obesity: trends and implications · 2017-09-28 · obesity: trends and implications . mark skillan,...
TRANSCRIPT
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OBESITY: TRENDS AND IMPLICATIONS
Mark Skillan, M.D. ACSW – SEAC November 18, 2011
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“ Obesity: Time bomb or dud? ”
USA Today
“ Obesity as an over-hyped crisis ”
Boston News
“ The supposed detrimental effects of obesity are actually exaggerated…”
Spektrum der Wissenschaft
“ The rising prevalence and severity of obesity are capable of offsetting the positive influences on longevity ”
New England Journal of Medicine
“ Obese children may have a lower life expectancy than their parents ”
New York Times
“ Obesity may stall trend of increasing longevity ”
Washington Post
2
Obesity in the media
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Obesity – A growing concern
Obesity Defined
Prevalence
Etiology
Health Consequences
Morbidity and Mortality Implications
Interventions & Challenges
The Future
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OBESITY: AN INSURER’S CONCERN
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Relation between mortality and body mass index
5
At a body mass index below 20 kg/m2 and above 25 kg/m2 there is an increase in relative mortality for men and women. Data from Lew, EA. Ann Intern Med 1985; 103:1024
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OBESITY DEFINED
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Overweight and obesity defined
Overweight: having extra body weight, for a particular height, from fat, muscle, bone, or water.
Obesity: having a high amount of excess body fat.
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Methods of detecting overweight and obesity
Scale
Skin-fold thickness
Waist circumference
Waist-to-hip circumference ratios
Body Mass Index (BMI)
- BMI = weight (in kgs) / height squared (in meters)
- Practical measure
- Accepted internationally (NHLBI, CDC, WHO, etc)
- Does not differentiate between lean mass and adiposity
- Based on statistical norms
Imaging techniques
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Classification of weight - adult
BMI Description Class of obesity Example 1.74 m
18.5 or less Underweight - less than 56 kg
18.5 – 24.9 Normal weight - 56 kg - 75 kg
25.0 – 29.9 Overweight 0 75 kg - 90 kg
30.0 – 34.9 Obesity I 90 kg - 106 kg
35.0 – 39.9 Obesity II 106 kg - 121 kg
40 or higher Extreme obesity III more than 121 kg
Body Mass Index (BMI) Weight (kg) Height (m2)
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Classification of weight - child and adolescent
Category Youth (2-20 yrs) Underweight BMI <5th percentile for age Normal weight BMI 5th to <85th percentile Overweight BMI 85th to <95th percentile Obesity BMI ≥ 95th percentile Class III obesity (super obesity) Not used*
10
Source: AAP: American Academy of Pediatrics; IOM: Institute of Medicine; ES: Endocrine society; CDC: Centers for Disease Control; IOTF: International obesity task force. * In children, a proposed definition of severe obesity is BMI > 120 percent of the 95th percentile.
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PREVALENCE
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Past and projected prevalence of overweight by country
Source: The Lancet 2011; 378:815-825 (DOI:10.1016/S0140-6736(11)60814-3)
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2000
*BMI ≥30, or about 30 lbs. overweight for 5’4” person
2010
1990
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
Obesity trends* among U.S. adults BRFSS, 1990, 2000, 2011
Source: Behavioral Risk Factor Surveillance System, CDC.
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Obesity & overweight prevalence 2010
Obesity
- Adults (BMI > 30): 33.8% (32.2% men, 35.5 % women)
- Children & Adolescents (ages 2-19) – 16.4%
Overweight and Obesity
- Adults (BMI > 25): 68 % (72.3% men, 64.1% women)
- Children & Adolescents (ages 2-19): 34.6%
Increasing percentage of those with BMI > 40
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Smoothed frequency distributions of body mass index for men and women aged 40 to 59 years in 1999-2000 and 2007-2008
15
Source: Flegal, K. M. et al. JAMA 2010;303:235-241
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Obesity – not only an adult concern…
Conditions now more commonly seen in children
High cholesterol
Type 2 Diabetes/Impaired Glucose Tolerance
High blood pressure
Social problems and poor self-esteem
Sleep disturbances
Orthopaedic problems
A major concern -
Obese children and adolescents are at increased risk to become overweight or obese adults
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Rising prevalence of overweight children (5-11)
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For this figure, the prevalence of overweight children is defined as the percent of children aged 5 to 11 with BMI > 85 percentile, using IOTF standards. IOT: International Obesity Task Force. Reproduced with permission from: Lobstein, T, Rigby, N, Leach, R. International Obesity Task Force. EU platform diet, physical activity, and health. International Obesity Task Force EU Platform Briefing Paper. Brussels 2005. Copyright © 2005 European Association for the Study of Obesity.
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Percentage of overweight children, ages 5 – 11
Source: International Obesity Task Force (IOTF), London, March 2005
0
5
10
15
20
25
30
1950 1960 1970 1980 1990 2000 2010
Netherlands Germany USA England Poland France
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Percentage of U.S. children and adolescents classified as obese, 1963-2008*
0
5
10
15
20
1963-70** 1971-74 1976-80 1988-94 1999-2000 2001-02 2003-06 2007-08
Ages 6-11 Ages 12-19
19
*>95th percentile for BMI by age and sex based on 2000 CDC BMI-for-age growth charts. ** 1963-1970 data are from 1963-1965 for children 6-11 years of age and from 1966-1970 for adolescents 12-17 years of age. Source: NCHS. Health, United States, 2010:With Special Feature on Death and Dying. Hyattsville, MD.2011
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Global prevalence of overweight in boys 2000-2006
% Overweight < 5%
5 – 9.9% 10 – 14.9% 15 – 19.9% 20 – 24.9% 25 – 29.9%
≥30%
Source: IASO/IATF
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ETIOLOGY
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Causes of obesity
Calories Ingested
Calories Burned
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Factors contributing to obesity
Genetics
Environment
Unhealthy diet
Sedentary lifestyle
Lack of physical activity
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Etiology of overweight and obesity
Weight Gain Follows Caloric Imbalance
- Calories Ingested (food + beverage) >
- Calories Expended (bodily functions + physical activity)
Determinants of Body Weight
- Genes and pre-natal factors
- Metabolism
- Behavior – food choices, eating habits, activity choices, sleep habits
- Environment – advertising
- Culture – ethnic differences
- Socioeconomic status – educational level
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HEALTH CONSEQUENCES
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Health consequences of obesity
Coronary Heart Disease
Type 2 Diabetes
Cancers
Hypertension
Lipid Disorders
Stroke
Liver and Gall Bladder Disease
Sleep apnea
Osteoarthritis
Infertility
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Obesity affects longevity via associated diseases
Stroke
Coronary heart disease
Left ventricular hyper-
trophy
Diabetes mellitus
Gyn abnormalities
Fatty liver
Cholelithiasis
Hypertension
Pulmonary disease
Sleep apnea
Depression
Arthroses
Pancreatitis
Malignant tumors
Back pain
Musculoskeletal
Dyslipidemia
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Prevalence of cardiovascular disease risk factors* in adults, USA 1961-2000
0
10
20
30
40
50
60
70
1960 1965 1970 1975 1980 1985 1990 1992 1995 2000
Year
Perc
ent o
f Pop
ulat
ion
Overweight Hypertension Smoking High Cholesterol
Source: NIH, NHLBI, Fact Book Fiscal Year 2003. Feb. 04
(*age adjusted)
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MORBIDITY AND MORTALITY IMPLICATIONS
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0
10
20
30
40
50
60
70
<22 22-22,9 23-23,9 24-24,9 25-26,9 27-28,9 29-30,9 31-32,9 33-34,9 >=35
BMI
Relative risk
Nurses Health Study: n=100,000 16 yr follow=up
Relationship between BMI and Risk of Type 2 Diabetes
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Prevalence of diabetes worldwide Percentage of people aged ≥ 20 with diabetes in 2000
15% and above 10% - 14.9% 5% - 9.9% below 5% no data
Source: WHO, 2007
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Relative Risk, All-Cause Mortality for A 1 C Levels
From Khaw, K, et al, Annals of Internal Medicine. 2004; 141(6):413
0.5
1
1.5
2
2.5
3
3.5
4
< 5 % 5 - 5.4 % 5.5 - 5.9 % 6.0 - 6.4 % 6.5 - 7.0 %
Women
Men
Risk
Ratio
Diabetes
Relative Risk, All-Cause Mortality for A 1 C Levels
From Khaw, K, et al, Annals of Internal Medicine. 2004; 141(6):413
0.5
1
1.5
2
2.5
3
3.5
4
< 5 % 5 - 5.4 % 5.5 - 5.9 % 6.0 - 6.4 % 6.5 - 7.0 %
Women
Men
Risk
Ratio
Diabetes
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Relation between age and rates of CHD with and without diabetes
20 0
40
60
80
100
120
140
160
180
200
220
240
Age (years)
Source: The Lancet, Vol. 368, July 1, 06 retrospective cohort, n=9MM
Num
ber o
f eve
nts
per 1
000
pers
on-y
ear
Diabetes, recent AMI No diabetes, recent AMI
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Increase in diseases attributable to rising obesity levels
0
10
20
30
40
50
60
70
80
2005 2010 2015 2020 2025 2030 2035
Time (years)
Incr
ease
%
Coronary heart disease Stroke Diabetes
Source: Foresight 2007, K. McPherson, University of Oxford; adjusted for age and gender
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Obesity and cancer risk
Women Men
Endometrium RR=5.42 Prostate RR=1.29
Cervix RR=2.39 Colorectal RR=1.73
Breast RR=1.53
Gall bladder RR=3.58
Possible causes:
1. Hormonal changes
Gynecological tumors, prostate
2. Dietary intake (e.g. high fat content)
Intestinal tract, gall bladder
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Relative risk of death in relation to BMI, age 50
0
0.5
1
1.5
2
2.5
3
3.5
18.5 20.9 23.4 24.9 26.4 27.9 29.9 34.9 39.9 >40
Rel
ativ
e R
isk
BMI
Men Women
36
Source: Adams KF, et al, NEJM 2006 355;8:763-778.
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Relative risk of death in relation to BMI, ages 50 to 71
0
0.5
1
1.5
2
2.5
18.5 20.9 23.4 24.9 26.4 27.9 29.9 34.9 39.9 >40
Rel
ativ
e R
isk
BMI
Men Women
37
Source: Adams KF, et al, NEJM 2006 355;8:763-778.
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COSTS
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Obese and overweight: 9.1 % of total annual US medical expenditures
Obese (BMI > 30) annual medical expenditures 36% higher than BMI 18.5-25
Grade III obesity – 3% workforce, 21% of obesity costs
Estimated annual employer cost of obesity per 1000 employees $285,000Associated medical care costs: $147 Billion (Finklestein, 2009)
Excess third party costs vs. normal weight: $1,429/yr.
Obesity costs
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Obesity costs
Indirect Costs: Absenteeism, Disability, Premature mortality, “Presenteeism”, Workmen’s Comp…
BMI > 40: 11.65 WC claims/100 FTE’s (vs. 5.8 for “normal” weight)
- 184 lost work days/100 FTE’s (vs. 14)
- Medical claims $51,000/100FTE’s (vs. $7500)
- Indemnity claims $59,000/100 FTE’s (vs. $5400)
Commonest claims: limbs, back / pain, sprain / falls, lifting
(Duke Health & Safety Surveillance System)
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INTERVENTIONS AND CHALLENGES
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Therapeutic goals
Weight loss
Normalize blood sugar
Improve lipids
Slow or halt progression of coronary heart disease
Reduce or resolve obstructive sleep apnea
Improve sense of well-being
Reduce cancer risk
Reduce liver and gall bladder disease risk
Improve fertility
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Interventions and challenges
Treatment goals – reduce or prevent complications associated with obesity
Interventions
Dietary modification
Exercise
Behavior modification
Drug therapy
Surgery
- Liposuction
- Bariatric Surgery
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Weight loss-induced reduction in blood pressure
0
2
4
6
8
10
>-9.5 -4.5 to -9.5 -2 to -4.5 +1 to -2 >+1
Fall
in d
iast
olic
BP,
mm
Hg
Weight change, kg
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Relationship between the quantity of weight lost and the fall in diastolic blood pressure in 308 moderately obese patients given a weight reduction regimen for 18 months. The patients began with a diastolic pressure between 80 and 89 mmHg; those who lost the most weight had the largest reduction in diastolic pressure. The decreases in the systolic pressure were similar. Source: Data from Stevens, VJ, Corrigan, SA, Obarzanek, E, et al, Arch Intern Med 1993; 153:849.
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Importance of body weight and exercise on development of type 2 diabetes
0
20
40
60
<24 24-25.9 >26
Rat
e of
type
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iabe
tes
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0,00
0 pa
tient
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Body mass index, kg/m2
<500 kcal/wk 500-1999 kcal/wk >2000 kcal/wk
45
Adjusted incidence of type 2 diabetes mellitus in 5990 men in relation to body mass index (BMI, in kg/m2) and the level of physical activity (in kcal/wk). The risk of type 2 diabetes was directly related to BMI, while regular exercise was protective except for men with a BMI below 24. Source: Data from Helmrich, SP, Ragland, DR, Leung, RW, Paffenbarger, PS, N Engl J Med 1991; 325:147.
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THE FUTURE
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100 million obese now –> 165 million by 2030
50% American Men Obese by 2030
US healthcare spending will rise by $66 Billion a year
Potential decline in US Life expectancy?
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Projections for 2030 if historical trend continues
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Measures to be considered
1. Tax on unhealthy food and beverages
2. Promote good nutrition
3. Promote physical activity
4. Limit or ban junk food advertising
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Conclusions
Explosion of obesity is a global problem
Obesity related disorders a growing problem for the foreseeable future
Childhood obesity is a special concern for both the intermediate and long term
Life: Trend reversal on longevity in the intermediate term cannot be excluded
Living benefits: increasing morbidity in the intermediate term appears assured
Without concerted interventions, outlook challenging
Continuous monitoring of epidemiologic trends necessary
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References
1. Prevalence and Trends in Obesity Among US Adults, 1999-2008 - Flegal, KM, et al, Journal of the American Medical Association. 2010; 303(3):235-241
2. Body Mass Index in a Prospective Cohort of U.S. Adults, Calle, EE, et al, New England Journal of Medicine. 1999; 341(15): 1097-1105
3. Mortality and Morbidity Liaison Committee – ISCS Body Mass Index Study – Roudebush, B, et al, Journal of Insurance Medicine. 2006; 38:167-180
4. Mortality and Weight: Insured Lives and the American Cancer Society Studies. Lew, E A, Annals of Internal Medicine. 1985; 103(6): 1024-1029
5. Overweight, Obesity and Mortality in a Large Prospective Cohort of Persons 50-71 Years Old - Adams, KF, et al, New England Journal of Medicine. 2006; 355(8): 763-778
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References (continued)
7. Excess Deaths Associated With Underweight, Overweight and Obesity – Flegal, KM, et al, JAMA. 2005; 293(15): 1861-1867
8. Cause-Specific Excess Deaths Associated with Underweight, Over weight and Obesity – Flegal, KM, et al, JAMA. 2007; 298(17): 2028-2037
9. Body Mass Index and Mortality in an Insured Population – Niverthi, M., et al, Journal of Insurance Medicine. 2001; 33: 321-328
10. Body Mass Index and Mortality Among 1.46 Million White Adults – Berrington deGonzalez, A., et al, New England Journal of Medicine 2010; 363(23): 2211-2219
11. Obesity and Mortality – Calle, E, et al, New England Journal of Medicine. 2005; 353(20):2197-99
12. Adolescent BMI Trajectory and Risk of Diabetes Versus Coronary Artery Disease – Tirosh, A., et al, New England Journal of Medicine. 2011; 364(14): 1315-1325
10/11/2011 51 Title of presentation and name of speaker
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References (continued)
13. Childhood Obesity, Other Cardiovascular Risk Factors and Premature death – Franks, P., et al New England Journal of Medicine. 2010; 326(6): 485-493
14. A Potential Decline in Life Expectancy in the United States in the 21st Century – Olshansky, SJ, et al, New England Journal of Medicine. 2005; 325(11): 1138-1145
15. Deadweight ? – The Influence of Obesity on Longevity – Preston, SH, New England Journal Of Medicine. 2005; 352(11): 1135-1137
16. Obesity and Its Relation to Mortality and Morbidity Costs – Behan, D, et al, Society of Actuaries. December 2010
17. Obesity and Workers’ Compensation - Ostbye, T, et al, Archives of Internal Medicine. 2007; 167(8):766-773
18. Indirect Costs of Obesity: a review of the current literature - Trogdon, JG, et al; Obesity Reviews. 2008; 9: 489-500
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References (continued)
19. Occupation-Specific Absenteeism Costs Associated with Obesity and Morbid Obesity – Crawley, J, et al, Journal of Occupational and Environmental Medicine. 2007; 49:1317-1324
20. Annual Medical Spending Attributable to Obesity: Payer- and Service-Specific Estimates - Finklestein, EA, et al, Heath Affairs 2009; 28(5): w822-w831
21. The Cost of Obesity Among Full-time Employees – Finklestein, E, et al, American Journal of Health Promotion. 2005; 20(1): 45-50
22. Medical Disability Advisor – 6th edition, Reed, P, et al
23. Health and Economic Burden of the Projected Obesity Trends in the U.S. and U.K. – Yang, Y, et al, The Lancet. 2011; 378(9793): 815-825
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Calculation of BMI
English formula for BMI: [ Weight in pounds ÷ Height in inches ÷ Height in inches ] × 703 Metric formula for BMI: Weight in Kilograms ÷ Height in meters ÷ Height in meters
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