OBESITY: TRENDS AND IMPLICATIONS. Mark Skillan, M.D. ACSW SEAC November 18, 2011

Transcription

1 OBESITY: TRENDS AND IMPLICATIONS Mark Skillan, M.D. ACSW SEAC November 18, 2011

2 Obesity in the media 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

3 Obesity A growing concern Obesity Defined Prevalence Etiology Health Consequences Morbidity and Mortality Implications Interventions & Challenges The Future

4 OBESITY: AN INSURER S CONCERN

5 Relation between mortality and body mass index 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 5

6 OBESITY DEFINED

7 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

8 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

9 Classification of weight - adult Body Mass Index (BMI) Weight (kg) Height (m 2 ) BMI Description Class of obesity Example 1.74 m 18.5 or less Underweight - less than 56 kg Normal weight - 56 kg - 75 kg Overweight 0 75 kg - 90 kg Obesity I 90 kg kg Obesity II 106 kg kg 40 or higher Extreme obesity III more than 121 kg

10 Classification of weight - child and adolescent Category Underweight Normal weight Overweight Obesity Class III obesity (super obesity) Youth (2-20 yrs) BMI <5th percentile for age BMI 5th to <85 th percentile BMI 85th to <95 th percentile BMI 95th percentile Not used* 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. 10

11 PREVALENCE

12 Past and projected prevalence of overweight by country Source: The Lancet 2011; 378: (DOI: /S (11) )

13 Obesity trends* among U.S. adults BRFSS, 1990, 2000, 2011 *BMI 30, or about 30 lbs. overweight for 5 4 person No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30% Source: Behavioral Risk Factor Surveillance System, CDC.

14 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

15 Smoothed frequency distributions of body mass index for men and women aged 40 to 59 years in and Source: Flegal, K. M. et al. JAMA 2010;303:

16 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

17 Rising prevalence of overweight children (5-11) 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 Copyright 2005 European Association for the Study of Obesity. 17

18 Percentage of overweight children, ages 5 11 Netherlands Germany USA England Poland France Source: International Obesity Task Force (IOTF), London, March 2005

19 Percentage of U.S. children and adolescents classified as obese, * 20 Ages 6-11 Ages ** *>95 th percentile for BMI by age and sex based on 2000 CDC BMI-for-age growth charts. ** data are from for children 6-11 years of age and from for adolescents years of age. Source: NCHS. Health, United States, 2010:With Special Feature on Death and Dying. Hyattsville, MD

20 Global prevalence of overweight in boys % Overweight < 5% 5 9.9% % % % % 30% Source: IASO/IATF

21 ETIOLOGY

22 Causes of obesity Calories Burned Calories Ingested

23 Factors contributing to obesity Genetics Environment Unhealthy diet Sedentary lifestyle Lack of physical activity 23

24 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

25 HEALTH CONSEQUENCES

26 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

27 Obesity affects longevity via associated diseases Stroke Coronary heart disease Left ventricular hypertrophy Diabetes mellitus Gyn abnormalities Fatty liver Cholelithiasis Hypertension Pulmonary disease Sleep apnea Depression Arthroses Pancreatitis Malignant tumors Back pain Musculoskeletal Dyslipidemia

28 Prevalence of cardiovascular disease risk factors* in adults, USA Percent of Population Year Overweight Hypertension Smoking High Cholesterol (*age adjusted) Source: NIH, NHLBI, Fact Book Fiscal Year Feb. 04

29 MORBIDITY AND MORTALITY IMPLICATIONS

30 Relationship between BMI and Risk of Type 2 Diabetes Relative risk < , , , , , , , ,9 >=35 BMI Nurses Health Study: n=100, yr follow=up

31 Prevalence of diabetes worldwide Percentage of people aged 20 with diabetes in 2000 no data below 5% 5% - 9.9% 10% % 15% and above Source: WHO, 2007

32 Relative Risk, All-Cause Mortality for A 1 C Levels 4 Diabetes 3.5 Relative Risk, All-Cause Mortality for A 1 C Levels Risk Diabetes Ratio Risk Ratio Women Men Women Men < 5 % % % % % 1 From Khaw, K, et al, Annals of Internal Medicine. 2004; 141(6): < 5 % % % % % From Khaw, K, et al, Annals of Internal Medicine. 2004; 141(6):413 32

33 Relation between age and rates of CHD with and without diabetes Diabetes, recent AMI No diabetes, recent AMI Number of events per 1000 person-year Age (years) Source: The Lancet, Vol. 368, July 1, 06 retrospective cohort, n=9mm

34 Increase in diseases attributable to rising obesity levels 80 Coronary heart disease Stroke Diabetes Increase % Time (years) Source: Foresight 2007, K. McPherson, University of Oxford; adjusted for age and gender

35 Obesity and cancer risk Women Men Endometrium RR=5.42 Prostate RR=1.29 Cervix RR=2.39 Colorectal RR=1.73 Breast Gall bladder RR=1.53 RR=3.58 Possible causes: 1. Hormonal changes Gynecological tumors, prostate 2. Dietary intake (e.g. high fat content) Intestinal tract, gall bladder

36 Relative risk of death in relation to BMI, age Relative Risk >40 BMI Men Women Source: Adams KF, et al, NEJM ;8:

37 Relative risk of death in relation to BMI, ages 50 to Relative Risk >40 BMI Men Women Source: Adams KF, et al, NEJM ;8:

38 COSTS

39 Obesity costs Obese and overweight: 9.1 % of total annual US medical expenditures Obese (BMI > 30) annual medical expenditures 36% higher than BMI 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.

40 Obesity costs Indirect Costs: Absenteeism, Disability, Premature mortality, Presenteeism, Workmen s Comp BMI > 40: WC claims/100 FTE s (vs. 5.8 for normal weight) 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

41 INTERVENTIONS AND CHALLENGES

42 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

43 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

44 Weight loss-induced reduction in blood pressure 10 Fall in diastolic BP, mmhg > to to to -2 >+1 Weight change, kg 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:

45 Importance of body weight and exercise on development of type 2 diabetes 60 Rate of type 2 diabetes per 10,000 patient-years < >26 Body mass index, kg/m2 <500 kcal/wk kcal/wk >2000 kcal/wk 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:

46 THE FUTURE

47 Projections for 2030 if historical trend continues 100 million obese now > 165 million by % American Men Obese by 2030 US healthcare spending will rise by $66 Billion a year Potential decline in US Life expectancy? 47

48 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

49 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

50 References 1. Prevalence and Trends in Obesity Among US Adults, Flegal, KM, et al, Journal of the American Medical Association. 2010; 303(3): Body Mass Index in a Prospective Cohort of U.S. Adults, Calle, EE, et al, New England Journal of Medicine. 1999; 341(15): Mortality and Morbidity Liaison Committee ISCS Body Mass Index Study Roudebush, B, et al, Journal of Insurance Medicine. 2006; 38: Mortality and Weight: Insured Lives and the American Cancer Society Studies. Lew, E A, Annals of Internal Medicine. 1985; 103(6): Overweight, Obesity and Mortality in a Large Prospective Cohort of Persons Years Old - Adams, KF, et al, New England Journal of Medicine. 2006; 355(8):

51 References (continued) 7. Excess Deaths Associated With Underweight, Overweight and Obesity Flegal, KM, et al, JAMA. 2005; 293(15): Cause-Specific Excess Deaths Associated with Underweight, Over weight and Obesity Flegal, KM, et al, JAMA. 2007; 298(17): Body Mass Index and Mortality in an Insured Population Niverthi, M., et al, Journal of Insurance Medicine. 2001; 33: Body Mass Index and Mortality Among 1.46 Million White Adults Berrington degonzalez, A., et al, New England Journal of Medicine 2010; 363(23): Obesity and Mortality Calle, E, et al, New England Journal of Medicine. 2005; 353(20): Adolescent BMI Trajectory and Risk of Diabetes Versus Coronary Artery Disease Tirosh, A., et al, New England Journal of Medicine. 2011; 364(14): Title of presentation and name of speaker 10/11/

52 References (continued) 13. Childhood Obesity, Other Cardiovascular Risk Factors and Premature death Franks, P., et al New England Journal of Medicine. 2010; 326(6): A Potential Decline in Life Expectancy in the United States in the 21 st Century Olshansky, SJ, et al, New England Journal of Medicine. 2005; 325(11): Deadweight? The Influence of Obesity on Longevity Preston, SH, New England Journal Of Medicine. 2005; 352(11): Obesity and Its Relation to Mortality and Morbidity Costs Behan, D, et al, Society of Actuaries. December Obesity and Workers Compensation - Ostbye, T, et al, Archives of Internal Medicine. 2007; 167(8): Indirect Costs of Obesity: a review of the current literature - Trogdon, JG, et al; Obesity Reviews. 2008; 9:

53 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: Annual Medical Spending Attributable to Obesity: Payer- and Service-Specific Estimates - Finklestein, EA, et al, Heath Affairs 2009; 28(5): w822-w The Cost of Obesity Among Full-time Employees Finklestein, E, et al, American Journal of Health Promotion. 2005; 20(1): 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):

54 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