Health is Not Measured in Pounds

Transcription

1 Health is Not Measured in Pounds Arya M Sharma, MD. PhD, FRCPC Research Chair for Obesity Research & Management University of Alberta Medical Director Alberta Provincial Obesity Program Edmonton, AB, Canada 1

2 Sharma AM, 1995 Venus of Willendorf ~ 25,000 BC Museum of Natural History, Vienna, Austria 2

3 June 18 th, 2013: The AMA recognizes obesity as a disease requiring a range of medical interventions to advance obesity treatment and prevention AMA position statement What is Obesity? A condition characterized by excess body fat that threatens or affects socioeconomic, mental or physical health Sharma

4 What is Ideal Weight? Desirable Weight introduced in 1943 by the Metropolitan Life Insurance Company (MLIC) in standard height-weight tables for men and women Met Life Tower (1911) Metropolitan Life Insurance Company (MLIC) Standard Height-Weight Tables for Women BMI=19.3 kg/m 2 BMI=25.6 kg/m2 4

5 Quetelet Index (1832) body weight (Kg) height (m) 2 Renamed Body Mass Index by Ancel Keys in 1972 Adolphe Quetelet ( ) BMI and Body Fat European South Asian Yajnik CS, Lancet Jan 10;363(9403):163. DXA scan of two individuals with the same BMI but markedly different percent body fat Yudkin & Yainik, Lancet

6 Relationship Between BMI and Percent Body Fat in Men and Women Body Fat (%) Women Men Body Mass Index (kg/m 2 ) Adapted from: Gallagher et al. Am J Clin Nutr 2000;72:694. BMI and Risk of Cardiovascular Mortality Calle et al. NEJM

7 the surgical treatment benefit with respect to cardiovascular events was not related to baseline BMI or waist circumference no significant relationships between weight change and cardiovascular events could be demonstrated Although weight loss in general is desirable for obese patients, the overweight condition by itself is not informative. Physicians need to know an individual patient s risk factor profile before initiating therapy. 7

8 Anatomical Terms Used to Describe Obesity (historical) Cellular hyperplastic hypertrophic) Sharma AM & Kushner RF, IJO 2009;33, 289 Anatomical Terms Used to Describe Obesity (historical) Cellular hyperplastic hypertrophic) Somatotypes ectomorphic, mesomorphic endomorphic Sharma AM & Kushner RF, IJO 2009;33, 289 8

9 Anatomical Terms Used to Describe Obesity (historical) Cellular hyperplastic hypertrophic) Somatotypes ectomorphic, mesomorphic endomorphic Body segment central peripheral Sharma AM & Kushner RF, IJO 2009;33, 289 Anatomical Terms Used to Describe Obesity (historical) Cellular hyperplastic hypertrophic) Somatotypes ectomorphic, mesomorphic endomorphic Body segment central peripheral Distribution pattern android (male) gynoid (female) Sharma AM & Kushner RF, IJO 2009;33, 289 9

10 Anatomical Terms Used to Describe Obesity (historical) Cellular hyperplastic hypertrophic) Somatotypes ectomorphic, mesomorphic endomorphic Body segment central peripheral Distribution pattern android gynoid Depot visceral subcutaneous ectopic (visceral, subcutaneous, ectopic)) Sharma AM & Kushner RF, IJO 2009;33,

11 Edmonton Obesity Staging System (EOSS) Stage 2 co-morbidity Stage 1 moderate moderate Stage 3 Stage 0 Obesity Stage 4 Sharma AM & Kushner RF, Int J Obes

12 EOSS Predicts Mortality in NHANES III Padwal R, Sharma AM et al. EOSS Predicts Mortality at Every Level of BMI NHANES III Overweight Padwal R, Sharma AM et al. 12

13 EOSS Distribution Across BMI Categories NHANES III ( ) Overweight 23 million 50 million 10 million Class III 6 million Padwal R, Sharma AM et al. 13

14 14

15 Excess Weight is Misleading, Confusing, and Difficult to Communicate You are likely to lose X lbs (requires no additional information) You are likely to lose X% of your body weight (requires understanding of percentages but can be easily translated into actual weight) You are likely to lose X% of excess weight (requires understanding of percentages as well as the terms excess and ideal weight and cannot be easily translated into actual weight) 15

16 healthy diet + physical activity healthy weight excess weight unhealthy diet + undermoving 16

17 Assumptions Underlying the Weight-Focused Paradigm of Obesity Management Adiposity poses significant mortality risk Adiposity poses significant morbidity risk Weight loss will prolong life Anyone who is determined can lose weight and keep it off through appropriate diet and exercise The pursuit of weight loss is a practical and positive goal The only way for overweight and obese people to improve health is to lose weight Obesity-related costs place a large burden on the economy, and this can be corrected by focused attention to obesity treatment and prevention Adapted from Bacon & Aphromar, Nutrition J, 2011 Health At Every Size (HAES) Intervention Paradigms Focus on health, not weight ( health promotion not obesity prevention ) Avoid weight-biased stigma Consider physical, emotional, social, occupational, intellectual, spiritual, and ecological aspects of health. Promote self-esteem, body satisfaction, and respect for body size diversity. Physical activity and eating advise should use a compassion-centered approach that encourages self-care rather than prescriptions. Weight is not a behavior and therefore not an appropriate target for behavior modification. DO NOT SET WEIGHT GOALS! Adapted from Bacon & Aphromar, Nutrition J,

18 Health At Every Size (HAES): Shifting the Paradigm from Weight to Health Encouraging Body Acceptance Supporting Intuitive Eating Supporting Active Embodiment Adapted from Bacon & Aphromar, Nutrition J, 2011 Outcomes of HAES Approach vs. Weight-Centred Interventions Evidence from six RCTs indicates that a HAES approach is associated with clinically relevant improvements in: physiological measures (e.g. blood pressure, blood lipids), health behaviors (e.g. physical activity, eating disorder pathology) psychosocial outcomes (e.g, mood, self-esteem, body image) self-esteem and eating behaviors. Adapted from Bacon & Aphromar, Nutrition J,

19 Targeting Resources to Those Who Will Benefit Most A primary focus on weight-loss irrespective of health status may not be the best use of limited resources, as long-term success of weight maintenance requires indefinite ongoing support and resources. In contrast, limiting weight-loss recommendations and treatments to those individuals most likely to benefit, helps channel limited resources to those patients, who need them most. It is likely that these benefits are more likely to be costeffective in both the short- and long-term. Best Weight: Whatever weight someone can achieve and maintain while living the healthiest lifestyle they can truly enjoy. Freedhoff & Sharma,

20 Best Weight as Treatment Target Weight targets (where indicated) should be guided by the concept of Best Weight, defined as the lowest weight a patient can sustain while still leading a life they enjoy. This concept is based on the notion that no one will sustain a lifestyle that is overly restrictive, significantly impairs quality of life or is unrealistic given their psychosocial and biomedical circumstances. Individuals will differ widely in what they consider a feasible and enjoyable lifestyle that they can sustain, which is why Best Weight will differ between individuals and Program measures focus on quality of life and patient s perceptions of programming value. Best Weight 20

21 21