OBESITY:   A “WEIGHTY” PROBLEM Sharon Phelan MD Native Women’s Health August 16, 2007
Objectives <ul><li>Describe the increasing problem </li></ul><ul><li>Identify the etiologies </li></ul><ul><li>Apply thera...
Disclosure of potential conflict <ul><li>I own shares of …... </li></ul>
Disclosure of potential conflict <ul><li>I own shares of …… </li></ul><ul><li>Krispy Kreme </li></ul>
 
 
 
Written for the public www.healthierus.gov/dietaryguidelines
Major Public Health Issue in US <ul><li>25%  or 34 million Americans are overweight </li></ul><ul><li>Increase from 1 in 8...
Demographics in Native Populations <ul><li>Malnutrition was problem as recently as the early 1960’s </li></ul><ul><li>Morb...
Definition of Obesity <ul><li>Obesity is simply the excess of body fat </li></ul><ul><li>Common Methods to Determine Body ...
Body Mass Index <ul><li>Healthy Weight 18.5*-24.9  (110-149) </li></ul><ul><li>Over Weight 25-29.9  (150-179) </li></ul><u...
Obesity Trends Among U.S. Adults between 1985 and 2003 <ul><li>Source of the data: </li></ul><ul><li>The data shown in the...
Obesity Trends* Among U.S. Adults BRFSS, 1985 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data  <10%  10%–14%
Obesity Trends* Among U.S. Adults BRFSS, 1990 No Data  <10%  10%–14%
Obesity Trends* Among U.S. Adults BRFSS, 1993 No Data  <10%  10%–14%   15%–19%
Obesity Trends* Among U.S. Adults BRFSS, 1996 No Data  <10%  10%–14%   15%–19%
Obesity Trends* Among U.S. Adults BRFSS, 1999 No Data  <10%  10%–14%   15%–19%  ≥20
Obesity Trends* Among U.S. Adults BRFSS, 2000 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data  <10%  10%–14%  ...
Obesity Trends* Among U.S. Adults BRFSS, 2001 <10%  10%–14%   15%–19%  20%–24%  ≥25%
(*BMI   30, or ~ 30 lbs overweight for 5’4” person) <10%  10%–14  15%–19%  20%–24%  ≥25% Obesity Trends* Among U.S. Adult...
Obesity* Trends Among U.S. Adults BRFSS, 2003 <10%  10%–14%  15%–19%  20%–24%  ≥25%
Obesity Trends* Among U.S. Adults BRFSS, 2004 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data  <10%  10%–14% ...
Obesity Trends* Among U.S. Adults BRFSS, 2005 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data  <10%  10%–14% ...
Morbidity Of Obesity <ul><li>Hypertension </li></ul><ul><li>Type II Diabetes </li></ul><ul><li>Hyperlipidemia </li></ul><u...
Morbidity Of Obesity <ul><li>Degenerative Joint Disease </li></ul><ul><li>Gout </li></ul><ul><li>Gallstones and Kidney Sto...
Morbidity Of Obesity <ul><li>Obstetric Implications – increase risk of </li></ul><ul><ul><li>PIH/Pre-eclampsia </li></ul><...
Morbidity Of Obesity <ul><li>Obstetric Implications </li></ul><ul><li>Gynecologic Implications </li></ul><ul><ul><li>Infer...
 
Obesity in Native Children Zephier et al.  Arch Pediatric Adolesc Med 2006;160:34-39
Albuq. Journal 2/9/05
Etiology of Obesity <ul><li>Obesity is a problem of Energy Regulation </li></ul><ul><li>Balance of calories consumed (CI) ...
Etiology of Obesity <ul><li>Obesity is the manifestation of genes and environment </li></ul><ul><li>Obesity is a complex d...
Gene Effect Environmental Effect Monogenic  Syndromes Obesity Susceptible Genes Stress Exercise Food Intake Culture
Gene Effect Environmental Effect Monogenic  Syndromes Obesity Susceptible Genes Stress Exercise Food Intake Culture Less t...
Etiology <ul><li>Humans evolved in an environment of subsistence existence </li></ul><ul><li>Certain ethnic groups may hav...
Impact of Reproductive Hormones <ul><li>High Risk Events for Weight Gain </li></ul><ul><ul><li>Pre-menstrual cravings  </l...
Obesity in the Maternity Clinic
Environmental Effects <ul><li>Culture – probably more acquired habit than truly culture </li></ul><ul><li>Food Intake – ch...
Culture <ul><li>Ethnic foods and developed tastes </li></ul><ul><ul><li>Shift from hunter/gather or farming with increased...
Culture <ul><li>Ethnic foods and developed tastes </li></ul><ul><li>Community norms </li></ul><ul><ul><li>Big (obese) chil...
Culture <ul><li>Ethnic foods and developed tastes </li></ul><ul><li>Community norms </li></ul><ul><li>Socioeconomic factor...
Culture <ul><li>Ethnic foods and developed tastes </li></ul><ul><li>Community norms </li></ul><ul><li>Socioeconomic factor...
Anglo women internalize the current standard of female beauty
Motivators for Native Women <ul><li>Being “Skinny” not valued </li></ul><ul><li>Avoiding diabetes is important </li></ul><...
Societal Stigma of Obesity <ul><li>Obese people can be described in negative terms. This leads to the individual  </li></u...
 
Food Intake
Food Intake
Food Intake
Food Intake
Food Intake <ul><li>Overeating </li></ul><ul><li>Fat Intake </li></ul><ul><li>Carbohydrate and Fiber Intake </li></ul><ul>...
Modifiers in Caloric Intake <ul><li>Satiety is mainly determined by food volume not by calories </li></ul><ul><li>Metaboli...
Exercise/Physical Activity <ul><li>Work involves less physical activity </li></ul><ul><li>Obtaining food is less labor int...
Screening for Obesity <ul><li>Calculate BMI - </li></ul><ul><ul><li>Every 5 years (AHA) </li></ul></ul><ul><ul><li>Key age...
Intervention with Positive Screen <ul><li>Determine if patient is receptive to </li></ul><ul><li>intervention. </li></ul><...
Evaluation of Obesity - History <ul><li>weight at 18 y.o. and pattern of gain  </li></ul><ul><li>family history of obesity...
Evaluation of Obesity - Physical <ul><li>Height and weight; Hip and Waist circumferences </li></ul><ul><li>Rule out eviden...
Evaluation of Obesity - Labs <ul><li>Cholesterol screen for baseline </li></ul><ul><li>Fasting Blood Sugar </li></ul><ul><...
Intervention <ul><li>Prevention is key </li></ul><ul><li>Diet modification </li></ul><ul><li>Increased Physical Activity <...
Patient Education <ul><li>Situation is a result of inadequate physical activity for the amount of food ingestion. </li></u...
Modifiers of Caloric Expenditure <ul><li>Caloric Expenditure is the sum of: </li></ul><ul><li>Resting Metabolic Rate:  60-...
Energetics of Weight Loss <ul><li>3500 kcal per pound of fat </li></ul><ul><li>Daily deficit of 500 kcal/day results in 1 ...
Common Diet Strategies <ul><li>Very Low Carbohydrate (50 gm/d) </li></ul><ul><li>Individuals mobilize the CHO stored in bo...
Albuquerque Journal 3/5/05
Common Diet Strategies <ul><li>Very Low Fat Diets  (Ornish and Pritikin diets) </li></ul><ul><li>Amount of weight loss is ...
Common Diet Strategies <ul><li>Moderate Fat Diets (40-45 gm/day). </li></ul><ul><li>Carbohydrates are classified by  </li>...
Common Diet Strategies <ul><li>High Protein Diets – Atkins and South Beach  </li></ul><ul><li>Emphasize high protein intak...
Albuquerque Journal 1/27/05
Diet Industry <ul><li>Over 5 billion a year in non-prescription therapies </li></ul><ul><li>Most promise large weight loss...
Promised in 30 days or money back
My personal favorite – Wash away your blues and your pounds.
Key Aspect of Dietary Change <ul><li>Life style change not a temporary modification </li></ul><ul><li>Diet implies you go ...
Increase Physical Activity <ul><li>Assess current activity level </li></ul><ul><li>Identify activities that are enjoyed </...
Barriers to Physical Activity <ul><li>Community expectation </li></ul><ul><li>Weather </li></ul><ul><li>Safety – narrow ro...
Increase Physical Activity <ul><li>Promote increased energy expenditure </li></ul><ul><li>Formal exercise vs. increased da...
Medications <ul><li>Appetite Suppressants </li></ul><ul><ul><li>Antihistamines </li></ul></ul><ul><ul><li>Amphetamines </l...
Pharmacologic Treatment Summary <ul><li>All medications promote modest weight loss, which may significantly reduce diabete...
Obesity Surgery Summary <ul><li>Bariatric procedures result in: </li></ul><ul><ul><li>greater sustained weight loss than n...
Surgical Intervention <ul><li>Reserved for morbidly obese (>40 BMI) or less if significant co-morbidities </li></ul><ul><l...
Principles of Intervention <ul><li>Need to treat as a chronic disease </li></ul><ul><li>Anticipate relapses and multiple t...
Traditional Approach to Weight Loss <ul><li>Use conventional health education </li></ul><ul><li>Use internal locus of cont...
Principles for Program in AI Population <ul><li>Target Groups not individuals </li></ul><ul><li>Promote social support and...
Need for Tribal Support <ul><li>Tribes have demonstrated the commitment to group solidarity in historic and contemporary r...
Promising Strategies in AI Communities <ul><li>Health promotion programs that foster collective self-esteem and common goa...
Promising Strategies in AI Communities <ul><li>Health promotion programs that foster collective self-esteem and common goa...
Treatment Overview <ul><li>One to two thirds of weight lost is regained in one year and most by five years </li></ul><ul><...
Definition of Success <ul><li>Weight loss </li></ul><ul><li>Duration of maintaining loss </li></ul><ul><li>Changes in fat ...
Obesity and Health <ul><li>Weight reductions of  5 to 7 % of body weight is associated with: </li></ul><ul><ul><li>lower b...
Prevention of Obesity <ul><li>Maintenance of a normal weight, or weight gain prevention, is important in addressing the ob...
Conclusion <ul><li>Obesity treatment must involve two components: </li></ul><ul><li>1. Treatment must be a multidisciplina...
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  • We have never had an epidemic like this that we have been able to track so thoroughly and see. As I told you, this is conservative. About 60 million adults, or 30 percent of the adult population, are now obese, which represents a doubling of the rate since 1980.
  • We have never had an epidemic like this that we have been able to track so thoroughly and see. As I told you, this is conservative. About 60 million adults, or 30 percent of the adult population, are now obese, which represents a doubling of the rate since 1980.
  • Obesity: A weighty problem

    1. 1. OBESITY: A “WEIGHTY” PROBLEM Sharon Phelan MD Native Women’s Health August 16, 2007
    2. 2. Objectives <ul><li>Describe the increasing problem </li></ul><ul><li>Identify the etiologies </li></ul><ul><li>Apply therapeutic approaches appreciating cultural and environmental challenges </li></ul><ul><li>Examine the role of providers in prevention/treatment for women </li></ul>
    3. 3. Disclosure of potential conflict <ul><li>I own shares of …... </li></ul>
    4. 4. Disclosure of potential conflict <ul><li>I own shares of …… </li></ul><ul><li>Krispy Kreme </li></ul>
    5. 8. Written for the public www.healthierus.gov/dietaryguidelines
    6. 9. Major Public Health Issue in US <ul><li>25% or 34 million Americans are overweight </li></ul><ul><li>Increase from 1 in 8 (1991) to 1 in 5 (1998) are obese </li></ul><ul><li>Racial distribution: 45% black women; 35% Hispanic women, 25% white women and 45% of American Indian women </li></ul><ul><li>Women are generally at increased risk </li></ul>
    7. 10. Demographics in Native Populations <ul><li>Malnutrition was problem as recently as the early 1960’s </li></ul><ul><li>Morbidity/mortality was from infectious disease now from diabetes, CVD and obesity related cancers </li></ul><ul><li>Infant mortality changed from 63/1000 in 1955 to 7/1,000 in 1991 </li></ul><ul><li>Currently 41% of native children are overweight or obese </li></ul>Compher Journal of Transcultural Nursing 2006;17:217-223
    8. 11. Definition of Obesity <ul><li>Obesity is simply the excess of body fat </li></ul><ul><li>Common Methods to Determine Body Fat </li></ul><ul><li>Body Mass Index </li></ul><ul><li>Body circumference: Waist <85cm or < 35” for women) </li></ul><ul><li>Waist to hip ratio: >.91 is problematic </li></ul>
    9. 12. Body Mass Index <ul><li>Healthy Weight 18.5*-24.9 (110-149) </li></ul><ul><li>Over Weight 25-29.9 (150-179) </li></ul><ul><li>Obesity </li></ul><ul><ul><li>Class I 30 - 34.9 (180-209) </li></ul></ul><ul><ul><li>Class II 35 - 39.9 (210-239) </li></ul></ul><ul><ul><li>Class III > 40 ( > 240) </li></ul></ul><ul><li>( weight in pounds for 5’5” woman) </li></ul><ul><li>International Obesity Task Force </li></ul>
    10. 13. Obesity Trends Among U.S. Adults between 1985 and 2003 <ul><li>Source of the data: </li></ul><ul><li>The data shown in these maps were collected through CDC’s Behavioral Risk Factor Surveillance System (BRFSS). Each year, state health departments use standard procedures to collect data through a series of monthly telephone interviews with U.S. adults. </li></ul><ul><li>Prevalence estimates generated for the maps may vary slightly from those generated for the states by BRFSS (http://aps.nccd.cdc.gov/brfss) as slightly different analytic methods are used. </li></ul>
    11. 14. Obesity Trends* Among U.S. Adults BRFSS, 1985 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14%
    12. 15. Obesity Trends* Among U.S. Adults BRFSS, 1990 No Data <10% 10%–14%
    13. 16. Obesity Trends* Among U.S. Adults BRFSS, 1993 No Data <10% 10%–14% 15%–19%
    14. 17. Obesity Trends* Among U.S. Adults BRFSS, 1996 No Data <10% 10%–14% 15%–19%
    15. 18. Obesity Trends* Among U.S. Adults BRFSS, 1999 No Data <10% 10%–14% 15%–19% ≥20
    16. 19. Obesity Trends* Among U.S. Adults BRFSS, 2000 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20
    17. 20. Obesity Trends* Among U.S. Adults BRFSS, 2001 <10% 10%–14% 15%–19% 20%–24% ≥25%
    18. 21. (*BMI  30, or ~ 30 lbs overweight for 5’4” person) <10% 10%–14 15%–19% 20%–24% ≥25% Obesity Trends* Among U.S. Adults BRFSS, 2002
    19. 22. Obesity* Trends Among U.S. Adults BRFSS, 2003 <10% 10%–14% 15%–19% 20%–24% ≥25%
    20. 23. Obesity Trends* Among U.S. Adults BRFSS, 2004 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25%
    21. 24. Obesity Trends* Among U.S. Adults BRFSS, 2005 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
    22. 25. Morbidity Of Obesity <ul><li>Hypertension </li></ul><ul><li>Type II Diabetes </li></ul><ul><li>Hyperlipidemia </li></ul><ul><li>Coronary Heart Disease </li></ul><ul><li>Cancer: </li></ul><ul><ul><li>Endometrial </li></ul></ul><ul><ul><li>Breast </li></ul></ul><ul><ul><li>Colon </li></ul></ul>
    23. 26. Morbidity Of Obesity <ul><li>Degenerative Joint Disease </li></ul><ul><li>Gout </li></ul><ul><li>Gallstones and Kidney Stones </li></ul><ul><li>Gastric Reflux </li></ul><ul><li>Sleep apnea </li></ul><ul><li>Increased surgical risks </li></ul><ul><li>Depression </li></ul>
    24. 27. Morbidity Of Obesity <ul><li>Obstetric Implications – increase risk of </li></ul><ul><ul><li>PIH/Pre-eclampsia </li></ul></ul><ul><ul><li>C/S rate </li></ul></ul><ul><ul><li>Gestational Diabetes </li></ul></ul><ul><ul><li>Macrosomia </li></ul></ul><ul><ul><li>Twins (DC/DA) </li></ul></ul><ul><ul><li>Neural Tube Defects </li></ul></ul><ul><ul><li>Long term implications for fetus/child </li></ul></ul>
    25. 28. Morbidity Of Obesity <ul><li>Obstetric Implications </li></ul><ul><li>Gynecologic Implications </li></ul><ul><ul><li>Infertility </li></ul></ul><ul><ul><li>Menstrual Irregularities </li></ul></ul><ul><ul><li>Ovulation problems </li></ul></ul><ul><ul><li>Reproductive Cancers </li></ul></ul><ul><ul><li>Metabolic Syndrome </li></ul></ul>
    26. 30. Obesity in Native Children Zephier et al. Arch Pediatric Adolesc Med 2006;160:34-39
    27. 31. Albuq. Journal 2/9/05
    28. 32. Etiology of Obesity <ul><li>Obesity is a problem of Energy Regulation </li></ul><ul><li>Balance of calories consumed (CI) and calories expended (CE) </li></ul><ul><li>If </li></ul><ul><ul><li>CI –CE <0 weight is lost </li></ul></ul><ul><ul><li>CI – CE = 0 weight is stable </li></ul></ul><ul><ul><li>CI – CE > 0 weight is gained </li></ul></ul>
    29. 33. Etiology of Obesity <ul><li>Obesity is the manifestation of genes and environment </li></ul><ul><li>Obesity is a complex disorder of appetite regulation and energy metabolism </li></ul><ul><li>The obesity phenotype is expressed in a permissive society </li></ul>
    30. 34. Gene Effect Environmental Effect Monogenic Syndromes Obesity Susceptible Genes Stress Exercise Food Intake Culture
    31. 35. Gene Effect Environmental Effect Monogenic Syndromes Obesity Susceptible Genes Stress Exercise Food Intake Culture Less than 3% of Type III obese children
    32. 36. Etiology <ul><li>Humans evolved in an environment of subsistence existence </li></ul><ul><li>Certain ethnic groups may have a “thrifty” gene </li></ul><ul><li>There is no limit to the </li></ul><ul><li>body’s ability to store </li></ul><ul><li>fat </li></ul>
    33. 37. Impact of Reproductive Hormones <ul><li>High Risk Events for Weight Gain </li></ul><ul><ul><li>Pre-menstrual cravings </li></ul></ul><ul><ul><li>Pregnancy </li></ul></ul><ul><ul><li>Lactation </li></ul></ul><ul><ul><li>Perimenopausal </li></ul></ul><ul><li>Affect Preference for Macronutrients </li></ul><ul><li>Affect Activity Levels </li></ul><ul><li>Gynecoid versus Android Distribution </li></ul>
    34. 38. Obesity in the Maternity Clinic
    35. 39. Environmental Effects <ul><li>Culture – probably more acquired habit than truly culture </li></ul><ul><li>Food Intake – choices and portion size </li></ul><ul><li>Exercise – work or pleasure </li></ul><ul><li>Stress – comfort foods </li></ul>
    36. 40. Culture <ul><li>Ethnic foods and developed tastes </li></ul><ul><ul><li>Shift from hunter/gather or farming with increased vegetables and low fat foods to fast food and </li></ul></ul><ul><ul><li>sweet drinks </li></ul></ul>Compher Journal of Transcultural Nursing 2006;17:217-223
    37. 41. Culture <ul><li>Ethnic foods and developed tastes </li></ul><ul><li>Community norms </li></ul><ul><ul><li>Big (obese) children are healthy </li></ul></ul><ul><ul><li>Food is key to community/family </li></ul></ul><ul><ul><li>functions and expectation to </li></ul></ul><ul><ul><li>eat large amounts or one is </li></ul></ul><ul><ul><li>being rude </li></ul></ul><ul><ul><li>Loss of expectation of </li></ul></ul><ul><ul><li>activity </li></ul></ul>Doshi et al. Jour of Women’s Health 2006;15:919
    38. 42. Culture <ul><li>Ethnic foods and developed tastes </li></ul><ul><li>Community norms </li></ul><ul><li>Socioeconomic factors </li></ul><ul><ul><li>Healthy foods cost </li></ul></ul><ul><ul><li>Fresh food not available </li></ul></ul><ul><ul><li>Remote locations </li></ul></ul><ul><ul><li>WIC often uses “surplus” </li></ul></ul><ul><ul><li>foods </li></ul></ul>Curran et al. Health Ed Research 2005;20:719-719
    39. 43. Culture <ul><li>Ethnic foods and developed tastes </li></ul><ul><li>Community norms </li></ul><ul><li>Socioeconomic factors </li></ul><ul><li>National “norms” </li></ul><ul><ul><li>Native population is </li></ul></ul><ul><ul><li>less impacted by this </li></ul></ul><ul><ul><li>Are susceptible to </li></ul></ul><ul><ul><li>TV advertisement </li></ul></ul>
    40. 44. Anglo women internalize the current standard of female beauty
    41. 45. Motivators for Native Women <ul><li>Being “Skinny” not valued </li></ul><ul><li>Avoiding diabetes is important </li></ul><ul><li>Being accepted/supported by family and community </li></ul>Doshi et al. Journal of Women’s Health 2006;15:919
    42. 46. Societal Stigma of Obesity <ul><li>Obese people can be described in negative terms. This leads to the individual </li></ul><ul><li>Having low self-esteem </li></ul><ul><li>Developing depression </li></ul><ul><li>Becoming hostile </li></ul><ul><li>Being frustrated </li></ul><ul><li>But some cultures see being overweight or obese desirable. </li></ul>
    43. 48. Food Intake
    44. 49. Food Intake
    45. 50. Food Intake
    46. 51. Food Intake
    47. 52. Food Intake <ul><li>Overeating </li></ul><ul><li>Fat Intake </li></ul><ul><li>Carbohydrate and Fiber Intake </li></ul><ul><ul><li>High glycemic index </li></ul></ul><ul><ul><li>Complex carbohydrates </li></ul></ul>
    48. 53. Modifiers in Caloric Intake <ul><li>Satiety is mainly determined by food volume not by calories </li></ul><ul><li>Metabolic “cost” of converting food to body fat is variable: 25% for complex carbohydrates vs. 3% for fats. </li></ul><ul><li>Stored fat has little effect on appetite </li></ul><ul><li>Native populations do not see connection between obesity and health issues </li></ul>
    49. 54. Exercise/Physical Activity <ul><li>Work involves less physical activity </li></ul><ul><li>Obtaining food is less labor intensive </li></ul><ul><li>Recreation involves more spectator activities </li></ul><ul><li>Television </li></ul><ul><li>Computers </li></ul><ul><li>Electronic games </li></ul>
    50. 55. Screening for Obesity <ul><li>Calculate BMI - </li></ul><ul><ul><li>Every 5 years (AHA) </li></ul></ul><ul><ul><li>Key age periods (Institute of Medicine) </li></ul></ul><ul><li>BMI of > 22 at 18yo </li></ul><ul><li>Interval weight gain of 5-10# </li></ul><ul><li>Waist or Waist/Hip Ratio </li></ul><ul><li>Approach from perspective of prevention </li></ul>
    51. 56. Intervention with Positive Screen <ul><li>Determine if patient is receptive to </li></ul><ul><li>intervention. </li></ul><ul><ul><li>If not: Briefly outline potential risks of weight, interventions available, and willingness to help </li></ul></ul><ul><ul><li>If yes: Stress this is a like a chronic illness that will require a multiple facet approach. </li></ul></ul><ul><li>Many do NOT relate obesity to diabetes and do not identify obesity until Type III. </li></ul>Adams et al. Obesity Research 2005;13:146
    52. 57. Evaluation of Obesity - History <ul><li>weight at 18 y.o. and pattern of gain </li></ul><ul><li>family history of obesity </li></ul><ul><li>medications </li></ul><ul><li>review of systems for co-morbidities </li></ul><ul><li>current dietary pattern </li></ul><ul><li>current exercise or physical activity </li></ul><ul><li>current and prior attempt to lose weight </li></ul>
    53. 58. Evaluation of Obesity - Physical <ul><li>Height and weight; Hip and Waist circumferences </li></ul><ul><li>Rule out evidence other endocrine anomalies </li></ul><ul><li>Blood pressure </li></ul><ul><li>Evidence of co-morbidities </li></ul>
    54. 59. Evaluation of Obesity - Labs <ul><li>Cholesterol screen for baseline </li></ul><ul><li>Fasting Blood Sugar </li></ul><ul><li>TSH </li></ul><ul><li>Other testing as indicated by history and physical </li></ul>
    55. 60. Intervention <ul><li>Prevention is key </li></ul><ul><li>Diet modification </li></ul><ul><li>Increased Physical Activity </li></ul><ul><li>Incorporate healthy live styles into culture </li></ul><ul><li>Minimize stress related with intervention </li></ul>
    56. 61. Patient Education <ul><li>Situation is a result of inadequate physical activity for the amount of food ingestion. </li></ul><ul><li>Increases risk of diabetes, cardiovascular disease, ob complications and certain cancers </li></ul><ul><li>Intervention requires regular physical activity. </li></ul><ul><li>Diet should create daily deficit of 500-1000 kcal. </li></ul>
    57. 62. Modifiers of Caloric Expenditure <ul><li>Caloric Expenditure is the sum of: </li></ul><ul><li>Resting Metabolic Rate: 60-75% </li></ul><ul><li>Thermic Effect of Food: 10% </li></ul><ul><li>Thermic Effect of Exercise: 15-30% </li></ul>
    58. 63. Energetics of Weight Loss <ul><li>3500 kcal per pound of fat </li></ul><ul><li>Daily deficit of 500 kcal/day results in 1 pound per week. </li></ul>
    59. 64. Common Diet Strategies <ul><li>Very Low Carbohydrate (50 gm/d) </li></ul><ul><li>Individuals mobilize the CHO stored in body with also a loss of tissue water and minerals. Minimal actual fat loss. </li></ul><ul><li>Quick loss but temporary </li></ul>
    60. 65. Albuquerque Journal 3/5/05
    61. 66. Common Diet Strategies <ul><li>Very Low Fat Diets (Ornish and Pritikin diets) </li></ul><ul><li>Amount of weight loss is related to fat reduction (as a proxy for calories) </li></ul><ul><li>10% decrease can result in 10 # in 6 months </li></ul>
    62. 67. Common Diet Strategies <ul><li>Moderate Fat Diets (40-45 gm/day). </li></ul><ul><li>Carbohydrates are classified by </li></ul><ul><ul><li>Glycemic index (Sugar Busters) </li></ul></ul><ul><ul><li>Balanced reduction (Weight Watchers </li></ul></ul>
    63. 68. Common Diet Strategies <ul><li>High Protein Diets – Atkins and South Beach </li></ul><ul><li>Emphasize high protein intake low carbohydrates. With Atkins there are no fat restrictions. </li></ul>
    64. 69. Albuquerque Journal 1/27/05
    65. 70. Diet Industry <ul><li>Over 5 billion a year in non-prescription therapies </li></ul><ul><li>Most promise large weight loss in a short time – exercise optional </li></ul><ul><li>Others resort to diuretics and eating disorders </li></ul><ul><li>Aids to achieving the perfect body - </li></ul>
    66. 71. Promised in 30 days or money back
    67. 72. My personal favorite – Wash away your blues and your pounds.
    68. 73. Key Aspect of Dietary Change <ul><li>Life style change not a temporary modification </li></ul><ul><li>Diet implies you go off and do not maintain </li></ul><ul><li>Portion Size </li></ul><ul><li>Selection of food types </li></ul>
    69. 74. Increase Physical Activity <ul><li>Assess current activity level </li></ul><ul><li>Identify activities that are enjoyed </li></ul><ul><li>Match activities to patient’s ability </li></ul><ul><li>Set reasonable goals </li></ul><ul><li>Make a daily activity </li></ul>
    70. 75. Barriers to Physical Activity <ul><li>Community expectation </li></ul><ul><li>Weather </li></ul><ul><li>Safety – narrow roads, dogs, snakes </li></ul><ul><li>Time – demands of family </li></ul><ul><li>Lack of support from family </li></ul><ul><li>No community sponsored activities </li></ul>Doshi and Jiles. Journal of Women’s Health 2006;15:919 Thompson et al. Women and Health. 2002;36:59-74
    71. 76. Increase Physical Activity <ul><li>Promote increased energy expenditure </li></ul><ul><li>Formal exercise vs. increased daily activity </li></ul><ul><li>Balance intensity with duration </li></ul><ul><li>Provides benefits even without appreciable weight loss </li></ul><ul><li>Can increase lean body mass </li></ul><ul><li>Strive for 150 minutes/wk </li></ul>
    72. 77. Medications <ul><li>Appetite Suppressants </li></ul><ul><ul><li>Antihistamines </li></ul></ul><ul><ul><li>Amphetamines </li></ul></ul><ul><ul><li>Sibutramine </li></ul></ul><ul><li>Antidepressants </li></ul><ul><li>Lipase Inhibitors </li></ul><ul><li>Increase Energy Expenditure (caffeine and Ephedrine) </li></ul><ul><li>Peptides (e.g. Leptin) </li></ul>
    73. 78. Pharmacologic Treatment Summary <ul><li>All medications promote modest weight loss, which may significantly reduce diabetes mellitus and cardiovascular risk factors. </li></ul><ul><li>No head-to-head trials of comparative efficacy exist to suggest differences in efficacy. </li></ul><ul><li>Side effect profile differs among drugs and probably drives the choice of agent on an individual basis. </li></ul>
    74. 79. Obesity Surgery Summary <ul><li>Bariatric procedures result in: </li></ul><ul><ul><li>greater sustained weight loss than nonsurgical treatments in very obese individuals (BMI  40) </li></ul></ul><ul><ul><li>improvements in some health outcomes (reduction in diabetes and sleep apnea, improved quality of life) </li></ul></ul><ul><li>Data not conclusive </li></ul><ul><ul><li>suggests greater sustained weight loss from surgery than non-surgical treatment for BMI 35-40 </li></ul></ul>
    75. 80. Surgical Intervention <ul><li>Reserved for morbidly obese (>40 BMI) or less if significant co-morbidities </li></ul><ul><li>Patients refractory to traditional diet, activity, behavior modification and medications </li></ul><ul><li>Surgical mortality </li></ul><ul><li>Long term complications </li></ul>
    76. 81. Principles of Intervention <ul><li>Need to treat as a chronic disease </li></ul><ul><li>Anticipate relapses and multiple treatment cycles </li></ul><ul><li>Do not set goal solely on weight lost </li></ul><ul><li>Emphasize lifestyle changes to minimize regaining </li></ul><ul><li>Discourage extreme diets that promote yo-yo in weight </li></ul>
    77. 82. Traditional Approach to Weight Loss <ul><li>Use conventional health education </li></ul><ul><li>Use internal locus of control </li></ul><ul><li>Environmental resources (paths, parks, playgrounds) still target the individual’s behavior change. </li></ul><ul><li>Weight is considered a personal issue </li></ul>
    78. 83. Principles for Program in AI Population <ul><li>Target Groups not individuals </li></ul><ul><li>Promote social support and collective efficacy </li></ul><ul><li>Friendly competition to affect health behavior change </li></ul><ul><li>Use influence of peers/family on food choices, physical activity and weight management. </li></ul>
    79. 84. Need for Tribal Support <ul><li>Tribes have demonstrated the commitment to group solidarity in historic and contemporary resistance to threats </li></ul><ul><li>Group behavior change holds greater promise for changing social norms and policies than an approach that looks at a group as a collection of individuals. </li></ul>Teufel-Shone Journal of Transcultural Nursing 2006;17:224-229
    80. 85. Promising Strategies in AI Communities <ul><li>Health promotion programs that foster collective self-esteem and common goal. </li></ul><ul><li>Competition in races or other competition </li></ul><ul><ul><li>Weight loss teams </li></ul></ul><ul><ul><li>Long relay walks (100 miles) </li></ul></ul><ul><ul><li>Visible physical activity – competitive dancing </li></ul></ul>Teufel-Shone Journal of Transcultural Nursing 2006;17:224-229
    81. 86. Promising Strategies in AI Communities <ul><li>Health promotion programs that foster collective self-esteem and common goal. </li></ul><ul><li>Competition in races or other competition </li></ul><ul><li>Marketing/promoting healthy foods and habits </li></ul>Teufel-Shone Journal of Transcultural Nursing 2006;17:224-229
    82. 87. Treatment Overview <ul><li>One to two thirds of weight lost is regained in one year and most by five years </li></ul><ul><li>“ Going on a diet” implies eventual stopping </li></ul><ul><li>Potential for doing more physical and psychological harm than benefit - be careful </li></ul><ul><li>Weight comes back at the same rate it came off </li></ul>
    83. 88. Definition of Success <ul><li>Weight loss </li></ul><ul><li>Duration of maintaining loss </li></ul><ul><li>Changes in fat versus fat free mass </li></ul><ul><li>Inches loss </li></ul><ul><li>Improved activity tolerance </li></ul><ul><li>Improvement in comorbid conditions </li></ul>
    84. 89. Obesity and Health <ul><li>Weight reductions of 5 to 7 % of body weight is associated with: </li></ul><ul><ul><li>lower blood pressure </li></ul></ul><ul><ul><li>improved cholesterol </li></ul></ul><ul><ul><li>lower risk of developing diabetes </li></ul></ul>
    85. 90. Prevention of Obesity <ul><li>Maintenance of a normal weight, or weight gain prevention, is important in addressing the obesity problem </li></ul><ul><li>Key element for prevention is caloric balance </li></ul><ul><li>Establish life-long habits for nutrition and physical activity </li></ul>
    86. 91. Conclusion <ul><li>Obesity treatment must involve two components: </li></ul><ul><li>1. Treatment must be a multidisciplinary, culturally appropriate approach as for most chronic diseases </li></ul><ul><li>2. There must be more focus on prevention especially at critical points such as childhood, pregnancy and menopause. </li></ul>
    87. 92. Comments from Audience
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