obesity – growing epidemic center for disease control and prevention 2006
TRANSCRIPT
Obesity – Growing epidemic
Center for Disease Control and Prevention 2006
Obesity – Growing epidemic
• 65% Americans overweight or obese
• 30-40% Americans are obese (~100 million)– Doubled in past 20 years– Tripled in past 30 years
Obesity Trends* Among U.S. AdultsBRFSS, 1985
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14%
Obesity Trends* Among U.S. AdultsBRFSS, 1986
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14%
Obesity Trends* Among U.S. AdultsBRFSS, 1987
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14%
Obesity Trends* Among U.S. AdultsBRFSS, 1988
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14%
Obesity Trends* Among U.S. AdultsBRFSS, 1989
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14%
Obesity Trends* Among U.S. AdultsBRFSS, 1990
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14%
Obesity Trends* Among U.S. AdultsBRFSS, 1991
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%
Obesity Trends* Among U.S. AdultsBRFSS, 1992
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%
Obesity Trends* Among U.S. AdultsBRFSS, 1993
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%
Obesity Trends* Among U.S. AdultsBRFSS, 1994
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%
Obesity Trends* Among U.S. AdultsBRFSS, 1995
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%
Obesity Trends* Among U.S. AdultsBRFSS, 1996
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%
Obesity Trends* Among U.S. AdultsBRFSS, 1997
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% ≥20%
Obesity Trends* Among U.S. AdultsBRFSS, 1998
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% ≥20%
Obesity Trends* Among U.S. AdultsBRFSS, 1999
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% ≥20%
Obesity Trends* Among U.S. AdultsBRFSS, 2000
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% ≥20%
Obesity Trends* Among U.S. AdultsBRFSS, 2001
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
Obesity Trends* Among U.S. AdultsBRFSS, 2002
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%
Obesity Trends* Among U.S. AdultsBRFSS, 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. AdultsBRFSS, 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. AdultsBRFSS, 2005
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
Obesity Trends* Among U.S. AdultsBRFSS, 2006
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
Obesity Trends* Among U.S. AdultsBRFSS, 2007
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
Obesity Trends* Among U.S. AdultsBRFSS, 2008
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
Obesity Trends* Among U.S. AdultsBRFSS, 2008
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
Obesity Trends* Among U.S. AdultsBRFSS, 2008
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
Among U.S. Veterans, theprevalence of obesity may be as high as 75%
United States 65%Australia 59%Russia 54%United Kingdom 51%Brazil 36%China 15%
Overweight
Europe>50% are overweight30% BMI>30 kg/m210% BMI>40 kg/m2
Rizzello et al., Obes Surg 2010; 20:55
Obesity – Growing epidemic
• National Health and Nutrition Examination Survey (NHANES)• Obesity data 2007-8 compared to data 1999-2006• First trend toward plateau:
Flegal KM et.al., JAMA 2010; 303(3)
Obesity – Growing epidemic
• National Health and Nutrition Examination Survey (NHANES)• Obesity data 2007-8 compared to data 1999-2006• First trend toward plateau:
Flegal KM et.al., JAMA 2010; 303(3)
GOOD NEWS?!
Obesity – Health impact
Obesity – Health impact
• Comorbid conditions– Type 2 diabetes/Insulin resistance– Cardiovascular disease– Hypercholesterolemia, Hyperlipidemia– Hypertension– Osteoarthritis– Cancer– Liver disease (nonalcoholic steatohepatitis)– Obstructive sleep apnea
Obesity – Health impact
Type 2 DM
NormalBMI
Obesity – Health impact
Type 2 DM CAD
NormalBMI BMI
Obesity – Health impact
Type 2 DM CAD
Hypertension
NormalBMI BMI
Obesity – Health impact
Type 2 DM CAD
Hypertension Osteoarthritis
NormalBMI
Must A, et.al., JAMA 1999:1523
Obesity – Health impact
• Mortality from all causes increases with BMI
Adams KF, et.al., NEJM 2006; 355:763
Obesity – Health impact
Schauer, D. P. et al. Arch Surg 2010;145:57
Obesity – Health impactYears of Life Lost—BMI and Age
Men
Women
Fontaine KR, JAMA 2003; 289:187
Obesity – Health impact
• In both men and women, BMI is associated with higher rates of death due to Cancer– Esophagus– Colon/Rectum– Liver– Gallbladder– Pancreas– Kidney– Non-Hodgkin’s lymphoma– Multiple myeloma
Calle EE et.al., NEJM 2003; 348:1625
Obesity – Health impact
--Men and women with BMI>40 kg/m2 haddeath rates from all cancers that were 52% (men)and 62% (women) higher than the rates in normal weight individuals.
- Risk of mortality from cancer according to BMI (for men)
Calle EE et.al., NEJM 2003; 348:1625
Obesity – Health impactRi
sk o
f Pan
crea
tic C
ance
r
--Obesity in early adulthood
greater risk of pancreatic cancer and a younger age of disease onset
Li et.al., JAMA 2009; 301:2553
Obesity – Economic burden
Obesity – Economic burden
• Overweight and obesity account for nearly 10% of total U.S. medical expenditures
• >$100 billion
• Morbid obesity associated with >$11 billion direct health care costs
Center Disease Control and Prevention 2009
Obesity – Economic burden
0
1000
2000
3000
4000
5000
6000
7000
8000
9000Obesity-attributable direct medical costs, by state Center for Disease Control & Prev
State
Mill
ions
$
Obesity – Economic burden
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
New York: $6.1 Billion
Texas: $5.3
Obesity-attributable direct medical costs, by state Center for Disease Control & Prev
State
Mill
ions
$
California: $7.7 Billion
Obesity – Economic burden Mean per capita annual health care expenditure
BMI
20-24.9
Dol
lars
25-29.9 30-34.9 35-39.9
0
500
1000
1500
2000
2500
3000
3500
4000
>40
$2,127$2,358
$2,873$3,058
$3,506
Women aged 25-34
Wee et.al., Am J Public Health 2005
Surgical Treatment of Morbid Obesity
Surgical Treatment of Morbid Obesity
• Rationale:– Significant and durable weight loss– Improvement/Resolution of co-morbid conditions– Decrease mortality– Improved quality of life
Significant and durable weight loss
• NIH Consensus Development Conference:
“Severe obesity is a chronic, intractable disorder…Surgical procedures [Bariatric Operations] are capable of inducing significant weight loss and amelioration of most of the co-morbid conditions that have been studied.”
Significant and durable weight loss
• Meta-analysis 22,000 patients• Variable duration of follow-up• Total Percent Excess Weight Loss = 61%
• 47.5% Adjustable gastric band• 61.6% Gastric bypass• 70.1% Biliopancreatic diversion
Buchwald H et.al., JAMA 2004;292:1724
Significant and durable weight loss
• 10-year post-operativefollow-up:
• %EWL = 54-67%(All bariatric operations)
O’Brien et.al., Obes Surg 2006;16:1032Sjostrom L et.al., NEJM 2007;357:741
Significant and durable weight loss
• 10-year post-operativefollow-up:
• %EWL = 54-67%(All bariatric operations)
O’Brien et.al., Obes Surg 2006;16:1032Sjostrom L et.al., NEJM 2007;357:741
Significant and durable weight loss
• Medical Treatment:
• Prospective, randomized trial• 1-year follow-up
Stefanick et.al., NEJM 1998;339:12
Weight loss method (No. patients) Weight Loss
Exercise alone (43 patients) 0.4 kg
Diet alone (46 patients) 2.7 kg
Diet + Exercise (43 patients) 3.1 kg
Significant and durable weight loss
• Medical Treatment:
• Double-blind placebo-controlled trials + >1-yr follow-up
Padwal et.al., Cochrane Database, Issue 4, 2009
Agent Mechanism of Action
Number of Patients
Total Weight Loss
Orlistat Fat malabsorption
10, 631 2.9 kg
Rimonabant Anorectic 6,365 4.7 kg
Sibutramine Appetite Supressant
2,623 4.2 kg
Significant and durable weight loss
• Medical Treatment:
– There is no reliable, durable medical treatment of morbid obesity.
– Nearly all patients (95-97%) regain most or all of the weight that was lost within 2-5 years following diet or drug treatment.
– Average amount of weight loss is relatively small (2-10% of Excess Weight Loss)
0
50,000
100,000
150,000
200,000
250,000
1992 1997 2002 2003 2005 2007
Bariatric operations performed in the U.S. (1992-2007)
16,200
205,000
Significant and durable weight loss
Improvement of Co-morbid Conditions
Improvement of Co-morbid Conditions
Effect on Hypertension
Improvement of Co-morbid Conditions
Effect on Obstructive Sleep Apnea
Improvement of Co-morbid ConditionsEffect on Type 2 Diabetes
Improvement of Co-morbid Conditions
• Meta-analysis -- 135,246 patientsTotal Gastric
BandingGastroplasty Gastric
bypassBPD/DS
% EWL 55.9 46.2 55.5 59.7 63.6
% resolved overall
78.1 56.7 79.7 80.3 95.1
% resolved <2 yrs
80.3 55.0 81.4 81.6 94.0
% resolved >2 yrs
74.6 58.3 77.5 70.9 95.9
Buchwald H et al., Am J Med 2009;122:248
Bariatric Surgery – Life Expectancy
Bariatric Surgery – Life ExpectancyReference Follow-up
DurationDecrease in Mortality
MacDonald et.al.
9 years 88%
Flum et.al. 4.4 years 33%
Christou et.al. 5 years 89%
O’Brien et.al. 12 years 73%
Sowemimo et.al.
4.4 years 50%
Adams et.al. 7.1 years 40%
Sjostrom et.al.
14 years 31%
Sjostrom L et.al., NEJM 2007;357:741
MacDonald et.al., J Gastrointest Surg 1997; 1:213-220Flum et.al., JACS 2004;199:543O’Brien et.al., Obes Surg 2006; 16:1032-1040Sowemimo et.al., Surg Obes Relat Dis 2007; 1:73-77
Christou et.al., Ann Surg 2004;240:416Adams et.al., NEJM 2007; 357:753-761
Bariatric Surgery – Life Expectancy
Adams et.al., NEJM 2007; 357:753-761
• Retrospective study comparing 7,925 patients who had gastric bypass vs. 7,925 patients severely obese controls.
• Matched for age, sex, BMI
• Mean f/u = 7.1 years
Cause of death
RYGB vs. Car drivers
p-value
All mortality 40% decrease
<0.001
CV disease 56% decrease
0.54
All cancers 60% decrease
<0.001
Diabetes 92% decrease
<0.005
Bariatric Surgery – Life Expectancy
Schauer, D. P. et al. Arch Surg 2010;145:57
Years gained – BMI and Age
1. Every age group benefits, women and men.
2. The greatest benefit is in the younger population.
3. For any age, the greatest benefit is in the heaviest population.