Obesity, it’s time for a paradigm shift!

Daniela Connelly MD MPH

what is obesity

insulin resistance cortisol time dependency

nutrition and insulin free states

stress reduction and trauma awareness

triaging by generationno square peg in a round hole

recap/ questions

why is obesity a problem?

what caused this epidemic?

what is obesity?

• chronic, relapsing, multi-factorial, neurobehavioral disease,

• an increase in body fat promotes adipose tissue dysfunction and abnormal fat mass physical forces

• adverse metabolic, biomechanical, and psychosocial health consequences.

Fat Mass Disease (FMD)

• Endocrine/metabolic:

‒Elevated blood glucose

‒Elevated blood pressure

‒Dyslipidemia

‒Other metabolic diseases

‒Cancer

• Biomechanical/structural:

‒Stress on weight-bearing joints

‒ Immobility

‒Tissue compression (i.e., sleep apnea, gastrointestinal reflux, high blood pressure, etc.)

‒Tissue friction

Sick Fat Disease (SFD)

OVER 300 diseases are related directly to obesity

Sick Fat disease • Myocardial infarction, stroke,

peripheral vascular disease, hypertension, type 2 diabetes, gout, PCOS, infertility, nephrolithiasis, glomerulopathy, renal cancer, nonalcoholic fatty liver disease, cholelithiasis, breast cancer, endometrial cancer, esophageal cancer, colon cancer, pancreatic cancer, prothrombotic state, multiple myeloma...

Fat Mass Disease• congestive heart failure, PE,

hypertension, stroke, varicose veins, shortness of breath, OSA, hypoventilation syndrome, Pickwickian syndrome, asthma, intracranial hypertension, nerve entrapment (meralgia parestheticaand CTS, osteoarthritis ( knees/ hips), immobility, low back pain, myalgia, impaired balance, gait disturbance, GERD, hernias, stasis pigmentation, venous stasis ulcers, cellulitis, skin tags, intertrigo, carbuncles...

Mortality and BMI

why is obesity a problem:

diabetes

• Obesity, in particular, BMI ≥35, is associated with a substantial increase in the risk of developing diabetes and imposes a large economic burden.

• There is a >6-fold increase in diabetes risk for class III obese (BMI≥40) individuals, compared to normal weight individuals

• to “maintain” a diabetes prevalence of 10%, we need a 25% reduction in obesity prevalence (2075)

Leung MYM, Carlsson N, Colditz GA, Chang S-H. The Burden of Obesity on Diabetes in the United States: Medical Expenditure Panel Survey, 2008–2012. Value in health : the journal of the International Society for

Pharmacoeconomics and Outcomes Research. 2017;20(1):77-84. doi:10.1016/j.jval.2016.08.735.

April 24, 2003 N Engl J Med 2003; 348:1625-1638 DOI: 10.1056/NEJMoa021423

People with obesity at the time of Cancer diagnosis have a 75% higher risk of death compared to normal weighed individuals

Cost to Employers

• workers with obesity are twiceas likely to file workers’ compensation claims

• the cost of medical care for patients with obesity is seven times higher than the claims for non-obese workers

• cost of medical care is significantly higher because pre-existing heart disease, hypertension and diabetes

• Obesity significantly impacts the treatment and outcome of workers’ compensation claims

• An injured worker suffering from chronic disease experiences a slow and complicated recoveryfrom the treatment of industrial injuries

Duke University Medical Center

Cost to Employers

• The obese cohort is 10 % more likely than the normal-weight cohort to claim SSDI below age 50

• 66% more likely above age 50

• On average, the per person lifetime societal costs were found to be $92,235 greater for a person with obesity ($2013)

• adults with obesity spend 43% more on direct healthcare costs (Finkelstein 2012)

• There are substantial societal costs of high obesity rates in the United States, including productivity costs in the workplace and disability claims costs

• “Even if lifetime costs of obesity, such as health care, can be contained, the increase in the number of Americans with obesity foreshadows substantial societal costs”

https://www.brookings.edu/wp-content/uploads/2015/05/0512-Obesity-Presentation-v6-RM.pdf

how did this epidemic happen?

the guardian 08/15/2018

CDC

trend in obesity prevalence by educational attainment, US adults aged 25+

J Community Health. 2011 Feb; 36(1): 94–110.Published online 2010 Jun 12. doi: 10.1007/s10900-010-9287-9

agricultural policies?

• changes in agricultural policies (farm bill) induced the promotion of grain based commodities (corn)

• “Among the justifications for the 1973 U.S. Farm Bill was to assure consumers a plentiful supply of food at reasonable prices” Siegel

• Subsidized food commodities are foods made from federally funded crops to ensure the American population has an adequate supply of food, thus they tend to be non-perishable, or storable, e.g., corn, wheat, rice, to reduce the risk of spoiling.

• HFCS cheaply enters into the food chain

USDA

since 1976, why the sudden steep rise? many theories...

decrease in cost of foodboth child and adult body weight in low-

socioeconomic families was more sensitive to absolute food prices than that of their counterparts from non-poor households

the reduction in the relative prices of food at home from 1976 to 2001 contributed to a 14.7% growth in obesity prevalence and that the reduction in the relative prices of food away from home might add another 3.4% increase in obesity prevalence among adults living in metropolitan areas

Access to unhealthy food has increased in the past few decades.

decreased cost of fuel/ more commuting/ less walking

immigration

female labor force/ more meals are prepared outside the home/ cheaper

reduction in breast feeding/ increased formula fed babies and earlier introduction of solids

The risk of obesity among children is lowest when neither parent is obese, higher when one parent is obese, and highest when both parents are obese

Children and youth ages 8 to 18 spend an average of more than 7.5 hours each day using entertainment media, including TV, computers, video games, cell phones and movies, and only one-third of high school students get the recommended levels of physical activity.

certain food additives and refined carbohydrates cause neurotransmitter changes (serotonin and dopamine release) that provoke cravings and increased appetite

obesogenic environments: research has shown that the build environment can have an effect on obesity levels in a community. This research provided the strongest support for food stores (supermarkets instead of smaller grocery/convenience stores), places to exercise, and safety as potentially influential on obesity for disadvantaged groups.

The Science of Obesity

Management: An Endocrine

Society Scientific

Statement

“Genetic, environmental, and behavioral factors influence the development of obesity, and both the general public and health professionals stigmatize those who suffer from the disease.

Obesity is associated with and contributes to a shortened life span, type 2 diabetes mellitus, cardiovascular disease, some cancers, kidney disease, obstructive sleep apnea, gout, osteoarthritis, and hepatobiliary disease, among others.

Weight loss reduces all of these diseases in a dose-related manner—the more weight lost, the better the outcome”

The Science of Obesity

Management: An Endocrine

Society Scientific

Statement

“Genetic, environmental, and behavioral factors influence the development of obesity, and both the general public and health professionals stigmatize those who suffer from the disease.

Obesity is associated with and contributes to a shortened life span, type 2 diabetes mellitus, cardiovascular disease, some cancers, kidney disease, obstructive sleep apnea, gout, osteoarthritis, and hepatobiliary disease, among others.

Weight loss reduces all of these diseases in a dose-related manner—the more weight lost, the better the outcome”

“Weight regain is expected in all patients, especially when

treatment is discontinued.”

systems thinking problem archetype: fixes that fail

METABOLIC ADAPTATION

Cummings DE, Shannon MH. Roles for Ghrelin in the Regulation of Appetite and Body Weight. Arch Surg.2003;138(4):389–396. doi:10.1001/archsurg.138.4.389

need for a new dietary paradigm

• paradigm of the time: Reduction in energy intake by food restriction, combined with encouragement of energy expenditure by exercise remains the most widely used form of treatment. All long term studies show no effect on long term weight loss...

• new paradigm?

INSULIN RESISTANCE AS THE UNDERLYING CAUSE

OF OBESITY –an evolving disease

model

a story of dueling theories

• Silbermann, invented the Calorie in 1852. Other texts state that a German physician, Julius Mayer, effectively invented the Calorie in a study he published in 1848. Hargrove credits the French chemist Nicholas Clement with the invention, however, citing lecture notes from Clement that define the term as early as 1819.

• It was in 1921 that Canadian physician Frederick Banting and medical student Charles H. Best would be credited with discovering the hormone insulinin the pancreatic extracts of dogs.

FOOD

store as glycogen and “leftovers” as fat

abundant FAT STORES

metabolic energy

FOOD

store as glycogen and “leftovers” as fat

abundant FAT STORES

metabolic energy

effect of insulin

insulin resistance

Jason Fung MD – The Obesity Code

Jason Fung MD – The Obesity Code

Jason Fung MD – The Obesity Code

Insulin state balance over time

insulin-dominant state insulin –deficient

insulin dominant state

1970s

1990s

Bellisle, F., McDevitt, R., & Prentice, A. (1997). Meal frequency and energy balance. British Journal of Nutrition, 77(S1), S57-S70. doi:10.1079/BJN19970104

“Portion size, and the number of eating/drinking occasions have accounted for most of the total energy change intake in the last 30 years”

Jason Fung, MDThe Obesity Code2016

it’s all about avoiding insulin dominant states

address insulin resistance and weight loss together

sugarAvoid

simple carbs/ starchesAvoid

large “eating windows” ...6am to 9pm...large meal before bed..Avoid

fructose corn syrup, fructose sweeteners Avoid

fasting (8/16/24 x 3) to reverse insulin resistance Consider

compressing food episodes (eat, but not all the time...)Consider

the warrior meal, eat 2-3 times a day – not more, snacks count...Consider

increase fiber, vegetables, fruits, healthy fats (ask me about keto!)Increase

our solutions to the insulin problem

• double down on “rethink your drink”

• no artificial sweeteners, no sugar, no simple carbs (flour)

• 35g of fiber/ day

• promote understanding of low insulin states via healthy weight seminars

• no snacking – not even fruit...

• promote only 2-3 meals a day

• fasting protocol 8/16; 24hr

• promote the “warrior” meal plan

• redesign focus of work breaks (i.e. not eating every 3 hours), offer alternate activities

stress and weight gain: what's the connection?

• elevations in blood sugar

• central obesity

• insulin resistance

• OBESITY

• diabetes

• hypertension

• In times of stress, the body diverts a lot of the pregnenolone toward stress hormone production and away from sex

• hormone production

• microaggressions

• domestic violence

• poor sleep

• poverty

• financial distress

• legal jeopardy

stress

cortisol steal:

sex hormones

cortisol release

insulin increase

effect of stress in weight gain is higher in women

Work Stress, Obesity and the Risk of Type 2 Diabetes: Gender‐Specific Bidirectional Effect in the Whitehall II Study. Alexandros M. Heraclides Tarani Chandola Daniel R. Witte Eric J. Brunner First published: 06 September 2012 https://doi.org/10.1038/oby.2011.95

acute stress

chronic stress

emotional dysregulation, increased cortisol, insulin resistance

shift work

obstructive sleep apnea

adapted from: January 2017: Asian Journal of Pharmaceutical and Clinical Research 10(1):242-244 DOI: 10.22159/ajpcr.2017.v10i1.15067

sleep and obesity...

possible workplace solutions to the cortisol problem

Increased behavioral health interventions:

adverse childhood events

trauma informed care

group visits

MBSR (mindfulness based stress reduction) – group class format for patients enrolled in weight loss programming

Movement therapies such a QI GONG, TAI CHI, yoga

biometric marker: waist circumference, saliva cortisol

risk of obesity increases depending on obesity states of parents

Moms who are over weight are more likely to have babies that are heavy. Gestational diabetes affects DM and obesity status in offspring

insulin resistance can take years to reverse

epigenetic factors prior to conception will affect offspringsrisk of obesity and DM

post bariatric

care

bariatric care

medications

nutrition

lifestyle and sleep

• implicit bias among medical professionals

• obesity became a “disease” in 08/2013

• obesity is time dependent

• “exercise and diet” will get you 3.1 kg weight loss

• paradigm shift • leptin and ghrelin,

insulin and cortisol... obesity is a hormonal disease

• metabolic adaptation

post bariatric

care

surgery

medications

nutrition

lifestyle and sleep lifestyle coaching, sleep health, treat OSA, move more-sit less

insulin resistance, increase insulin deficient state, fasting, health weight seminars

obesity is a chronic disease, effective medications for long term use are available and under utilized – health plan

50% of employees have obesity, 10% suffer extreme obesity, 14% are diabetic, all would benefit from a surgical approach, less than 1% access curative surgery

Makary MA, Clark JM, Shore AD, et al. Medication Utilization and Annual Health Care Costs in Patients With Type 2 Diabetes Mellitus Before and After Bariatric Surgery. Arch Surg. 2010;145(8):726–731. doi:10.1001/archsurg.2010.150

2008: ROI in 2-3 years due to decreased healthcare utilization

nu

trit

ion REDUCE

INSULIN TRIGGERS/ STATES

stre

ss CONTROL CORTISOL TRIGGERS

tim

e Reversal of obesity is time dependent tr

eatm

ent lifestyle

medications

surgery

THANK YOUDaniela Connelly MD MPH

danielaconnellymd@gmail.com