The Global Obesity Pandemic

JHI Partners ForumOctober 2, 2012

Richard R. Rubin, PhD

Professor, Medicine and Pediatrics

The Johns Hopkins University School of Medicine

rrubin4@jhmi.edu

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

6Source: CDC/National Center for Health Statistics, National Health Exam Survey

U.S. adult population overweight or obesePercentage, age 20-74

• Obesity levels in the 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

5

10

15

20

25

30

35

40

45

50

55

60

65

70

ObeseOverweight

1966 20061976 1986 1996

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

93.2

0

25

50

75

100

Relationship Between BMI and Risk of Type 2 Diabetes

Chan J et al. Diabetes Care 1994;17:961.Colditz G et al. Ann Intern Med 1995;122:481.

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Body Mass index (kg/m2)

Men

Women

<22 <23 23-23.9 24-24.9 25-26.9 27-28.9 29-30.9 31-32.9 33-34.9 35+

1.0

2.91.0

4.31.0

5.01.5

8.12.2

15.8

4.4

27.6

40.3

54.0

6.711.6

21.3

42.1

Sample data suggest that obese adults can incur close to twice the annual health care costs of normal weight adults

15

7,555

6,120

4,675

3,950

<25 30-34* *35-39 *40+

*18%

*91%*55%

Healthcare costs by BMI*$/capita, 2007

* 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

BMIWeighted average cost of the obese is $5,500

Normal weightObese

Medical Management of Obesity

Kimberly Gudzune, MD, MPH

Assistant Professor of Medicine

Johns Hopkins Digestive Weight Loss Center

Johns Hopkins International Partners ForumOctober 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 ObesityNormal 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 lbs5’ 4” woman @ 146 lbs

Class I obesity BMI 30.0-34.9 kg/m2 5’ 11” man @ 215 lbs5’ 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 lbs5’ 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 AssessmentWaist 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

Modified from Kushner & Pendarvis 1999

Medical Care

BehavioralCare

ExerciseNutrition

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 obesity-related 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

Cancer• Colorectal cancer• Prostate cancer• Endometrial cancer• Cervical cancer• Breast cancer• Ovarian cancer• Pancreatic cancer

Reproductive/GU• PCOS• Infertility• Incontinence

Medications Associated with Weight Gain

Disease Type of Medication

How they cause weight gain Examples

High Blood Pressure

Beta-blockers1

-Reduced resting energy expenditure & thermogenesis-Increased tiredness-Reduced exercise tolerance-Increased insulin resistance

MetoprololAtenololCarvedilol

Allergies Anti-histamines2

-Increased appetite Diphenhydramine

Anti-inflammatory

Cortico-steroids2-3

-Impaired glucose tolerance-Increased truncal fat

Prednisone

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

GlyburideGlipizideGlimepiride

Diabetes mellitus

Thiazolidinediones (TZDs)

-Increased adipogenesis-Fluid retention-Increased appetite

PioglitazoneRosiglitazone

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

FluoxetineSertralineParoxetine

Depression Tricyclic Antidepressants (TCAs)

-Increased appetite AmitriptylineNortriptyline

Schizo-phrenia

Atypical Antipsychotics

-Increased appetite and binge eating

OlanzipineQuetiapineRisperidone

From Malone 2005

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 co-morbid condition profile

• Address patient nutrition education and skill deficiencies

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Copyright restrictions may apply. Dansinger, M. L. et al. JAMA 2005;293:43-53.

One-Year Changes in Body Weight By Diet Group and By Adherence Level

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

Janelle W. Coughlin, Ph.D.Johns Hopkins School of Medicine

Department of Psychiatry and Behavioral Sciences

Johns Hopkins Medicine International Partners ForumOctober 2, 2012

Behavioral Lifestyle Interventions for Obesity: The Foundation for Change

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

Surgery

Pharmacotherapy

Lifestyle Modification

Diet Physical Activity

BMI

Obesity Treatment Pyramid

Dietary Approaches to Lifestyle Modification

Calorie Deficit ~1200-2000 kcal/d

Dietary Approaches:Low-fatLow-carbohydrateMediterranean Low-glycemic loadPortion-controlled

diets

Increasing Physical Activity

> 180 m/wk MVPA for weight loss Must also include caloric restrictionAssociated with a number of health improvements,

independent of weight lossCritical for long-term weight loss maintenance

~ 60 m/d MVPACan be performed in short boutsIncreasing other lifestyle activities is also

effective > 2000 steps for weight loss; > 6000 to avoid

regain

Behavioral Strategies•Self-monitoring•Goal Setting•Stimulus control•Problem solving•Cognitive restructuring•Relapse Prevention

Increase self-efficacy and social support

Motivational Interviewing

Weight Loss MaintenancePatients gain ~

1/3 of 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

There is significant 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 DesignPhase IN=1685

Behavioral weight loss intervention

Weight loss ≥4 kg

Yes No

Phase II Randomization

N=1032

Self-directed control group

Personal Contact

Interactive Technology

No furthercontact

Phase I6 months

Phase II30 months

Data collection prior to Phase I, at randomization, then every 6 months

Change from initial weight

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-8

-6

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-2

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-6 0 6 12 18 24 30

Months after Randomization

Wei

ght

chan

ge,

kg

Self-directed Interactive technology Personal Contact

-2.9 -3.3 -4.2

Svetkey et al., 2008

Remote/Telephone-delivered

Technology-Based

PCP-Enhanced or Promoted

Design

Control

Remote

In-Person

Randomization

= Measured weights and other outcomes

Baseline 6 Mo 12 Mo 24 Mo

InterventionsRemote In-Person

Mode of Delivery Telephone only Group meetingsIndividual meetings

Telephone

Coach Healthways Hopkins

Coach support Case management

Study website Educational modules Self-monitoring tools

Tailored emails

Physician Roles SupportiveReview weight progress reports

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Control Remote In-Person

Months after Randomization

We

igh

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, kg

-4.6*

-0.8

-4.3*

*P <0.001 (vs control)Appel et al, NEJM 2011;365:1959-68

Surgery

Pharmacotherapy

Lifestyle Modification

Diet Physical Activity

BMI

Does lifestyle modification enhance the effects of weight loss medications and surgery?

Thank You

Wadden et al., (March, 2012). Circulation