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The Problem: Obesity in America

The Problem: Obesity in America. Lori A. Lemberg, M.D. Adapted from MCE Conferences March 14-16, 2011 Lecture presented by Frank J. Domino, M.D. Barbara Olendzki, RD, MPH. World Wide Rates of overweight and obesity, 2000-2004. US 66.3% UK 63.0% Mexico 62.3%

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The Problem: Obesity in America

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  1. The Problem: Obesity in America Lori A. Lemberg, M.D. Adapted from MCE Conferences March 14-16, 2011 Lecture presented by Frank J. Domino, M.D. Barbara Olendzki, RD, MPH

  2. World Wide Rates of overweight and obesity, 2000-2004 US 66.3% UK 63.0% Mexico 62.3% Canada 57.5% Greece 57.1% New Zealand 56.2% Germany 49.2% Italy 42.6%

  3. Consequences of Obesity 66% of Americans are overweight* 22% of Americans are obese Deaths from Obesity: 300,000 premature deaths associated with obesity annually (CDC) 25,000/month, 5,769/week, 821/day, 34/hour. 450,000 from tobacco-related disease 10.4 million people with type II diabetes 47 million with metabolic syndrome *CDC 2006

  4. Is treating obesity a way to save the economy? • 2003: 9.1 % of U.S. health expenditures* • Estimated annual medical spending due to overweight and obesity (BMI >25) to be as much as $92.6 billion in 2002 dollars* • 2006: 10% of U.S. expenditures** • $147 billion in 2006 dollars** • (Afghan war ~ 28 Billion per year over 8 Yrs) *Finkelstein EA; Health Affairs Web Exclusive. 2003; W3:219-226. **Finkelstein EA; Health Affairs 28, no. 5 (2009): w822-w831

  5. Obesity Trends* Among U.S. AdultsBRFSS, 1985 No Data <10% 10%–14% (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)

  6. Obesity Trends* Among U.S. AdultsBRFSS, 2007 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

  7. Obesity Trends* Among U.S. AdultsBRFSS, 2009 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

  8. State-specific Prevalence of Obesity* Among U.S. Adults, by Race/Ethnicity, 2006-2008 White non-Hispanic Black non-Hispanic Hispanic (*BMI 30)

  9. Childhood Obesity

  10. What else has changed? Humans have a genotype that permits energy intake > expenditure Political decisions & industrialization of farms  growth of grain for livestock, rather than humans 1st in recorded history cost of meat < vegetables. ↑ portion sizes, ↑ fat intakes, sweetened beverages Lack of physical activity: ↓ Manual Labor, Computer/Screen time, increased automation allows for less activity @ home “What’s for Take Out?” 1.2 vs > 5.0 per week

  11. BAGEL 20 Years Ago Today 140 calories 3-inch diameter 350 calories 6-inch diameter If you rake the leaves for 50 minutes you will burn the extra 210 calories.* Calorie Difference: 210 calories 5 days/wk X 50 weeks=15.6 lb.

  12. CHEESEBURGER 20 Years Ago Today 333 calories 590 calories Calorie Difference: 257 calories If you lift weights for1 hour and 30 minutes,you will burn approximately 257 calories.*

  13. FRENCH FRIES You need to walk for1 hour and 10 minutes to burn approximately 400 extra calories 20 Years Ago Today 210 Calories 2.4 ounces 610 Calories 6.9 ounces Difference: 400 Calories

  14. How can WE help our patients? What are the barriers to providing good nutritional counseling? • Time • Knowledge of current guidelines • Effectiveness of interventions

  15. “Successful Losers” The National Weight Control Registry >5000 successful losers Members lost an average of 66 lbs (range=30-300 lbs) x 5.5 years (= 1 lb/month x 5 years) 78% eat breakfast every day. 75% weigh them self at least once a week. 62% watch < 10 hours of TV per week. 90% exercise, about 1 hour per day. http://www.nwcr.ws

  16. What about the average person?Daily Practices Survey 2004 US > 18 Yrs. “Successful Weight Loss Maintainers” Eat Fast Food < 2/Week > 5 Fruits & Vegetables/day ** AND 150 Minutes physical activity (25 Min/Day)

  17. Action Plan • Action Plan • Based upon patient’s suggestion • Provide options for patient • Be open to whatever they suggest • ALWAYS schedule Follow up with agreed upon Goal

  18. First Some Basics Training

  19. Calories Energy IN vs Energy OUT 3500 calories= 1 pound 500 calories/day x 1 Week = 1 lb +10 calories/day = 1 lb weight/year

  20. Body Weight Ideal Body Weight:Women: 100 lbs first 5 feet + 5 lbs/inch. +/- 10% Men: 106 lbs for first 5 feet + 6 lbs/inch +/- 10% Calories Needed to Maintain Weight Active male: Lb x 15 = total calories per day. Active female: Lb x 12 = total calories per day. Inactive male: Lb x 13 = total calories per day. Inactive female: Lb x 10 = total calories per day.

  21. Daily Requirements Female adult (5’4”) ~ 1,500 calories/day Male adult (5’7”) ~ 2,250 calories/day Remember: Fat = 9 Kcal/gm Protein = 4 Kcal/gm CHO = 4 Kcal/gm Alcohol = 7 Kcal/gm

  22. What is a Serving Size? Meats: 3 oz. (deck of cards) Dairy: 4 oz = ½ cup Grains: ½ cup or 1 slice bread Veg: ½ cup cooked or 1 cup raw Fruit: ½ cup cut up or 1 medium

  23. The Label Look at serving size saturated fat dietary fiber sugars Glance at carbohydrate Read ingredients (for hydrogenated oils and whole grains)

  24. 5 Steps to Healthy Diet • Increase Fiber • Increase Water 16 Oz before meals • Prescribe Exercise • MINDFULLY Eat Calorie “hypodense” foods • Limit Screen Time to < 10 Hr/week

  25. 24 Hour Dietary Recall

  26. “Tell me everything you ate and drank yesterday, starting with breakfast.”

  27. “Oh no, not yesterday!”

  28. Count Fruit and Vegetable Servings • Goal: 10 servings/day •  25-30 Grams of Fiber • Min: 5 servings/day (15 Grams/Day) • Potatoes, Pasta &White Rice do NOT count

  29. Water Consumption and Dietingfor Adults • RCT over 12 weeks of adults • Compared Low Calorie Diet vs. Low Calorie Diet + 16 Oz water prior to each meal • 44% RRR (~4.5 Lbs) greater weight loss in Water group. Obesity. 2010; 18(2): 300-7

  30. Apples to Oranges… Calories • 1 Orange 40 • 8 Oz OJ 120 • 8 Oz Cola 100 • Coffee Black 2 • Coffee + 2 Sugar 30 • Coffee + 1 Oz Cream 100 • StarBucks Café Mocha 400

  31. Simple Approach Simple Rule:

  32. 3. Prescribe… EXERCISE 6300 adults Observational Study Dx: Sed Lifestyle HTN, DM, OB, M/Skel “Inactive” Baseline = 33% At 3 Months= 17%; At 12 Months = 20% BMJ 2008: 337:a2084 Scandinavian Journal of Medicine and Science in Sports, doi: 10.1111/j.1600-0838.2008.00820.x WALK

  33. How Much and What Kind of Exercise???? No one knows what is ideal for weight loss. For CHD: 30-50 Min Aerobic exercise 5 days/week. For Weight loss: Aerobic + Weight training 5 days per week No “after exercise treat”

  34. Why bother? • Weight loss • Reduced cardiovascular and all-cause mortality • Cognitive benefits Anxiolytic effects of exercise: a meta-analysis J Sports & Exer Psychol. 2008 Aug; 30(f):392-410 • Improved quality of life (RCT) Martin , Exercise dose and quality of life. Arch Int Med. 2009;169(3):269-78. • The cost of NOT exercising: the STRRIDE trial • We are health role models Warburton DE Health benefits of physical activity: the evidence. CMAJ. 2006;174(6):801-9.

  35. STRRIDE Study: Cost of NOT exercising • RCT, 4 groups • INTERVENTION: • Low amount/Mod intensity, • Low amount/Vigorous intensity, • High amount/Vigorous • Low/High: 120 min vs 200 min • Intensity: Moderate 40-55% V02 max, High 65-80% • Non-exercisers: +1% body weight, +8.6% visceral fat in 6 months! • Exercisers: -1-2% body weight, no change/-7% visc. Fat Slentz CA, STRRIDE; J Appl Physiol. 2005;99:1613-8.

  36. 1. Exercise efficiently2. Keep your lifestyle active3. Incorporate resistance training

  37. Exercising efficiently: Interval training and “threshold” http://www.xiser.com/store/pdf/Sprint_Interval_Training.pdf • HIIT as a health promotion strategy Gibala, MJ. High-intensity interval training: a time efficient strategy for health promotion? Curr Sports Med Reports. 2007;6:211-3. • HIIT training increases aerobic and anaerobic capacity Tabata I, Nishimura K, et al. Effects of moderate-intensity endurance and high-intensity intermittant training on anaerobic capacity and V02 max. Med Sci Sports Exerc. 1996;28(10):1327-30

  38. 2. Keep lifestyle active

  39. Lifestyle Importance DESIGN: 16 week RCT in 40 obese women, both observing similar diet, 16 wk and 1 yr follow up INTERVENTION: structured aerobic activity or moderate lifestyle activity OUTCOME MEASURES: body weight and composition changes, cardiovascular risk profile, physical fitness RESULTS: at 1 year, equivalent reductions in triglycerides, LDL, HDL, resting DBP; lifestyle group had significantly greater reductions in total cholesterol, resting SBP, increased VO2 max, depression scales, maintained weight loss Anderson RE, Wadden TA, Bartlett SJ, et al. Effects of lifestyle activity vs structured aerobic exercise in obese women. JAMA. 1999;281:335-340

  40. 3. Incorporate resistance training

  41. How does resistance training provide lasting benefits? Muscle mass as a “metabolic sink” • Increased insulin sensitivity • Decreased HbA1c (0.5%-1.0%) Maintain muscle mass lost with age (1 lb/yr after 50) Increased strength (falls in the elderly!) Increased basal metabolism beyond expected with adding muscle (21 kcal/kg vs 28-218 kcal/kg) Reduced visceral fat on par with aerobic exercise Increased bone mineral density Recommend: single set of 8-10 reps covering major muscle groups min 2x/week Braith RW Circulation. 2006;113:2642-50.

  42. How little is “enough”? • Simple answer: whatever you can fit into your day, anything is better than nothing • Better answer: Review of observational cohort studies of exercise and reduction in all-cause mortality • 1000 kcal/week associated with 20-30% risk reduction Haennel RG and Lemire F. Physical activity to prevent cardiovascular disease: How much is enough? Can Fam Physician. 2002;48:65-71.

  43. Fitness is more important than fatness METHODS: 58 sedentary obese men and women, 12 wk supervised aerobic exercise (500 kcal, 70% max HR, 5 times/wk) OUTCOME MEASURES: body composition, aerobic capacity, BP, psychological response score, measured at weeks 0 and 12 RESULTS: 26/58 had less than predicted weight loss, but all had significantly increased aerobic capacity and positive mood, decreased SBP/DBP, waist circumference, resting HR • The concept of exercise “nonresponder” • No association between weight loss and improvements in health markers King NA, Hopkins M, et al. Beneficial effects of exercise: shifting the focus from body weight to other markers of health. Br J Sports Med. 2009;43:924-7. I was short, fat and bald when I started running, but after running nearly every day for more than 30 years and covering about 70,000 miles...I am still short, fat, and bald. But I suspect I'm in much better shape than I'd be if I didn't run. – Steve Blair

  44. Workout to recommend • Warm-up • HIIT • 20 seconds on/10 seconds off • 8 sets • Resistance training • Turkish getup • Kettlebell swing • Squat jumps (see YouTube for demonstrations)

  45. Other things to consider… • Calcium: Calcium is needed for fecal fat excretion. Systematic review found supplementation of about 1,200 mg of calcium per day leads to an increase in fecal fat excretion. Obes Rev 2009; 10(4): 475-86

  46. Sleep: A small pilot study compared a low calorie diet w/either 5.5 hours of sleep vs 8.5 hours over 14 days. 8.5 hr had greater weight loss of body fat, and less hunger. The authors postulate it was due to the neuroendocrine changes decreased sleep induces. Ann Intern Med 2010; 153: 435-441

  47. Chronic PPIs: Case control study obesity developed in patients with GERD who were treated chronically with PPIs vs other treatments World J Gastro 2009; 15(38): 4794-4798

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