. Retrieved from
http://www.cdc.gov/obesity/data/trends.html
Percent of Obese (BMI > 30) in U.S. Adults
Overweight and Obesity. (2010). Centers for Disease Control and Prevention. Retrieved from
http://www.cdc.gov/obesity/data/trends.html
What Causes It?
•
•
•
•
Increased Food Intake
Increased Alcohol Consumption
Sedentary Lifestyle
Genetics
– children of obese parents are 10 times more likely to be
obese than children with parents of normal weight
• Antidepressants/Antipsychotics
• Hypothyroidism (5-10 pound gain)
Obesity. (2010). National Center for Biotechnology Information.
Complications













High blood pressure (hypertension )
High blood cholesterol (dyslipidemia )
Type 2 (non-insulin dependent) diabetes
Coronary heart disease
Angina pectoris
Congestive heart failure
Stroke
Gallstones
Cholescystitis and cholelithiasis
Gout
Osteoarthritis
Obstructive sleep apnea
Some types of cancer (such as
endometrial, breast, prostate, and colon)
 Complications of pregnancy such as;




gestational diabetes, gestational
hypertension and preeclampsia as well as
complications in operative delivery (i.e.,
c-sections).
Poor female reproductive health (such as
menstrual irregularities, infertility,
irregular ovulation)
Bladder control problems (such as stress
incontinence)
Uric acid nephrolithiasis
Psychological disorders (such as
depression, eating disorders, distorted
body image, and low self-esteem)
Health Impact. (2006). Department of Veterans Affairs. Retrieved from
http://www.move.va.gov/whyMove_health.asp
Who is at Risk?
• People who are at higher risk for obesity
include:
– Lower income groups
– Former smokers
– People with chronic mental illness
– People with disabilities
– People with a sedentary lifestyle
Obesity. (2010). National Center for Biotechnology Information.
Who Else Is At Risk?
Veterans!
How Is This Possible?
• New recruits must pass medical evaluation to
enter military service, which would screen out
those with serious pre-existing obesity or obesityrelated chronic conditions.
• Physical fitness is mandated throughout a military
career, and some evidence suggests that higher
exercise levels are maintained after discharge
from service.
• Tobacco smoking has also been found to be more
common among Veterans than among nonVeterans – which might limit weight gain.
Koepsell, T., Littman, A., & Forsberg, C. (2011). Obesity, overweight, and their life course
trajectories in veterans and non-veterans. Obesity. Advance online publication.
Veterans Receiving Care at VA
“Veterans who received health care from the VA
had higher rates of obesity than the general
population, with significant levels of associated
comorbid disease and disability, and low rates of
preventive health behaviors.”
“The results of the current study show a substantial
health burden from obesity among Veterans
cared for by the VA.”
Nelson, K. (2006). The burden of obesity among a national probability sample of veterans. Journal of General
Internal Medicine. 21(9):915-9.
Recent Study
 National Health and Nutrition Examination
Survey (NHANES)
– Examined data from 1999 – 2008
– Looked at individuals aged 30 years or older
• 21,974 non-Veterans
• 3,768 Veterans
– Height, weight, and waist circumference were assessed by direct
measurement in all years, and self-reported height and weight were
also obtained in all years
– Age of leaving military not known
– Rate of increase in BMI since age 25 years was significantly higher for
Veterans aged 30 – 44 years compared to same age non-Veterans.
Koepsell, T., Littman, A., & Forsberg, C. (2011). Obesity, overweight, and their life course trajectories in veterans and nonveterans. Obesity. Advance online publication.
Waist Circumference
• Fat stored around the middle of the body (the waist
or abdomen) can put you at risk for:
o
o
o
o
o
High Blood Pressure
High Blood Cholesterol
Type-2 Diabetes
Heart Disease
Stroke
• This risk increases with a waist size
o 35 inches or greater for women
o 40 inches or greater for men.
MOVE! Q&A. (2010). US Department of Veterans Affairs. Retrieved from
http://www.move.va.gov/QandA.asp#MOVE!
Did You Know?
Studies have shown that extra weight around
the waistline is more dangerous to the heart
than extra weight that is on the hips and
thighs.
MOVE! Q&A. (2010). US Department of Veterans Affairs. Retrieved from
http://www.move.va.gov/QandA.asp#MOVE!
Veteran Weight(%)
Body Mass Index (BMI)
24.6%
BMI Greater than 25
BMI Less than 25
75.4%
Koepsell, T., Littman, A., & Forsberg, C. (2011). Obesity, overweight, and their life course
trajectories in veterans and non-veterans. Obesity. Advance online publication.
Non-Veteran Weight (%)
Body Mass Index (BMI)
34.6%
65.4%
BMI Greater than 25
BMI Less than 25
Koepsell, T., Littman, A., & Forsberg, C. (2011). Obesity, overweight, and their life course
trajectories in veterans and non-veterans. Obesity. Advance online publication.
Veteran Weight (%)
20.6
Percent
Body Fat
18.4
23.3
WaistStature
Ratio
31.1
30.8
13.9
5
10
15
Low
Lowest
24.3
0
High
31.2
31.5
14.1
Waist
Circumfer
ence
Highest
30.6
30.3
20
25
30
35
Koepsell, T., Littman, A., & Forsberg, C. (2011). Obesity, overweight, and their life course trajectories in veterans and nonveterans. Obesity. Advance online publication.
Veteran and Non-Veteran Comparison
Above Average Weight (%)
90
81.5%
80
79.8%
70
60
55.4% 52.3%
54.5%
52.8%
50
Veteran
40
Non-Veteran
30
20
10
0
Waist Circumference Waist-Stature Ratio
Percent Body Fat
Koepsell, T., Littman, A., & Forsberg, C. (2011). Obesity, overweight, and their life course trajectories in veterans and
non-veterans. Obesity. Advance online publication.
Study #2
• VA Statistical Information
– Cross-sectional analysis of 1,803, 323 veterans
receiving outpatient care at 136 VA medical facilities
in 2000
– BMI calculated with data broken into groups based on
gender and examined by age and race/ethnicity
– Of 93,290 women American Veterans receiving care,
68.4% were at least overweight, with 37.4% classified
as obese.
– Of 1,710,032 men, 73.0% were at least overweight,
with 32.9% being obese.
Das, S., Kinsinger, L., Yancy, W., Wang, A., Ciesco, E., Burdick, M., & Yevich, S. (2005). Obesity prevalence among
veterans at veterans affairs medical facilities. American Journal of Preventive Medicine: 28(3), 291 – 294.
Male vs. Female Veteran Weight
Overweight vs. Normal/Underweight
73.0%
68.4%
Male
27.0% 31.6%
Overweight
Female
Normal/Underweight
Das, S., Kinsinger, L., Yancy, W., Wang, A., Ciesco, E., Burdick, M., & Yevich, S. (2005). Obesity prevalence among
veterans at veterans affairs medical facilities. American Journal of Preventive Medicine: 28(3), 291 – 294.
Male vs. Female Veteran Weight
45
40
35
30
40.1%
31.0%
32.9%
37.4%
25
Male
20
15
Female
10
5
0
Overweight
Obese
Das, S., Kinsinger, L., Yancy, W., Wang, A., Ciesco, E., Burdick, M., & Yevich, S. (2005). Obesity prevalence among
veterans at veterans affairs medical facilities. American Journal of Preventive Medicine: 28(3), 291 – 294.
Female Veteran BMI (%) by Race
45
39.1
40
30.8
29.1
African Americans
White
Hispanic
3.1
1.1
3.2
5.1
3.7
7.2
6.8
2.6
5
7.5
8.9
9.1
10
Unknown
8.9
11.1
15
Asian American
18
18.3
19.5
22.2
20
22.4
23.6
25
34.1
34.4
35
30
Native Americans
0
Overweight (BMI 25 29)
Class I Obese (BMI 30 - Class II Obese (BMI 35 34.9)
39.9)
Class III Obese (BMI ≥
40)
Das, S., Kinsinger, L., Yancy, W., Wang, A., Ciesco, E., Burdick, M., & Yevich, S. (2005). Obesity prevalence among veterans at
veterans affairs medical facilities. American Journal of Preventive Medicine: 28(3), 291 – 294.
Male Veteran BMI (%) by Race
40
42
38.2
42.8
38.9
36.3
38.8
45
Native Americans
African Americans
35
White
30
22.7
21.4
22.3
20.3
23.4
25
Hispanics
Asian Americans
20
2.7
2.1
2.3
3.5
3
3.5
5
7
4.8
6.2
7.8
6.8
8.2
10
13.7
15
Unknown
0
Overweight (BMI 25 - Class I Obese (BMI 30 - Class II Obese (BMI 35 Class III Obese (BMI ≥
40)
29.9)
34.9)
- 39.9)
Das, S., Kinsinger, L., Yancy, W., Wang, A., Ciesco, E., Burdick, M., & Yevich, S. (2005). Obesity prevalence among veterans at
veterans affairs medical facilities. American Journal of Preventive Medicine: 28(3), 291 – 294.
We Know There’s a
Problem…
Now What?
Prevention
“Many diseases can be prevented, yet health
care systems do not make the best use of their
available resources to support this process. All
too often, health care workers fail to seize
patient interactions as opportunities to inform
patients about health promotion and disease
prevention strategies.”
Integrating prevention into healthcare. (2011). World Health Organization. Retrieved from
http://www.who.int/mediacentre/factsheets/fs172/en/
Primary Prevention
• Primary prevention is the prevention of a
disease before it occurs.
• Given that many conditions are preventable,
every health care interaction should include
prevention support.
– When patients are provided with information and skills to
reduce health risks, they are more likely to eat healthy
foods and to engage in physical activity.
Integrating prevention into healthcare. (2011). World Health Organization. Retrieved from
http://www.who.int/mediacentre/factsheets/fs172/en/
Primary Prevention
• A collaborative management approach at the
primary health care level with patients, their families
and other health care actors is a must to effectively
prevent many major contributors to the burden of
disease.
Make prevention an element of every
health care interaction!!
Integrating prevention into healthcare. (2011). World Health Organization. Retrieved from
http://www.who.int/mediacentre/factsheets/fs172/en/
What If Prevention
Is Not An Option?
Treatment
• Types of Treatment:
– Exercise
– Diet
– Weight Loss Medications
– Surgery
• Gastric Bypass
• Laparoscopic Gastric Banding
Obesity. (2010). National Center for Biotechnology Information.
Exercise
• Adults need at least:
 2 Hours and 30 Minutes (150
minutes) of moderate-intensity
aerobic activity (i.e. brisk walking)
every week
AND
 Muscle-strengthening activities on
2 or more days a week that work
all major muscle groups (legs,
hips, back, abdomen, chest,
shoulders, and arms).
How much physical activity do adults need? (2011). Centers for Disease Control and Prevention. Retrieved from
http://www.cdc.gov/physicalactivity/everyone/guidelines/adults.html
Barriers for Exercising
1.
2.
3.
4.
5.
6.
Lack of Interest
Shortness of Breath
Joint Pain
Perceived Lack of
Fitness
Lack of Energy
Doubt that Exercise Can
Lengthen Life
Crombie, I., Irvine, L., Williams, B., McGinnins, A., Slane, P., Alder, E., & McMurdo, M. Why older people do not
participate in leisure time physical activity: a survey of activity levels, beliefs and deterrents. Age and Ageing
2004; 33: 287–292
Diet Recommendations
• The Dietary Guidelines for Americans, 2010, released
on January 31, 2011, emphasize three major goals for
Americans:
1.
2.
3.
Balance calories with physical activity to manage weight
Consume more of certain foods and nutrients such as fruits,
vegetables, whole grains, fat-free and low-fat dairy products,
and seafood
Consume fewer foods with sodium (salt), saturated fats, trans
fats, cholesterol, added sugars, and refined grains
Dietary Guidelines for Americans, 2010. (2011). U.S. Department of Health and
Human Services.
http://www.health.gov/dietaryguidelines/dga2010/DietaryGuidelines2010.pdf
Weight Loss Medications
• If lifestyle changes do not promote weight loss after
6 months, drugs should be considered.
• Many side effects related to many medications
• Many drugs are constanly being pulled from market
NHLBI Obesity Education Intiative: The Practical Guide. Retrieved from
http://www.move.va.gov/download/Resources/NIH_Obesity_Guidelines_Practical_Guide.pdf
Weight Loss Medications
Prescription Medications for the Treatment of Obesity. (2010). National Institutes of Health. Retrieved from
http://win.niddk.nih.gov/Publications/prescription.htm#fdameds
Surgical Treatment
Laparoscopic Gastric Banding - the surgeon places a
band around the upper part of your stomach, creating a small
pouch to hold food. The band helps you limit how much food
you eat by making you feel full after eating small amounts
Gastric Bypass - helps you lose weight by changing how
your stomach and small intestine handle the food you eat.
After the surgery, you will not be able to eat as much as
before, and your body will not absorb all the calories and
other nutrients from the food you eat.
Obesity. (2010). National Center for Biotechnology Information.
Laparoscopic Gastric Banding
Gastric Bypass
What is the VA
Doing?
What is the VA Doing?
• MOVE! Program
– MOVE! is VA's national weight management program
for veterans.
– All VA facilities have been mandated to initiate MOVE!
or an alternative weight management program.
– The MOVE! Program has been designed for both men
and women.
– The MOVE! Program is designed for veterans of all
ability levels.
MOVE! Q&A. (2010). US Department of Veterans Affairs. Retrieved from
http://www.move.va.gov/QandA.asp#MOVE!
MOVE! Success Story!
• Ernie Lohmann
– Bay Pines VA Healthcare
System
– After 4 years in program,
Ernie lost 225 pounds!
– Discontinued all three of
his diabetes medications!
– Sleep apnea has all but
disappeared!
– "It’s like a whole new
life."
What is the VA Doing?
• Weight Loss Medications
Weight Loss Medications
 Sibutramine
• An appetite suppress, working via norepinephrine and
serotonergic mechanisms in the brain.
 Orlistat (Xenical)
• Orlistat is approved for the management of obesity, including:
– Weight loss and weight management when used in conjunction with
a reduced-calorie diet
– Reduce the risk of weight regain after prior weight loss
– Also, indicated for obese patients with an initial body mass index
greater than 30 / greater than 27 in the presence of other risk
factors.
• In the gastrointestinal tract it prevents the breakdown of
triglycerides into free fatty acids, thus inducing a caloric deficit
by reducing systemic absorption of fat.
National PBM Drug Monograph: Orlistat Monograph. (2005). VHA Pharmacy Benefits Management Strategic Healthcare Group and
the Medical Advisory Panel. Retrieved from http://www.move.va.gov/download/Resources/NationalPBMDrugMonographOrlistat.pdf
What is the VA Doing?
• Surgery
– Weight loss surgery is not typically the first option
for weight loss.
– It is available at some VA facilities for suitable
candidates.
• As of July 2004, more than 800 bariatric operations
have been performed at VA medical centers.
MOVE! Q&A. (2010). US Department of Veterans Affairs. Retrieved
from http://www.move.va.gov/QandA.asp#MOVE!
What is the VA Doing?
• Pre-Bariatric Surgery Treatment and Assessment
– Patients with a body mass index (BMI) of more than 40
may be considered.
– Those having a BMI between 35 - 40 with significant comorbid medical conditions offering the potential of
improvement by surgically-induced weight loss may also
be considered.
– Patients must have demonstrated prior attempts at weight
loss and compliance with prior treatment regimens.
• Must have enrolled in MOVE! for a period of not less than 3
months.
CRITERIA AND STANDARDS FOR BARIATRIC SURGERY. (2005). VHA HANDBOOK 1102.6. Retrieved from
http://www.move.va.gov/download/Resources/BariatricSurgery/BariatricSurgeryHandbook.pdf
What is the VA Doing?
• Contraindications for Bariatric Surgery
– Current tobacco smokers; patients must abstain from smoking for at
least 6 weeks prior to surgery
– Patients with oxygen dependent chronic obstructive pulmonary
disorder (COPD)
– Patients with active hepatitis B or cirrhosis
– Patients with congestive heart failure or pulmonary hypertension
unresponsive to treatment
– Patients having had multiple abdominal operations, complicated
incisional hernias, or infection resulting in a multiple, diffuse, or
severe intra-abdominal infection
– Patients with major psychoses and/or any non-compliance with
prescribed treatment regimens
– Patients who were active substance abusers within a period of 1-year
prior to the referral
CRITERIA AND STANDARDS FOR BARIATRIC SURGERY. (2005). VHA HANDBOOK 1102.6. Retrieved from
http://www.move.va.gov/download/Resources/BariatricSurgery/BariatricSurgeryHandbook.pdf
Conclusion
• Overweight/Obese individuals are a growing
population.
• Many complications result from being
overweight/obese.
• Veterans are more likely to be overweight
when compared to non-Veterans.
• Primary prevention is crucial to prevent
• Many treatment options are available (but
PREVENTION is best!)
References
• Obesity. (2010). National Center for
Biotechnology Information. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmedhealth/
PMH0004552/
• Overweight and Obesity. (2010). Centers for
Disease Control and Prevention. Retrieved
from
http://www.cdc.gov/obesity/defining.html