# Presentation: 142989

## OBESITY: A “WEIGHTY” PROBLEM

- Sharon Phelan MD
- Native Women’s Health
- August 16, 2007

## Objectives

- Describe the increasing problem
- Identify the etiologies
- Apply therapeutic approaches appreciating cultural and environmental challenges
- Examine the role of providers in prevention/treatment for women

## Disclosure of potential conflict

- I own shares of ......

## Disclosure of potential conflict

- I own shares of ......
-           Krispy Kreme

## Slide 5

## Slide 6

## Slide 7

## Written for the public

- www.healthierus.gov/dietaryguidelines

## Major Public Health Issue in US

- 25%  or 34 million Americans are overweight
- Increase from 1 in 8 (1991) to 1 in 5 (1998) are obese
- Racial distribution: 45% black women; 35% Hispanic women, 25% white women and 45% of American Indian women
- Women are generally at increased risk

## Demographics in Native Populations

- Malnutrition was problem as recently as the early 1960’s
- Morbidity/mortality was from infectious disease now from diabetes, CVD and obesity related cancers
- Infant mortality changed from 63/1000 in 1955 to 7/1,000 in 1991
- Currently 41% of native children are overweight or obese

- Compher Journal of Transcultural Nursing 2006;17:217-223

## Definition of Obesity

- Obesity is simply the excess of body fat
- Common Methods to Determine Body Fat
- Body Mass Index
- Body circumference: Waist  <85cm  or < 35” for women)
- Waist to hip ratio: >.91 is problematic

## Body Mass Index

- Healthy Weight	18.5*-24.9     (110-149)
- Over Weight	25-29.9            (150-179)
- Obesity
- Class I 		30 - 34.9        (180-209)
- Class II 		35 - 39.9	        (210-239)
- Class III 	        _>_ 40	         (_>_240)
- 				( weight in pounds for 5’5” woman)
- International Obesity Task Force

## Obesity Trends Among U.S. Adults between 1985 and 2003

***Source of the data:***
- The data shown in these maps were collected through CDC’s Behavioral Risk Factor Surveillance System (BRFSS). Each year, state health departments use standard procedures to collect data through a series of monthly telephone interviews with U.S. adults.
- Prevalence estimates generated for the maps may vary slightly from those generated for the states by BRFSS (http://aps.nccd.cdc.gov/brfss) as slightly different analytic methods are used.

## Obesity Trends* Among U.S. AdultsBRFSS, 1985

**(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)**

## Obesity Trends* Among U.S. AdultsBRFSS, 1990

- Obesity Trends* Among U.S. AdultsBRFSS, 1990

## Obesity Trends* Among U.S. AdultsBRFSS, 1993

- Obesity Trends* Among U.S. AdultsBRFSS, 1993

## Obesity Trends* Among U.S. AdultsBRFSS, 1996

- Obesity Trends* Among U.S. AdultsBRFSS, 1996

## Obesity Trends* Among U.S. AdultsBRFSS, 1999

- Obesity Trends* Among U.S. AdultsBRFSS, 1999

## Obesity Trends* Among U.S. AdultsBRFSS, 2000

- Obesity Trends* Among U.S. AdultsBRFSS, 2000

**(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)**

## Obesity Trends* Among U.S. AdultsBRFSS, 2001

-                     <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)**

-          <10%           10%–14            15%–19%          20%–24%            ≥25%

**Obesity Trends* Among U.S. Adults****BRFSS, 2002**

## Obesity* Trends Among U.S. AdultsBRFSS, 2003

- Obesity* Trends Among U.S. AdultsBRFSS, 2003

-          <10%           10%–14%         15%–19%          20%–24%            ≥25%

## Obesity Trends* Among U.S. AdultsBRFSS, 2004

- Obesity Trends* Among U.S. AdultsBRFSS, 2004

**(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)**

**No Data          <10%           10%–14%****	****    15%–19%           20%–24%        **  **≥25%**

**Notes:**
We have never had an epidemic like this that we have been able to track so thoroughly and see. As I told you, this is conservative.
About 60 million adults, or 30 percent of the adult population, are now obese, which represents a doubling of the rate since 1980.

## Obesity Trends* Among U.S. AdultsBRFSS, 2005

- Obesity Trends* Among U.S. AdultsBRFSS, 2005

**(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)**

** ****No Data          <10%           10%–14%****	****    15%–19%           20%–24%          25%–29%           ≥30%**

**Notes:**
We have never had an epidemic like this that we have been able to track so thoroughly and see. As I told you, this is conservative.
About 60 million adults, or 30 percent of the adult population, are now obese, which represents a doubling of the rate since 1980.

## Morbidity Of Obesity

- Hypertension
- Type II Diabetes
- Hyperlipidemia
- Coronary Heart Disease
- Cancer:
- Endometrial
- Breast
- Colon

## Morbidity Of Obesity

- Degenerative Joint Disease
- Gout
- Gallstones and Kidney Stones
- Gastric Reflux
- Sleep apnea
- Increased surgical risks
- Depression

## Morbidity Of Obesity

- Obstetric Implications – increase risk of
- PIH/Pre-eclampsia
- C/S rate
- Gestational Diabetes
- Macrosomia
- Twins (DC/DA)
- Neural Tube Defects
- Long term implications for fetus/child

## Morbidity Of Obesity

- Obstetric Implications
- Gynecologic Implications
- Infertility
- Menstrual Irregularities
- Ovulation problems
- Reproductive Cancers
- Metabolic Syndrome

## Slide 29

## Obesity in Native Children

- Zephier et al.  Arch Pediatric Adolesc Med 2006;160:34-39

## Albuq. Journal 2/9/05

## Etiology of Obesity

- Obesity is a problem of Energy Regulation
- Balance of calories consumed (CI) and calories expended (CE)
- If
- CI –CE <0            weight is lost
- CI – CE = 0		weight is stable
- CI – CE > 0		weight is gained

## Etiology of Obesity

- Obesity is the manifestation of genes and environment
- Obesity is a complex disorder of appetite regulation and energy metabolism
- The obesity phenotype is expressed in a permissive society

## Obesity

- Environmental Effect

- Monogenic
- Syndromes

- Susceptible
-  Genes

- Stress

- Exercise

- Food Intake

- Culture

## Obesity

- Environmental Effect

- Monogenic
- Syndromes

- Susceptible
-  Genes

- Stress

- Exercise

- Food Intake

- Culture

- Less than 3% of Type III obese children

## Etiology

- Humans evolved in an environment of subsistence existence
- Certain ethnic groups may have a “thrifty” gene
- There is no limit to the
-    body’s ability to store
-    fat

## Impact of Reproductive Hormones

- High Risk Events for Weight Gain
- Pre-menstrual cravings
- Pregnancy
- Lactation
- Perimenopausal
- Affect Preference for Macronutrients
- Affect Activity Levels
- Gynecoid versus Android Distribution

## Obesity in the Maternity Clinic

## Environmental Effects

- Culture – probably more acquired habit than truly culture
- Food Intake – choices and    portion size
- Exercise – work or pleasure
- Stress – comfort foods

## Culture

- Ethnic foods and developed tastes
- Shift from hunter/gather or farming with increased vegetables and low fat foods to fast food and
-   sweet drinks

- Compher Journal of Transcultural Nursing 2006;17:217-223

## Culture

- Ethnic foods and developed tastes
- Community norms
- Big (obese) children are healthy
- Food is key to community/family
-    functions and expectation to
-    eat large amounts or one is
-    being rude
- Loss of expectation of
-    activity

- Doshi et al. Jour of Women’s Health 2006;15:919

## Culture

- Ethnic foods and developed tastes
- Community norms
- Socioeconomic factors
- Healthy foods cost
- Fresh food not available
- Remote locations
- WIC often uses “surplus”
-   foods

- Curran et al. Health Ed Research 2005;20:719-719

## Culture

- Ethnic foods and developed tastes
- Community norms
- Socioeconomic factors
- National “norms”
- Native population is
-   less impacted by this
- Are susceptible to
-   TV advertisement

## Anglo women internalize the current standard of female beauty

## Motivators for Native Women

- Being “Skinny” not valued
- Avoiding diabetes is important
- Being accepted/supported by family and community

- Doshi et al. Journal of Women’s Health 2006;15:919

## Societal Stigma of Obesity

- Obese people can be described in negative terms. This leads to the individual
- Having low self-esteem
- Developing depression
- Becoming hostile
- Being frustrated
- But some cultures see being overweight or obese desirable.

## Slide 47

## Food Intake

## Food Intake

## Food Intake

## Food Intake

## Food Intake

- Overeating
- Fat Intake
- Carbohydrate and Fiber Intake
- High glycemic index
- Complex carbohydrates

## Modifiers in Caloric Intake

- Satiety is mainly determined by food volume not by calories
- Metabolic “cost” of converting food to body fat is variable:     25% for complex carbohydrates  vs.  3% for fats.
- Stored fat has little effect on appetite
- Native populations do not see connection between obesity and health issues

## Exercise/Physical Activity

- Work involves less physical activity
- Obtaining food is less labor intensive
- Recreation involves more spectator activities
- Television
- Computers
- Electronic games

## Screening for Obesity

- Calculate BMI -
- Every 5 years (AHA)
- Key age periods (Institute of Medicine)
- BMI of _>_ 22 at 18yo
- Interval weight gain of 5-10#
- Waist or Waist/Hip Ratio
- Approach from perspective of prevention

## Intervention with Positive Screen

- Determine if patient is receptive to
- intervention.
- If not: Briefly outline potential risks of weight, interventions available, and willingness to help
- If yes: Stress this is a like a chronic illness that will require a multiple facet approach.
- Many do NOT relate obesity to diabetes and do not identify obesity until Type III.

- Adams et al. Obesity Research 2005;13:146

## Evaluation of Obesity - History

- weight at 18 y.o. and pattern of gain
- family history of obesity
- medications
- review of systems for co-morbidities
- current dietary pattern
- current exercise or physical activity
- current and prior attempt to lose weight

## Evaluation of Obesity - Physical

- Height and weight; Hip and Waist circumferences
- Rule out evidence other endocrine anomalies
- Blood pressure
- Evidence of co-morbidities

## Evaluation of Obesity - Labs

- Cholesterol screen for baseline
- Fasting Blood Sugar
- TSH
- Other testing as indicated by history and physical

## Intervention

- Prevention is key
- Diet modification
- Increased Physical Activity
- Incorporate healthy live styles into culture
- Minimize stress related with intervention

## Patient Education

- Situation is a result of inadequate physical activity for the amount of food ingestion.
- Increases risk of diabetes, cardiovascular disease, ob complications and certain cancers
- Intervention requires regular physical activity.
- Diet should create daily deficit of 500-1000 kcal.

## Modifiers of Caloric Expenditure

- Caloric Expenditure is the sum of:
- Resting Metabolic Rate:  	60-75%
- Thermic Effect of Food:   	10%
- Thermic Effect of Exercise:  	15-30%

## Energetics of Weight Loss

- 3500 kcal per pound of fat
- Daily deficit of 500 kcal/day results in 1 pound per week.

## Common Diet Strategies

- Very Low Carbohydrate (50 gm/d)
- Individuals mobilize the CHO stored in body with also a loss of tissue water and minerals. Minimal actual fat loss.
- Quick loss but temporary

## Albuquerque Journal 3/5/05

## Common Diet Strategies

- Very Low Fat Diets  (Ornish and Pritikin diets)
- Amount of weight loss is related to fat reduction (as a proxy for calories)
- 10% decrease can result in 10 # in 6 months

## Common Diet Strategies

- Moderate Fat Diets (40-45 gm/day).
- Carbohydrates are classified by
- Glycemic index (Sugar Busters)
- Balanced reduction (Weight Watchers

## Common Diet Strategies

- High Protein Diets – Atkins and South Beach
- Emphasize high protein intake low carbohydrates. With Atkins there are no fat restrictions.

## Albuquerque Journal

- 1/27/05

## Diet Industry

- Over 5 billion a year in non-prescription therapies
- Most promise large weight loss in a short time – exercise optional
- Others resort to diuretics and eating disorders
- Aids to achieving the perfect body -

## Promised in 30 days or money back

## My personal favorite –

- Wash away your blues and your pounds.

## Key Aspect of Dietary Change

- Life style change not a temporary modification
- Diet implies you go off and do not maintain
- Portion Size
- Selection of food types

## Increase Physical Activity

- Assess current activity level
- Identify activities that are enjoyed
- Match activities to patient’s ability
- Set reasonable goals
- Make a daily activity

## Barriers to Physical Activity

- Community expectation
- Weather
- Safety – narrow roads, dogs, snakes
- Time – demands of family
- Lack of support from family
- No community sponsored activities

- Doshi and Jiles. Journal of Women’s Health 2006;15:919
- Thompson et al. Women and Health. 2002;36:59-74

## Increase Physical Activity

- Promote increased energy expenditure
- Formal exercise vs. increased daily activity
- Balance intensity with duration
- Provides benefits even without appreciable weight loss
- Can increase lean body mass
- Strive for 150 minutes/wk

## Medications

- Appetite Suppressants
- Antihistamines
- Amphetamines
- Sibutramine
- Antidepressants
- Lipase Inhibitors
- Increase Energy Expenditure (caffeine and Ephedrine)
- Peptides  (e.g. Leptin)

## Pharmacologic Treatment Summary

- All medications promote modest weight loss, which may significantly reduce diabetes mellitus and cardiovascular risk factors.
- No head-to-head trials of comparative efficacy exist to  suggest differences in efficacy.
- Side effect profile differs among drugs and probably drives the choice of agent on an individual basis.

## Obesity Surgery Summary

- Bariatric procedures result in:
- greater sustained weight loss than nonsurgical treatments in very obese individuals (BMI  40)
- improvements in some health outcomes (reduction in diabetes and sleep apnea, improved quality of life)
- Data not conclusive
- suggests greater sustained weight loss from surgery than non-surgical treatment for BMI 35-40

## Surgical Intervention

- Reserved for morbidly obese (>40 BMI) or less if significant co-morbidities
- Patients refractory to traditional diet, activity, behavior modification and medications
- Surgical mortality
- Long term complications

## Principles of Intervention

- Need to treat as a chronic disease
- Anticipate relapses and multiple treatment cycles
- Do not set goal solely on weight lost
- Emphasize lifestyle changes to minimize regaining
- Discourage extreme diets that promote yo-yo in weight

## Traditional Approach to Weight Loss

- Use conventional health education
- Use internal locus of control
- Environmental resources (paths, parks, playgrounds) still target the individual’s behavior change.
- Weight is considered a personal issue

## Principles for Program in AI Population

- Target Groups not individuals
- Promote social support and collective efficacy
- Friendly competition to affect health behavior change
- Use influence of peers/family on food choices, physical activity and weight management.

## Need for Tribal Support

- Tribes have demonstrated the commitment to group solidarity in historic and contemporary resistance to threats
- Group behavior change holds greater promise for changing social norms and policies than an approach that looks at a group as a collection of individuals.

- Teufel-Shone Journal of Transcultural Nursing 2006;17:224-229

## Promising Strategies in AI Communities

- Health promotion programs that foster collective self-esteem and common goal.
- Competition in races or other competition
- Weight loss teams
- Long relay walks (100 miles)
- Visible physical activity – competitive dancing

- Teufel-Shone Journal of Transcultural Nursing 2006;17:224-229

## Promising Strategies in AI Communities

- Health promotion programs that foster collective self-esteem and common goal.
- Competition in races or other competition
- Marketing/promoting healthy foods and habits

- Teufel-Shone Journal of Transcultural Nursing 2006;17:224-229

## Treatment Overview

- One to two thirds of weight lost is regained in one year and most by five years
- “Going on a diet” implies eventual stopping
- Potential for doing more physical and psychological harm than benefit - be careful
- Weight comes back at the same rate it came off

## Definition of Success

- Weight loss
- Duration of maintaining loss
- Changes in fat versus fat free mass
- Inches loss
- Improved activity tolerance
- Improvement in comorbid conditions

## Obesity and Health

- Weight reductions of  5 to 7 % of body weight is associated with:
-  lower blood pressure
- improved cholesterol
- lower risk of developing diabetes

## Prevention of Obesity

- Maintenance of a normal weight, or weight gain prevention, is important in addressing the obesity problem
- Key element for prevention is caloric balance
- Establish life-long habits for nutrition and physical activity

## Conclusion

- Obesity treatment must involve two components:
- 	1. Treatment must be a multidisciplinary, culturally appropriate approach  as for most chronic diseases
- 	2. There must be more focus on prevention especially at critical points such as childhood, pregnancy and menopause.

## Comments from Audience