OBESITY: FROM HUNTING AND GATHERING TO TV AND TAKE

OUTScott Lear, PhD

Pfizer/Heart & Stroke Foundation Chair in Cardiovascular Prevention Research at St. Paul’s Hospital

Professor, Faculty of Health Sciences, Simon Fraser UniversityMember, Division of Cardiology, Providence Health Care

Principal Investigator, Heart and Lung Institute, Providence Health Care

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

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

³35

BMI

Rel

ativ

e ris

k of

dea

th

Never-smokers, no history of heart disease

Calle EE et al. NEJM 1999; 341:1097-105

ObesityInsulin

Resistance

Type IIDiabetes

Dyslipidemia

Hypertension

CardiovascularDisease

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

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!?!?

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

BMI and Mortality- Is there a relationship?

Flegal et al. JAMA 2013:309;71.

BMI and Mortality in Older Adults

Winter et al. Am J Clin Nut 2014:99;875.

Waist to Hip Ratio Increases Risk of MI Despite Low BMI

Yusuf S et al. Lancet 2005;366:1640.

Visceral Adipose Tissue

Subcutaneous Adipose Tissue

Fat loss occurs when energy in < energy out.

The Energy Balance

Energy In

Energy Out

Weight Management

MetabolismPhysical activity

Food

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)

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

All Calories are Not Created Equal

A Model of Connections

Perceptions of Causes and Responsibility of Obesity

Tompson et al. Obesity in the United States: Public Perceptions. Assoc. Press- NORC 2012.

PURE Vancouver Communities

UrbanSemi-Urban

Semi-Rural

Analysis based on 2681 participants.

Measures of Obesity by Region

Urban Semi-urban Semi-rural25

25.5

26

26.5

27

27.5

28

Bod

y M

ass

Inde

x (k

g/m

2)

Urban Semi-urban Sub-urban79

80

81

82

83

84

85

86

87

88

Wai

st c

ircum

fere

nce

(cm

)

p<0.001

p<0.001

Lear SA, et al. Unpublished data from PURE Study.

Assessing the Environment

1 segment

1 se

gment

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

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.

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

Combine Participants and Environment Features

Beer by Sachan; Apple & Fast Food by Creative Stall; Cutlery by Pham Thi Dieu Linh

Participant A

500 metres500 metresRestaurant Density = 3Fast Food Density = 1Pub Density = 1

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

Device Ownership and Prevalence of Obesity/Diabetes

0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3HIC UMIC LMIC LIC

0

5

10

15

20

25

30

35

Country Income Level and Device Ownerhsip

Prev

alen

ce (%

)

*****

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

So what can we do?

Look AHEAD Trial- Type 2 Diabetes

reduction in risk factors andadvanced kidney disease

Look AHEAD. NEJM 2013; 369:145.

Out of Sight (and Reach) Out of Mind (Mouth)

Wansink B, et al. Int J Obesity 2006:30;871-875.

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.

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.

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.

We are sitting ourselves to death!!

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

Time to Stand Up for Our Health!

Dunstan D W et al. Diabetes Care 2012;35:976-983

Time to Stand Up for Our Health!

Dunstan D W et al. Diabetes Care 2012;35:976-983.

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

Resources Canadian Obesity Network

http://www.obesitynetwork.ca/

http://www.obesitynetwork.ca/resources

Weight Watchershttps://www.weightwatchers.com/ca/en

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

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.