Taking a Weight off Health Care Systems

Arya M. Sharma, MD/PhD, FRCPC

Scientific DirectorCanadian Obesity Network

Professor and Chair in Obesity Research & ManagementUniversity of Alberta

Medical DirectorAlberta Health Services Provincial Obesity Strategy

Vital Statistic: Waist Circumference

Sharma AM, 1995

Overweight

Obesity in Canada

1985 2010

30% 60%Obese 20%6%

Severely Obese1% 6%

Statistics Canada 2010

Obesities are heterogeneous complex disorders of multiple etiologies characterized by excess body fat that threatens or affects socioeconomic, mental or physical health

Sharma 2007

After covariate adjustment, the hospitalization and physician costs were respectively 40% and 22% higher

among obese and overweight adults than among normal-weight adults.

2008 Cost of Obesity in Australia estimated at $ 58 Billion

Cost of Obesity in Canada?

58 Billion / 20 Million x 33 Million =

$ 95 Billion!

www.drsharma.ca

All interventions affect 15-50 year olds except the lastwhich is for all ages 15-100yr

England’s predicted future Health Service costs based on either no action or reductions in adult BMI

0

2

4

6

88

Annual Costs£Billion

22.2

20.9

19.7

18.4

17.1

2009 2019 2029 2039 2049 2059

Reduction in BMI units

BMI All ages Cap at 30;50% effective

20+yrs: BMI -4 units

No Action

Childhood prevention

6-10 yrs

2004 2014 2024 2034 2044

1049

654

240

-164

-366

38

1453

Year

Ann

ual c

osts

£ M

illio

nsAnnual Diabetes Costs in England with Different Obesity Prevention Strategies

http://www.bis.gov.uk/foresight/our-work/projects/current-projects/tackling-obesities

Transport, Mobility &

Patient Safety

Wound and Skin Care

Personal Hygiene

Instrumentation

Provider Safety

Sensitivity

Exercise & Physical Therapy

Bariatric Care

Nursing

Medicine

Physiotherapy

Occupational Therapy

Exercise

Nutrition

EMS

Transportation Services

Can we Change Weight Bias in Health Professionals?

Behaviour

Overeating

Undermoving

What?

Biology

Culture

Environment

Psychology

Why?

Bias & Stigma éBias & Stigma ê

Sharma AM, 2011

Societal influencesIndividual psychology

Biology

Activity environment

Individual activityFood

ConsumptionFood Production

June 20, 2011June 20, 2011

Why Obesity is More About Calories In than Out

Number of Kcal you can burnburn in a minute

Number of Kcal you can eat or drink in a minute

~5 Kcals>500 Kcals

Our Genes Have Changed!

Depression and Appetite

Addictions

Protection

BMI and Body Fat

DXA scan of two individuals with the same BMI but markedly different percent body fat

European South Asian

Yajnik CS, Lancet. 2004 Jan 10;363(9403):163.

Yudkin & Yainik, Lancet 2004

Edmonton Obesity Staging System (EOSS)

Stage 0

Sharma AM & Kushner RF, Int J Obes 2009

Stage 1

Stage 2

Stage 3

Stage 4

co-morbidity

moderate

moderate

Obesity

EOSS Predicts Mortality in NHANES III

Padwal R, Sharma AM et al. CMAJ 2011

EOSS Predicts Mortality at Every Level of BMINHANES III

Padwal R, Sharma AM et al. CMAJ 2011

Overweight

EOSS Distribution Across BMI CategoriesNHANES III (1988-1994)

15%

28%

47%

10%

5%

17%

64%

14%

Class II

8%

19%

59%

14%

Class I

5%14%

67%

14%EOSS Stage 0EOSS Stage 1EOSS Stage 2

Overweight

ClassIII

Padwal R, Sharma AM et al. CMAJ 2011

50 million

23 million

10 million

6 million

Isn’t Obesity Simple?

EnergyIn

EnergyOut

+/- +/-

Energy Regulation is Complex!

Diet Exercise

Sharma AM 2007

Genetics

Phases of Obesity Treatment

Phase I(Weight Loss)

3-6 months

Phase II(Weight-Loss Maintenance)

Indefinitely

When you stop treatment,the disease comes back!

Wei

ght

www.drsharma.ca

Treatment Success

Years

Lifestyle (LS) ~ 3-5%

LS+Surgery ~ 20-30%

LS+Pharmacotherapy ~ 5-15%

www.drsharma.ca

-8

-6

-4

-2

0

0 1 2 3 4

Wei

ght C

hang

e (k

g)

Years from Randomization

Placebo

Metformin

Lifestyle

Diabetes Prevention StudyMean Weight Change

The DPP Research Group, NEJM 346:393-403, 2002

1 2 3 4

Risk reduction for Type 2 Diabetes:

• Metformin: 31% • Lifestyle: 58%

Common Bariatric Surgical Procedures

AdjustableGastric-Banding

VerticalSleeve-Gastrectomy

Roux-n-YGastric Bypass

www.drsharma.ca

Bariatric Surgery Reduces Mortality in Swedish Obese Subjects (n=2010 vs. 2037)

Sjostrom L et al. NEJM 2007;357:741-52

30% Reduction in All Cause Mortality

Use of Diabetes Medication Before and After Bariatric Surgery (n=2235)

Makary MA et al. Arch Surg 2010;145:726

Surgery resulted in long-term incremental cost–utility ratios of $ <1.000–$40,000 (2009 USD) per quality-

adjusted-life-year compared with non-surgical treatment.

J Gen Intern Med 2011; 26:1183–94

46

Obesity is a Chronic DiseaseRecognize that obesity is a chronicdisease and a root cause of many

other chronic diseases

Obesity care should reflect a chronic disease treatment approach that

is scalable based on patient needs

The service delivery model shouldbe driven by patient needs and

clear clinical objectives

Obesity care should be an integral part of the core health service

delivery system

47

Building the Foundation for Optimal Chronic Disease Management

48

Program Pathway for Coordinating Care

49

Clinical Pathways for Standardization of care

50

Framework for Measuring Success Performance

www.obesitynetwork.ca