OBESITY: TRENDS AND IMPLICATIONS Mark Skillan, M.D. ACSW SEAC November 18, 2011
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
Obesity A growing concern Obesity Defined Prevalence Etiology Health Consequences Morbidity and Mortality Implications Interventions & Challenges The Future
OBESITY: AN INSURER S CONCERN
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
OBESITY DEFINED
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
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
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 18.5 24.9 Normal weight - 56 kg - 75 kg 25.0 29.9 Overweight 0 75 kg - 90 kg 30.0 34.9 Obesity I 90 kg - 106 kg 35.0 39.9 Obesity II 106 kg - 121 kg 40 or higher Extreme obesity III more than 121 kg
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
PREVALENCE
Past and projected prevalence of overweight by country Source: The Lancet 2011; 378:815-825 (DOI:10.1016/S0140-6736(11)60814-3)
Obesity trends* among U.S. adults BRFSS, 1990, 2000, 2011 *BMI 30, or about 30 lbs. overweight for 5 4 person 1990 2000 2010 No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30% Source: Behavioral Risk Factor Surveillance System, CDC.
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
Smoothed frequency distributions of body mass index for men and women aged 40 to 59 years in 1999-2000 and 2007-2008 Source: Flegal, K. M. et al. JAMA 2010;303:235-241 15
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
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 2005. Copyright 2005 European Association for the Study of Obesity. 17
Percentage of overweight children, ages 5 11 Netherlands Germany USA England Poland France 30 25 20 15 10 5 0 1950 1960 1970 1980 1990 2000 2010 Source: International Obesity Task Force (IOTF), London, March 2005
Percentage of U.S. children and adolescents classified as obese, 1963-2008* 20 Ages 6-11 Ages 12-19 15 10 5 0 1963-70** 1971-74 1976-80 1988-94 1999-2000 2001-02 2003-06 2007-08 *>95 th percentile for BMI by age and sex based on 2000 CDC BMI-for-age growth charts. ** 1963-1970 data are from 1963-1965 for children 6-11 years of age and from 1966-1970 for adolescents 12-17 years of age. Source: NCHS. Health, United States, 2010:With Special Feature on Death and Dying. Hyattsville, MD.2011 19
Global prevalence of overweight in boys 2000-2006 % Overweight < 5% 5 9.9% 10 14.9% 15 19.9% 20 24.9% 25 29.9% 30% Source: IASO/IATF
ETIOLOGY
Causes of obesity Calories Burned Calories Ingested
Factors contributing to obesity Genetics Environment Unhealthy diet Sedentary lifestyle Lack of physical activity 23
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
HEALTH CONSEQUENCES
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
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
Prevalence of cardiovascular disease risk factors* in adults, USA 1961-2000 70 60 Percent of Population 50 40 30 20 10 0 1960 1965 1970 1975 1980 1985 1990 1992 1995 2000 Year Overweight Hypertension Smoking High Cholesterol (*age adjusted) Source: NIH, NHLBI, Fact Book Fiscal Year 2003. Feb. 04
MORBIDITY AND MORTALITY IMPLICATIONS
Relationship between BMI and Risk of Type 2 Diabetes Relative risk 70 60 50 40 30 20 10 0 <22 22-22,9 23-23,9 24-24,9 25-26,9 27-28,9 29-30,9 31-32,9 33-34,9 >=35 BMI Nurses Health Study: n=100,000 16 yr follow=up
Prevalence of diabetes worldwide Percentage of people aged 20 with diabetes in 2000 no data below 5% 5% - 9.9% 10% - 14.9% 15% and above Source: WHO, 2007
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 3 4 3.5 Diabetes Ratio 2.5 2 Risk Ratio 3 2.5 2 Women Men Women Men 1.5 1.5 1 0.5 < 5 % 5-5.4 % 5.5-5.9 % 6.0-6.4 % 6.5-7.0 % 1 From Khaw, K, et al, Annals of Internal Medicine. 2004; 141(6):413 0.5 < 5 % 5-5.4 % 5.5-5.9 % 6.0-6.4 % 6.5-7.0 % From Khaw, K, et al, Annals of Internal Medicine. 2004; 141(6):413 32
Relation between age and rates of CHD with and without diabetes 240 220 200 Diabetes, recent AMI No diabetes, recent AMI Number of events per 1000 person-year 180 160 140 120 100 80 60 40 20 0 Age (years) Source: The Lancet, Vol. 368, July 1, 06 retrospective cohort, n=9mm
Increase in diseases attributable to rising obesity levels 80 Coronary heart disease Stroke Diabetes 70 60 Increase % 50 40 30 20 10 0 2005 2010 2015 2020 2025 2030 2035 Time (years) Source: Foresight 2007, K. McPherson, University of Oxford; adjusted for age and gender
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
Relative risk of death in relation to BMI, age 50 3.5 3 2.5 Relative Risk 2 1.5 1 0.5 0 18.5 20.9 23.4 24.9 26.4 27.9 29.9 34.9 39.9 >40 BMI Men Women Source: Adams KF, et al, NEJM 2006 355;8:763-778. 36
Relative risk of death in relation to BMI, ages 50 to 71 2.5 2 Relative Risk 1.5 1 0.5 0 18.5 20.9 23.4 24.9 26.4 27.9 29.9 34.9 39.9 >40 BMI Men Women Source: Adams KF, et al, NEJM 2006 355;8:763-778. 37
COSTS
Obesity costs Obese and overweight: 9.1 % of total annual US medical expenditures Obese (BMI > 30) annual medical expenditures 36% higher than BMI 18.5-25 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.
Obesity costs Indirect Costs: Absenteeism, Disability, Premature mortality, Presenteeism, Workmen s Comp BMI > 40: 11.65 WC claims/100 FTE s (vs. 5.8 for normal weight) - 184 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
INTERVENTIONS AND CHALLENGES
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
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
Weight loss-induced reduction in blood pressure 10 Fall in diastolic BP, mmhg 8 6 4 2 0 >-9.5-4.5 to -9.5-2 to -4.5 +1 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; 153:849. 44
Importance of body weight and exercise on development of type 2 diabetes 60 Rate of type 2 diabetes per 10,000 patient-years 40 20 0 <24 24-25.9 >26 Body mass index, kg/m2 <500 kcal/wk 500-1999 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; 325:147. 45
THE FUTURE
Projections for 2030 if historical trend continues 100 million obese now > 165 million by 2030 50% American Men Obese by 2030 US healthcare spending will rise by $66 Billion a year Potential decline in US Life expectancy? 47
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
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
References 1. Prevalence and Trends in Obesity Among US Adults, 1999-2008 - Flegal, KM, et al, Journal of the American Medical Association. 2010; 303(3):235-241 2. Body Mass Index in a Prospective Cohort of U.S. Adults, Calle, EE, et al, New England Journal of Medicine. 1999; 341(15): 1097-1105 3. Mortality and Morbidity Liaison Committee ISCS Body Mass Index Study Roudebush, B, et al, Journal of Insurance Medicine. 2006; 38:167-180 4. Mortality and Weight: Insured Lives and the American Cancer Society Studies. Lew, E A, Annals of Internal Medicine. 1985; 103(6): 1024-1029 5. Overweight, Obesity and Mortality in a Large Prospective Cohort of Persons 50-71 Years Old - Adams, KF, et al, New England Journal of Medicine. 2006; 355(8): 763-778
References (continued) 7. Excess Deaths Associated With Underweight, Overweight and Obesity Flegal, KM, et al, JAMA. 2005; 293(15): 1861-1867 8. Cause-Specific Excess Deaths Associated with Underweight, Over weight and Obesity Flegal, KM, et al, JAMA. 2007; 298(17): 2028-2037 9. Body Mass Index and Mortality in an Insured Population Niverthi, M., et al, Journal of Insurance Medicine. 2001; 33: 321-328 10. Body Mass Index and Mortality Among 1.46 Million White Adults Berrington degonzalez, A., et al, New England Journal of Medicine 2010; 363(23): 2211-2219 11. Obesity and Mortality Calle, E, et al, New England Journal of Medicine. 2005; 353(20):2197-99 12. Adolescent BMI Trajectory and Risk of Diabetes Versus Coronary Artery Disease Tirosh, A., et al, New England Journal of Medicine. 2011; 364(14): 1315-1325 Title of presentation and name of speaker 10/11/2011 51
References (continued) 13. Childhood Obesity, Other Cardiovascular Risk Factors and Premature death Franks, P., et al New England Journal of Medicine. 2010; 326(6): 485-493 14. 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): 1138-1145 15. Deadweight? The Influence of Obesity on Longevity Preston, SH, New England Journal Of Medicine. 2005; 352(11): 1135-1137 16. Obesity and Its Relation to Mortality and Morbidity Costs Behan, D, et al, Society of Actuaries. December 2010 17. Obesity and Workers Compensation - Ostbye, T, et al, Archives of Internal Medicine. 2007; 167(8):766-773 18. Indirect Costs of Obesity: a review of the current literature - Trogdon, JG, et al; Obesity Reviews. 2008; 9: 489-500
References (continued) 19. Occupation-Specific Absenteeism Costs Associated with Obesity and Morbid Obesity Crawley, J, et al, Journal of Occupational and Environmental Medicine. 2007; 49:1317-1324 20. Annual Medical Spending Attributable to Obesity: Payer- and Service-Specific Estimates - Finklestein, EA, et al, Heath Affairs 2009; 28(5): w822-w831 21. The Cost of Obesity Among Full-time Employees Finklestein, E, et al, American Journal of Health Promotion. 2005; 20(1): 45-50 22. 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): 815-825
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