Heart Centre Nursing Education Day - June 10

1. OBESITY: FROM HUNTING AND
GATHERING TO TV AND TAKE OUT
Scott Lear, PhD
Pfizer/Heart & Stroke Foundation Chair in Cardiovascular Prevention Research
at St. Paul’s Hospital
Professor, Faculty of Health Sciences, Simon Fraser University
Member, Division of Cardiology, Providence Health Care
Principal Investigator, Heart and Lung Institute, Providence Health Care

2. Obesity: Definition
 “Excess body fat accumulation that may impair
health”
 Usually measured by body mass index (BMI)
 Adults:
 A person’s body weight in kilograms divided by their
height in meters squared (kg/m2)
 Overweight: BMI 25.0-29.9 kg/m2
 Obese: BMI > 30.0 kg/m2
 Other measures include waist circumference,
waist to hip ratio

3. BMI and Cardiovascular
Disease Mortality
0.6
1.0
1.4
1.8
2.2
2.6
3.0 Men (n=84 376)
Women (n=217 857)
<18.5 18.5-
20-4
20.5-
21.9
22-
23.4
23.5-
24.9
25-
26.4
26.5-
27.9
28-
29.9
30-
31.9
32-
34.9
 35
BMI
Relativeriskofdeath
Never-smokers,
no history of heart disease
Calle EE et al. NEJM 1999; 341:1097-105

4. Obesity
Insulin
Resistance
Type II
Diabetes
Dyslipidemia
Hypertension
Cardiovascular
Disease

5. Health Risks Associated with
Obesity
•Type 2 diabetes
•Gallbladder
diseases
•Dyslipidemia
•Metabolic
syndrome
•Breathlessness
•Sleep apnea
•Cardiovascular
disease
•Hypertension
•Osteoarthritis
•Hyperuricemia,
gout
•Cancer
•Psychosocial
issues
•Reproductive
hormone
abnormalities
•Polycystic ovary
syndrome
•Impaired fertility
•Low back pain
•Fetal defects

6. Is this man obese?
 Weight = 106.8 kg (235
lbs)
 Height = 1.878 m (6’ 2”)
 Body mass index (BMI) =
30.3 kg/m2
 This man is clinically
obese!?!?

7. Body Mass Index and Mortality
Pischon T et al. NEJM 2008; 359:2105.
All-cause mortality based on 359 387 Europeans.
BMI with lowest risk:
Men = 25.3 kg/m2, women = 24.3 kg/m2

8. BMI and Mortality- Is there a
relationship?
Flegal et al. JAMA 2013:309;71.

9. BMI and Mortality in Older Adults
Winter et al. Am J Clin Nut 2014:99;875.

10. Waist to Hip Ratio Increases
Risk of MI Despite Low BMI
Yusuf S et al. Lancet 2005;366:1640.

11. Visceral Adipose Tissue
Subcutaneous Adipose Tissue

12. Fat loss occurs when energy in < energy out.
The Energy Balance
Energy In
Energy Out
Weight Management
Metabolism
Physical activity
Food

13. Meta-analysis of Weight Loss
Miller WC, et al. Int J Obesity 1997;21:941-947.
Variable
(studies)
Diet Only Exercise Only Diet and
Exercise
Weight Loss, kg 10.7 +0.5
(269)
2.9 +0.4
(90)
11.0 +0.6
(134)
Fat Loss, kg 7.8 +0.7
(48)
3.3 +0.5
(40)
9.0 +1.0
(33)
BMI Decrease 4.0 +0.4
(53)
0.8 +0.1
(27)
4.2 +0.4
(43)
Weight Loss at
One Year, kg
6.6 +0.5
(91)
6.1 +2.1
(7)
8.6 +0.8
(54)

14. Caloric Costs of Common
Activities
Activity Kilocalories at 1 hr/5
times/week
Time to Expend 1 kg
Fat (7700 kcal)
Walking Briskly
3 mph
1050 Over 7 weeks
Stationary Bicycling 1500 Over 5 weeks
Resistance Training 900 Over 8 weeks

15. All Calories are Not Created Equal

16. A Model of Connections

17. Perceptions of Causes and
Responsibility of Obesity
Tompson et al. Obesity in the United States: Public Perceptions. Assoc. Press- NORC 2012.

18. PURE Vancouver Communities
Urban
Semi-
Urban
Semi-
Rural
Analysis based on 2681 participants.

19. Measures of Obesity by Region
25
25.5
26
26.5
27
27.5
28
Urban Semi-urban Semi-rural
BodyMassIndex(kg/m2)
79
80
81
82
83
84
85
86
87
88
Urban Semi-urban Sub-urban
Waistcircumference(cm)
p<0.001
p<0.001
Lear SA, et al. Unpublished data from PURE Study.

20. Assessing the Environment

21. Green spaces/parks/public squares (free) Bowling centres
Outdoor skating rinks (free)
Golf courses and country clubs
Skiing facilities
Bicycle Lanes (optional)
One per segment, where present.
Do capture some examples of different bike lane
demarcation.
Small area – record waypoint in middle
Large area – record waypoints at edges
Look for other features of interest on park grounds,
and record additional waypoints where present.
Photograph all park facilities/features.
Public recreational courts (free)
e.g. tennis, basketball courts; skateboard parks;
paved/turf sports areas
Fitness and recreational sports centres ($)
Supermarket and grocery stores Beer, wine and liquor stores
Specialty food stores
Full-service restaurants
Limited-service restaurants
Drinking places (alcoholic beverages)
Convenience stores/general store
Meat or fish/seafood stores/market stores
Fruit and vegetable stores/market stores
Baked goods stores
Confectionary or nut stores
Nutrition related:
Physical Activity
related:
Environment Features

22. Built Environment Features by
Region
Urban Semi-urban Semi-rural
Sport fields 113 163 83
Grocery stores 41 37 9
Convenience stores 93 127 29
Fruit & veg. stores 15 6 3
Full-service restaurants 411 295 40
Fast food restaurants 380 275 64
Community centres 20 21 3
Places of worship 128 118 25
Lear SA, et al. Unpublished data from PURE Study.

23. Mapping Environment Features
Beer by Sachan; Apple & Fast Food by Creative Stall; Cutlery by Pham Thi Dieu Linh
Pub / Liquor Store
Restaurant
Fast Food
Market / Grocery

24. Combine Participants and
Environment Features
Beer by Sachan; Apple & Fast Food by Creative Stall; Cutlery by Pham Thi Dieu Linh
Participant A
500 metres500 metres
Restaurant Density = 3
Fast Food Density = 1
Pub Density = 1

25. Associations with Obesity
Defined by Waist to Hip Ratio
Predictor Variable Odds Ratio 95% CI
Fast Food (500m) 1.05*** 1.02 – 1.08
Bars/Pubs (500m) 1.12** 1.02 – 1.23
Markets (500m) 0.83*** 0.75 – 0.91
Restaurants (500m) 0.98* 0.96 – 0.99
Adjusted for age, sex, socioeconomic status, population density.
6339 participants from three cities in Canada

26. Device Ownership and Prevalence
of Obesity/Diabetes
0
5
10
15
20
25
30
35
0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3
HIC UMIC LMIC LIC
Prevalence(%)
Country Income Level and Device Ownerhsip
**
***
Prevalence of obesity (blue bars) and diabetes (red bars) by cumulative device ownership (television, car and computer).
HIC = high income countries; UMIC = upper middle income countries; LMIC = lower middle income countries; LIC = lower
income countries
* p<0.01 for trend, ** p<0.001 for trend
*
Lear SA, et al. CMAJ 2014:186:258

27. So what can we do?

28. Look AHEAD Trial- Type 2 Diabetes
reduction in risk factors and
advanced kidney disease
Look AHEAD. NEJM 2013; 369:145.

29. Out of Sight (and Reach) Out of
Mind (Mouth)
Wansink B, et al. Int J Obesity 2006:30;871-875.

30. Clean Your Plate??
 Participants assigned
to either regular soup
in bowl or refilling
bowl.
 Those eating from
refilling bowl ate 73%
more calories.
 Assessment of being
full and perceived
caloric consumption
no different.
Wansink B, et al. Obesity Res 2005:13;93-100.

31. Start Your Day Off with a Meal
 Nearly 3000 people (79% women) who lost >30 lbs
for > 1 year from U.S. National Weight Loss
Registry.
Wyat HR, et al. Obesity Res 2002:10;78-82.

32. Early Bird Loses More Weight
 Observational study
of 510 people in
weight loss clinics.
 ‘early eaters’
compared to ‘late
eaters’
 Early eaters lost 5 lbs
more.
Garaulet, et al. Int J Obesity 2013;1-8.

33. We are sitting ourselves to death!!

34. Sitting, even if active, can be
deadly...
Women Men
Patel AV, et al. Am J Epidemiol 2010:172;419-429.
Total Physical Activity (MET-hours/week)
blue <3, red 3-5, green >5 hours sitting per day

35. Time to Stand Up for Our Health!
Dunstan D W et al. Diabetes Care 2012;35:976-983

36. Time to Stand Up for Our Health!
Dunstan D W et al. Diabetes Care 2012;35:976-983.

37. Take Home Message
 Obesity increases the risk for
cardiovascular disease.
 It’s a complex situation with no easy
solutions.
 Weight loss is possible but very
challenging:
 Better to concentrate on healthy lifestyle behaviours and
not weight
 Preventing weight gain or maintaining weight may be best
option

38. Resources
 Canadian Obesity Network
 http://www.obesitynetwork.ca/
 http://www.obesitynetwork.ca/resources
 Weight Watchers
 https://www.weightwatchers.com/ca/en

39. Objectives
 Describe obesity as a risk factor for IHD
 Describe the impact of obesity on IHD
 Describe the long-term outcomes related to
obesity
 Describe current evidence on interventions
to minimize poor outcomes
 List useful resources available to support
nurses in discussing to patients about
weight

40.  We don't need everything to address specifically with PTCA
etc... but the more we can bring it back somewhat to heart
disease the better. We know that obesity is a cardiac risk
factor..so the more we can understand obesity the better we
can help understand our patients and help our patients. As
far as our objective #4, I think this is refering to the
interventions to reduce obesity and therefore minimize
cardiac risk factors. You could simply discuss what you said
that outcomes after interventions is poor. You don't have to
address anything that you don't feel well versed in. I think
even stating that we have to help people with their weight
loss issue before they become obese...in order for them to
have any chance.