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The Obesity Epidemic: This is your Life

The Obesity Epidemic: This is your Life. Block 10 April, 2004 Arlo Kahn, M.D. UAMS Dept. of Family and Preventive Medicine Arkansas Center for Health Improvement UAMS College of Public Health. Objectives. What’s happening? What are patients doing? Diets, drugs, activity

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The Obesity Epidemic: This is your Life

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  1. The Obesity Epidemic:This is your Life Block 10 April, 2004 Arlo Kahn, M.D. UAMS Dept. of Family and Preventive Medicine Arkansas Center for Health Improvement UAMS College of Public Health

  2. Objectives What’s happening? What are patients doing? Diets, drugs, activity What can physicians do? Counsel, prescribe, cut, advocate

  3. No Data <10% 10%-14% 15-19% 20-24% 25% Obesity* Trends Among U.S. AdultsBRFSS, 1988 (*BMI 30, or ~ 30 lbs overweight for 5’4” person)

  4. No Data <10% 10%-14% 15-19% 20-24% 25% Obesity Trends Among U.S. AdultsBRFSS, 1990

  5. No Data <10% 10%-14% 15-19% 20-24% 25% Obesity Trends Among U.S. AdultsBRFSS, 1991

  6. No Data <10% 10%-14% 15-19% 20-24% 25% Obesity Trends Among U.S. AdultsBRFSS, 1992

  7. No Data <10% 10%-14% 15-19% 20-24% 25% Obesity Trends Among U.S. AdultsBRFSS, 1993

  8. No Data <10% 10%-14% 15-19% 20-24% 25% Obesity Trends Among U.S. AdultsBRFSS, 1994

  9. No Data <10% 10%-14% 15-19% 20-24% 25% Obesity Trends Among U.S. AdultsBRFSS, 1995

  10. No Data <10% 10%-14% 15-19% 20-24% 25% Obesity Trends Among U.S. AdultsBRFSS, 1996

  11. No Data <10% 10%-14% 15-19% 20-24% 25% Obesity Trends Among U.S. AdultsBRFSS, 1997

  12. No Data <10% 10%-14% 15-19% 20-24% 25% Obesity Trends Among U.S. AdultsBRFSS, 1998

  13. No Data <10% 10%-14% 15-19% 20-24% 25% Obesity Trends Among U.S. AdultsBRFSS, 1999 Source: BRFSS, CDC.

  14. No Data <10% 10%-14% 15-19% 20-24% 25% Obesity Trends Among U.S. AdultsBRFSS, 2000

  15. No Data <10% 10%-14% 15-19% 20-24% 25% Obesity Trends Among U.S. AdultsBRFSS, 2001 Source: Mokdad A H, et al. JAMA 2003;289:1 Source: Mokdad A H, et al. JAMA 1999;282:16;2003;289:1

  16. No Data <10% 10%-14% 15-19% 20-24% 25% Obesity Trends Among U.S. AdultsBRFSS, 2002 Source: Mokdad A H, et al. JAMA 2003;289:1 Source: Mokdad A H, et al. JAMA 1999;282:16;2003;289:1

  17. US Adult Obesity Prevalence NHANES 1999-2000      Predicted 2010 Black Women    50.0              57.0%             White Women   30.8               40.0               Black Men        28.7               33.0               White Men        27.8               37.7    L Roux, MM Yore, NAASO 2003 Annual Scientific Meeting

  18. 400,000 300,000 100,000 90,000 30,000 20,000 Tobacco Diet/Activity Alcohol Microbial Sexual Illicit use of agents behavior drugs Actual Causes of Death in the United States, 1990 Source: McGinnis JM, Foege WH. JAMA 1993;270:2207-12.

  19. Actual Causes of Death in the United States, 2000 • Tobacco: 435,000 deaths • Poor diet and physical inactivity 400,000 deaths “Poor diet and physical inactivity may soon overtake tobacco as the leading cause of death” Mokdad, AH et al. JAMA. 2004;291:1238-1245

  20. RAND Research Obesity is linked to rates of chronic illnesses higher than living in poverty, and much higher than smoking or drinking. Sturm R. The Effects of Obesity, Smoking, and Problem Drinking on Chronic Medical Problems and Health Care Costs. Health Affairs. 2002;21(2):245-253. Sturm R, Wells KB. Does Obesity Contribute As Much to Morbidity As Poverty or Smoking? Public Health. 2001;115:229-295

  21. The Risks of Overweight • coronary heart disease, congestive heart failure • cancer of breast, prostate, colon, uterus, liver, kidney, pancreas, esophagus • stroke • Arthritis, gout • gallbladder disease • incontinence, poor female reproductive health • sleep apnea, asthma, other respiratory problems • hypertension, diabetes mellitus, high cholesterol

  22. The Costs: 2000 • Cost of obesity in U.S.: $117 Billion (>17% increase from 1996) • Cost of obesity in Arkansas: ~$1.2 Billion • 9.4 percent of the national health care expenditures in the United States are directly related to obesity and physical inactivity

  23. Obesity in Arkansas • 7th highest rate of physical inactivity • 84.6% of Arkansas adults are at risk for health problems related to lack of exercise • 21 percent increase in the number of Arkansans who have diabetes from 1993 – 2000 • Type 2 diabetes at ACH 2 cases in mid 90’s >100 cases last year

  24. Adult BMI Chart Weight (lbs) 260 270 280 290 300 190 200 210 220 230 240 250 120 130 140 150 160 170 180 5'0" 5'2" 5'4" 5'6" Height 5'8" 5'10" 6'0" 6'2" 6'4"

  25. GenerationXXL

  26. BMI BMI Boys: 2 to 20 years BMI BMI

  27. Girls: 2 to 20 years

  28. Percentage of U.S. Children and Adolescents Who Were Overweight* Ages 12-19 Ages 6-11 1963-70 data are from 1963-65 for children 6-11 years of age and from 1966-70 for adolescents 12-17 years of age * >95th percentile for BMI by age and sex based on 2000 CDC BMI-for-age growth charts Source: National Center for Health Statistics

  29. Percentage of U.S. Children and Adolescents Who Were Overweight* 14 13 Ages 12-19 5 4 Ages 6-11 * >95th percentile for BMI by age and sex based on 2000 CDC BMI-for-age growth charts **Data are from 1963-65 for children 6-11 years of age and from 1966-70 for adolescents 12-17 years of age Source: National Center for Health Statistics

  30. 84th General Assembly Act 1220 of 2003AN ACT TO CREATE A CHILD HEALTH ADVISORY COMMITTEE; TO COORDINATE STATEWIDE EFFORTS TO COMBAT CHILDHOOD OBESITY AND RELATED ILLNESSES; TO IMPROVE THE HEALTH OF THE NEXT GENERATION OF ARKANSANS; AND FOR OTHER PURPOSES.

  31. The Arkansas BMI Initiative Act 1220 : Beginning in the 2003-2004 school year, each school district shall annually • Measure the BMI of each K-12th grade student and report it to parent • Explain to parents the possible health effects of body mass index, nutrition and physical activity

  32. The Numbers • In May, 2004 BMI health letters will go out to parents of 450,000 Arkansas public school students. • Based on data from the Cambridge schools, ~34% of students may be in the “overweight” or “risk of overweight” categories, with about 17% in each category. • In the Cambridge study on response to BMI report cards (1396 elementary students), parents of 25% of children in these categories reported that they planned to seek medical service for this problem. • 3. If Arkansas numbers are similar, it is possible that parents of 38,000 students will seek medical care related to the BMI report. (450,000 x .34 x.25 = 38,250.)

  33. Rationale for the BMI Initiative • Treatment of adult obesity has had less than satisfactory outcomes. Prevention is most promising. • Overweight school-age children have a 50% probability of becoming obese adults. • Overweight adolescents have a 70-80% probability of becoming obese adults. • Many children do not make regular doctor visits, and when they do, BMI is not routinely checked. (2002 study found that less than 20% of pediatricians were checking BMI.) • While parents often recognize when their children are extremely overweight, many parents do not recognize less extreme overweight that still poses health and emotional risks to their kids. • Many parents do not know the risks of overweight.

  34. Rationalefor usingBMI in Children and Adolescents to Assess for Weight-related Risks • 95th percentile for age corresponds to BMI of 30 in young adult (obesity) • 85th percentile for age corresponds to BMI of 25 in young adult (overweight) • Compared with DEXA, 95% of children with BMI >95th percentile had increases in body fat • BMI percentile predicts CVD risk: 60% of 5-10 year old kids>95th percentile have at least 1 additional risk, 15% have 2 or more

  35. BMI in Children and Adolescents:Limitations • Weight and height do not directly measure body fatness • Additional criteria are necessary to determine whether someone with BMI>95th percentile is overfat (e.g. tricep skinfold thickness) as opposed to overweight because of increased muscle or bone mass • Changes in BMI over time may be as important as single reading

  36. What are your patients doing about obesity? 29% of men and 44% of women trying to lose weight About 20% of report restricting calories or increasing physical activity

  37. What Can Physicians Do • Counsel • Diets • Drugs • Surgery • Advocacy

  38. Treating Obesity Without Frustration

  39. Goal • Learn how to work with obese patients in a manner that is effective, minimizes physician frustration, shows respect for the patient and maintains good communication

  40. PROBLEM: CAD and Type II DM S: Ms. X is a 35 year old who was diagnosed as having diabetes sometime in the last several months at the time of her admission for angioplasty with two coronary stents placed in her LAD. She is currently taking 10 mg of Glipizide b.i.d. and 12 units of Humulin 100 at night. She says that she checks her BS up to 4 times q.d., and they are always in the upper 100s and lower 200s. She takes Monopril 10 mg. q.d., Lipitor 10 mg. b.i.d. , aspirin 325 mg. enteric coated, and Prozac 40 mg. q.d. She has lost l5 lbs. since her diagnosis, approximately 3 months ago, but has not lost any weight recently. Smokes 1ppd. O: Current weight is 235#. Height is 5’4”. BMI 40.5.

  41. Assuming you want to address her obesity, how would you proceed?

  42. The Good Old 4-A Technique • ASK • ADVISE • ASSIST • ARRANGE

  43. ASK Assess readiness to change “Do you want to work on losing weight”? If ready, assess previous and current efforts and obstacles

  44. When asked if she is interested in addressing any of her lifestyle issues at this time she said that she would be interested in addressing her weight. She is supposed to be on a l500 calorie diet, but she has never really counted calories, so she is not sure what she is actually consuming. She is not able to identify any single foods that she eats frequently that she thinks are bad for her. She drinks 2% milk, and apparently has several servings a day. She was unaware that this is actually high fat milk. She is supposed to be exercising about 30 minutes 3 times a week, but rarely does more than twice a week. She doesn't like exercise and doesn't like dieting. She feels that being asymptomatic with regard to respiratory, cardiovascular, GI, and musculoskeletal systems reinforces her lack of motivation.

  45. Readiness to Change • Precontemplation (not interested) • Contemplation (6 months) • Preparation (within a month) • Action (working on it) • Maintenance

  46. Obstacles • Unaware of current intake • Unaware of high calorie foods • Doesn’t like exercise or dieting • Feels fine

  47. ADVISE Give brief personalized advice: her risks of overweight benefits to her of controlling weight

  48. ASSIST How to assist depends on Stage of Readiness to Change!!!

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