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  1. 1. Obesity
  2. 2. What do you think of these people?
  3. 3. Pathophysiology <ul><li>Excess body fat frequently resulting in significant impairment of health </li></ul><ul><li>Overweight vs. Obese </li></ul>
  4. 4. Prevalence <ul><li>30% U.S. adults > 20 yrs. are obese (CDC 2002 using BMI and circumference) </li></ul><ul><li>38% black women, 27% Hispanic women, 21% white women are obese (CDC 2003) </li></ul><ul><li>Students: 14% male, 7% female are overweight (CDC 2002) </li></ul><ul><li>66% U.S. adults are overweight or obese (NHANES 2003-2004) </li></ul><ul><li>Males: 67.3% overweight, 27.5% obese Females: 61.9% overweight, 33.4% obese (JAMA 2001 using BMI) </li></ul>
  5. 5. Obesity and Children <ul><li>17.1% age 2-19 are overweight (CDC 2003-2004) </li></ul><ul><ul><li>Higher rates in Hispanic and black girls </li></ul></ul><ul><li>Girls: 1999-13.8% overweight, 2004- 16%; no significant change in prevalence in women </li></ul><ul><li>1 in 4 overweight children is already showing early signs of Type 2 diabetes, 61% have 1 additional CAD risk factor </li></ul><ul><li>Overweight children are more likely to be overweight as adults </li></ul>
  6. 7. Causes <ul><li>High fat and high calorie diet and physical inactivity are most important factors </li></ul><ul><li>Contributing factors include: hypothalamic, endocrine, genetic disorders </li></ul>
  7. 8. Causes, cont’d <ul><li>Decreased insulin sensitivity </li></ul><ul><li>Increased fasting insulin </li></ul><ul><li>Increased insulin response to glucose </li></ul><ul><li>Decreased growth hormone </li></ul><ul><li>Increased Cholesterol synthesis and excretion </li></ul><ul><li>Decreased hormone-sensitive lipase </li></ul><ul><li>*altered insulin function may be primary mechanism in the etiology and maintenance of obesity </li></ul>Altered Physiological instability of caloric balance includes:
  8. 9. Classification Systems <ul><li>Height Weight Tables </li></ul><ul><ul><li>Obese if one weighs 20% more than desired weight defined by table </li></ul></ul><ul><li>BMI- >27.3 men, >27.8 women at increased risk </li></ul><ul><ul><li>Acceptable range: 20-25 </li></ul></ul><ul><ul><li>Mildly overweight: 25.1-27 </li></ul></ul><ul><ul><li>Moderately overweight/obese: 27.1-30 </li></ul></ul><ul><ul><li>Markedly obese: 30.1-40 </li></ul></ul><ul><ul><li>Morbidly obese: >40 </li></ul></ul>
  9. 10. Classification Systems, cont’d <ul><li>Body Fat Percentage </li></ul><ul><ul><li>Minimal- 5% males, 8% females </li></ul></ul><ul><ul><li>Below avg.-5-15% males, 14-23% females </li></ul></ul><ul><ul><li>Above avg.-16-25% males, 24-32% females </li></ul></ul><ul><ul><li>At risk- >25% male, >32% females </li></ul></ul><ul><li>Phenotype </li></ul><ul><ul><li>Type 1: excess body mass or % body fat </li></ul></ul><ul><ul><li>Type 2: android pattern </li></ul></ul><ul><ul><li>Type 3: excess abdominal visceral fat </li></ul></ul><ul><ul><li>Type 4: gynoid pattern </li></ul></ul>
  10. 11. Classification Systems, cont’d <ul><li>Cell Morphology </li></ul><ul><ul><li>Hypertrophic vs. hyperplastic </li></ul></ul><ul><li>Circumference </li></ul><ul><ul><li>Waist: >102 cm males, >88 cm females </li></ul></ul><ul><ul><li>Waist/hip: >.913 males, >.861 females </li></ul></ul>
  11. 12. Medicine and Management <ul><li>Exercise and physical activity- most important management tactic </li></ul><ul><ul><li>Increase daily activity </li></ul></ul><ul><ul><li>Physical conditioning </li></ul></ul><ul><li>Diet- reduce fat intake and total caloric intake </li></ul><ul><li>Medical techniques- starvation diets, gastroplasties, jejunoileal bypass, jaw wiring, intragastric balloons, fat excision, anti-obesity medications </li></ul><ul><li>Appetite suppressants (stimulation of sympathetic nervous system)- amphetamines, synthetic amines, isoindoles, caffeine. Seratonin uptake inhibitors have been marketed for this purpose but is not approved by the FDA </li></ul>
  12. 13. Effects on Exercise Response <ul><li>Low physical work capacity because of excess weight </li></ul><ul><li>Obesity often occurs with other diseases and confounding influences of those diseases may be involved in exercise testing </li></ul><ul><ul><li>Special attention to exercise blood pressure responses and glucose intolerance </li></ul></ul>
  13. 14. Effects of Exercise Training on Disease <ul><li>Effective in reducing body weight in moderate obesity but may not be as effective in morbidly obese </li></ul><ul><li>Physical activity promotes regional fat loss in abdominal sites; exercise is more efficient in those with android patterning (decreasing abdominal fat decreases the risk for disease) </li></ul>
  14. 15. Effects of Exercise Training on Disease, cont’d <ul><li>Physical activity is the most important factor in maintenance of weight loss </li></ul><ul><li>Exercise training effects on glucose </li></ul><ul><ul><li>Decrease fasting glucose </li></ul></ul><ul><ul><li>Decrease fasting insulin </li></ul></ul><ul><ul><li>Increase glucose tolerance </li></ul></ul><ul><ul><li>Decrease insulin resistance </li></ul></ul>
  15. 16. 2005 Prevalence of Recommended Physical Activity
  16. 17. Recommendations for Exercise Prescription <ul><li>Exercise Testing </li></ul><ul><ul><li>Additional helpful info: weight history (cycling), medical history, motivation and readiness (HRA), nutrition/eating habits, body composition </li></ul></ul><ul><ul><li>*primary objective of testing is exercise prescription, determine physical work capacity for intensity selection </li></ul></ul>
  17. 18. Exercise Programming <ul><li>Prescription must optimize energy expenditure and minimize potential for injury </li></ul><ul><li>Activity must be enjoyable and fit into lifestyle </li></ul><ul><li>Goal of treatment with exercise is to expend more calories, but the approach is debatable </li></ul><ul><li>Total energy expended for an activity includes: expenditure during activity, recovery period (EPOC) </li></ul>
  18. 19. Exercise Programming, cont’d <ul><li>2 shorter sessions vs. 1 longer session </li></ul><ul><li>(higher intensity will have a longer recovery  expend more calories; longer session will effect substrate utilization) </li></ul>
  19. 20. Exercise Programming, cont’d <ul><li>Mode: non-weight bearing if HX of injury, walking, increase ADL, resistance training </li></ul><ul><li>Frequency: daily or minimally 5 days a week </li></ul><ul><li>Duration: 40-60 minutes accumulated per day </li></ul><ul><li>Intensity: 50-70% VO2max </li></ul>
  20. 21. Exercise Programming, cont’d <ul><li>Special Considerations </li></ul><ul><ul><li>Motivation for change (goals and decision/balance sheets) </li></ul></ul><ul><ul><li>Injury prevention (overuse prevention, injury history, warm-up, cool-down, gradual progression, low impact/non-weight bearing, thermoregulation, temperature and humidity, hydration, clothing/footwear </li></ul></ul>