Section 1 Review
Medical Complications of Obesity
Pulmonary disease
abnormal function
obstructive sleep apnea
hypoventilation syndrome
Nonalcoholic fatty liver
disease
Idiopathic intracranial
hypertension
Stroke
Cataracts
steatosis
steatohepatitis
cirrhosis
Coronary heart disease
Diabetes
Dyslipidemia
Hypertension
Gall bladder disease
Severe pancreatitis
Gynecologic abnormalities
Cancer
abnormal menses
infertility
polycystic ovarian syndrome
breast, uterus, cervix
colon, esophagus, pancreas
kidney, prostate
Osteoarthritis
Skin
Gout
Phlebitis
venous stasis
Complications of Childhood
obesity
Relationship Between Weight Gain
in Adulthood and Risk of Type 2
Diabetes
Mellitus
6
Men
Relative Risk
5
Women
4
3
2
1
0
-10
-5
0
5
10
Weight Change (kg)
Willett et al. N Engl J Med 1999;341:427.
15
20
Diagnosing the Metabolic Syndrome
Diagnosis is established when 3 of these risk factors are present.
Risk Factor
Abdominal obesity
(Waist circumference)
Men
Women
TG
HDL-C
Defining Level
>102 cm (>40 in)
>88 cm (>35 in)
150 mg/dL
Men
<40 mg/dL
Women
<50 mg/dL
Blood pressure
130/85 mm Hg
Expert Panel on Detection, Evaluation, and Treatment of High
Blood
Cholesterol
in Adults. JAMA 2001;285:2486-2497.
Fasting
glucose
110 mg/dL
Increase in Cost Compared
with Lean Subjects (%)
Increase in Healthcare Costs Among Obese
Compared with Lean (BMI <25 kg/m2) Patients*
100
Healthcare visits
Pharmacy
Laboratory tests
All outpatient services
All inpatient services
Total healthcare
80
60
40
20
0
BMI 30-34 kg/m2
BMI >35 kg/m2
*HMO Setting: Northern California Kaiser Permanente.
Quesenberry CP Jr et al. Arch Intern Med. 1998;158:466-472.
• “Doc, I am fat because
my hormones are out
of whack. I know I
don’t eat too much.
Can you check out
what’s wrong with me
and give me a pill to fix
it..”
Hormonal Causes of Obesity
•
•
•
•
Cushings Syndrome (glucocorticoid excess)
Most treatments for Diabetes Mellitus type 2
NOT Hypothyroidism
Very few (less than 1%) of patients are obese
due to hormonal problems, but a substantial
number are obese in part due to diabetes
treatment or treatment with glucocorticoids
Selected Medications That
Can Cause Weight Gain
• Psychotropic medications

Diabetes medications
– Tricyclic antidepressants
– Insulin
– Monoamine oxidase
inhibitors
– Sulfonylureas
– Specific SSRIs
– Thiazolidinediones

Highly active antiretroviral
therapy

Tamoxifen

Steroid hormones
– Atypical antipsychotics
– Lithium
– Specific anticonvulsants
• -adrenergic receptor
blockers
– Glucocorticoids
– Progestational steroids
SSRI=selective serotonin reuptake inhibitor
• “Yea, I know about
balancing food and
activity, but I don’t
don’t eat that much.”
• “I don’t eat more than
other people”
• “I only eat salads.”
Discrepancy Between Reported and Actual Energy
Intake and Expenditure
3000
Energy Intake
Energy Expenditure
*
2500
Kcal/d
2000
1500
*
1000
500
0
Reported Actual
*P<0.05 vs reported.
Lichtman et al. N Engl J Med 1992;327:1893.
Reported Actual
• “My problem is
my metabolism is
slow. Anything at
all that I eat turns
to fat.”
Relationship Between Resting Energy Expenditure
and Fat-free Mass
REE (kcal/24 h)
3000
Lean females
Obese females
Lean males
Obese males
2000
1000
0
0
30
40
50
60
70
Fat-Free Mass (kg)
REE = Resting energy expenditure
Owen. Mayo Clin Proc 1988;63:503.
80
90
100
• “Any time I try to lose weight, my
metabolism slows down so much that I
can’t lose weight.”
Energy Metabolism Before and After Weight Loss
Energy Expenditure (kcal/d)
Mean BMI Reduced from 31 to 23 kg/m2
3500
3000
Resting Energy
Expenditure
Total Energy Expenditure
*
*
2500
2000
1500
*
*
After
Predicted
1000
500
0
Before
*P<0.05 vs before weight loss
Amatruda et al. J. Clin Invest 1993;92:1236.
Before
After
Predicted
• “So obesity is all
genetic. There’s
nothing I can do.”
Gene-Environment Interaction
in the Pathogenesis of Obesity
Body Mass Index (kg/m2)
50
40
P <0.0001
Pima Indians
30
20
10
0
Maycoba, Mexico
Ravussin E et al. Diabetes Care 1994;17:1067-1074.
Arizona
Effect of Portion Size on Energy
Intake
Amount Consumed (g)
500
400
300
200
100
0
500
625
750
1000
Amount of Macaroni and Cheese Served (g)
Rolls et al. Am J Clin Nutr. 2000 Dec;76(6):1207-13.
Relationship Between Adiposity and
Frequency of Eating in a Restaurant
Percent Body Fat
55
45
35
25
15
Partial r = 0.35; P = 0.005
5
0.8
0.9
1.0
1.1
1.2
1.3
1.4
1.5
Log Restaurant Food Consumption per Month
McCrory et al. Obes Res 1999;7:564.
Prevalence of Obesity by Hours of TV per Day:
NHES Youth Aged 12-17 in 1967-70 and NLSY Youth Aged
10-15 in 1990
Prevalence
(%)
40
35
30
25
NHES 1967-70
NLSY 1990
20
15
10
5
0
0-1
1-2
2-3
3-4
4-5
TV Hours Per Day (Youth Report)
>5
• “There are too many. We can’t treat
obesity because we would be treating
everyone with everything.”
Expert Panel of NHLBI: Assessing
Obesity - BMI, Waist Circumference,
and Disease Risk
Disease Risk Relative to Normal
Weight and Waist Circumference
Category
BMI
Men 40 in
Men >40 in
Women 35 in Women >35 in
<18.5
—
—
Normal*
18.5-24.9
—
—
Overweight
25.0-29.9
Increased
High
Obesity
30.0-34.9
35.0-39.9
High
Very high
Very high
Very high
Underweight
Extreme obesity
40
Extremely high Extremely high
*An increased waist circumference can denote increased disease risk even in persons of normal weight.
Adapted from Clinical guidelines. National Heart, Lung, and Blood Institute Web site. Available at:
http://www.nhlbi.nih.gov/nhlbi/cardio/obes/prof/guidelns/ob_gdlns.htm. Accessed July 31, 1998.
Expert Panel of NHLBI: Overall Risk of Obesity
• Evaluate the potential presence of other risk
factors.
• Some conditions associated with obesity put
patients at high risk for subsequent mortality,
and will require aggressive modification.
• Other obesity associated conditions are less
lethal, but still require treatment.
• Among the risks to consider are: coronary
heart disease, other atherosclerotic diseases,
type 2 diabetes mellitus, sleep apnea,
gynecological abnormalities, osteoarthritis,
gallstones, stress incontinence,
hypertension, cigarette smoking,
hyperlipidemia, and family history of early
coronary disease.
Expert Panel of NHLBI: Therapy Decision
• Therapy is Recommended:
– BMI > 30
– BMI 25 - 29.9, a dangerous waist
circumference and 2 or more risk
factors.
• Individuals at lesser risk should be
counseled about useful lifestyle changes
if they are ready for a change.
• “So what can we
do? There are all
these diets and pills
on the TV, but
nothing seems to
work very well. Is
there anything that
actually helps.”
NHLBI Expert Panel: Goals of Therapy
• Reduce body weight and maintain a lower
body weight for the long term.
• An initial weight loss target of 10% of
body weight, lost over six months is
recommended and will be medically
significant. The rate of weight loss should
be 1 -2 pounds each week.
• Evidence indicates that greater rates of
weight loss do not achieve better longterm results.
• After the first six months of weight loss
therapy, the priority should be weight
maintenance through combined changes
in diet, physical activity, and behavior.
Obese Patients Have
Unrealistic Weight Loss Goals
Outcome
Weight (lbs)
% Reduction
Initial
218
0
Dream
135
38
Happy
150
31
Acceptable
163
25
Disappointed
180
17
Foster et al. J Consult Clin Psychol 1997;65:79.
NHLBI Expert Panel: Changes in “Lifestyle”
or Priorities
Food
• “Diets” chosen should be long-term
• Reduced 500 to 1000 from baseline in calories
• Targeting 30% or less of calories as fat
• Individualized.
Activity
• Activity is most useful in maintaining weight loss
• Goal of 30 minutes of moderate activity every day
• Increase everyday activity by taking the stairs, etc.
Providing Prepackaged Meals
Enhances Weight Loss
Weekly
Treatment
Maintenance
Weight Change (kg)
0
Control
-2
Behavior Therapy +
Self-selected Diet
-4
-6
-8
-10
Behavior Therapy + Food Provision
-12
0
6
Months
12
18
P=0.0001 treatment vs control.
P=0.0002 behavior therapy + self-selected diet vs behavior therapy + food provision.
Jeffery et al. J Consult Clin Psychol 1993;61:1038.
“I don’t think I need to
change what I am
eating.
I am going to work out
and lose it that way.”
Physical Activity Alone Results
in Minimal Weight Loss
Control Group
Stefanick 1998
Exercise Group
Stefanick 1998a
*
*
Anderssen 1995
Hammer 1989
Verity 1989
Rönnemaa 1988
Wood 1988
*
-7.0
-5.0
Wood 1983
*
-3.0
-1.0
*P<0.05 vs control group Weight loss (kg)
Duration of each study ranged from 4 to 12 months.
Wing. Med Sci Sports Exerc 1999;31(suppl):S547.
1.0
Relationship Between Physical Activity and
Maintenance of Weight Loss
P<0.001
Subjects Exercising (%)
100
80
60
40
20
0
Not Maintained
Maintained
Weight Loss Pattern
Kayman et al. Am J Clin Nutr 1990;52:800.
Considerable Physical Activity is Necessary for
Weight Loss Maintenance
Concomitant Behavior Therapy
Change in Weight (kg)
Weekly
0
-2
-4
-6
-8
-10
-12
-14
-16
0
Biweekly
Monthly
<150 min/wk
>150 min/wk
*P<0.05
>200 min/wk
6
12
Time (months)
Jakicic et al. JAMA 1999;282:1554.
18
Change in Percent Overweight
Effect of Decreasing Sedentary Activities vs
Increasing Physical Activities on Body Weight in
Children 6-12 Years Old
0
-5
Increased Physical Activity
-10
-15
-20
Decreased Sedentary Activity
-25
0
4
Time (months)
Epstein et al. Health Psychol 1995;14:109.
8
12
• “This is so hard. Is
there any good
news?”
Diabetes Prevention Program (DPP)
• Hypothesis: Can diabetes be delayed or prevented by
addressing risk factors: impaired glucose tolerance,
overweight and sedentary life - using lifestyle changes or
metformin?
• 3234 pts of mean age 51, BMI 34, 68% women, 45%
minorities and impaired glucose tolerance were
randomized to 3 groups at 27 US centers:
– Usual care (control)
– Metformin 850 mg BID
– Lifestyle intervention –
• Goal of 7% weight loss by Food Pyramid, NCEP 1
diet
• Goal of 150 min/wk moderate activity (brisk
walking)
Diabetes Development in
Diabetes Prevention Program
“Obesity treatment and
behavior change are too
hard. I don’t have time to
do this in my clinic.”
Practical Behavior Change
• Physicians make a difference
• Repetition and follow-up are most useful
• Likely better to do with 2-5 minutes repeatedly than
with an hour at once
• Education can be done in pieces
• Let them know that you know it’s hard and that the
environment is against them
• Encourage patients to find their own goals
(motivational interviewing techniques) but encourage
specificity - go beyond “watch what I eat”
Five Steps to Facilitate
Behavior Change
1
Identify behavior change goal
2
3
Review when, where, and how behaviors
will be performed
Have patient keep record of behavior change
4 Review progress at next treatment visit
5
Congratulate patient on successes (do not
criticize shortcomings)
Wadden and Foster. Med Clin North Am 2000;84:441.
Cardinal Behaviors of Successful Long-term Weight
Management
National Weight Control Registry Data
• Self-monitoring:
– Diet: record food intake daily, limit certain foods or
food quantity
– Weight: check body weight >1 x/wk
• Low-calorie, low-fat diet:
– Total energy intake:
1300-1400 kcal/d
– Energy intake from fat: 20%-25%
• Eat breakfast daily
• Regular physical activity: 2500-3000 kcal/wk
(eg, walk 4 miles/d)
Klem et al. Am J Clin Nutr 1997;66:239.
McGuire et al.Int J Obes Relat Metab Disord 1998;22:572.
Weight Loss (%)
Long-term Weight Loss is Improved with Longterm Maintenance Therapy
0
-2
-4
-6
-8
-10
-12
-14
-16
-18
No maintenance tx
Maintenance tx
Diet and
behavior
modification
therapy
0 1 2
3 4
P <0.05
5 6 7
8 9 10 11 12 13 14 15 16 17
Time (mo)
Perri et al. J Consult Clin Psychol 1988;56:529.
Assessing Weight Loss Readiness
• Motivation:
• Stress level:
• Psychiatric
issues:
Patient seeks weight reduction
Free of major life crises
Free of severe depression,
substance abuse, bulimia nervosa
Patient can devote 15-30 min/d to
weight control for next 26 weeks
• Time availability:
YES
Patient Ready?
Initiate weight loss
therapy
NO
Prevent weight gain
and explore barriers to
weight reduction
Prevention
• Breastfeeding when possible
• Plotting BMI at each visit
• Anticipatory guidance: 5-2-1-0
– “5 a day” fruits and vegetables
– Less than 2 hr/day of screen time
– At least 1 hour of moderate activity each day
– No sweet drinks