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Beyond BMI –Beyond BMI –
New Perspectives onNew Perspectives onObesityObesityVirend K. Somers MD, PhDVirend K. Somers MD, PhD
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ObesityObesity
• De%ined by the (!O)NI! as an ecess o%De%ined by the (!O)NI! as an ecess o%body %at percenta"e o% *body %at percenta"e o% *
+ - men+ - men
+ /- women+ /- women
• Body %at percenta"eBody %at percenta"e variesvaries important$yimportant$yaccordin" to se, a"e and race.accordin" to se, a"e and race.
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BMI
(ei"hthei"ht
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Bac&"ro'ndBac&"ro'ndObesity De%initionObesity De%inition
• 5$inicians and epidemio$o"ists o%ten5$inicians and epidemio$o"ists o%tenre$y on body mass inde 2BMI4 tore$y on body mass inde 2BMI4 to
dia"nose obesitydia"nose obesity
• BMIBMI 6ow 1 7 89.- &")m6ow 1 7 89.- &")m,, Norma$ 1 89.- : ;.< &")mNorma$ 1 89.- : ;.< &")m,,
Overwei"ht 1 - : <.< &")mOverwei"ht 1 - : <.< &")m,,
Obese 1 /3 : /<.< &")mObese 1 /3 : /<.< &")m,, =treme$y obese 1=treme$y obese 1 ++ ;3 &")m;3 &")m,,
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BMI >dvanta"esBMI >dvanta"es
• Simp$e and reprod'cib$eSimp$e and reprod'cib$e
• >ssociated with cardiovasc'$ar 25V4>ssociated with cardiovasc'$ar 25V4ris& %actors ris& %actors
• 6ow and hi"h BMI are associated6ow and hi"h BMI are associatedwith increased morta$ity and 5Vwith increased morta$ity and 5Veventsevents
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Do yo' &now yo'r BMI#Do yo' &now yo'r BMI#
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BMI Disadvanta"esBMI Disadvanta"es Obesity ParadoObesity Parado
0$e"a$, K. M. et a$. JAMA 33?. @omero:5orra$, >. et a$. Lancet 33A.
enera$enera$
Pop'$ationPop'$ation5>D5>D
Pop'$ationPop'$ation
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@es'$ts@es'$ts
• Cnderwei"ht*Cnderwei"ht* BMI 27 34 stron"$y associatedBMI 27 34 stron"$y associatedwith an increased $on":term morta$ity and otherwith an increased $on":term morta$ity and other5V events.5V events.
• Overwei"ht*Overwei"ht* BMI 2BMI 2++- – <.<4 associated with- – <.<4 associated withbetter s'rviva$ and %ewer 5V events.better s'rviva$ and %ewer 5V events.
• Obese*Obese* BMI /3, not si"ni%icant$y associatedBMI /3, not si"ni%icant$y associatedwith $on":term morta$ity and other 5V events inwith $on":term morta$ity and other 5V events inpatients with 5>D.patients with 5>D.
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Possib$e =p$anationsPossib$e =p$anations
• 6ow BMI*6ow BMI*
O$der patientsO$der patients
5ancer and other co:morbidities5ancer and other co:morbidities
6ow $ean mass and hi"h body %at6ow $ean mass and hi"h body %at
• =$evated BMI*=$evated BMI*
Fo'n"er Fo'n"er
Better treatment#Better treatment#
Preserved or increased $ean mass ratherPreserved or increased $ean mass rather thanthanecess in body %atecess in body %at
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5onc$'sions5onc$'sions
• Mechanisms 'nder$yin" this apparent$yMechanisms 'nder$yin" this apparent$yparadoica$ re$ationship are 'nc$ear, b'tparadoica$ re$ationship are 'nc$ear, b'tthey may re$ate to the de%inition o% obesitythey may re$ate to the de%inition o% obesity
itse$%itse$% 2BMI42BMI4 • BMI 'nab$e to di%%erentiate between B0 BMI 'nab$e to di%%erentiate between B0
and $ean m'sc$e massand $ean m'sc$e mass
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New Perspectives on ObesityNew Perspectives on Obesity
• BMI and the obesity paradoBMI and the obesity parado
• !ow "ood is BMI in dia"nosin" obesity#!ow "ood is BMI in dia"nosin" obesity#
• Imp$ications o% centra$ obesityImp$ications o% centra$ obesity
• Does s$eepin" $ess ma&e 's %at#Does s$eepin" $ess ma&e 's %at#
• Mana"ement o% the hi"h ris& obeseMana"ement o% the hi"h ris& obesepatientpatient
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ObGectiveObGective
• >ssess the>ssess the dia"nostic per%ormancedia"nostic per%ormance o%o%BMIBMI in detectin" ecess in B0 inin detectin" ecess in B0 in
patients with 5>Dpatients with 5>D H..+ - in men.+ - in men.
+ /- in women.+ /- in women.
Dia"nostic Per%ormance*Dia"nostic Per%ormance* Sensitivity,Sensitivity,
Speci%icity, corre$ation coe%%icients betweenSpeci%icity, corre$ation coe%%icients between
BMI and both, B0 and 6M.BMI and both, B0 and 6M.
H B0 estimated 'sin" air disp$acement p$ethysmo"raphy
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MethodsMethods
• > cross:sectiona$ desi"n o%> cross:sectiona$ desi"n o% 8/,A388/,A38 s'bGectss'bGects2a"e 3:?<.< years ;9 men4 %rom the Jhird2a"e 3:?<.< years ;9 men4 %rom the JhirdNationa$ !ea$th and N'trition =aminationNationa$ !ea$th and N'trition =amination
S'rvey 2N!>N=S III4.S'rvey 2N!>N=S III4.
• Bioe$ectrica$ impedance ana$ysis was 'sedBioe$ectrica$ impedance ana$ysis was 'sed
to estimate B0 and 6M. !ei"ht and wei"htto estimate B0 and 6M. !ei"ht and wei"htmeas'rements were 'sed to ca$c'$ate BMImeas'rements were 'sed to ca$c'$ate BMI2&")m2&")m,,4.4.
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Body 0at vs. 6ean MassBody 0at vs. 6ean Mass
@omero:5orra$, >. et a$. Int J Obes (Lond) 339.
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38A S'perbow$ : Denver Broncos38A S'perbow$ : Denver Broncos
388 M0M=@ L s$ide: 388 M0M=@ L s$ide:
8989
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5onc$'sions5onc$'sions
• Obesity de%ined as a BMIObesity de%ined as a BMI ++ /3 &")m/3 &")m missesmissesmore than ha$% more than ha$% o% the patients with 5>D witho% the patients with 5>D withrea$ B0 :obesity.rea$ B0 :obesity.
• >$tho'"h BMI had a "ood corre$ation with>$tho'"h BMI had a "ood corre$ation withB0 it a$so had aB0 it a$so had a "ood corre$ation with"ood corre$ation with$ean mass$ean mass..
• In men BMI corre$ated better with $ean massIn men BMI corre$ated better with $ean mass
than with B0 whi$e in women BMIthan with B0 whi$e in women BMIcorre$ated better with B0 than $ean mass.corre$ated better with B0 than $ean mass.Jhis mi"ht ep$ain theJhis mi"ht ep$ain the better dia"nosticbetter dia"nosticper%ormance o% BMI in womenper%ormance o% BMI in women..
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5onc$'sions5onc$'sions
• BMI %ai$s to discriminate between %atBMI %ai$s to discriminate between %atmass and $ean mass in the CSmass and $ean mass in the CSpop'$ation, has a poor dia"nosticpop'$ation, has a poor dia"nostic
per%ormance and poor associationper%ormance and poor associationwith adverse events.with adverse events.
• Other meas'res that discriminateOther meas'res that discriminatebetween %at mass and $ean mass,between %at mass and $ean mass,especia$$y those acco'ntin" %or centra$especia$$y those acco'ntin" %or centra$obesity 2e" (!@4 are needed.obesity 2e" (!@4 are needed.
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Variabi$ity o% B0Variabi$ity o% B0in Peop$e within Peop$e with
BMIBMI - &")m- &")m
@an"e* 8/.9 to /-./ @an"e* A. to ;.9
@omero:5orra$, >. et a$. Int J Obes (Lond) 339.
2n 1 -;4 2n 1 -;4
---- AA33 8989
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!ypotheses!ypotheses
• S'bGects considered to have norma$S'bGects considered to have norma$body wei"ht based on BMI, co'$d sti$$body wei"ht based on BMI, co'$d sti$$
have a hi"h body %at 2B04 contenthave a hi"h body %at 2B04 content• NNorma$orma$ ((ei"htei"ht OObesity,besity, N(ON(O
• N(ON(O s'bGects have a hi"her preva$ences'bGects have a hi"her preva$enceo% metabo$ic syndrome ando% metabo$ic syndrome andcardiometabo$ic dysre"'$ationcardiometabo$ic dysre"'$ation
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De%initionsDe%initions
• NNorma$orma$ ((ei"htei"ht OObesitybesity
• Norma$ BMI 1 89.-:;.<Norma$ BMI 1 89.-:;.< &")m&")m
• B0 B0 + 3+ 3 menmen+ /3+ /3 womenwomen
• Metabo$ic SyndromeMetabo$ic Syndrome• >JP III criteria>JP III criteria
• Jraditiona$ 5V ris& %actorsJraditiona$ 5V ris& %actors• Dys$ipidemia 2N5=P >JP:III4, !JN 2N5 ?4, DM 2>D>4,Dys$ipidemia 2N5=P >JP:III4, !JN 2N5 ?4, DM 2>D>4,
smo&in", 5VD 2MI stro&e4smo&in", 5VD 2MI stro&e4
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Preva$ence o% N(OPreva$ence o% N(O
• -?.--?.- in men andin men and -/.--/.- in womenin women
(ei"hted preva$ences(ei"hted preva$ences
-/.
A8.;
?3.;
A8.;
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Dose @esponseDose @esponse
H >dG'sted %or a"e and race
Se:Speci%ic $owest 'arti$e 'sed as the re%erence
HH HH
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N(O and Metabo$ic SyndromeN(O and Metabo$ic Syndrome
[email protected] 28.3 : .9;4
HH Odds ratio adG'sted %or a"e and raceOdds ratio adG'sted %or a"e and race
[email protected] 28.8A : .;4
HO@18./9 28.3 : 8.9?4
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N(O and Metabo$ic SyndromeN(O and Metabo$ic Syndrome
[email protected] 28.A : -.3<4
HH Odds ratio adG'sted %or a"e and raceOdds ratio adG'sted %or a"e and race
[email protected] 2-.;A : ?./4
HO@18.?? 28.89 : .?4
[email protected] 28.3? : .;A4
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N(O and 5V Morta$ityN(O and 5V Morta$ity
M=NM=N (OM=N(OM=NBody %at 7 3Body %at 7 3
Body %at + 3Body %at + 3
2N(O42N(O4
Body %at 7 /3Body %at 7 /3
Body %at + /3Body %at + /3
2N(O42N(O4
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5o'tinho JE6opeQ:
imeneQ 0, >55
38
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Disc'ssionDisc'ssionMain 0indin"sMain 0indin"s
• 8 o't o% s'bGects8 o't o% s'bGects with a norma$ BMI has anwith a norma$ BMI has anecess in B0ecess in B0 2N(O42N(O4
• ;- mi$$ion >mericans ;- mi$$ion >mericans
• N(ON(O associated with cardiometabo$icassociated with cardiometabo$icdysre"'$ation 2MetS4dysre"'$ation 2MetS4
• CnawareCnaware o% increased ris& d'e to theiro% increased ris& d'e to their
norma$ BMInorma$ BMI
• N(ON(O mi"ht be re$ated to increased 5Vmi"ht be re$ated to increased 5Vmorta$ity, especia$$y womenmorta$ity, especia$$y women
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New Perspectives on ObesityNew Perspectives on Obesity
• BMI and the obesity paradoBMI and the obesity parado
• !ow "ood is BMI in dia"nosin" obesity#!ow "ood is BMI in dia"nosin" obesity#
• Imp$ications o% centra$ obesityImp$ications o% centra$ obesity
• Does s$eepin" $ess ma&e 's %at#Does s$eepin" $ess ma&e 's %at#
• Mana"ement o% the hi"h ris& obeseMana"ement o% the hi"h ris& obesepatientpatient
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New Perspectives on ObesityNew Perspectives on Obesity
• BMI and the obesity paradoBMI and the obesity parado
• !ow "ood is BMI in dia"nosin" obesity#!ow "ood is BMI in dia"nosin" obesity#
• Imp$ications o% centra$ obesityImp$ications o% centra$ obesity
• Does s$eepin" $ess ma&e 's %at#Does s$eepin" $ess ma&e 's %at#
• Mana"ement o% the hi"h ris& obeseMana"ement o% the hi"h ris& obesepatientpatient
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5entra$5entra$vs.vs.
Non:centra$ obesityNon:centra$ obesity
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Viscera$ >dipose Jiss'eViscera$ >dipose Jiss'e
• -:8- o% tota$ body %at-:8- o% tota$ body %at• More metabo$ica$$y activeMore metabo$ica$$y active
than s'bc'taneo's %atthan s'bc'taneo's %at
• >ssociated with hi"her>ssociated with hi"herpreva$ence o%preva$ence o%cardiovasc'$ar andcardiovasc'$ar andmetabo$ic ris& %actorsmetabo$ic ris& %actorsand disordersand disorders
Ve"a et a$., 5$in =ndocrino$ Metab 33AVe"a et a$., 5$in =ndocrino$ Metab 33AMahabadi et a$., ='r !eart 33<Mahabadi et a$., ='r !eart 33<
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BMI vs. (!@BMI vs. (!@
F's'%, S. Lancet 33-/AA*8A;3:<.
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9:wee&s
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• Do'b$e b$inded @andomiQed contro$$edDo'b$e b$inded @andomiQed contro$$edtria$tria$
• $ean hea$thy h'mans$ean hea$thy h'mans
• @andomiQation : 8 5ontro$*; ainers@andomiQation : 8 5ontro$*; ainersVisit
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0$ow Mediated Vasodi$atation0$ow Mediated Vasodi$atation
Image at baseline
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5 min
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(image acquisition)
5orretti, M5 et a$. JACC 33
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5ase =amp$e5ase =amp$e
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=ndothe$ia$ Dys%'nction by Jerti$es o% Viscera$=ndothe$ia$ Dys%'nction by Jerti$es o% Viscera$0at ain in the 0at ain ro'p0at ain in the 0at ain ro'p
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Potentia$ MechanismsPotentia$ Mechanisms
• Viscera$ %at acc'm'$ation may ca'seViscera$ %at acc'm'$ation may ca'seincrease in BP thro'"h "reater secretion o%*increase in BP thro'"h "reater secretion o%*
• > third %actor may drive increases in both> third %actor may drive increases in bothviscera$ %at and BPviscera$ %at and BP
• !P> ais activation!P> ais activation
0@==:0>JJF
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New Perspectives on ObesityNew Perspectives on Obesity
• BMI and the obesity paradoBMI and the obesity parado
• !ow "ood is BMI in dia"nosin" obesity#!ow "ood is BMI in dia"nosin" obesity#
• Imp$ications o% centra$ obesityImp$ications o% centra$ obesity
• Does s$eepin" $ess ma&e 's %at#Does s$eepin" $ess ma&e 's %at#
• Mana"ement o% the hi"h ris& obeseMana"ement o% the hi"h ris& obesepatientpatient
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Increase o% Me$atonin and Ind'ction o% S$eep by Dar&ness
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S$eep Deprivation Ind'ced by theS$eep Deprivation Ind'ced by theIn%ormation !i"hwayIn%ormation !i"hway
2388 S$eep in >merica Po$$ %rom the NS042388 S$eep in >merica Po$$ %rom the NS04
• Jwo thirds o% en F 28< to < yrs4 and oneJwo thirds o% en F 28< to < yrs4 and onethird o% en 'se a socia$ networ&in" sitethird o% en 'se a socia$ networ&in" sitebe%ore bedbe%ore bed
• Peop$e who tet be%ore bed 2ha$% o% en F4Peop$e who tet be%ore bed 2ha$% o% en F4are more $i&e$y to be s$eepy and driveare more $i&e$y to be s$eepy and drivewhi$e drowsywhi$e drowsy
• ? o% 83 Brits are tweetin", po&in", s'r%in"? o% 83 Brits are tweetin", po&in", s'r%in"and writin" on wa$$s at ni"ht instead o%and writin" on wa$$s at ni"ht instead o%"oin" to s$eep 2Jrave$od"e S'rvey)raham"oin" to s$eep 2Jrave$od"e S'rvey)rahamones4ones4
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RATINGS OF HUNGER AND APPETITE
p level % changeHUNGER (cms) 6.0 ± 0.5 7.2 ± 0.4 <0.01 +24%GLOBAL APPETITE (cms) 39.7 ± 3.0 47.7 ± 3.4 0.010 +23%
AFTER 2 DAYS OF4-H BEDTIME
AFTER 2 DAYS OF10-H BEDTIME
GLOBALAPPETITE
HUNGER
9 11 13 15 17 19 21
CLOCK TIME
3.5
5.5
7.5
22
32
42
52
Spiegel et al, Ann Int Med, 141 (2004), 846-850
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• Simp$e randomiQation strati%ied by "ender to s$eepin"Simp$e randomiQation strati%ied by "ender to s$eepin" ad libad libor red'ction in time in bed byor red'ction in time in bed by 88 ) )//
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New Perspectives on ObesityNew Perspectives on Obesity
• BMI and the obesity paradoBMI and the obesity parado
• !ow "ood is BMI in dia"nosin" obesity#!ow "ood is BMI in dia"nosin" obesity#
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•Mana"ement o% the hi"h ris& obeseMana"ement o% the hi"h ris& obesepatientpatient
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@eco"nition, Dia"nosis and@eco"nition, Dia"nosis and
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• n 1 A? random$y se$ected patients dischar"edn 1 A? random$y se$ected patients dischar"ed
a%ter MI, between 8)8)38 and 8)/8)3a%ter MI, between 8)8)38 and 8)/8)3
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@es'$ts@es'$ts
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New Perspectives on ObesityNew Perspectives on Obesity
• BMI and the obesity paradoBMI and the obesity parado
• !ow "ood is BMI in dia"nosin" obesity#!ow "ood is BMI in dia"nosin" obesity#
• Imp$ications o% centra$ obesityImp$ications o% centra$ obesity
• Does s$eepin" $ess ma&e 's %at#Does s$eepin" $ess ma&e 's %at#
• Mana"ement o% the hi"h ris& obeseMana"ement o% the hi"h ris& obesepatientpatient
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“ “
Can Johnny come out and eat?” Can Johnny come out and eat?”
>c&now$ed"ements>c&now$ed"ements
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"• 0rancisco 6opeQ:imeneQ, M.D.0rancisco 6opeQ:imeneQ, M.D.
•Prachi Sin"h, Ph.D.Prachi Sin"h, Ph.D.
• 0atima !. Sert:K'niyoshi, Ph.D.0atima !. Sert:K'niyoshi, Ph.D.
•Jhais 5o'tinhoJhais 5o'tinho
• >be$ @omero:5orra$, M.D.>be$ @omero:5orra$, M.D.
• Diane =. Davison, @.N.Diane =. Davison, @.N.
•Michae$ D. ensen, M.D.Michae$ D. ensen, M.D.
•>ndy 5a$vin, M.D.>ndy 5a$vin, M.D.
•Naima 5ovassin, Ph.D.Naima 5ovassin, Ph.D.
• Virend K. Somers, M.D., Ph.D.Virend K. Somers, M.D., Ph.D.
0'ndin"*0'ndin"* Nationa$ Instit'tes o% !ea$thNationa$ Instit'tes o% !ea$th
>merican !eart >ssociation>merican !eart >ssociation
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Jhan& yo'Jhan& yo'