# Presentation: 632542

## Overweight and Obesity:  

**Overweight and Obesity:  **
**Steps Towards Health**

## Overweight and Obesity

- Overweight
- Knee Pain
- High Blood Pressure
- Pre-Diabetes

**Notes:**
Story Telling 
Use a patient you have worked with to illustrate one or more of the following:
Behavioral and/or environmental etiologies of obesity
Complications of obesity

Overweight and obese individuals are at increased risk for many diseases and health conditions, including the following:
Hypertension 
High total cholesterol or high levels of triglycerides
Type 2 diabetes 
Coronary heart disease 
Stroke 
Gallbladder disease 
Osteoarthritis 
Sleep apnea and respiratory problems 
Some cancers (endometrial, breast, and colon)
www.cdc.gov

## The Epidemic

**The Epidemic**

**Notes:**
Over the last 15 years, obesity among U.S. adults has increased to epidemic proportions. 
During the past 20 years there has been a dramatic increase in obesity in the United States. In 1991, four states had obesity prevalence rates of 15–19 percent and no states had rates at or above 20 percent. In 2004, 7 states had obesity prevalence rates of 15–19 percent; 33 states had rates of 20–24 percent; and 9 states had rates more than 25 percent (no data for one state). www.cdc.gov

You can see that California is in the second highest prevalence group of 20-24% shown in yellow.

The Centers for Disease Control feels that obesity represents a greater threat to America than terrorism. 
“The biggest problem we face in America is not terrorism. The biggest health problem we’re facing is obesity.”  Dr. Julie Gerberding, CDC

## Overweight and Obesity Defined

**Overweight **BMI = 25 -29

**Obese**
- BMI = 30 +

**Notes:**
What is BMI?  
For adults, overweight and obesity ranges are determined by using weight and height to calculate a number called the “body mass index” (BMI). BMI is used because, for most people, it correlates with their amount of body fat. 

Let’s take a few minutes to determine what our body mass index or BMI is. On the left side of the table is your height. On the top of the table is your weight.

BMI = (Weight in Pounds) ÷ (Height in inches) ÷ (Height in inches) x 703

An adult who has a BMI between 25 and 29 is considered overweight - the light green area on the table. An adult who has a BMI of 30 or higher is considered obese - the dark green area of the table. 

It is important to remember that although BMI correlates with the amount of body fat, BMI does not directly measure body fat. As a result, some people, such as athletes, may have a BMI that identifies them as overweight even though they do not have excess body fat. www.cdc.gov

## Facts about obesity

- Over 60% of U.S. adults are overweight or obese
- The average American gains 1.5-2 pounds/year from 20-40 years old
- Increased weight (BMI level) is directly linked with health risks

**Facts about obesity**

**Notes:**
In the U.S. in 2004, about 60% of adults were overweight or obese. 
36.8% overweight, 23.1% obese CDC BRFSS 2004

The average weight gain among U.S. adults 20 to 40 years old is 1.5-2.0 pounds per year. 

This means that even adults with a normal weight, on average, are becoming overweight.
Science. 299:7;853-855 (2003)

Overweight and obese individuals are at increased risk for many diseases and health conditions, including the following:
Hypertension 
High total cholesterol or high levels of triglycerides
Type 2 diabetes 
Coronary heart disease 
Stroke 
Gallbladder disease 
Osteoarthritis 
Sleep apnea and respiratory problems 
Some cancers (endometrial, breast, and colon)

www.cdc.gov

## What are the causes of obesity?

**Genes and Culture**
**Personal Health Choices**
- Increased Calories Eaten
- Decreased Physical Activity
**Community and Environment**
- Easy Access to High Calorie Foods
- Decreased Access to Physical Activity

**Notes:**
Body weight is the result of behavior, genes, culture, and environment. 

Although genes and culture play a role in obesity, the epidemic increase of obesity is not due to genetic changes. "Despite obesity having strong genetic determinants, the genetic composition of the population does not change rapidly. Therefore, the large increase in . . . [obesity] must reflect major changes in non-genetic factors." Hill, James O., and Trowbridge, Frederick L. Childhood obesity: future directions and research priorities. Pediatrics. 1998; Supplement: 571.

Personal health choices play an important role in obesity. Overweight and obesity result from an energy imbalance. This involves eating too many calories and not getting enough physical activity. 

Behavior and environment play a large role causing people to be overweight and obese. These are the greatest areas for prevention and treatment actions.
www.cdc.gov

## Key to Having a Healthy Weight

- Know Yourself
- Take Action
- Make it Easier to be Healthy

**Key to Having a Healthy Weight**

**Notes:**
The epidemic of obesity is a very serious problem. 

Stopping the epidemic of obesity will require everyone to take action. Even people with a healthy weight, need to have a plan on how they are going to keep from gaining weight.

The good news is that everyone can work towards a healthier weight by...
 Knowing yourself
 Taking Action
 Making it Easier to be Healthy

## Know Yourself

- What are the situations where I tend to eat or drink more than I should?
- What gets in the way with being active or exercising?
- How do I keep track of my eating, activity and weight?
- How do I handle stress?

**Notes:**
Knowing yourself is the first step to a healthy weight. Think about the situations and reasons which keep you from eating healthy and being active. Then think about ways to overcome the obstacles. Research shows that weighing yourself once a week is a good way to prevent weight gain.

Strategies used for successful long term weight maintenance (loss >=10% maintained >= 1 year)*.
Eating a diet low in fat
Eating breakfast every day
Frequently monitoring one’s weight (once/week)
High levels of physical activity (1 hour moderate activity/day) with resistive training
Findings from the National Weight Control Registry
Wing RR, Hill JO. Successful weight loss maintenance. Ann Rev Nutr. 2001;21:323-341

Stress is a key issue in weight gain.  Life circumstances and the emotions that are involved, can often trigger unhealthy emotional eating and weight gain. 
Childhood issues and dysfunctional family dynamics
Pregnancy and post-partum
Job/Career change
Death of a loved one or involvement in a tragic event
Marriage/Divorce
Depression
History or abuse
History of alcoholism or drug abuse in family

Key to preventing weight gain is finding healthy approaches for dealing with your emotions.

## Take Action

- Set reasonable goals (10% weight loss over 6 months)
- If you can’t lose weight, try not to gain weight
- Little things make a difference!
- Eat breakfast every day
- Eat smaller portions
- Take the stairs

**Notes:**
The second step is taking action. Before you take action, it is good to know what your goal is.
Research shows that many overweight people want to lose more weight than they need to (to improve health). 
[397 Obese Individuals (mean wt 109kg) 
Dream Weight = 64.4 kg (24.5% dec)
Disappointed Weight = 90.1 kg (15.6% dec)
Arch of Int Med Vol 161 No 17 pp. 2133-2139 Sept 2001]

Having a reasonable goal will improve your success. If you are overweight - losing 10% of your current weight over 6 months can really improve your health.
[Initial Goal: to reduce body weight by approximately 10% from baseline over a period of 6 months. If this goal is achieved, further weight loss can be attempted, if indicated through further evaluation.
BMI 27-35: deficits of 300 to 500 kcal/day will result in weight losses of about 1⁄2 - 1 lb/week.
BMI > 35: deficits of 500 to 1,000 kcal/day will lead to weight losses of about 1 - 2 lb/week. 

After 6 months of weight loss treatment, efforts to maintain weight loss consisting of dietary therapy, physical activity and behavior therapy should be continued indefinitely. (NIH- The Practical Guide to the Identification, Evaluation and Treatment of Overweight & Obesity in Adults)]

If you have trouble losing weight or are already at a healthy weight, maintaining your weight is a good first step. Research shows that simple things like eating breakfast every day can help with weight maintenance.
[Findings from the National Weight Control Registry
Successful long term weight maintenance (loss >=10% maintained >= 1 year)*.
Strategies used:
Eating a diet low in fat
Eating breakfast every day
Frequently monitoring one’s weight (once/week)
High levels of physical activity (1 hour moderate activity/day) with resistive training
Wing RR, Hill JO. Successful weight loss maintenance. Ann Rev Nutr. 2001;21:323-341]

## Take Action

- Physical Activity
- Increase gradually
- Goal: 30- 60 minutes or more of daily moderate to vigorous activity
- Healthy Eating
- Fruits - 2 cups per day
- Vegetables - 2 1/2 cups per day
- Whole-Grain - 3 or more 1 ounce servings per day
- Low-Fat Dairy - 3 cups per day

**Take Action**

## Make it Easier to Be Healthy

- Buy low fat, fresh foods
- Find activities which are fun and convenient
- Advocate that schools and work sites offer healthy foods

**Make it Easier to Be Healthy**

**Notes:**
The last step is to make it easy to make healthy choices. Buying healthy foods is an easy thing that all people can do. Parking your car farther from your destination, taking the stairs and exercising with a friend can also make it easier to be active. Working in your schools and communities to make healthy eating and active living easier is another important thing that we can do to stop the epidemic.

[People may make decisions based on their environment or community. For example, a person may choose not to walk to the store or to work because of a lack of sidewalks. Communities, homes, and workplaces can all influence people's health decisions. Because of this influence, it is important to create environments in these locations that make it easier to engage in physical activity and to eat a healthy diet. The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity 2001 identified action steps for several locations that may help prevent and decrease obesity and overweight. The following table provides some examples of these steps.
Home
Reduce time spent watching television and in other sedentary behaviors 
Build physical activity into regular routines 
Schools
Ensure that the school breakfast and lunch programs meet nutrition standards 
Provide food options that are low in fat, calories, and added sugars 
Provide all children, from pre-kindergarten through grade 12, with quality daily physical education 
Work
Create more opportunities for physical activity at work sites 
Community
Promote healthier choices including at least 5 servings of fruits and vegetables a day, and reasonable portion sizesEncourage the food industry to provide reasonable food and beverage portion sizes Encourage food outlets to increase the availability of low-calorie, nutritious food itemsCreate opportunities for physical activity in communities 
www.cdc.gov]

## Kaiser Permanente’s Approach to Obesity

- BMI screening and counseling
- Information and personalized online programs on Physician Home Pages (_[www.kp.org/mydoctor](http://www.kp.org/mydoctor)__)_
- Pedometers, weight management classes, Weight Watcher discounts
- Community health improvement activities

**Notes:**
At Kaiser Permanente we take obesity very seriously and offer a wide variety of resources and tools to help you take steps towards your health. 

Our physicians have been trained on how to measure BMI and provide counseling on healthy eating and physical activity.

Our Healthy Lifestyles online programs include personalized programs on Weight Management, Healthy Eating, Stress Management and Total Health Assessment.

Every Kaiser physician has a home page on the internet. Information, internet programs and local health education programs can be accessed through the physician home pages. Kaiser members can also contact their physician through their physician home page by secure e mail.

In addition, Kaiser Permanente is working to address obesity in our communities through financial grants, legislation and community education such as our Educational Theatre program “Zip’s Great Day!” for schools.

## Live Long and Thrive

**Notes:**
In conclusion...
Use a patient success story to illustrate that important changes can be made:  
Successful strategies to have a healthy weight and/or use of KP programs or resources
Reduction of co-morbid risk factors
Environmental approaches

Thank you for your time and attention. We have 10 minutes for questions...

Diets: 
All popular diets result in short term weight loss. Macronutrient composition does not seem to play a major role. Obesity Research Vol.9 Suppl. 1 March 200. 
Successful weight loss among dieters is almost 25% (loss >=10%; maintained >= 1 year) A leading consumer union survey of 32,213 dieters published June 2002
There is insufficient evidence to make recommendations for or against the use of low-carbohydrate diets. Low-carbohydrate diets may be an effective means of achieving short-term weight loss without significant adverse effects on serum lipid levels, glycemic control, or blood pressure. JAMA. 289(14):1837-1850, April 9, 2003
Weight Management Programs
Structured commercial weight loss programs (Weight Watchers) provide modest weight loss (-6.5 lbs) but more than self-care (-0.5 lbs) over a 2 year period. JAMA. 2003;289:1792-1798
Only 3% of dieters used weight loss programs (26% success rate). A leading consumer union survey of 32,213 dieters published June 2002
Medications
Only used in conjunction with weight loss programs and result in only an additional weight loss of 6 to 10 pounds. Side effects can be significant. Lancet. 2005;365:1389-1397 
The safety and effectiveness of over-the-counter and herbal weight loss medications is unknown Ann Intern Med. 2005;142:525-531. 
Surgery (bariatric)
Surgery is sometimes considered for a BMI over 40. Laparoscopic roux-en-y-gastric bypass is a common procedure. Complications: death =< 1%, perioperative complications 3-20%. Long term weight loss at 5-15 years appears to be 49-62% of excess body weight*. As many as 25% may need repeat surgery. * Annals of Surgery Vol 227 pp. 637-644 1998