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OBESITY: TRENDS AND IMPLICATIONS
Mark Skillan, M.D. ACSW – SEAC November 18, 2011
“ 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
Obesity – A growing concern
Obesity Defined
Prevalence
Etiology
Health Consequences
Morbidity and Mortality Implications
Interventions & Challenges
The Future
OBESITY: AN INSURER’S CONCERN
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
OBESITY DEFINED
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.
7
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
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)
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.
PREVALENCE
Past and projected prevalence of overweight by country
Source: The Lancet 2011; 378:815-825 (DOI:10.1016/S0140-6736(11)60814-3)
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.
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
14
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
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
16
Rising prevalence of overweight children (5-11)
17
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.
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
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
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
ETIOLOGY
Causes of obesity
Calories Ingested
Calories Burned
Factors contributing to obesity
Genetics
Environment
Unhealthy diet
Sedentary lifestyle
Lack of physical activity
23
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
24
HEALTH CONSEQUENCES
Health consequences of obesity
Coronary Heart Disease
Type 2 Diabetes
Cancers
Hypertension
Lipid Disorders
Stroke
Liver and Gall Bladder Disease
Sleep apnea
Osteoarthritis
Infertility
26
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
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)
MORBIDITY AND MORTALITY IMPLICATIONS
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
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
32
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
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
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
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
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.
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.
COSTS
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
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)
40
INTERVENTIONS AND CHALLENGES
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
42
Interventions and challenges
Treatment goals – reduce or prevent complications associated with obesity
Interventions
Dietary modification
Exercise
Behavior modification
Drug therapy
Surgery
- Liposuction
- Bariatric Surgery
43
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
44
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.
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
2 d
iabe
tes
per 1
0,00
0 pa
tient
-yea
rs
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.
THE FUTURE
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?
47
Projections for 2030 if historical trend continues
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
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
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
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
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
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
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
54