Obesity:

Ob it C Causes,
Consequences s & Treatment

Gary
y D. Fo
oster, Ph.D.

Center for Obesity Research and

Educcation
Temple University School of Medicine
 Overv
view

1. Discriminattion
2
2. P
Prevalence
l e
3. Consequen
q nces
4. Treatment
5
5. Expectationns
 Obesity Trends* Among
A U.S. Adults
BRFSSS 1985
S,
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%

 Obesity Trends* Among
A U.S. Adults
BRFSSS 1986
S,
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%

 Obesity Trends* Among
A U.S. Adults
BRFSSS 1987
S,
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%

 Obesity Trends* Among
A U.S. Adults
BRFSSS 1988
S,
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%

 Obesity Trends* Among
A U.S. Adults
BRFSSS 1989
S,
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%

 Obesity Trends* Among
A U.S. Adults
BRFSSS 1990
S,
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%

 Obesity Trends* Among
A U.S. Adults
BRFSSS 1991
S,
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19%

 Obesity Trends* Among
A U.S. Adults
BRFSSS 1992
S,
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19%

 Obesity Trends* Among
A U.S. Adults
BRFSSS 1993
S,
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19%

 Obesity Trends* Among
A U.S. Adults
BRFSSS 1994
S,
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19%

 Obesity Trends* Among
A U.S. Adults
BRFSSS 1995
S,
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19%

 Obesity Trends* Among
A U.S. Adults
BRFSSS 1996
S,
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19%

 Obesity Trends* Among
A U.S. Adults
BRFSSS 1997
S,
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% ≥20%

%
 Obesity Trends* Among
A U.S. Adults
BRFSSS 1998
S,
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% ≥20%

%
 Obesity Trends* Among
A U.S. Adults
BRFSSS 1999
S,
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% ≥20%

%
 Obesity Trends* Among
A U.S. Adults
BRFSSS 2000
S,
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% ≥20%

%
 Obesity Trends* Among
A U.S. Adults
BRFSSS 2001
S,
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

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

 Obesity Trends* Among
A U.S. Adults
BRFSS
S 2002
S,
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

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

 Obesity Trends* Among
A U.S. Adults
BRFSSS 2003
S,
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

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

 Obesity Trends* Among
A U.S. Adults
BRFSSS 2004
S,
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

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

 Obesity Trends* Among
A U.S. Adults
BRFSSS 2005
S,
(*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
A U.S. Adults
BRFSSS 2006
S,
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

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

 Medical Complic
p cations of Obesity
y
Pulmonary disease Idiopathic intracranial
abnormal function hypertension
obstructive sleep apnea Stroke
hypoventilation syndrome
Cataracts
Nonalcoholic fatty liver Coronary heart disease
disease
Diabetes
steatosis
steatohepatitis Dyslipidemia
cirrhosis Hypertension

G ll bladder
Gall bl dd disease
di Severe pancreatitis

Gynecologic abnormalities Cancer

abnormal menses breast, uterus, cervix
infertility colon,
colon esophagus
esophagus, pancreas
polycystic ovarian syndrome kidney, prostate

Osteoarthritis
Phlebitis
Skin venous stasis
Gout
 Direct Cost* of Chhronic Diseases in
the United States
S (2006)
80
$83.3
$ $71.4
70
ns $)*

60 $59.2
Cost (Billion

50
Direct C

40
$31.9
30
$27.0

Type 2 Obesity Coronary

C Hypertension Arthritis
Diabetes Heart Disease
1 ADA Diabetes Care, 2003;26:917 4. Hodgson TA A et al. Med Care 2001;39:599
2 Finkelstein EA, Obes Res 2004;12 5 Yelin & Callah
han. Arthritis Rheum 1995;38:1351
3 Hodgeson TA et al. Medical Care 1999:37:994.
Who is Paying and How Much is being
Paid for Overweiight and Obesity?
•Insurance Category •Annuaal Cost (%) •Amount
•Ovwt & Obesity ($ billions) Ovwt
($,billions)
•Out-of-Pocket •77.3% & •$7.1
Obesity
•Private
Pi t •88.2%
8 2% $19 8
•$19.8

•Medicaid •88.8% •$3.7

•Medicare •11.1% •$20.9

•Total •99.1% •$51.5

Finkelstein et al. Health Affairs.May 2003:219

Obesity’s Growing Prevaalence & Treatment Costs
are Impacting Private Heealth Insurance Spending

• •1987
1987 •2002
2002
•Percent of Obese Adults •12.61 •23.83
Spending Attributable to
•Spending
Obesity
• Spending per member (dollars) •272 •1,244
• Private insurance spending •3.6 •36.5
(billions, USD)
• % of private insurance spendinng •2.0 •11.6

Thorpe, KE et al. Health Affairs, 2005;W5-317-325:

 –Major Cost Driivers of Obesity are:
–Prevalence
–Severity
S i
Aging
–Aging
–Each Unit Incrrease in BMI is
Associated witth a 2.3% Increase
in Health Care Costs.1
e Costs

1. Raebel MA, et al. Arch Intern Med 2004;164:2135-2140

 Obesity is Asssociated with a
Greater Loss inn Productivity
Mean Annual Work
W Days Lost

Men Women 8.82

6.22
5.5 5.35 5.85
5.18

Healthy Weight Ov
verweight Obese

Thompson, D.et al. Am J Health Promot 1998;12:120-127

And, Greater Raates of Disability
Percent Unable to Work
12.6
Men Women 9.6

7.9
5.9
47
4.7 5.6

Healthy Weight Ov
verweight Obese

Thompson, D.et al. Am J Health Promot 1998;12:120-127

Behaviora
al Factors

•Dietaryy in
ntake
•Physical
y activityy
 Environmen
ntal Factors
• Marketing
–Bigger packages, mu ultiple unit pricing,
quantity limits
–Bigger equals cheap per
»“Supersize”
»22 oz soda for $2.
$ 50 versus 44 oz for
$3.00
–All-you-can-eat
All you can eat buffe
ets
 Energy Savers
p
personal computers
p tele-commutingg
cellular phones e-mail/Internet
sshopping
opp g by pphone
o e ood de
food delivery
ve y se
services
v ces
phone extensions dishwashers
escalators/elevators cable movies
drive-thru windows computer games
intercoms moving sidewalks
remote controls garage door openers
 Obesity
y Trreatment
Guidellines
The Practical Guide
can be found at:

NHLBI web site:

www.nhlbi.nih.gov
The Obesityy Society
y
web site:
www.obesity.org
 Guide for Selecting
g Obesity Treatment
BMI Category
C (kg/m2)

Treatment 25-26.9 27-29.9

9 30-34.9 35-39.9 >40

Diet, Exercise,
B h i T
Behavior Tx + + + + +
Pharmaco- With co
o-
th
therapy morbidit
bidities
i + + +
With co-
Surgery
morbidities
biditi +

The Practical Guide: Identification, Evaluation, and Treatment of Overweight and

Obesity in Adults. October 2000, NIH Pub. No.00-4 4084
Self-Monitorin
ngg Food Intake
• Types
yp of foodss
• Portion sizes
• Calories (reduce by 500 kcal/d)
• Times places, and activities
Times,
• Thoughts
g and moods
 Changes in Body
B Weight
4

2
Change inn Weightt (kg)

0
Placebo
-2 Metformin

-44 Lif
Lifestyle
l

-6
C

-8
0 0.5 1 1.5 2 2.5 3 3.5 4

Yeaar
Diabetes Preventioon Program Research Group. N Engl J Med 2002;346,393-403
 Diabetes Preveention Program
g
40
Placebo
dence

30
%)

Metformin
of Diiabetes (%
ative Incid

Lifestyle
20
Cumula

10

0
0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0
Year
Diabetes Prevention Program Research Group. N Engl
E J Med. 2002;346,393-403.
 Portion Conttrolled Meals
Portion-Cont
• Provide fixed-portionn and calorie amounts
• Reduce choices and contact
c with problem
f d
foods
• Are convenient to usse
• Satisfy appetite (monnotony and sensory
specific
ifi satiety)
i )
• Facilitate dietary adh
herence
 Meal Replacements Enhance Initial and
Long term Weight
Long-term W Loss
Phase 1*
1 Phase 2

CF MR-1
0
Percentaage Weightt Loss

MR-2
10

15
0 2 4 6 8 10 12 18 24 30 36 45 51
*1200–1500 kcal/d diet prescription. T
Time (mo)
CF=conventional foods.
MR-2=replacements for 2 meals, 2 snacks daily.
MR-1=replacements for 1 meal, 1 snack daily.
Ditschuneit et al. Am J Clin Nutr 1999;69:198.
Fletchner-Mors et al. Obes Res 2000;8:399.
The Dieter’s Dilemma
 Calories or
o Carbs?
• N: 43
• Weeks:
W k 6 (i
(inpati
tient)
t)
• Diets: Isocaloriic ((1000 kcal/d))
(15% vs.. 45% CHO)
• Weight Loss: 88.99 + 0.
0 6 kg 7.5
7 5 + 0.5
0 5 kg

Golay. IJO, 1996.

 Weight
g Loss – 6 Months
1
-1
-3
Change
e

-5 Low
Low-
Carbohydrate
-7 *
Low-Calorie
%C

9
-9
-11
*
-13 *
*
-15
a
hm

y
er

ah

nc
st

*
re

am

Ya
Fo
B

S
 Weigh
ht Loss
1 Year
Y
0
-1
-2
3
-3
-4
hange

-5 Low-Carb
6
-6
% Ch

-7 Low-Cal
-8
9
-9
-10 Foster et al. NEJM, 2003.,
-11 Stern et al Ann Intern Med, 2004,
-12 Dansinger et al. JAMA 2005
Foster Stern nsinger
Dan
 Lip
pids
1 Year Changes
C
20 *
15
10
Low-Carb Foster
5
0 Low-Cal Foster
-5 Low Carb-Stern
% Change

-10 Low Cal-Stern

-15
*
-20
-25
-30
* *
ol

es
L

L
er

LD

rid
H
st

ce
le

ly
ho

ig
C

Tr
l
ta

Foster et al. NEJM, 2003., Stern et al

To

Ann Intern Med, 2004

 Antiobesity Agennts: How They
Workk
Selective
Releasing Reuptake Lipase
Agents Agent Inhibitor Inhibitor

5-HT NE DA
A 5-HT NE DA
Dexamphetamine +++ ++
++
Phentermine +++ ++
++
Sibutramine +++ +++ +

Orlistat +++

5-HT = serotonin; NE = noradrenaline; DA

A = dopamine

1Bray GA.
GA Ann Intern Med 2):707. 2Beales PL,
Med. 1993;119(7 pt 2):707 PL Kopelmaan PG
PG. PharmacoEconomics.
PharmacoEconomics 1994;5(suppl 1):18.
1):18
3Buckett WR et al. Prog Neuropsychopharmacol Biol Psychiatry. 1988;112:575.
4Drent ML et al. Int J Obes Relat Metab Disord. 1995;19:221. 5Heal DJ
J et al. Psychopharmacology (Berl). 1992;107:303.
 Drugs Approveed by FDA for
Treating Obesity
Status Gene
eric Name Trade Name

Rx Sibu
utramine Meridia

Rx Orlistat Xenical

OTC Orrlistat 60mg alli

(Approved 2/07)
Approved in Europe Riimonabant Acomplia/Zimulti
but not U.S.
 STORM
M Trial
Weight Loss Weight Maintenance
230
Placebo
225
Bodyy Weight ((lb)

220

215
210

205
200
Sib t
Sibutramine
i
195
0 2 4 6 8 10 12 14 16 18 20 22 24
Month
*Same diet, exercise for sibutramine, placebo;
P 0.001, sibutramine vs placebo for weight mainten
nance
Adapted with permission from James WPT et al. Lancet. 2000;356:22119.
 STORM: Changee in Vital Signs—
Baseline to 24 Monnths in Sibutramine
Treatmennt Group
Mean Change
Sib
butramine Placebo
BP, mm Hg
Systolic 0.1 –4.7
Diastolic 2.3 –1.6
Pulse rate (bpm) 4.1 –1.9

James WPT et al. Lancet. 2000;356:2119.

 STORM: Safety and Tolerability—
% off P
Patients
ti t Reporting
R ti AEs*
AE *
Weight Maintenance Phase
Weight Loss Phas
se Placebo Sibutramine
(n=605) (n=115) (n=352)
Infection 14 22 22
Flu syndrome 7 10 14
Headache 23 18 14
Increased appetite 4 12 14
Pharyngitis 7 13 13
Dry mouth 39 3 9
Constipation 19 4 9
Asthenia 6 11 7
Insomnia 12 3 8

*Frequency of 10% in any treatment group; reporte

ed as therapy-related
James WPT et al. Lancet. 2000;356:2119.
 Orlistat: Weight Loss and Maintenance
O
Over 2 Years
0
–1 Placebbo
Orlista
at
–2
eight (%)

–3 P<0.001 vs
s placebo at 1 and 2 years
–4
–5
5
Change in Body We

–6
–7
–8
–9
–10
–11
–12

–10 0 10 20 30 40 50 60 70 80 90 100 110

W
Week
SB DB DB

Slightly Weight
hypocaloric diet maintenance
SB = single blind; DB = double blind (eucaloric) diet
Adapted with permission from Sjöström L et al. Lancet. 1998;352:167
7.
Orlistat: Safety—A Adverse Events (AEs)
at 1 Year
40
Pla
acebo n=340
acebo, n 340

31% Orllistat, n=343

30

20%
20
%

18%

10%
10
7% 7%
5%
3%
1% 0%
0
Fatty/Oily Increased Oily Fecal Fecal
Stool Defecation Spotting Urgency Incontinence

• There is concern about fat-soluble vitamin absorpption

Sjöström L et al. Lancet. 1998;352:167.

 alli vs. Xenical
X
Use OTC Rx

Dosage 60 mg 120 mg

Target Pop Overweight BMI > 27 kg/m2 or > 30kg/m2

(w/ co-morbidities) or (without)

Indication Weight Loss Weight Loss & Maintenance

A Range
Age R 18
18+ 12+
12

GI AEs
(withdrawal rates) 32
3.2 54
5.4

Behavioral myalliplan.com Xenicare

S
Support
t Program
P
 Goals for Weight
W Loss

“The initial goal of weeight loss therapy for

overweight patients is a reduction in body
weight of about 10%… …moderate weight loss
of this magnitude can significantly decrease
the severity of obesity-asssociated risk factors.”

NHLBI, 1998
 Subject
j Cha
aracteristics

60 obese women1 397 obese individuals2

354 women
43 men

40.0 + 8.7 years

43.1 + 10.9 years

99.1 + 12.3 kg 109.0 + 28.9 kg

BMI = 36.3 + 4.3 kg/m2 BMI = 39.3 + 9.5 kg/m2

1Foster et al. JCCP 65(1) 79-85 1997

2Foster et al Arch Int Med. 161 2133-2139 2001
 Goal Weights
W
• Averaged
g 32% reductiion in bodyy weight g
• Three times greater thhan the goals
recommendedd d bby the
h NNational
i l Academy
A d off
Science and Departme
p ent of Agriculture
g
• Greatly exceeds weighht losses of nonsurgical
treatments
 Defined Weights
W
Dream Weight
A weight you would choose if you could weigh whatever you
wanted.
Happy Weight
This weight is not as ideal as the first one. It is a weight,
however, that you would be happy too achieve.
Acceptable Weight
A weight that you would not be b particularly happy with, but one
that you could accept, since it is lesss than your current weight.
Disappointed Weight
A weight that is less than your current weight, but one that you
could not view as successful in any w way. You would be disappointed if
this were your final weight after the program.
p
Fooster et al, J Consult Clin Psychol, 1997
 Defined Weights
W
1997
7 2001
% Reducction1 % Reduction2
Dream 38%% 38
38.4%
4%
Happy 31%% 30.9%
Acceptable 25% 24
24.9%
9%
Disappointed 17%% 15.7%

1Foster et al. JCCP 65(1) 79-85 1997

2Foster et al Arch Int Med. 161 2133-22139 2001
 % Achieving Defined Weights
W at Week 48 (N=45)
W i ht loss:
Weight l : 16.3
16 3 + 7.2
7 2 kg
k
Happy
Acceptable
9%
24% D
Dream = 0%

20%
4
47% Did not reach
Disappointed
Disappointed Weight

F
Foster et al, J Consult Clin Psychol, 1997.
 Principles
p annd Practices
• Simplicity
p y
– Engagement
– Enrollment
E ll
– Implementation
p
• Structure
– Duration
– Intake
– Activity
 Principles
p annd Practices
• Accountabilityy
Employees
E l
Employers

• Incentives
Enrollment
Participation/Success
 Principles
p annd Practices
• Expectations
p

– Weight
– Non-weight
Non weight
– Fees