Obesity – Growing epidemic Center for Disease Control and Prevention 2006.

Obesity – Growing epidemic

Center for Disease Control and Prevention 2006


• 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%



No Data <10% 10%–14%



No Data <10% 10%–14%



No Data <10% 10%–14%



No Data <10% 10%–14%



No Data <10% 10%–14%



No Data <10% 10%–14% 15%–19%



No Data <10% 10%–14% 15%–19%



No Data <10% 10%–14% 15%–19%



No Data <10% 10%–14% 15%–19%



No Data <10% 10%–14% 15%–19%



No Data <10% 10%–14% 15%–19%



No Data <10% 10%–14% 15%–19% ≥20%



No Data <10% 10%–14% 15%–19% ≥20%



No Data <10% 10%–14% 15%–19% ≥20%



No Data <10% 10%–14% 15%–19% ≥20%



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



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



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



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



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



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



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



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



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



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


• 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)


• 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


• Comorbid conditions– Type 2 diabetes/Insulin resistance– Cardiovascular disease– Hypercholesterolemia, Hyperlipidemia– Hypertension– Osteoarthritis– Cancer– Liver disease (nonalcoholic steatohepatitis)– Obstructive sleep apnea


Type 2 DM

NormalBMI


Type 2 DM CAD

NormalBMI BMI


Type 2 DM CAD

Hypertension

NormalBMI BMI


Type 2 DM CAD

Hypertension Osteoarthritis

NormalBMI

Must A, et.al., JAMA 1999:1523


• Mortality from all causes increases with BMI

Adams KF, et.al., NEJM 2006; 355:763


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


• 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


--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


• 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


0

1000

2000

3000

4000

5000

6000

7000

8000

9000Obesity-attributable direct medical costs, by state Center for Disease Control & Prev

State

Mill

ions

$


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.”


• 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


• 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


• 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


• 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



• 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



– 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


Improvement of Co-morbid Conditions


Effect on Hypertension


Effect on Obstructive Sleep Apnea

Improvement of Co-morbid ConditionsEffect on Type 2 Diabetes


• 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


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


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.

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Obesity – Growing epidemic Center for Disease Control and Prevention 2006.

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