Dr. Shahebina Walji MD Clinical Lecturer, University of Calgary Medical Director, Calgary Weight Management Centre info@cwmc.ca 403.272.2962
Impact of obesity on Canadians Obesity as a chronic medical condition Benefits of weight reduction Challenge of managing obesity Changing landscape of obesity treatment
Obesity is defined as an abnormal or excessive accumulation of fat tissue to the extent that health is impaired. BMI is the preferred measure of obesity BMI = body weight (kg) (height [m]) 2 Classification BMI (kg/m 2 ) Underweight <18.5 Normal range 18.5 and <25 Overweight 25 and <30 Obesity 30 Obese class I 30 and <35 Obese class II 35 and <40 Obese class III 40
Number of Canadians Disease prevalence reported by Statistics Canada in 2011 8,000,000 7,000,000 6,000,000 5,000,000 Obesity Class III Obesity Class II Severe obesity is as common as COPD and about 10x more common than breast cancer. 4,000,000 3,000,000 2,000,000 Obesity Class I 1,000,000 Adults with Obesity High Blood Pressure Arthritis Asthma Diabetes Heart Disease Chronic Obstructive Pulmonary Disease Breast Cancer HIV Statistics Canada.
Various Cancers: - Breast - Prostate - Endometrial - Colon - Etc Sexual dysfunction Infertility Sleep apnea Lung disease Liver disease NAFLD NASH GI disease GERD Gallbladder disease Osteoarthritis Gout Neuropsychiatric disease Depression Dementia Stroke Skin disorders Cardiovascular disease Dyslipidemia Hypertension Left ventricular hypertrophy Coronary heart failure Type 2 diabetes Prediabetes Pancreatitis NIH. Obes Res 1998;6 Suppl 2:51S 209S; Schelbert. Prim Care 2009;36:271 85; Guh et al. BMC Public Health 2009;9:88
1. Must A et al. The disease burden associated with overweight and obesity. JAMA. 1999;282:1523 9. 2. Li C et al. Prevalence of self-reported clinically diagnosed sleep apnea according to obesity status in men and women: National Health and Nutrition Examination Survey, 2005 2006. Prev Med. 2010;51(1):18 23. 3. Freedhoff Y and Sharma AM. Best Weight: A practical guide to office-based obesity management. 1 st edition (2010). Canadian Obesity Network. 4. Janssen I. The Public Health Burden of Obesity in Canada. Can J Diabetes. 2013;(37):90 96.
$6.0 billion DIRECT COSTS >4% of Canada s total health care budget Direct costs only this number does not include indirect costs. 1. Anis I et al. Obesity and overweight in Canada: an updated cost-of-illness study. Obesity Reviews. 2010;(11):31 40. 2. Aitken RJ et al. Current and future costs of cancer, heart disease and stroke attributable to obesity in Australia - a comparison of two birth cohorts. Asia Pac J Clin Nutr. 2009;18(1):63 70. 3. Janssen I. The Public Health Burden of Obesity in Canada. Can J Diabetes. 2013;(37):90 96. 4. Anis I et al. Obesity and overweight in Canada: an updated cost-of-illness study. Obesity Reviews. 2010;(11):31 40.
% Respondents Absent Present, not functioning fully Absenteeism and presenteeism are more common for people with obesity, and costs both employees (in lost wages) and employers (in work not completed) 1,2 20 18 16 14 12 10 9.2 10.1 12.7 18.3 18.1 8.8 11 16.2 8 7 7.4 7.2 6 4 4.4 2 0 Underweight (n= 1150) Normal weight (n = 25,043) Overweight (n = 19,238) BMI 30-35 (n = 7,131) BMI 35-40 (n = 1,913) BMI > 40 (n = 2496) N ~ 57,000 Canadian workers surveyed on absence from work or reduced productivity, in the previous WEEK 1. Colditz GA. Economic costs of obesity. Am J Clin Nutr. 1992;(55):503S 507S. 2. Sanchez Bustillos A et al. Work productivity among adults with varied Body Mass Index: Results from a Canadian population-based survey. J Epidemiol Glob Health. In press.
75% have tried to lose weight for over 11 years. 25% have tried countless times to lose weight 33% withdraw from social situations 50% state that weight has had a negative impact on relationships with friends, family and/or spouses. 55% have low self-esteem Health Quality Council of Alberta s 2012 Satisfaction and Experience with Health Care Services Survey OBESITY IN CANADA. A Joint report from the Public health Agency of Canada and the Canadian Institute of Health Information. 2011
Weight stigma almost parallels racial discrimination. Weight bias results in inequities in employment, health care and education;
BMI: 45.2 PMHx: OA knees, bilateral Hypertension Sleep Apnea Reflux Meds: Naproxen Nexium Coversyl Goals: Improve mobility so that she can be more active Reduce blood pressure Improve quality of life
YEARS At physician s office for support
Why does this happen? Does she keep failing? Should she just try harder? Should she just eat less and move more? Is this her fault? Do WE understand the challenge our friends, families, patients and coworkers are up against??
How does the body regulate weight and appetite? Why do we gain weight?
OBESITY Calorie intake Calorie burning Hedonic input Experienced palatability or pleasure Obesogenic Environment Inactive, sedentary workplace, high sugar high fat foods, fast foods, bigger portion sizes etc NEUROHORMONAL SIGNALING Adipose tissue Pancreas Stomach and Gut Genetics Medications 1. Badman, Flier. Science 2005;307:1909 14; 2. US Department of Health and Human Services, 1998. NIH Publication No. 98-4083
Energy intake Energy expenditure Hunger Desire to eat HUNGER HORMONES FULLNESS HORMONES ENERGY CONSERVATION ABILITY TO BURN CALORIES Adipose tissue Stomach and gut CCK, cholecystokinin; GLP-1, glucagon-like peptide-1; PYY, peptide YY. 1. Schwartz A & Doucet É. Obes Rev. 2010;11:531 547. 2. Sumithran P et al. N Engl J Med. 2011;365:1597 1604. 3. Rosenbaum M et al. Am J Physiol Regul Integr Comp Physiol. 2003;285:R183 R192.
YEARS
www.drsharma.com
Obesity is a chronic and often progressive condition not unlike diabetes or hypertension. Obesity Canada 2007 guidelines Obesity is a chronic medical condition requiring long-term intervention of 3 main types: lifestyle modification, medication and surgery. obesity is a primary disease, and the full force of our medical knowledge should be brought to bear on the prevention and treatment of obesity as a primary disease entity Obesity is a chronic disease, prevalent in both developed and developing countries, and affecting children as well as adults Recognizing obesity as a disease will help change the way the medical community tackles this complex issue that affects approximately one in three Americans FDA agrees with these comments that obesity is a disease Being overweight, i.e., being more than one's ideal weight but less than obese, however, is not a disease. Obesity is not a lifestyle problem.
We should continue to advocate for effective public policy, education and awareness to prevent obesity, but we must also provide better care and treatment. Declaring obesity as a chronic disease can help both of these efforts.
Benefits of 5 10% weight loss Reduction in risk of type 2 diabetes 1 Reduction in CV risk factors 2 Improvements in blood lipid profile 3 Improvements in blood pressure 4 Improvements in severity of obstructive sleep aponea 5,6 Improvements in health-related quality of life 7,8 1. Knowler et al. N Engl J Med 2002;346:393 403; 2. Li et al. Lancet Diabetes Endocrinol 2014;2:474 80; 3. Datillo et al. Am J Clin Nutr 1992;56:320 8; 4. Wing et al. Diabetes Care 2011;34:1481 6; 5. Foster et al. Arch Intern Med 2009;169:1619 26; 6. Kuna et al. Sleep 2013;36:641 9; 7. Warkentin et al. Obes Rev 2014;15:169 82; 8. Wright et al. J Health Psychol 2013;18:574 86
1. Canadian Obesity Network. 5As of Obesity Management. Downloaded from www.obesitynetwork.ca on November 17, 2014. 2. Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. NEJM. 2002;346(6):393 404. 3. World Health Organization Consultation on Obesity. Obesity: Preventing and Managing the Global Epidemic. 2000. 4. Wing RR et al. Benefits of modest weight loss in improving cardiovascular risk factors in overweight and obese individuals with type 2 diabetes. Diabetes Care. 2011;34(7):1481 6. 5. Peppard PE et al. Longitudinal study of moderate weight change and sleep-disordered breathing. JAMA. 2000;284(23):3015 21. 6. Warkentin LM et al. The effect of weight loss on health-related quality of life: systematic review and meta-analysis of randomized trials. Obes Rev. 2014;15(3):169 82.
Potential impact of a 5% average BMI reduction in the US by 2020: disease rates Potential impact of a 5% average BMI reduction in the US by 2020: cost savings 3.5 million cases of hypertension avoided 0.3 million cases of cancer avoided 2.9 million cases of heart disease and stroke avoided 3.6 million cases of diabetes avoided 1.9 million cases of arthritis avoided Comorbidity Potential savings ($ billion) Heart disease and stroke 110 Diabetes 77 Arthritis 20 Hypertension 15 Cancer 7 Total 229 F as in Fat 2012. Available at: http://healthyamericans.org/assets/files/tfah2012fasinfatfnlrv.pdf [Accessed June 17, 2014].
Lifestyle (LS) Surgery ~ 1-5% LS + Pharmacotherapy ~ 5-15% LS + Surgery ~ 20-40% Health behaviour modification Obese Class 2 BMI 35 kg/m 2 Obese Class 1 BMI 30 kg/m 2 Overweight BMI 25 kg/m 2 0 1 2 Years Adapted from Lau DCW et al. Can Med Assoc J 2007;176 (8 suppl):s1-s13
0.1% of eligible subjects receive surgery annually Padwal et al. Int J Health Equity 2012
Number of programs per million overweight/obese people 60 50 Non-surgical programs Surgical programs 40 30 20 10 0 BC AB SK MB ON QC NB NS PEI NL YK NT NU Provinces and territories Figure 1. Number of programs per million of overweight or obese population in Canada in 2011. (Source: Statistics Canada, CANSIM, table 105-0501 and Catalogue no. 82-221-X. Last modified: 2012-06-19) Rosa Fortin et al. BMC Health Services Research 2014;14:69
Body weight (kg) 104 102 Weight loss Weight maintenance 100 98 96 94 92 90 Control Medication 88 0 2 4 6 8 10 12 14 16 18 20 22 24 Month James et al. Lancet 2000;356:2119 25
Low Mean weight loss Medium High Significant gaps in obesity treatment Treatment options Million Adults 7 6 6.5M Bariatric surgery 5 4 3 2 Pharmacotherapy 1 0 Adults with obesity With comorbidities Under care of a HCP 5.5K Adults treated with Rx (monthly) Diet and exercise Low Medium High Complexity of treatment *New promising medications have been developed and are becoming available for clinicians to use to support their patients BUT will they be accessible to patients?* Sources: Population & Obesity counts - Statistics Canada 2013; Xenical prescription estimate from CDH report 2014; Canadian Market Map 2014 - various sources based on global assessment US CDC, Decision Resources 2012; Martin et al. Surg Obes Relat Dis 2010;6:8 15; GWU 2012: Obesity Drug Outcome Measures: A Consensus Report of Considerations Regarding Pharmacologic Intervention. Available at: https://publichealth.gwu.edu/pdf/obesitydrugmeasures.pdf [Accessed June 17, 2014]
At physician s office for support
9 months later Weeks
3 months later Discontinue BP meds Discontinue Reflux meds More energy More productive 9 months later Weeks
Obesity is a chronic medical condition impacting many Canadians both individually and societally Modest weight reduction carries many health and economic benefits, but there is an unmet need in Canada The landscape of obesity understanding and treatment is changing Change needs to happen in every sector of society
November 19, 2015 6:00-8:00 PM Parkdale Community Centre