Causes, Temple University. School of Medicine

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1 Obesity: Causes, Consequences s & Treatment Gary D. Foster, Ph.D. Center for Obesity Research and Education Temple University School of Medicine

2 Overv view 1. Discrimination 2. Prevalence e 3. Consequen nces 4. Treatment 5. Expectation ns

8 Obesity Trends* Among U.S. Adults BRFSS S, 1985 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14%

9 Obesity Trends* Among U.S. Adults BRFSS S, 1986 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14%

10 Obesity Trends* Among U.S. Adults BRFSS S, 1987 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14%

11 Obesity Trends* Among U.S. Adults BRFSS S, 1988 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14%

12 Obesity Trends* Among U.S. Adults BRFSS S, 1989 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14%

13 Obesity Trends* Among U.S. Adults BRFSS S, 1990 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14%

14 Obesity Trends* Among U.S. Adults BRFSS S, 1991 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19%

15 Obesity Trends* Among U.S. Adults BRFSS S, 1992 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19%

16 Obesity Trends* Among U.S. Adults BRFSS S, 1993 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19%

17 Obesity Trends* Among U.S. Adults BRFSS S, 1994 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19%

18 Obesity Trends* Among U.S. Adults BRFSS S, 1995 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19%

19 Obesity Trends* Among U.S. Adults BRFSS S, 1996 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19%

20 Obesity Trends* Among U.S. Adults BRFSS S, 1997 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% %

21 Obesity Trends* Among U.S. Adults BRFSS S, 1998 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% %

22 Obesity Trends* Among U.S. Adults BRFSS S, 1999 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% %

23 Obesity Trends* Among U.S. Adults BRFSS S, 2000 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% %

24 Obesity Trends* Among U.S. Adults BRFSS S, 2001 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% 24% 25%

25 Obesity Trends* Among U.S. Adults BRFSS S, 2002 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% 24% 25%

26 Obesity Trends* Among U.S. Adults BRFSS S, 2003 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% 24% 25%

27 Obesity Trends* Among U.S. Adults BRFSS S, 2004 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% 24% 25%

28 Obesity Trends* Among U.S. Adults BRFSS S, 2005 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30%

29 Obesity Trends* Among U.S. Adults BRFSS S, 2006 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30%

30 Medical Complic cations of Obesity Pulmonary disease abnormal function obstructive sleep apnea hypoventilation syndrome Nonalcoholic fatty liver disease steatosis steatohepatitis cirrhosis Idiopathic intracranial hypertension Stroke Cataracts Coronary heart disease Diabetes Dyslipidemia Hypertension Gall bladder disease Gynecologic abnormalities abnormal menses infertility polycystic ovarian syndrome Osteoarthritis Skin Gout Severe pancreatitis Cancer breast, uterus, cervix colon, esophagus, pancreas kidney, prostate Phlebitis venous stasis

31 Direct Cost* of Chronic Diseases in the United States (2006) $83.3 $71.4 Direct Cost (Billion ns $)* $59.2 $31.9 $27.0 Type 2 Diabetes Obesity Coronary Heart Disease Hypertension Arthritis 1 ADA Diabetes Care, 2003;26:917 2 Finkelstein EA, Obes Res 2004;12 3 Hodgeson TA et al. Medical Care 1999:37: Hodgson TA et al. Med Care 2001;39:599 5 Yelin & Callah han. Arthritis Rheum 1995;38:1351

32 Who is Paying and How Much is being Paid for Overwei ight and Obesity? Insurance Category Out-of-Pocket Annual Cost (%) Ovwt & Obesity 7.3% Amount ($,billions) Ovwt & $7.1 Obesity Private Pi 8 82% 8.2% $19.8 Medicaid 8.8% $3.7 Medicare Total 11.1% $ % $51.5 Finkelstein et al. Health Affairs.May 2003:219

33 Obesity s Growing Prevalence & Treatment Costs are Impacting Private He ealth Insurance Spending Percent of Obese Adults Spending Attributable to Obesity Spending per member (dollars) Private insurance spending (billions, USD) % of private insurance spending , Thorpe, KE et al. Health Affairs, 2005;W :

34 Major Cost Drivers of Obesity are: Prevalence Severity Aging Each Unit Increase in BMI is Associated with a 2.3% Increase in Health Care Costs Raebel MA, et al. Arch Intern Med 2004;164:

35 Obesity is Associated with a Greater Loss in Productivity Mean Annual Work Days Lost Men Women Healthy Weight Ov verweight Obese Thompson, D.et al. Am J Health Promot 1998;12:

36 And, Greater Rates of Disability Percent Unable to Work 12.6 Men Women Healthy Weight Ov verweight Obese Thompson, D.et al. Am J Health Promot 1998;12:

37 Behavioral Factors Dietary intake Physical activity

41 Environmental Factors Marketing Bigger packages, multiple unit pricing, quantity limits Bigger equals cheaper» Supersize»22 oz soda for $2. 50 versus 44 oz for $3.00 All-you-can-eat buffe ets

44 Energy Savers personal computers cellular phones shopping by phone phone extensions escalators/elevators drive-thru windows intercoms remote controls tele-commuting /internet food delivery services dishwashers cable movies computer games moving sidewalks garage door openers

45 Obesity Treatment Guidelines The Practical Guide can be found at: NHLBI web site: The Obesity Society web site:

46 Guide for Selecting Obesity Treatment BMI Category (kg/m 2 ) Treatment >40 Diet, Exercise, Behavior Tx Pharmaco- therapy Surgery With co- morbidit ies With co- morbidities + The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. October 2000, NIH Pub. No

47 Self-Monitoring Food Intake Types of foods Portion sizes Calories (reduce by 500 kcal/d) Times, places, and activities Thoughts and moods

48 Changes in Body Weight 4 Change in Weight (kg) Year Placebo Metformin Lifestyle Diabetes Prevention Program Research Group. N Engl J Med 2002;346,

49 Diabetes Prevention Program 40 Placebo dence %) ative Incid iabetes (% Cumula of Di Metformin Lifestyle Year Diabetes Prevention Program Research Group. N Engl J Med. 2002;346,

50 Portion-Cont trolled Meals Provide fixed-portion and calorie amounts Reduce choices and contact with problem foods Are convenient to use Satisfy appetite (monotony and sensory specific satiety) Facilitate dietary adh herence

51 Meal Replacements Enhance Initial and Long-term Weight Loss Phase 1* Phase 2 t Loss 0 CF MR-1 Percenta age Weight 5 10 MR * kcal/d diet prescription. Time (mo) CF=conventional foods. MR-2=replacements for 2 meals, 2 snacks daily. MR-1=replacements for 1 meal, 1 snack daily. Ditschuneit et al. Am J Clin Nutr 1999;69:198. Fletchner-Mors et al. Obes Res 2000;8:399.

54 The Dieter s Dilemma

55 Calories or Carbs? N: 43 Weeks: 6(i (inpati ent) Diets: Isocaloric (1000 kcal/d) (15% vs. 45% CHO) Weight Loss: kg kg 0.5 Golay. IJO, 1996.

56 Weight Loss 6 Months * Low- Carbohydrate Low-Calorie * * * Breh hm Foste ster Samah aha Yanc ncy * %Change

57 Weight Loss 1 Year % Ch hange Foster Stern Dansinger Low-Carb Low-Cal Foster et al. NEJM, 2003., Stern et al Ann Intern Med, 2004, Dansinger et al. JAMA 2005

58 Lipids 1 Year Changes Change % 20 * Total Cholesterol LDL HDL * * Triglycerides * Low-Carb Foster Low-Cal Foster Low Carb-Stern Low Cal-Stern Foster et al. NEJM, 2003., Stern et al Ann Intern Med, 2004

59 Antiobesity Agents: How They Work Agents Releasing Agent Reuptake Inhibitor Selective Lipase Inhibitor 5-HT NE DA 5-HT NE DA Dexamphetamine Phentermine Sibutramine Orlistat HT = serotonin; NE = noradrenaline; DA = dopamine 1 Bray GA. Ann Intern Med. 1993;119(7 pt 2): Beales PL, Kopelma an PG. PharmacoEconomics. 1994;5(suppl 1):18. 3 Buckett WR et al. Prog Neuropsychopharmacol Biol Psychiatry. 1988;12: Drent ML et al. Int J Obes Relat Metab Disord. 1995;19: Heal DJ et al. Psychopharmacology (Berl). 1992;107:303.

60 Drugs Approved by FDA for Treating Obesity Status Gene eric Name Trade Name Rx Sibutramine Meridia Rx Orl istat Xenical OTC (Approved 2/07) Approved in Europe but not U.S. Or rlistat 60mg Rimonabant alli Acomplia/Zimulti

61 STORM Trial Weight Loss Weight Maintenance Placebo Body Weight (lb) *Same diet, exercise for sibutramine, placebo; P 0.001, sibutramine vs placebo for weight maintenance Adapted with permission from James WPT et al. Lancet. 2000;356:2119. Sibutramine i Month

62 STORM: Change in Vital Signs Baseline to 24 Mon nths in Sibutramine Treatment Group BP, mm Hg Systolic Diastolic Pulse rate (bpm) Mean Change Sibutramine Placebo James WPT et al. Lancet. 2000;356:2119.

63 STORM: Safety and Tolerability % of fpatients t Reporting AEs* Infection 14 Flu syndrome 7 Headache 23 Increased appetite 4 Pharyngitis 7 Dry mouth 39 Constipation 19 Asthenia 6 Insomnia 12 Weight Loss Phase Placebo Sibutramine (n=605) (n=115) (n=352) *Frequency of 10% in any treatment group; reported as therapy-related James WPT et al. Lancet. 2000;356:2119. Weight Maintenance Phase

65 Orlistat: Weight Loss and Maintenance Over 2Y Years in Body We eight (%) Change Placebo Orlista at P<0.001 vs placebo at 1 and 2 years SB DB Week DB Slightly hypocaloric diet SB = single blind; DB = double blind Adapted with permission from Sjöström L et al. Lancet. 1998;352:167. Weight maintenance (eucaloric) diet

66 Orlistat: Safety Adverse Events (AEs) at 1 Year % Pla acebo, n=340 Orlistat, n=343 % 20 20% 18% % Fatty/Oily Stool 7% Increased Defecation 1% Oily Spotting There is concern about fat-soluble vitamin absorption 3% 10% Fecal Urgency 0% 7% Fecal Incontinence Sjöström L et al. Lancet. 1998;352:167.

67 se alli vs. Xenical OTC Rx osage arget Pop ndication 60 mg Overweight Weight Loss 120 mg BMI > 27 kg/m 2 or > 30kg/m 2 (w/ co-morbidities) or (without) Weight Loss & Maintenance ge Range 18+ I AEs withdrawal rates) ehavioral upport Program myalliplan.com Xenicare

68 Goals for Weight Loss The initial goal of weight loss therapy for overweight patients is a reduction in body weight of about 10% moderate weight loss of this magnitude can significantly decrease the severity of obesity-associated risk factors. NHLBI, 1998

69 Subject Characteristics 60 obese women years kg BMI = kg/m obese individuals women 43 men years kg BMI = kg/m 2 1 Foster et al. JCCP 65(1) Foster et al Arch Int Med

70 Goal Weights Averaged 32% reduction in body weight Three times greater than the goals recommended ddby the National lacademy of Science and Departme ent of Agriculture Greatly exceeds weight losses of nonsurgical treatments

71 Defined Weights Dream Weight A weight you would choose if wanted. you could weigh whatever you Happy Weight This weight is not as ideal as the first one. It is a weight, however, that you would be happy to achieve. Acceptable Weight A weight that you would not be particularly happy with, but one that you could accept, since it is lesss than your current weight. Disappointed Weight A weight that is less than your current weight, but one that you could not view as successful in any way. You would be disappointed if this were your final weight after the program. Foster et al, J Consult Clin Psychol, 1997

72 Defined Weights % Reduction % Reduction 2 ream 38% 38.4% appy 31% 30.9% cceptable 25 % 24.9% isappointed 17% 15.7% 1 Foster et al. JCCP 65(1) Foster et al Arch Int Med

73 % Achieving Defined Weights at Week 48 (N=45) Weight loss: k 7.2 kg Acceptable 24% 9% Happy Dream = 0% Disappointed 20% 47% Did not reach Disappointed Weight Foster et al, J Consult Clin Psychol, 1997.

76 Principles and Practices Simplicity Engagement Enrollment Implementation Structure Duration Intake Activity

77 Principles and Practices Accountability Employees Employers Incentives Enrollment Participation/Success

78 Principles and Practices Expectations Weight Non-weight Fees

How to Achieve Medical Weight Loss in 2012

How to Achieve Medical Weight Loss in 2012 Gary D. Foster, Ph.D. Laure H. Carnell Professor of Medicine, Public Health, and Psychology Director, Center for Obesity Research and Education Temple University