Transcript Document

Obesity: A Metabolic Perspective
Obesity Trends* Among U.S. Adults
BRFSS, 1985
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
Obesity Trends* Among U.S. Adults
BRFSS, 1986
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
Obesity Trends* Among U.S. Adults
BRFSS, 1987
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
Obesity Trends* Among U.S. Adults
BRFSS, 1988
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
Obesity Trends* Among U.S. Adults
BRFSS, 1989
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
Obesity Trends* Among U.S. Adults
BRFSS, 1990
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
Obesity Trends* Among U.S. Adults
BRFSS, 1991
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
Obesity Trends* Among U.S. Adults
BRFSS, 1992
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
Obesity Trends* Among U.S. Adults
BRFSS, 1993
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
Obesity Trends* Among U.S. Adults
BRFSS, 1994
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
Obesity Trends* Among U.S. Adults
BRFSS, 1995
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
Obesity Trends* Among U.S. Adults
BRFSS, 1996
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
Obesity Trends* Among U.S. Adults
BRFSS, 1997
(*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, 1998
(*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, 1999
(*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, 2000
(*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, 2001
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
≥25%
Obesity Trends* Among U.S. Adults
BRFSS, 2002
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
≥25%
Obesity Trends* Among U.S. Adults
BRFSS, 2003
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
≥25%
Obesity Trends* Among U.S. Adults
BRFSS, 2004
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
≥25%
Obesity Trends* Among U.S. Adults
BRFSS, 2005
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
Obesity as a Risk Factor for CAD
The Importance of Abdominal Fat
Android Obesity
Gynoid Obesity
Sharma 2002
Obesity and Metabolic Risk
Abdominal vs. Peripheral Obesity
Large Insulin-Resistant
Adipocytes
Small Insulin-Sensitive
Adipocytes
Android Obesity
Sharma 2002
Gynoid Obesity
Obesity and Cardiovascular Risk
Dyslipidaemia
Total-C  • LDL-C 
Triglycerides 
Apo-B  • HDL-C 
Endothelial
dysfunction
Hypertension
Left ventricular
hypertrophy
Congestive heart failure
Visceral
Obesity
Prothrombosis
Fibrinogen 
PAI-1 
Insulin resistance
Glucose intolerance
Hyperglycaemia
Type 2 diabetes
Renal
Hyperfiltration
Albuminuria
Inflammatory
Response 
“Corpulence is not only a disease itself, but the
harbinger of others”
Hippocrates
10 March 2004
Common Morbidities linked with Obesity
Stroke
Sleep Apnoea
Heart disease
Gall bladder disease
Cardiovascular risk
factors
Diabetes
Osteoarthritis
Hormonal abnormalities
Hyperuricaemia
and gout
Cancer
Consequences
Prevalence of Obesity in 15-24 Year
Old Europeans (BMI>30)
Ireland
8.0%
UK
3.5%
Netherlands
4.8%
Belgium
Germany
3.0%
Sweden
2.0%
Finland
4.1%
1.2%
Luxembourg
Denmark
Portugal
Austria
3.3%
2.5%
1.5%
Spain
1.4%
5.2%
France
1.8%
Martinez JA, Public Health Nutr 1999;2(1A):125-33
Italy
1.0%
Greece
11.0%
Cases of Type 2 Diabetes/100,000
Incidence of Type 2 Diabetes in
Junior High School Japanese Children
14
12
10
8
6
4
1976-80
1981-85
ADA - Consensus statement reported in Diabetes Care 2000;22(12):381
1991-95
“Most of these persons
will not stay in treatment for obesity.
Of those who stay in treatment
most will not lose weight.
Of those who do lose weight,
most will regain it”.
Stunkard 1972
Treating obesity: how and why
Treatment efficacy?
• There is no community intervention
programme worldwide that has successfully
allowed long term weight loss (maintenance)
• Overall failure rate after 4 years is 96%
• Minnesota ‘Pound of Prevention’ study
indicated the mean weight gain prevented
was <1kg
Treatment efficacy?
• Long term studies indicate only a small
proportion of people lose and then maintain
lost weight
• Predictors of success:
– Continuous consumption of low-energy, low-fat
food, <25%
– Food diary
– Breakfast
Management Goals
Moderate weight loss of 5 to 10 kg will
have a major effect on obesity
co-morbidities • impaired glucose metabolism
• hypertension
• dyslipidaemia
• sleep apnea
• polycystic ovary syndrome
The weight loss needs to be sustained
Treatment benefits?
Diabetes Prevention Program (USA)
N=3234 (67% female); IGT
50.6 years,
Weight 94.8kg
BMI 34 kg/m2
2.8 years
Lifestyle intervention
Metformin
Placebo
Treatment benefits?
Diabetes Prevention Program Research Group 346 (6): 393,
Figure 2 February 7, 2002
Treatment benefits?
Goal weight
loss: 7%
(6.6kg)
Diabetes Prevention Program Research Group 346 (6): 393,
Figure 1 February 7, 2002
Treatment benefits?
Diabetes Care 28:888-894, 2005
Treatment benefits?
Diabetes Care 28:888-894, 2005
Obesity management
strategies
• Diet
• Physical activity
• Pharmacotherapy
• Surgery
Obesity management
strategies
• Diet
– Best achieved by a combination of
hypocaloric/low fat diet
– Aim to reduce intake by 2000-2500 kJ/day
– 32000 kJ = 1kg
– 0.5kg / week
Obesity management
strategies
• Diet
• Physical activity
– 30 mins 3 times a week is not sufficient to
allow weight loss or to maintain lost weight
– Current recommendations: 60-80 mins
moderate intensity exercise daily
Obesity management
strategies
• Diet
• Physical activity
• Pharmacotherapy
– Duromine
– Fluoxetine
– Sibutramine
– Xenical
– Optifast
Sibutramine:
mechanism of action
• Serotonin (5-HT) and noradrenaline reuptake
inhibitor.
• Dual mode of action:
– reduces food intake by enhancing satiety
– increases energy expenditure by enhancing
resting metabolic rate
• Side effects
– Hypertension, tachycardia
– Serotonin syndrome (SSRI’s, anti-psychotics)
McNeely and Goa. Drugs 1998.
Xenical :
mechanism of action
• Inhibits gastrointestinal lipases which are
required for the systemic absorption of
dietary fat
• Prevents the absorption of 30% of dietary
fat
• Safe with minimal systemic absorption
and no accumulation
• Significant GI side effects
SCGH prescriptions for Xenical and
Sibutramine
6 months therapy
Xenical
(n=8)
Sibutramine
(n=8)
Kg
-1kg
-4kg
HbA1c
-0.7%
0%
10% lose >10 kg at 6-12 months
Management of Obesity: Objectives
•
Prevention of weight gain
• Encourage sustainable weight loss over longer
term
•
Promotion of weight loss
• 0.5 to 1.0kg per month is reasonable
• Up to a 10% reduction in body weight over a 12
month period
•
Improvement of co-morbidities
• Attainable with a weight loss as low as 5%
•
Encouragement of active lifestyle
• Broaden concepts of activity
•
•
Improvement in quality of life
Enhance feelings of “well-being”
* NHLBI Clinical Guidelines 1998