The Obesity Epidemic: The Obesity Epidemic:

Considerations Regarding Considerations Regarding

Children and YouthChildren and Youth

Barry A. Franklin, Ph.D.Barry A. Franklin, Ph.D.

William Beaumont HospitalWilliam Beaumont Hospital

Royal Oak, Michigan, U.S.A.Royal Oak, Michigan, U.S.A.

e-mail: bfranklin@beaumont.edue-mail: bfranklin@beaumont.edu

Using BMI to Using BMI to Categorize Categorize

Normal Weight, Normal Weight, Overweight, and Overweight, and

ObesityObesity

Body Mass Index (BMI) kg/mBody Mass Index (BMI) kg/m22

< 25 is “normal”< 25 is “normal” 25-30 “Overweight”25-30 “Overweight” 30-35 Grade I Obesity30-35 Grade I Obesity 35-40 Grade II Obesity35-40 Grade II Obesity 40-45 Grade III Obesity40-45 Grade III Obesity 45-50 Morbid Obesity45-50 Morbid Obesity > 50 “Superobese”> 50 “Superobese”

How is BMI MeasuredHow is BMI Measuredin Children and Teens?in Children and Teens?

Because boys and girls grow at Because boys and girls grow at different rates, BMI for children is different rates, BMI for children is age-and gender-specific, and must age-and gender-specific, and must be calculated for each child on an be calculated for each child on an individual basis.individual basis.

Clinical growth charts are used to Clinical growth charts are used to calculate BMI in children and calculate BMI in children and adolescents. adolescents. See:See:

http://www.cdc.gov/growthcharts/http://www.cdc.gov/growthcharts/

Children and Teens WhoseChildren and Teens WhoseBMI-For-Age is:BMI-For-Age is:

≥ ≥ 9595thth

percentilepercentile ObeseObese

8585thth - < 95 - < 95thth percentilepercentile

at risk for at risk for overweightoverweight

55thth - < 85 - < 85thth percentilepercentile normal weightnormal weight

< 5< 5thth

percentilepercentile underweightunderweight

55 5050 8585 9595

The Obesity The Obesity EpidemicEpidemic

Millions of Millions of YearsYears

2020 YearsYears

The Spread of ObesityThe Spread of Obesityin the United States*in the United States*

* Mokdad, AH et al. JAMA 1999;282:1519-1522* Mokdad, AH et al. JAMA 1999;282:1519-1522

The proportion of US adults who are The proportion of US adults who are classified as obese (BMI classified as obese (BMI 30 kg/m 30 kg/m22) rose ) rose 49%49% between 1991 and 1998, with the between 1991 and 1998, with the greatest increases among the youngest age greatest increases among the youngest age group, most educated, and those of group, most educated, and those of Hispanic ethnicity.Hispanic ethnicity.

During this time period, During this time period, obesityobesity increasedincreased inin everyevery statestate, in both sexes, and across all , in both sexes, and across all age groups, races, educational levels, and age groups, races, educational levels, and smoking statuses.smoking statuses.

Obesity Prevalence RatesObesity Prevalence Rates

Centers for Disease Control & Prev. 2003. Trend MapsCenters for Disease Control & Prev. 2003. Trend Maps

Obesity Prevalence RatesObesity Prevalence Rates

Centers for Disease Control & Prev. 2003. Trend MapsCenters for Disease Control & Prev. 2003. Trend Maps

Obesity Prevalence RatesObesity Prevalence Rates

Centers for Disease Control & Prev. 2003. Trend MapsCenters for Disease Control & Prev. 2003. Trend Maps

No No ButtsButts About It About It

An estimated 65% of Americans – over 100 million – are overweight or obese.

Even the clinically severe obese are Even the clinically severe obese are

increasing: between 1986 and 2000, increasing: between 1986 and 2000,

those with BMI > 30, 40 and 50 kg/m², those with BMI > 30, 40 and 50 kg/m²,

respectively, have doubled, quadrupled, respectively, have doubled, quadrupled,

and quintupled in the United States.and quintupled in the United States.

Sturm R. Arch Int Med 2003;163:2146Sturm R. Arch Int Med 2003;163:2146

Morbid ObesityMorbid Obesity

The owners based the casket specifications on simple observations of The owners based the casket specifications on simple observations of the world around them. "It's just going to local restaurants or walking the world around them. "It's just going to local restaurants or walking in a normal Wal-Mart - people are getting wider and they're getting in a normal Wal-Mart - people are getting wider and they're getting thicker."thicker."

Goliath CasketsGoliath Caskets

Supersizing Doesn’t StopSupersizing Doesn’t Stop

Today, more than twice as Today, more than twice as

many children – and almost many children – and almost

three times as many teens – three times as many teens –

are overweight as compared are overweight as compared

with 1980.with 1980.*Hedley AA et al. JAMA 2004;291:2847*Hedley AA et al. JAMA 2004;291:2847

Ogden CL et al. JAMA 2002;288:1728Ogden CL et al. JAMA 2002;288:1728

Racial and Ethnic DisparitiesRacial and Ethnic DisparitiesAmong children and adolescents, obesity Among children and adolescents, obesity is more common in African Americans is more common in African Americans and Hispanics. and Hispanics.

Unhealthy foods at home and in Unhealthy foods at home and in schoolschool

Lack access to safe places to Lack access to safe places to play (eg., parks)play (eg., parks)

Many fast-food restaurants; few Many fast-food restaurants; few healthy marketshealthy markets

Limited economic resourcesLimited economic resources

Obesity and Obesity and Chronic DiseasesChronic Diseases

Diabetes

Diabetes

Heart Disease

Heart DiseaseCancerCancer

Musculoskeletal DisordersMusculoskeletal Disorders

Health Consequences of ObesityHealth Consequences of Obesity

Type II diabetesType II diabetes

Coronary heart diseaseCoronary heart disease

Certain types of cancerCertain types of cancer

HypertensionHypertension

OsteoarthritisOsteoarthritis

Gallbladder diseaseGallbladder disease

Insulin resistance (syndrome X)Insulin resistance (syndrome X)

Worsening Trends in Diabetes and ObesityWorsening Trends in Diabetes and Obesity

10

12

14

16

18

20

22

4

5

6

7

8

1992

1994

1996

1998

2000

ObesityDiabetes

Pre

vale

nc

e (

%)

Pre

vale

nc

e (

%)

Mokdad et al. JAMA. 1999;282:1519; Mokdad et al. Diabetes Care. 2000;23:1278;Mokdad et al. JAMA. 1999;282:1519; Mokdad et al. Diabetes Care. 2000;23:1278;Mokdad et al. Diabetes Care. 2001;24:412; Mokdad et al. JAMA. 2001;286:1195; Mokdad et al. Diabetes Care. 2001;24:412; Mokdad et al. JAMA. 2001;286:1195;

Mokdad et al. JAMA. 2000;284:1650.Mokdad et al. JAMA. 2000;284:1650.

1992

1994

1996

1998

2000

Numbers of persons with diabetes Numbers of persons with diabetes

will more than double by 2030will more than double by 2030

AHA. Heart Disease and Stroke Statistics–2005 Update.AHA. Heart Disease and Stroke Statistics–2005 Update.Wild S et al. Diabetes Care. 2004;27:1047-53.Wild S et al. Diabetes Care. 2004;27:1047-53.

00

1010

2020

3030

4040

20022002

118% increase118% increase

US population US population with diabeteswith diabetes

(millions)(millions)

20302030

13.913.9

30.330.3

YearYear

Pulmonary diseasePulmonary diseaseabnormal functionabnormal functionobstructive sleep apneaobstructive sleep apneahypoventilation syndromehypoventilation syndrome

Nonalcoholic fatty liver Nonalcoholic fatty liver diseasediseasesteatosissteatosissteatohepatitissteatohepatitiscirrhosiscirrhosis

CoronaryCoronary heartheart diseasedisease

DiabetesDiabetes

DyslipidemiaDyslipidemia

HypertensionHypertension

Gynecologic abnormalitiesGynecologic abnormalitiesabnormal mensesabnormal mensesinfertilityinfertilitypolycystic ovarian syndromepolycystic ovarian syndrome

OsteoarthritisOsteoarthritis

SkinSkin

Gall bladder diseaseGall bladder disease

CancerCancerbreast, uterus, cervixbreast, uterus, cervixcolon, esophagus, pancreascolon, esophagus, pancreaskidney, prostatekidney, prostate

PhlebitisPhlebitisvenous stasisvenous stasis

GoutGout

Medical Complications of ObesityMedical Complications of ObesityIdiopathic intracranial Idiopathic intracranial hypertensionhypertension

StrokeStroke

CataractsCataracts

Severe pancreatitisSevere pancreatitis

Lower Life Expectancy:Lower Life Expectancy:Higher Health CostsHigher Health Costs

Overweight/obese 40 year old man Overweight/obese 40 year old man or woman will lose 3 to 7 years of or woman will lose 3 to 7 years of life.life.

For adults with BMI > 45, life For adults with BMI > 45, life expectancy decreases by up to 20 expectancy decreases by up to 20 years.years.

As BMI increases, so does the As BMI increases, so does the number of sick days, medical number of sick days, medical claims, and health care costs.claims, and health care costs.

HealthcareHealthcare

Obesity

IncreasedLDL-C

HTN

DiabetesDecreased

HDL-C

Thrombosis IncreasedTG

Inflammation(hs-CRP)

MetabolicSyndrome

Obesity: The Only Central Risk FactorObesity: The Only Central Risk Factor

Ortho/PMR Pulm/Asthma/Sleep

CAD

Heart Failure

Atrial Fib

VTE

0.6

1.0

1.4

1.8

2.2

2.6

3.0

Relationship Between BMI and Relationship Between BMI and Cardiovascular Disease MortalityCardiovascular Disease Mortality

Rel

ativ

e R

isk

of D

eath

Body Mass index

<18.5

MenMen

WomenWomen

Calle et al. N Engl J Med 1999;341:1097.

18.5–

20.4

20.5–

21.9

22.0–

23.4

23.5–

24.9

25.0–

26.4

26.5–

27.9

28.0–

29.9

30.0–

31.9

32.0–

34.9

35.0–

39.9

>40.0

Lean Overweight Obese

60%60% of overweight children of overweight children

between ages 5 to 10 already between ages 5 to 10 already

have have 11 coronary heart disease coronary heart disease

risk factor.risk factor.

Clogged ArteriesClogged ArteriesShowing Up in KidsShowing Up in Kids

Children with heart disease risk factors – obesity, high Children with heart disease risk factors – obesity, high blood pressure, diabetes & high cholesterol – already blood pressure, diabetes & high cholesterol – already show indications of fatty build-up in their arteries that show indications of fatty build-up in their arteries that could cause heart attacks when they’re adults.could cause heart attacks when they’re adults.

Primary prevention of heart disease must start in Primary prevention of heart disease must start in childhood.childhood.

3,630 children, ages 5-18 took part in 26 studies across 3,630 children, ages 5-18 took part in 26 studies across the globe.the globe.

In many cases, children with heart disease risk factors In many cases, children with heart disease risk factors showed early signs of atherosclerosis.showed early signs of atherosclerosis.

Obesity shortens the average lifespan, and if Obesity shortens the average lifespan, and if

childhood obesity continues to increase, it childhood obesity continues to increase, it

could cut out 2 to 5 years from the average could cut out 2 to 5 years from the average

lifespan. lifespan.

The current generation of The current generation of

children may become the first in children may become the first in

American history to live shorter American history to live shorter

lives than their parents.lives than their parents.

CausesCausesof Obesityof Obesity

Sedentary

Sedentary

Lifestyle

Lifestyle

High Caloric

High CaloricIntakeIntake

Environment

Environment

GeneticsGenetics

Genetic Contribution?Genetic Contribution?

The genetic contribution to individual

variations in body weight and fat

stores lies somewhere between 25%

and 70%.

Bouchard C et al. HumBiol 1985;57:61Bouchard C et al. HumBiol 1985;57:61Cardon LR et al. HumBiol 1994;66:465Cardon LR et al. HumBiol 1994;66:465Stunkard AJ et al. JAMA 1986;256:51Stunkard AJ et al. JAMA 1986;256:51Stunkard AJ et al. NEJM 1986;314:193Stunkard AJ et al. NEJM 1986;314:193

Genetics contribute to the Genetics contribute to the

overweight / obesity problem, overweight / obesity problem,

but do not explain the 2-3 fold but do not explain the 2-3 fold

increase in prevalence over the increase in prevalence over the

last several decades.last several decades.

““the first generation the first generation where children will die where children will die before their parents”before their parents”

International Congress on Obesity – International Congress on Obesity – August 2002August 2002

Actually, 8 million Actually, 8 million children & adolescents children & adolescents are overweight.are overweight.

Over the last two Over the last two decades, the rates for decades, the rates for overweight adolescents overweight adolescents have tripled.have tripled.

Marketing and Advertising in SchoolsMarketing and Advertising in Schools Vending machines (CDC 2000)Vending machines (CDC 2000)

• 43% elementary schools43% elementary schools• 74% middle schools74% middle schools• 98% high schools98% high schools

Exclusive soft drink contractsExclusive soft drink contracts• Half of districtsHalf of districts

Direct advertising on vending machines, Direct advertising on vending machines, scoreboards, posters, book covers, banners and scoreboards, posters, book covers, banners and Channel OneChannel One• 7 out of 10 ads for fast food, candy, soft drinks & chips7 out of 10 ads for fast food, candy, soft drinks & chips

Children exposed to 40,000 commercials/yearChildren exposed to 40,000 commercials/year• Candy – 32%Candy – 32%• Sweetened cereals – 31%Sweetened cereals – 31%• Fast food – 9%Fast food – 9%

Physical education has been reduced or Physical education has been reduced or

eliminated in many schools. Daily eliminated in many schools. Daily

participation in physical education participation in physical education

classes has declined among high school classes has declined among high school

students from 42% in 1991 to 25% in 1995. students from 42% in 1991 to 25% in 1995.

Children seldom walk or ride bikes Children seldom walk or ride bikes

anymore (parents drive them).anymore (parents drive them).

Children’s Television ViewingChildren’s Television Viewing

Data from Multiple referencesData from Multiple references

3535

3030

2525

2020

1515

1010

55

00

1940

1940

1945

1945

1950

1950

1955

1955

1960

1960

1965

1965

1970

1970

1975

1975

1980

1980

1985

1985

1990

1990

1995

1995

YearYear

Sed

en

tary

Tim

eS

ed

en

tary

Tim

e(H

rs T

V V

iew

ed

/Wk)

(Hrs

TV

Vie

wed

/Wk)

Technology’s Sedentary Seduction*Technology’s Sedentary Seduction*

A survey of young people ages 8 to 18 showed A survey of young people ages 8 to 18 showed their daily activities accounted for the following their daily activities accounted for the following hours:hours:

• Watching TV – 3 hrs. 51 min.Watching TV – 3 hrs. 51 min.

• Using the computer – 1 hr. 2 min.Using the computer – 1 hr. 2 min.

• Video games – 49 min.Video games – 49 min.

• Reading – 43 min.Reading – 43 min.

*Generation M: Media in the Lives of 8-18 year olds*Generation M: Media in the Lives of 8-18 year olds Menlo Park, Calif: Kaiser Family Foundation 2005Menlo Park, Calif: Kaiser Family Foundation 2005

68% 68% of children now have a of children now have a TVTV in their in their

bedroomsbedrooms and and 31%31% have a have a computercomputer. Kids . Kids

with a TV watch about 1.5 hours/day more than with a TV watch about 1.5 hours/day more than

those who don’t. Kids who have a computer those who don’t. Kids who have a computer

use it about 45 minutes more per day than use it about 45 minutes more per day than

those who don’t.those who don’t.

Kaiser Family FoundationKaiser Family FoundationMenlo Park, CA:2005Menlo Park, CA:2005

Am J Cardiol 2001;87:1093Am J Cardiol 2001;87:1093

Weapons of Mass DestructionWeapons of Mass Destruction

GLUTTONYGLUTTONY SLOTHSLOTH

Eating Out : Haste Makes WaistsEating Out : Haste Makes Waists 46% of food dollars are spent outside the 46% of food dollars are spent outside the

homehome

44% eat at a restaurant on any given day44% eat at a restaurant on any given day

Restaurant portion sizes tend to be 2-3 Restaurant portion sizes tend to be 2-3 times “normal”times “normal”

Positive relationship between eating out, Positive relationship between eating out, increased calories and body weightincreased calories and body weight

Restaurant meals tend to be higher in fat Restaurant meals tend to be higher in fat and calories, and lower in fiber, vitamins and calories, and lower in fiber, vitamins and minerals, than foods prepared at and minerals, than foods prepared at homehome

Children eat nearly twice as many calories Children eat nearly twice as many calories

(770) at restaurants as they do during a meal at (770) at restaurants as they do during a meal at

home (420).home (420).

Zoumas-Morse C et al. J Am Diet Assoc 2001;101:923Zoumas-Morse C et al. J Am Diet Assoc 2001;101:923

Predominantly black neighborhoods have 1 Predominantly black neighborhoods have 1 additional fast-food restaurant per square mile additional fast-food restaurant per square mile compared with predominantly white compared with predominantly white neighborhoods.neighborhoods.

These findings suggest that black and low-These findings suggest that black and low-income populations have more convenient income populations have more convenient access to fast food.access to fast food.

Block JP et al. Am J Prev Med 2004;27:211Block JP et al. Am J Prev Med 2004;27:211

More convenient access likely leads to More convenient access likely leads to

increased consumption of fast food in these increased consumption of fast food in these

populations, and may help to explain the populations, and may help to explain the

increased prevalence of obesity among black increased prevalence of obesity among black

and low-income populations.and low-income populations.

Block JP et al. Am J Prev Med 2004;27:211Block JP et al. Am J Prev Med 2004;27:211

Contemporary Work EnvironmentContemporary Work Environment Extended drive timeExtended drive time

MeetingsMeetings

Computer interactionsComputer interactions

Cell phonesCell phones

Sitting on or waiting Sitting on or waiting for airplanesfor airplanes

Desk workDesk work

TeleconferencesTeleconferences

Operating conveyorsOperating conveyors

DictaphonesDictaphones

Increasingly we are paid to think, to provide specific sedentary skills, or to communicate or process information.

Vending MachinesVending Machines

dotdotourour

WorkplacesWorkplaces distributing cheapdistributing cheap

snackssnacks

Lack of Sleep Lack of Sleep Excess Weight Excess Weight

Subjects who slept ≤ 4 hrs/night were 73% Subjects who slept ≤ 4 hrs/night were 73%

more likely to be obese than those who more likely to be obese than those who

slept the recommended 7 to 9 hrs/night. slept the recommended 7 to 9 hrs/night.

Those who averaged 5 hrs/night had a 50% Those who averaged 5 hrs/night had a 50%

greater risk, and those who got 6 hrs/night greater risk, and those who got 6 hrs/night

were just 23% more likely to be were just 23% more likely to be

substantially overweight.substantially overweight.North American Association for the Study of Obesity,North American Association for the Study of Obesity,Annual Scientific Meeting, Nov. 14-18,2004Annual Scientific Meeting, Nov. 14-18,2004

RECENT TRENDSRECENT TRENDS

Pizza - PizzaPizza - Pizza

Buy one pizza, get one freeBuy one pizza, get one free

Nutrition Action, 2001Nutrition Action, 2001..

Portion Sizes Have IncreasedPortion Sizes Have Increased

0

100

200

300

400

500

600

700

CA

LO

RIE

S

19551955

20012001

19551955

2001200119551955

20012001

2.3 oz2.3 oz 6.9 oz6.9 oz0

100

200

300

400

500

600

700

CA

LO

RIE

S

2.3 oz2.3 oz 6.9 oz6.9 oz 6.5 oz6.5 oz 20 oz20 oz 1.1 oz1.1 oz 3.7 oz3.7 oz

French FriesFrench Fries Soft DrinksSoft Drinks Candy BarsCandy Bars

The “Super-Sizing” of AmericaThe “Super-Sizing” of America“This year, Americans will spend more

money on fast food than on higher education…”

Eric Schlosser. Eric Schlosser. Fast Food Nation: The Dark Side of the All-American MealFast Food Nation: The Dark Side of the All-American Meal ..Harper Collins. 2002.Harper Collins. 2002.

??

Denny’s Beer Barrel Pub in Pennsylvania known for the Denny’s Beer Barrel Pub in Pennsylvania known for the world’s largest burger which weighs in at world’s largest burger which weighs in at NINE poundsNINE pounds. . It’s main appeal “No One has Finished It!”It’s main appeal “No One has Finished It!”

For $23.95 it comes with all the fixins:For $23.95 it comes with all the fixins:2 Tomatoes2 TomatoesHalf a head of lettuceHalf a head of lettuce12 slices of American cheese12 slices of American cheeseFull cup of peppersFull cup of peppers2 Onions2 OnionsPlus a river of Mayo, Mustard and KetchupPlus a river of Mayo, Mustard and Ketchupand topped with Pickles!and topped with Pickles!

NOW THAT’S ONE BIG BURGER!!!!!NOW THAT’S ONE BIG BURGER!!!!!

The Elimination of Physical Activity From The Elimination of Physical Activity From Our Daily Lives in the 21st CenturyOur Daily Lives in the 21st Century

1900 A.D.1900 A.D. 2006 A.D.2006 A.D.WalkingWalking

Riding bike to schoolRiding bike to schoolStairsStairsSweeping with broomSweeping with broomPlowing fieldPlowing fieldPicking cropsPicking cropsFiling papersFiling papersCarrying messagesCarrying messagesWashing dishesWashing dishesPainting a house with brushPainting a house with brushSawing a tree limbSawing a tree limbWashing clothesWashing clothesHanging clothes out to dryHanging clothes out to dryShoveling snowShoveling snowSharpening pencilSharpening pencilWalking to libraryWalking to libraryOpening cansOpening cans

No sidewalks, electric scooter, motorized No sidewalks, electric scooter, motorized walkways, automobilewalkways, automobile

Unsafe streetsUnsafe streetsElevators, escalatorsElevators, escalatorsVacuumingVacuumingTractor with air conditioning and radioTractor with air conditioning and radioMechanized harvestersMechanized harvestersComputersComputersE-mail, telephone, faxE-mail, telephone, faxDishwasherDishwasherSpray paintSpray paintPower sawPower sawWashing machineWashing machineDryerDryerSnow blowerSnow blowerElectric pencil sharpenerElectric pencil sharpenerInternetInternetElectric can openerElectric can opener

Percentage of All Trips Made By Percentage of All Trips Made By Automobile, 1977 - 1995Automobile, 1977 - 1995

89.3

87.1

85.083.9

81

82

83

84

85

86

87

88

89

90

1977 1983 1990 1995

Per

cen

t

National Personal Transportation Survey, 1995

Percentage of All Trips Made From Percentage of All Trips Made From Home by Walking, 1977 - 1995Home by Walking, 1977 - 1995

5.5

7.2

8.5

9.3

01

234

5678

910

1977 1983 1990 1995

Per

cen

t

National Personal Transportation Survey, 1995

Fitness,Fitness,Fatness and MortalityFatness and Mortality

Physical Fitness Physical Fitness Mortality and Obesity*Mortality and Obesity*

Overweight men demonstrated higher Overweight men demonstrated higher mortality rates compared with normal mortality rates compared with normal weight men.weight men.

Fit men (those who exercised Fit men (those who exercised regularly) had comparable mortality regularly) had comparable mortality regardless of BMI.regardless of BMI.

Normal weight men who were unfit Normal weight men who were unfit were nearly 3 times as likely to die were nearly 3 times as likely to die young compared with their young compared with their overweight counterparts who overweight counterparts who exercised.exercised.

*Barlow et al. Int J Obesity 1995;19:S41-44*Barlow et al. Int J Obesity 1995;19:S41-44

nnMan-yearsMan-years

(MY)(MY)# of# of

DeathsDeaths

Age-adj Age-adj rate/10,000 rate/10,000

MYMY< 27 BMI< 27 BMI

Low*Low*Moderate**Moderate**HighHigh††

17,17817,17825,53725,53764,10364,10357,00457,004

133133180180119119

52.152.128.628.620.020.0

27-30 BMI27-30 BMILow*Low*Moderate**Moderate**HighHigh††

5,2775,27715,00015,00020,74920,7497,3417,341

636367671717

49.149.129.829.819.719.7

> 30 BMI> 30 BMILowLowMod-HighMod-High

2,9342,93414,30114,3018,2408,240

75751919

62.162.118.018.0

* Fitness quintile 1 **Fitness quintiles 2 & 3 * Fitness quintile 1 **Fitness quintiles 2 & 3 ††Fitness quintiles 4 and 5Fitness quintiles 4 and 5

Low Cardiovascular Fitness Increases Relative Low Cardiovascular Fitness Increases Relative Risk of All-Cause Mortality vs. Being FitRisk of All-Cause Mortality vs. Being Fit

0

1

2

3

4

5

Fit

Unfit

Non-smok

er

Smok

er Fit

Unfit

Non-smok

er

Smok

er Fit

Unfit

Non-smok

er

Smok

er

Rela

tive R

isk

Normal weightNormal weight(18.5 - 24.9 kg/m(18.5 - 24.9 kg/m22))

OverweightOverweight(25-29.9 kg/m(25-29.9 kg/m22))

ObeseObese(> 30 kg/m(> 30 kg/m22))

Wei M. et al. JAMA 1999;282:1547Wei M. et al. JAMA 1999;282:1547

Although physical activity or

exercise training may not make all

people lean, it appears that an active

way of life may have important

health benefits, even for those who

remain overweight.

Treatment Options:Treatment Options:Lifestyle ModificationLifestyle Modification

Themes in Obesity TreatmentThemes in Obesity Treatment

Prevent weight gain if your Prevent weight gain if your weight in normal rangeweight in normal range

Lose weight if you are Lose weight if you are overweight (BMI ≥ 25 < 30) overweight (BMI ≥ 25 < 30) with co-morbidities or are with co-morbidities or are obese (BMI > 30)obese (BMI > 30)

Even modest weight loss Even modest weight loss (e.g., 5-10% of body weight) is (e.g., 5-10% of body weight) is beneficial, benefit increases beneficial, benefit increases with greater weight losswith greater weight loss

Themes in Obesity TreatmentThemes in Obesity Treatment Weight is lost if the calorie intake is < the Weight is lost if the calorie intake is < the

energy expended in daily activities – the energy expended in daily activities – the breakdown by protein, fat & carbohydrate breakdown by protein, fat & carbohydrate is less critical.is less critical.

Physical activity is important (30-60 min/day) (Physical inactivity Physical activity is important (30-60 min/day) (Physical inactivity is another independent risk factor)is another independent risk factor)

Short-term rapid weight loss diets are usually failures in the long Short-term rapid weight loss diets are usually failures in the long runrun

Diet is more effective than exercise in causing initial weight lossDiet is more effective than exercise in causing initial weight loss

A regular exercise regimen is the best predictor of preventing A regular exercise regimen is the best predictor of preventing recurrent weight gainrecurrent weight gain

Four recent guidelines suggest that the Four recent guidelines suggest that the

30 minutes/day Surgeon General Report 30 minutes/day Surgeon General Report

and ACSM/CDC recommendation may and ACSM/CDC recommendation may

be insufficient to counteract the obesity be insufficient to counteract the obesity

trend in sedentary adults.trend in sedentary adults.

ACSM Position Stand. Med Sci Sports Exerc 2001;33:2145ACSM Position Stand. Med Sci Sports Exerc 2001;33:2145

Institute of Medicine. Dietary reference … 2002;3:3Institute of Medicine. Dietary reference … 2002;3:3

WHO. Diet, nutrition…Series 916. Geneva 2003WHO. Diet, nutrition…Series 916. Geneva 2003

Saris WHM et al. Obes Rev 2003;4:101Saris WHM et al. Obes Rev 2003;4:101

How Much Exercise is Enough?How Much Exercise is Enough?

Med. Sci. Sports Exerc. Vol 36, No. 1, pp. 79-85, 2004

0

5000

10000

15000

20000

25000

Sun Mon Tues Weds Thurs Fri Sat

Ste

ps

per

Day

Women (n=45)Men (n=51)

Bassett DR et al. Med Sci Sports Exerc 2004;36:79Bassett DR et al. Med Sci Sports Exerc 2004;36:79

Men reported 10 hrs / wk of vigorous physical Men reported 10 hrs / wk of vigorous physical activity (PA), 43 hrs / wk of moderate PA, and 12 activity (PA), 43 hrs / wk of moderate PA, and 12 hrs / wk of walking. Women reported 3 hrs / wk of hrs / wk of walking. Women reported 3 hrs / wk of vigorous PA, 39 hrs / wk of moderate PA, and 6 vigorous PA, 39 hrs / wk of moderate PA, and 6 hrs / wk of walking. hrs / wk of walking.

A total of 25% of the men and 27% of the women A total of 25% of the men and 27% of the women were overweight (BMI ≥ 25), and 0% of the men were overweight (BMI ≥ 25), and 0% of the men and 9% of the women were obese (BMI ≥ 30).and 9% of the women were obese (BMI ≥ 30).

Bassett DR, et al. MSSE 2004;36:79Bassett DR, et al. MSSE 2004;36:79

Lifestyle Activity: A New Paradigm Lifestyle Activity: A New Paradigm in Exercise Prescriptionin Exercise Prescription

The traditional model for getting people The traditional model for getting people more physically active (i.e., a regimented more physically active (i.e., a regimented exercise program) has been only exercise program) has been only marginally effective. Exercise marginally effective. Exercise professionals should consider broadening professionals should consider broadening their client’s recommendations, from the their client’s recommendations, from the traditional frequency, intensity, duration, traditional frequency, intensity, duration, and modes of training that are associated and modes of training that are associated with structured exercise programs, to with structured exercise programs, to promoting increased activity in daily living.promoting increased activity in daily living.

Health & Fitness Club(Rehab Facility)

Exercise Time: 32-37 minutesExercise Time: 32-37 minutes

20-25 minutes each way20-25 minutes each way

SITSITSPARINGLYSPARINGLY• watch TVwatch TV

• play computer gamesplay computer games

ENJOY LEISUREENJOY LEISUREACTIVITIESACTIVITIES

• golfgolf• bowlingbowling

• yardworkyardwork

STRETCH/STRETCH/STRENGTHENSTRENGTHEN

• curl-upscurl-ups• push-upspush-ups

• weight liftingweight lifting

2-3 Times/Wk2-3 Times/Wk

AEROBIC ACTIVITIESAEROBIC ACTIVITIES• long walkslong walks

• bikingbiking• swimmingswimming

3-5 Times/Wk3-5 Times/WkRECREATIONAL SPORTSRECREATIONAL SPORTS

• tennistennis• racquetballracquetball• basketballbasketball

• make extra steps in your daymake extra steps in your day• walk the dogwalk the dog

• take the stairs instead of the elevatortake the stairs instead of the elevator• park your car farther away and walkpark your car farther away and walk

EVERYDAYEVERYDAY

The ActivityThe ActivityPyramidPyramid

Start your weekly Start your weekly activity plan with activity plan with

the daily activities the daily activities at the base of the at the base of the

pyramid. Enhance pyramid. Enhance your fitness by your fitness by choosing other choosing other activities on the activities on the

pyramid.pyramid.

Move more, sit Move more, sit less.less.

Accumulating 10,000 Steps Per DayAccumulating 10,000 Steps Per Day

Pedometers can be helpful inPedometers can be helpful in

promoting increased activity inpromoting increased activity in

daily living, by progressively increasing daily step daily living, by progressively increasing daily step

totals. Accumulating ≥ 10,000 steps / day (the totals. Accumulating ≥ 10,000 steps / day (the

equivalent of walking roughly 5 miles) may equivalent of walking roughly 5 miles) may

improve health, fitness, or both, and meet or improve health, fitness, or both, and meet or

exceed current physical activity guidelines.exceed current physical activity guidelines.

TomatoesTomatoesRedRedWineWine

NutsNuts

BroccoliBroccoli

BlueberriesBlueberries

SalmonSalmon

GreenGreenTeaTea

GarlicGarlic

SpinachSpinach OatsOats

BagelsBagels PotatoesPotatoes

White breadWhite bread

White riceWhite rice

*Horowitz JM. 10 foods that pack a wallop. Time Magazine Jan 21, 2002*Horowitz JM. 10 foods that pack a wallop. Time Magazine Jan 21, 2002

Basic American Diet is Sweet, Basic American Diet is Sweet, Salty, and Full of FatSalty, and Full of Fat

Keys to Healthy EatingKeys to Healthy Eating• ↑ ↑ Omega-3 fatty acids (salmon)Omega-3 fatty acids (salmon)• ↑ ↑ Rough up your diet (↑ fiber)Rough up your diet (↑ fiber)• ↑ ↑ Fruits and vegetablesFruits and vegetables• Drink waterDrink water• Get an oil change (monounsaturated fats, olive oil, Get an oil change (monounsaturated fats, olive oil,

canola)canola)• Avoid stick margarineAvoid stick margarine• ↑ ↑ Consumption of beans and nutsConsumption of beans and nuts• Dress salads lightlyDress salads lightly• Be picky about poultryBe picky about poultry• Hide the sugar bowl and salt shakerHide the sugar bowl and salt shaker• Figure out “fast food”Figure out “fast food”

SuccessSuccessStoriesStories

Fraudulent Gadgets, Fraudulent Gadgets,

Gimmicks and Gimmicks and

Unfounded ClaimsUnfounded Claims

Thickness of Subcutaneous Fat and Thickness of Subcutaneous Fat and Activity of Underlying Muscles*Activity of Underlying Muscles*

There was a mean difference in circumference of There was a mean difference in circumference of

2.25 and 1.15 cm between hypertrophied and less 2.25 and 1.15 cm between hypertrophied and less

active forearms of male and female tennis players, active forearms of male and female tennis players,

respectively. However, the greater amount of respectively. However, the greater amount of

exercise in the playing arm of tennis players was exercise in the playing arm of tennis players was

not accompanied by diminished fat deposits over not accompanied by diminished fat deposits over

that arm.that arm.

IMPLICATIONS SpotSpotReductionReduction

*Gwinup G et al. Ann Intern Med 1971;74:408*Gwinup G et al. Ann Intern Med 1971;74:408

Effects of Sit-Up Exercise Training on Effects of Sit-Up Exercise Training on Adipose Cell Size and Adiposity*Adipose Cell Size and Adiposity*

This study examined the effects of a 27-day sit-up exercise This study examined the effects of a 27-day sit-up exercise training program on adipose cell size and adiposity. Fat training program on adipose cell size and adiposity. Fat biopsies were taken from the abdomen, subscapular, and biopsies were taken from the abdomen, subscapular, and gluteal sites by gluteal sites by needleneedle aspiration in 19 subjects: aspiration in 19 subjects:

(13 experimental, 6 controls; (13 experimental, 6 controls; ¯̄ ± SD age = 19.4 ± 2.3 yrs; ± SD age = 19.4 ± 2.3 yrs; ¯̄ ± ± SD weight = 76.1 ± 7.3 kg) before and after a 5 day/wk SD weight = 76.1 ± 7.3 kg) before and after a 5 day/wk progressive training regimen. The total number of sit-ups progressive training regimen. The total number of sit-ups done was 5,004.done was 5,004.

xx xx

*Katch FI et al. Research Quarterly 1984;55:242*Katch FI et al. Research Quarterly 1984;55:242

*Katch FI et al. Research Quarterly 1984;55:242*Katch FI et al. Research Quarterly 1984;55:242

Although there were significant Although there were significant

decreases in cell diameter resulting decreases in cell diameter resulting

from the sit-up program, there were no from the sit-up program, there were no

differences in the differences in the raterate of change for of change for

cell diameter between sites.cell diameter between sites.

*Katch FI et al. Research Quarterly 1984;55:242*Katch FI et al. Research Quarterly 1984;55:242

The conventional sit-up exercise does The conventional sit-up exercise does

not preferentially reduce adipose cell not preferentially reduce adipose cell

size or subcutaneous fat thickness in size or subcutaneous fat thickness in

the abdominal region to a greater extent the abdominal region to a greater extent

compared with other adipose sites.compared with other adipose sites.

PRODUCTS:PRODUCTS: Fat Trappers, Fat Busters, Fat Whacker Fat Trappers, Fat Busters, Fat Whacker

INGREDIENTS: INGREDIENTS: Zinc, St. John’s Wort, Synephrine, Zinc, St. John’s Wort, Synephrine, Chromium, and Chitosan (fat absorber)Chromium, and Chitosan (fat absorber)

RESEARCH: RESEARCH: 15 studies 15 studies ingredients don’t work ingredients don’t work

ADVERSE EFFECTS: ADVERSE EFFECTS: Vitamin deficiencies (A, D, E, Vitamin deficiencies (A, D, E, K); Contraindicated in people with CAD, diabetes, K); Contraindicated in people with CAD, diabetes, HTNHTN

ConclusionsConclusions

The 100-Calorie Target: The The 100-Calorie Target: The Energy GapEnergy Gap

The median weight gain in the adult The median weight gain in the adult U.S. population is ~ 1.8 pounds/year. U.S. population is ~ 1.8 pounds/year. This represents a positive energy This represents a positive energy imbalance of only 15 calories per imbalance of only 15 calories per day over the course of a year. At the day over the course of a year. At the 9090thth percentile, the imbalance is only percentile, the imbalance is only 50 calories per day. Thus, 50 calories per day. Thus, preventing weight gain in 90% of the preventing weight gain in 90% of the population would take a daily population would take a daily increase in energy expenditure of increase in energy expenditure of only 100 calories or a decrease in only 100 calories or a decrease in intake of 100 calories or some intake of 100 calories or some combination.combination.

Bo

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TimeTime

EnergyEnergyGapGap

AmericaAmerica on the on the

movemoveSteps to aSteps to aHealthier Healthier

Way of LifeWay of Life

Hill Jo et al. Science 2003;299:853Hill Jo et al. Science 2003;299:853

Environmental influences provide the most likely Environmental influences provide the most likely explanation for the current obesity epidemic (i.e., explanation for the current obesity epidemic (i.e.,

).).

Aerobic fitness is inversely related to mortality. Aerobic fitness is inversely related to mortality. Moreover, fitness decreases the mortality risk in Moreover, fitness decreases the mortality risk in normal weight , overweight , and obese normal weight , overweight , and obese individuals.individuals.

Environmental changes, sensible caloric Environmental changes, sensible caloric restriction, increased physical activity, drug restriction, increased physical activity, drug therapy and surgery are the preferred treatment therapy and surgery are the preferred treatment options.options.

Take Home MessagesTake Home Messages

““the perfect storm”the perfect storm”

Take Home Messages Take Home Messages

Overweight people have demonstrated a Overweight people have demonstrated a growing “appetite” for quick-fix weight loss growing “appetite” for quick-fix weight loss products – few of which are legitimate and many products – few of which are legitimate and many of which may be dangerous.of which may be dangerous.

The AHA is uniquely positioned to address the The AHA is uniquely positioned to address the causes and consequences of obesity.causes and consequences of obesity.

American Heart Association’s American Heart Association’s Alliance for a Healthier GenerationAlliance for a Healthier Generation

Leading food manufacturers Leading food manufacturers (Campbell Soup, Dannon, Kraft, (Campbell Soup, Dannon, Kraft, Mars, Pepsi Co.) Mars, Pepsi Co.) development of development of healthy snacks and food items sold healthy snacks and food items sold in schools.in schools.

Availability of unsweetened juice, Availability of unsweetened juice, low and no-fat milk, and bottled low and no-fat milk, and bottled water in schools.water in schools.

Physical education and wellness Physical education and wellness programs for all students – not just programs for all students – not just athletes.athletes.

TheThe

UltimateUltimate

Weight Weight

LossLoss

Exercise?Exercise?