The Obesity/Diabetes Epidemic:Adiposopathy & Obesity-

The New Disease!Dx & (Rx) of Insulin Resistance & Early

DM (Part 1)Stan Schwartz MD, FACP, FACE

Private Practice, Ardmore

Obesity Program

Cardiometabolic Diabetes Center and Affiliate,

Main Line Health System

Emeritus, Clinical Associate Professor

University of Pennsylvania

Disclosures

Advisor

Takeda, Amylin, A-Z, BMS, Novo. Merck, Santarus

Speaker

Lilly, Amylin, Takeda, Novo, BMS, Santarus Merck, Astra-Zeneca

Duggal, Evidence-Based Medicine in Practice,, Int’l j. Clinical Practice,65:639-644,2011

Lecture Based on Evidence -Based PRACTICE

==EBM=Evidence Based Medicine

Has Led to Students/MDs who don’t Think

=Evidence Based Practice

==EBM=Evidence Based Medicine

Research Evidence

Randomized, ProspectivePublication TrialsCritical Appraisal

Patient-Based Experience

Clinical expertiseExpert OpinionsGuidelines

+

• Body Mass Index– Evaluates weight relative to height (kg/m2)

– Correlates highly with body fat, morbidity, and mortality

• Categories– Underweight (< 18.5 kg/m2)

– Normal weight (18.5-24.9 kg/m2)

– Overweight (25.0-29.9 kg/m2)

– Class I Obesity (30.0-34.9 kg/m2)

– Class II Obesity (35.0-39.9 kg/m2)

– Class III Obesity (> 40 kg/m2)

NIH National Heart, Lung, and Blood Institute. Obes Res. 1998;6(suppl 2):51S

Defining Obesity- A Disease, ADA 6/2013

Waist Circumference correlates with BMI- but BMI not closely correlated with IR- Leads to….

Even some HIGH BMI FOLK have normal IR

Leads to Concept-Metabolically Healthy Obese

Date of download: 12/14/2013

Copyright © American College of Physicians. All rights reserved.

Are Metabolically Healthy Overweight and Obesity Benign

Conditions?:

NO!!

THUS=

OXYMORON

Ann Intern Med. 2013;159(11):758-769. doi:10.7326/0003-4819-159-11-201312030-00008

Meta-analyses of various clinical characteristics, by metabolic–body mass index categories.

Data shown as weighted mean difference compared with metabolically healthy normal-weight persons (reference). To convert cholesterol, triglyceride, and glucose values to traditional units (mg/dL), divide by 0.0259, 0.0113, and 0.0555, respectively. HOMA-IR = Homeostasis Model Assessment of Insulin Resistance.* P < 0.05.

Obesity Paradox• some long-term studies have shown that weight loss in overweight and obesity is associated with increased

mortality coupled with many CV studies showing a better prognosis with a higher BMI

suggested that purposeful weight loss may not be beneficial and may even be detrimental in patients with CV diseases • In contrast, other studies assessing mortality based on body fat and lean mass suggested that subjects losing body fat rather than lean

mass have a lower mortality• Potential adverse effects of weight loss may be explained by wrong methods of wt. loss.

eg: starvation, very-low-calorie diets, liquid protein diets, and obesity surgeries have been associated with prolongation of the QTc interval and increased risk of malignant dysrhythmias (1), and various pharmacologic agents have either limited efficacy or considerable toxicity (70-72).

Overwhelming evidence supports the importance of obesity in the pathogenesis and progression of CV disease. Although an obesity paradox exists,, the constellation of data still support purposeful weight reduction in the prevention and treatment of CV diseases

Carl J. Lavie, MD; Richard V. Milani, MD; Hector O. Ventura, MDJ Am Coll Cardiol. 2009;53(21):1925-1932.

CHF outcomes better if Obese

Obesity Paradox:Metabolically Healthy Obese Patients still has

Increased CV rates and All Cause mortality

And have other adverse outcomes related to DJD and Sleep Apnea, for example

Outline• Epidemiology and Economics of obesity/diabetes

• Perspectives on Obesity

• Consequences of Obesity, Prediabetes, Obesity

• Obesity/ Diabetes Risk Factors,

• Obesity/ Diabetes Onset can be Prevented or Delayed – Early Risk Identification and Intervention.

• Medical Benefits to Weight Loss

• Treatment-CDC’s diabetes prevention program and other Evidence-Based Interventions- – Basics, – Next Lecture in Series

Overweight and Obesity Prevalence Increasing Among U.S. Adults

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10

20

30

40

50

60

70

1960-62 1971-74 1976-80 1988-94 1999-2002 2003-2004

NHANES Data Collection Period

Pre

va

len

ce

(%

)

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Obesity Overweight

Flegal KM et al. JAMA 2002;288:1723-27Hedley AA et al. JAMA 2004;291:2847-50Ogden CL et al. JAMA 2006;295:1549-55

Leads toDiabetesEpidemic

An Expensive Epidemic• 56 million Americans have a

BMI of 30-40– Had healthcare costs

36 percent greater than normal-weight

individuals– Had pharmacy costs

77 percent greater than normal-weight

individuals

• Nearly 10% of annual medical spending was for overweight and obese patients

• Total medical cost for obesity in 2003 was $75 billion.Finkelstein,Jan/2004Obesity Research

Sturm, Ph.D. Archives of Medicine

Direct Cost* of Chronic Diseases in the United States

*Adjusted to 1995 dollars.Wolf and Colditz. Obes Res 1998;6:97.

Hodgson and Cohen. Med Care 1999;37:994.

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Type 2 Diabetes

Obesity Coronary Heart Disease

Hypertension Stroke

$51.6

Dir

ect C

ost (

Bil

lion

s $)

*

$38.7

$18.4 $18.1

$53.2