Date post: | 02-Nov-2014 |
Category: |
Health & Medicine |
Upload: | plmiami |
View: | 505 times |
Download: | 1 times |
Management of Obesity in Women: Current Strategies
Robert Kushner, MDProfessor of Medicine
Northwestern University Feinberg School of Medicine
Clinical Director, Northwestern Comprehensive Center on Obesity
Disclosures
• Dr. Kushner has served on the Medical Advisory Boards for Amylin, Vivus, Orexigen and Allergan.
• He is the author of Dr. Kushner’s Personality Type Diet and Counseling Overweight Adults: The Lifestyle Patterns Approach and Toolkit
• Genetics• Biology• Environment• Society• Personal
responsibility• Weight gaining
medications
Health care Economics Ecology Diet Physical activity Social networks Stress and emotion
Multiple Determinants of Obesity
Life cycle
Your eight Gain
Weight-Life Events Graph
Your Weight Gain
Weight
Time
Weight Gain – Life Events Graph:Childhood and Adolescence
Childhood & Adolescent Obesity
• Screen time (TV, computer, video games, smart phone)
• Less exercise time during school
• Liquid calories (colas, juices)
• More meals eaten away from home
• Snacking
• Parenting and role modeling
Portion Sizes out of ControlPortion Sizes out of Control
‘Let’s Move’
• Nationwide campaign targeting childhood obesity– Getting parents more informed about nutrition
and exercise– Improving quality of food in schools– Making healthy foods more affordable and
accessible for families– Focusing more on physical education
The Pressure of Beauty Ideals
The Stigma of Obesity
Georgia Billboard Campaign
Relative Risks by BMI at Age 18 Relative Risks by BMI at Age 18
Adapted from Rich-Edwards et al. Adapted from Rich-Edwards et al. Am J Obstet GynecolAm J Obstet Gynecol. 1994;171:171-177.. 1994;171:171-177.
22
1.751.75
1.51.5
1.251.25
11
0.750.75
0.50.51515 2020 2525 3030 3535
44
3.53.5
33
2.52.5
22
1.51.5
11
0.50.5
001515 2020 2525 3030 3535
BMI at Age 18BMI at Age 18 BMI at Age 18BMI at Age 18
RelativeRelativeRiskRisk
RelativeRelativeRiskRisk
ReferenceReference
ReferenceReference
Menstrual Cycle IrregularityMenstrual Cycle Irregularity Primary Ovulatory InfertilityPrimary Ovulatory Infertility
Obesity and Infertility
Weight Gain – Life Events GraphPregnancy
Weight Gain – Life Events GraphPregnancy
Weight Gain – Life Events GraphPregnancy
• Postpartum weight retention
• Obstetric complications– Gestational
diabetes– Hypertension– Eclampsia– Caesarean delivery
• Stillbirth• Shoulder dystocia• Large baby• Shorter breast feeding• Fetal imprinting
– Developmental-origins for long-term risk
• Offspring obesity
Consequences of Maternal Weight Gain
Relationship Between Mother’s Weight and Child’s Risk of Obesity
Maternal BMI 2-yr olds 3-yr olds 4-yr olds
< 18.5 2.5 4.4 4.7
18.5 – 24.9 6.4 7.5 9.0
25 – 29.9 9.0 12.0 14.5
30 – 30.9 13.9 19.7 22.8
≥ 40 19.4 24.0 28.8
% Children Obese
Maternal BMI measured in the first trimester of child’s gestation
Whitaker RC. Pediatrics 2004;114(1): e29-e36
JAMA 2009;302:241
(11 – 20 lbs)
(15 – 25 lbs)
(25 – 35 lbs)
Weight Gain – Life Events GraphMidlife
Weight Gain – Life Events GraphMidlife
WomenWomenn=7018n=7018 <25<25 >>3030
Shortness of breathShortness of breathwalking upstairswalking upstairs 18.418.4 46.446.4
Chronic low back painChronic low back pain 17.817.8 24.724.7
Poor QOL:Poor QOL: Moderate activitiesModerate activities 18.418.4 36.036.0 Bending, kneelingBending, kneeling 20.720.7 48.348.3 Walking 1 blockWalking 1 block 4.54.5 15.415.4
Proportions of subjects, %Proportions of subjects, %
BMIBMI
Impairment of Health and Quality of Life
Lean et al, Arch Intern Med 1999 Lean et al, Arch Intern Med 1999
Prevalence (%) of Comorbidity Prevalence (%) of Comorbidity Among Among WomenWomen by Obesity Class* by Obesity Class*
Weight Status Category (%)†
Under-weight
Normal Over-weight
ObesityClass 1
ObesityClass 2
ObesityClass 3
Health Condition
Type 2 diabetes mellitus
Gallbladder disease
Coronary heart disease
High blood cholesterol
High blood pressure
Osteoarthritis
4.76
6.42
12.0
13.3
19.8
7.79
2.38
6.29
6.87
26.89
23.26
5.22
7.12
11.8
11.1
45.5
38.7
8.51
7.24
15.99
12.56
40.37
47.95
9.94
13.1
19.1
12.3
40.9
54.5
10.3
19.8
23.4
19.2
36.3
63.1
17.1
*N = 7,689.†Estimates are weighted to account for the sample design. Weight categories are based on the NHLBI classification.
(Must A, et al. JAMA. 1999)
0
10
20
30
40
50
60
70
80
90
100
<22 <23 23-23.9 24-24.9 25-26.9 27-28.9 29-30.9 31-32.9 33-34.9 35+0
10
20
30
40
50
60
70
80
90
100
<22 <23 23-23.9 24-24.9 25-26.9 27-28.9 29-30.9 31-32.9 33-34.9 35+
1.01.0 1.51.52.22.2
4.44.46.76.7
11.611.621.321.3
42.142.1
1.01.01.01.02.92.9 4.34.3 5.05.0
8.18.1 15.815.8
27.627.6
40.340.3
54.054.0
93.293.2
Relationship Between BMI and Risk of Type 2 Diabetes MellitusRelationship Between BMI and Risk of Type 2 Diabetes Mellitus
Chan J, et al. Diabetes Care. 1994;17:961-969. Colditz G, et al. Ann Intern Med. 1995;122:481-486.
Chan J, et al. Diabetes Care. 1994;17:961-969. Colditz G, et al. Ann Intern Med. 1995;122:481-486.
Body Mass Index (kg/m2)Body Mass Index (kg/m2)
Ag
e-A
dju
sted
Rel
ativ
e R
isk
Ag
e-A
dju
sted
Rel
ativ
e R
isk
■ Men ● Women■ Men ● Women
Abdominal Obesity Is Associated with Increased Risk of Developing Diabetes
<71[<27.9 in.]
71–75.9[27.9–29.8 in.]
76–81[29.9–31.9 in.]
81.1–86[32–33.9 in.]
86.1–91[34–35.8 in.]
91.1–96.3[35.9–37.9 in.]
>96.3[>38 in.]
24
20
16
12
8
4
0
Rel
ativ
e R
isk
Waist Circumference (cm)
Carey VJ, et al. Am J Epidemiol. 1997;145:614-619.
20-yr Changes in BMI and Waist Circumference Among Women
Data from NHANES completed during yrs 1976 - 2006
Body Mass Index (BMI) Waist Circumference (cm)
Black
White
Total
Hispanic
Kramer H, et al. J Diabetes Complications 2010;24:368-74
Differentiating Fat Depots
Changes in Weight and Body Composition Through the Menopausal Transition
Lovejoy JC et al. International J Obesity 2008;32:949-58
Changes in Hormones and Calories Through the Menopausal Transition
Lovejoy JC et al. International J Obesity 2008;32:949-58
Importance of Measuring Waist Circumference: BMI 25-29.9 (Overweight)
Prevalence, %
Hypertension
Type 2 DM
Hyper-chol
High LDL-C
Low HDL-C
Hyper-TG
Nl WC
23.0
2.7
17.2
19.3
35.3
21.7
High WC
44.8
10.6
26.2
27.2
49.0
36.3
Nl WC
12.3
1.6
19.4
13.6
10.0
10.6
High WC
37.5
10.0
35.2
26.6
15.0
21.8
Men (n=3081) Women (n=2606)
Janssen et al. Arch Intern Med 2002;162:2074-9
0.0
0.5
1.0
1.5
2.0
2.5
Folsom AR et al. Arch Intern Med. 2000;160:2117-2128.
Body Mass Index Tertile
3 2
3
11
2
Rel
ativ
e R
isk
Waist-H
ip R
atio
Tertile
Abdominal Fat Distribution Increases the Risk of Coronary Heart DiseaseThe Iowa Women’s Health Study
0
0.5
1
1.5
2
2.5
3
3.5
4
<20.0 20.0-22.4 22.5-24.9 25.0-27.4 27.5-29.9 30.0-34.9 ≥350
0.5
1
1.5
2
2.5
3
3.5
4
<20.0 20.0-22.4 22.5-24.9 25.0-27.4 27.5-29.9 30.0-34.9 ≥35
P < 0.001P < 0.001
Mu
ltiv
aria
te o
dd
s ra
tio
fo
r fr
equ
ency
of
GE
RD
sym
pto
ms
Mu
ltiv
aria
te o
dd
s ra
tio
fo
r fr
equ
ency
of
GE
RD
sym
pto
ms
●●
●●
●●●●
●● ●●
●●
2.93 (2.24-3.85)2.93 (2.24-3.85) 2.92 (2.35-3.62) 2.92 (2.35-3.62)
2.43 (1.96-3.01)2.43 (1.96-3.01)
2.20 (1.81-2.66)2.20 (1.81-2.66)
1.38 (1.13-1.67)1.38 (1.13-1.67)
0.67 (0.48-0.93)0.67 (0.48-0.93)
Gastroesophageal Reflux and Obese Women
Jacobson BC, et al. N Engl J Med. 2006;354:2340-2348.Jacobson BC, et al. N Engl J Med. 2006;354:2340-2348.
n = 2306 women with symptoms of heartburn, acid regurgitation, or bothn = 2306 women with symptoms of heartburn, acid regurgitation, or both
Body mass indexBody mass index
Association between body mass index and the risk of frequent symptoms of GERD
Association between body mass index and the risk of frequent symptoms of GERD
Obesity and Cancer Mortality Women
1.44
1.46
1.51
1.68
2.12
2.13
2.51
2.76
3.20
4.75
6.25
2.64*
2.51*
1.88*
0 1 2 3 4 5 6 7
Multiple myeloma (≥35)
Colon and rectum (≥40)
Ovary (≥35)
Liver (≥35)
All cancers (≥40)
Non-Hodgkin lymphoma (≥35)
Breast (≥40)
Gallbladder (≥30)
All other cancers (≥40)
Esophagus (≥30)
Pancreas (≥40)
Cervix (≥35)
Kidney (≥40)
Uterus (≥40)
Calle EE et al. N Engl J Med. 2003;348:1625-1638.Calle EE et al. N Engl J Med. 2003;348:1625-1638.
P≤.05, *relative risk for women who never smokedFor each relative risk, the comparison was between women in the highest BMI category and men in the reference category (BMI 18.5 to 24.9)
Relative Risk
Type of cancer
(highest BMI
category)
Current Approaches to Treating Obesity
● Diet, exercise, and behavioral therapy continue to be the mainstays of obesity treatment
● There is limited pharmacotherapy available. When possible, use weight-losing medications when treating co-morbidities
● A 5 – 10% weight loss improves many of the obesity-related metabolic
● Active weight loss and maintenance of lost weight requires ongoing support and use of resources
Waist circumference
Blood pressure
Blood glucose
Triglycerides
HDL-cholesterol
LDL-cholesterol
Insulin resistance
Thrombotic risk
Macronutrients To AddressIndividual Risk Factors
MetabolicSyndrome
DASH
Carbohydrate controlled
Omega–3 Fatty acids
Mediterranean, TLC
Mediterranean
Caloric Reduction
Manson JE et al. Arch Intern Med 2004;164:249-58
Summary
• There are multiple events in a woman’s life that predispose her to weight gain
• The reasons for weight gain at each time point differ – a combination of changing biology, hormonal status and life events
• It is important to implement preventive and treatment strategies to halt further weight gain and the development of ill health
Thank you!