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2. The Obesity Epidemic at the Interface of Psychiatry John Thomas Paruch, MD, PGY-5 East Carolina University Department of Psychiatric Medicine May 29, 2014

3. Disclosures

4. Objectives 1 of 2 • Introduce the topic of Overweight and Obesity (OAO) • Review the overall cost of OAO/Burden on “Healthcare System” and Society • Review important terminology related to OAO • Frame the relevance of OAO to Medicine and Psychiatry • Discuss the diagnostic role of obesity in DSM-5 (APA) and in ICD-10 (AMA)

5. Objectives 2 of 2 • Discuss the pathophysiology of adipose tissue • Define, review, and briefly discuss pharmaceutical interventions • Discuss the role of bariatric surgery, its cost, implications, and types • How to address OAO in the setting of Psychiatry • Introduce new concepts that may shape the future of medicine

6. Introduction • Overweight and Obesity (OAO): its contribution to overall well-being • Complications • Are we prepared? • Reimbursement • Training • Education • Ability • Time

7. Out on a limb • OAO as a topic in Psychiatry • How it may be relevant to your daily practice. • Consider the patients you see • Consider the impediments (financial, clinical, etc)

8. The Bridge to Nowhere

9. An Epidemic? • Thoughts on the obesity epidemic • 1960 til now… • Are you affected?

10. Bridging the Gap

11. The Costs: More than Money

12. Terminology • Obesity and Overweight (OAO) • Classes of obesity • Body mass index (BMI) • Adiposity • Adiposopathy • Obesogen • Adipogenesis • Adipocyte • Globesity • Metainflammation • “Adiposity-Based Chronic Disease”?

13. Obesity: WHO Classes

15. Excessive & “Sick” Fat • Adiposity - is excessive adipose tissue. • Adiposopathy - “sick fat” • Bays H, Abate N, Chandalia M. Adiposopathy: sick fat causes high blood sugar, high blood pressure, and dyslipidemia. Future Cardiol 2005; 1: 39–59.

16. Body Habitus

18. Adipogenesis • Process of cell differentiation by which preadipocytes become adipocytes. • One of the most intensively studied models of cellular differentiation.

19. Adipocyte • the “fat “cell • Fat-containing adipocytes constitute most of the adipose tissue volume • surrounded by fibrous connective tissue, collagen, nerves, and blood vessels • supporting framework contains “stromal vascular fraction” cells

20. Metainflammation • “chronic, low-grade inflammation in metabolic syndromes • MetS (macrophages infiltrate the adipose tissue of obese person, also the major source of TNF-a overexpression in adipose tissue ) • Contrast with acute inflammation: • sepsis (insulin resistance in this state adaptive for the organism) • Cildir1,K et al. Chronic adipose tissue inflammation: all immune cells on the stage. Trends in Molecular Medicine, August 2013, Vol. 19, No. 8

21. Obesogen • A dietary, pharmaceutical, and industrial compound that may alter metabolic processes and predispose some people to gain weight • “Endocrine disruptors” Newbold RR, et al. Environmental estrogens and obesity. Mol Cell Endocrinol 304 (1-284–89.892009. http://dx.doi.org/10.1016/j.mce.2009.02.024 JanesickA, Blumberg B. Endocrine disrupting chemicals and the developmental programming of adipogenesis and obesity. Birth Defects Res Part C Embryo Today Rev. 2011;93(1):34–50.http://dx.doi.org/10.1002/bdrc.20197

22. Cost of Obesity • estimated annual health care costs of obesity-related illness = $190.2 billion • nearly 21% of annual medical spending in the United States   • Childhood obesity = $14 billion in direct medical costs • If obesity rates were to remain at 2010 levels, the projected savings for medical expenditures would be $549.5 billion over the next two decades

23. Prevalence in North Carolina, 2010

24. Prevalence in North Carolina, 2011

25. Trends: 1960-2000 • Centers for Disease Control and Prevention. National Center for Health Statistics. National Health and Nutrition Examination Survey. Available from: ttp://www.cdc.gov/nchs/nhanes/ nhanes_questionnaires.htm.

26. Adult Weight Gain by age from 1960-2000

27. Childhood Weight Gain Trend: 1960 -2000

28. Prevalence of Obesity, 2007-2008

29. Obesity in the United States

30. Prevalence: Worldwide • Approximately 1.2 billion people in the world are overweight • at least 300 million are obese. • at least 300,000 deaths every year in the United States alone can be linked to obesity World Health Organization

31. Obesity in the World

32. Obesity by Country 31. Bolivia 62.2%

33. Nauru: You didn’t know?

34. Developed vs Undeveloped

35. Possible Explanations for Trends • Changes in Food, Access, Availability, Socioeconomics • Sedentary Behavior/Inactivity • Sleep Deprivation • Microbiome • Obesogens • Other

36. Adipose Cell Differentiation

37. White fat cell and brown fat cell. Note the single large lipid vacuole in the white fat cell and the numerous smaller lipid vacuoles in the brown fat cell. LV: lipid vacuole; M: mitochondria; N: nucleus. Adipose Tissue: White & Brown

38. Adipose Tissue: White & Brown

41. Hormones involved in Obesity

42. Deranged Metabolic Homeostasis

43. Obesity is a Disease: AMA

44. Obesity is not a Disease: APA

45. Eating Disorders: DSM 5

46. DSM 5: Binge Eating Disorder

47. DSM 5: Binge Eating Disorder • Criterion A

48. DSM 5: Binge Eating Disorder Criterion B

49. DSM 5: Binge Eating Disorder Criterion C, D, & E

50. Adiposity-Based Chronic Diseases