Management of Obesity in Women: Current Strategies

Robert Kushner, MDProfessor of Medicine

Northwestern University Feinberg School of Medicine

Clinical Director, Northwestern Comprehensive Center on Obesity

rkushner@northwestern.edu

Disclosures

• Dr. Kushner has served on the Medical Advisory Boards for Amylin, Vivus, Orexigen and Allergan.

• He is the author of Dr. Kushner’s Personality Type Diet and Counseling Overweight Adults: The Lifestyle Patterns Approach and Toolkit

• Genetics• Biology• Environment• Society• Personal

responsibility• Weight gaining

medications

Health care Economics Ecology Diet Physical activity Social networks Stress and emotion

Multiple Determinants of Obesity

Life cycle

Your eight Gain

Weight-Life Events Graph

Your Weight Gain

Weight

Time

Weight Gain – Life Events Graph:Childhood and Adolescence

Childhood & Adolescent Obesity

• Screen time (TV, computer, video games, smart phone)

• Less exercise time during school

• Liquid calories (colas, juices)

• More meals eaten away from home

• Snacking

• Parenting and role modeling

Portion Sizes out of ControlPortion Sizes out of Control

‘Let’s Move’

• Nationwide campaign targeting childhood obesity– Getting parents more informed about nutrition

and exercise– Improving quality of food in schools– Making healthy foods more affordable and

accessible for families– Focusing more on physical education

The Pressure of Beauty Ideals

The Stigma of Obesity

Georgia Billboard Campaign

Relative Risks by BMI at Age 18 Relative Risks by BMI at Age 18

Adapted from Rich-Edwards et al. Adapted from Rich-Edwards et al. Am J Obstet GynecolAm J Obstet Gynecol. 1994;171:171-177.. 1994;171:171-177.

22

1.751.75

1.51.5

1.251.25

11

0.750.75

0.50.51515 2020 2525 3030 3535

44

3.53.5

33

2.52.5

22

1.51.5

11

0.50.5

001515 2020 2525 3030 3535

BMI at Age 18BMI at Age 18 BMI at Age 18BMI at Age 18

RelativeRelativeRiskRisk

RelativeRelativeRiskRisk

ReferenceReference

ReferenceReference

Menstrual Cycle IrregularityMenstrual Cycle Irregularity Primary Ovulatory InfertilityPrimary Ovulatory Infertility

Obesity and Infertility

Weight Gain – Life Events GraphPregnancy

Weight Gain – Life Events GraphPregnancy

Weight Gain – Life Events GraphPregnancy

• Postpartum weight retention

• Obstetric complications– Gestational

diabetes– Hypertension– Eclampsia– Caesarean delivery

• Stillbirth• Shoulder dystocia• Large baby• Shorter breast feeding• Fetal imprinting

– Developmental-origins for long-term risk

• Offspring obesity

Consequences of Maternal Weight Gain

Relationship Between Mother’s Weight and Child’s Risk of Obesity

Maternal BMI 2-yr olds 3-yr olds 4-yr olds

< 18.5 2.5 4.4 4.7

18.5 – 24.9 6.4 7.5 9.0

25 – 29.9 9.0 12.0 14.5

30 – 30.9 13.9 19.7 22.8

≥ 40 19.4 24.0 28.8

% Children Obese

Maternal BMI measured in the first trimester of child’s gestation

Whitaker RC. Pediatrics 2004;114(1): e29-e36

JAMA 2009;302:241

(11 – 20 lbs)

(15 – 25 lbs)

(25 – 35 lbs)

Weight Gain – Life Events GraphMidlife

Weight Gain – Life Events GraphMidlife

WomenWomenn=7018n=7018 <25<25 >>3030

Shortness of breathShortness of breathwalking upstairswalking upstairs 18.418.4 46.446.4

Chronic low back painChronic low back pain 17.817.8 24.724.7

Poor QOL:Poor QOL: Moderate activitiesModerate activities 18.418.4 36.036.0 Bending, kneelingBending, kneeling 20.720.7 48.348.3 Walking 1 blockWalking 1 block 4.54.5 15.415.4

Proportions of subjects, %Proportions of subjects, %

BMIBMI

Impairment of Health and Quality of Life

Lean et al, Arch Intern Med 1999 Lean et al, Arch Intern Med 1999

Prevalence (%) of Comorbidity Prevalence (%) of Comorbidity Among Among WomenWomen by Obesity Class* by Obesity Class*

Weight Status Category (%)†

Under-weight

Normal Over-weight

ObesityClass 1

ObesityClass 2

ObesityClass 3

Health Condition

Type 2 diabetes mellitus

Gallbladder disease

Coronary heart disease

High blood cholesterol

High blood pressure

Osteoarthritis

4.76

6.42

12.0

13.3

19.8

7.79

2.38

6.29

6.87

26.89

23.26

5.22

7.12

11.8

11.1

45.5

38.7

8.51

7.24

15.99

12.56

40.37

47.95

9.94

13.1

19.1

12.3

40.9

54.5

10.3

19.8

23.4

19.2

36.3

63.1

17.1

*N = 7,689.†Estimates are weighted to account for the sample design. Weight categories are based on the NHLBI classification.

(Must A, et al. JAMA. 1999)

0

10

20

30

40

50

60

70

80

90

100

<22 <23 23-23.9 24-24.9 25-26.9 27-28.9 29-30.9 31-32.9 33-34.9 35+0

10

20

30

40

50

60

70

80

90

100

<22 <23 23-23.9 24-24.9 25-26.9 27-28.9 29-30.9 31-32.9 33-34.9 35+

1.01.0 1.51.52.22.2

4.44.46.76.7

11.611.621.321.3

42.142.1

1.01.01.01.02.92.9 4.34.3 5.05.0

8.18.1 15.815.8

27.627.6

40.340.3

54.054.0

93.293.2

Relationship Between BMI and Risk of Type 2 Diabetes MellitusRelationship Between BMI and Risk of Type 2 Diabetes Mellitus

Chan J, et al. Diabetes Care. 1994;17:961-969. Colditz G, et al. Ann Intern Med. 1995;122:481-486.

Chan J, et al. Diabetes Care. 1994;17:961-969. Colditz G, et al. Ann Intern Med. 1995;122:481-486.

Body Mass Index (kg/m2)Body Mass Index (kg/m2)

Ag

e-A

dju

sted

Rel

ativ

e R

isk

Ag

e-A

dju

sted

Rel

ativ

e R

isk

■ Men ● Women■ Men ● Women

Abdominal Obesity Is Associated with Increased Risk of Developing Diabetes

<71[<27.9 in.]

71–75.9[27.9–29.8 in.]

76–81[29.9–31.9 in.]

81.1–86[32–33.9 in.]

86.1–91[34–35.8 in.]

91.1–96.3[35.9–37.9 in.]

>96.3[>38 in.]

24

20

16

12

8

4

0

Rel

ativ

e R

isk

Waist Circumference (cm)

Carey VJ, et al. Am J Epidemiol. 1997;145:614-619.

20-yr Changes in BMI and Waist Circumference Among Women

Data from NHANES completed during yrs 1976 - 2006

Body Mass Index (BMI) Waist Circumference (cm)

Black

White

Total

Hispanic

Kramer H, et al. J Diabetes Complications 2010;24:368-74

Differentiating Fat Depots

Changes in Weight and Body Composition Through the Menopausal Transition

Lovejoy JC et al. International J Obesity 2008;32:949-58

Changes in Hormones and Calories Through the Menopausal Transition

Lovejoy JC et al. International J Obesity 2008;32:949-58

Importance of Measuring Waist Circumference: BMI 25-29.9 (Overweight)

Prevalence, %

Hypertension

Type 2 DM

Hyper-chol

High LDL-C

Low HDL-C

Hyper-TG

Nl WC

23.0

2.7

17.2

19.3

35.3

21.7

High WC

44.8

10.6

26.2

27.2

49.0

36.3

Nl WC

12.3

1.6

19.4

13.6

10.0

10.6

High WC

37.5

10.0

35.2

26.6

15.0

21.8

Men (n=3081) Women (n=2606)

Janssen et al. Arch Intern Med 2002;162:2074-9

0.0

0.5

1.0

1.5

2.0

2.5

Folsom AR et al. Arch Intern Med. 2000;160:2117-2128.

Body Mass Index Tertile

3 2

3

11

2

Rel

ativ

e R

isk

Waist-H

ip R

atio

Tertile

Abdominal Fat Distribution Increases the Risk of Coronary Heart DiseaseThe Iowa Women’s Health Study

0

0.5

1

1.5

2

2.5

3

3.5

4

<20.0 20.0-22.4 22.5-24.9 25.0-27.4 27.5-29.9 30.0-34.9 ≥350

0.5

1

1.5

2

2.5

3

3.5

4

<20.0 20.0-22.4 22.5-24.9 25.0-27.4 27.5-29.9 30.0-34.9 ≥35

P < 0.001P < 0.001

Mu

ltiv

aria

te o

dd

s ra

tio

fo

r fr

equ

ency

of

GE

RD

sym

pto

ms

Mu

ltiv

aria

te o

dd

s ra

tio

fo

r fr

equ

ency

of

GE

RD

sym

pto

ms

●●

●●

●●●●

●● ●●

●●

2.93 (2.24-3.85)2.93 (2.24-3.85) 2.92 (2.35-3.62) 2.92 (2.35-3.62)

2.43 (1.96-3.01)2.43 (1.96-3.01)

2.20 (1.81-2.66)2.20 (1.81-2.66)

1.38 (1.13-1.67)1.38 (1.13-1.67)

0.67 (0.48-0.93)0.67 (0.48-0.93)

Gastroesophageal Reflux and Obese Women

Jacobson BC, et al. N Engl J Med. 2006;354:2340-2348.Jacobson BC, et al. N Engl J Med. 2006;354:2340-2348.

n = 2306 women with symptoms of heartburn, acid regurgitation, or bothn = 2306 women with symptoms of heartburn, acid regurgitation, or both

Body mass indexBody mass index

Association between body mass index and the risk of frequent symptoms of GERD

Association between body mass index and the risk of frequent symptoms of GERD

Obesity and Cancer Mortality Women

1.44

1.46

1.51

1.68

2.12

2.13

2.51

2.76

3.20

4.75

6.25

2.64*

2.51*

1.88*

0 1 2 3 4 5 6 7

Multiple myeloma (≥35)

Colon and rectum (≥40)

Ovary (≥35)

Liver (≥35)

All cancers (≥40)

Non-Hodgkin lymphoma (≥35)

Breast (≥40)

Gallbladder (≥30)

All other cancers (≥40)

Esophagus (≥30)

Pancreas (≥40)

Cervix (≥35)

Kidney (≥40)

Uterus (≥40)

Calle EE et al. N Engl J Med. 2003;348:1625-1638.Calle EE et al. N Engl J Med. 2003;348:1625-1638.

P≤.05, *relative risk for women who never smokedFor each relative risk, the comparison was between women in the highest BMI category and men in the reference category (BMI 18.5 to 24.9)

Relative Risk

Type of cancer

(highest BMI

category)

Current Approaches to Treating Obesity

● Diet, exercise, and behavioral therapy continue to be the mainstays of obesity treatment

● There is limited pharmacotherapy available. When possible, use weight-losing medications when treating co-morbidities

● A 5 – 10% weight loss improves many of the obesity-related metabolic

● Active weight loss and maintenance of lost weight requires ongoing support and use of resources

Waist circumference

Blood pressure

Blood glucose

Triglycerides

HDL-cholesterol

LDL-cholesterol

Insulin resistance

Thrombotic risk

Macronutrients To AddressIndividual Risk Factors

MetabolicSyndrome

DASH

Carbohydrate controlled

Omega–3 Fatty acids

Mediterranean, TLC

Mediterranean

Caloric Reduction

Manson JE et al. Arch Intern Med 2004;164:249-58

Summary

• There are multiple events in a woman’s life that predispose her to weight gain

• The reasons for weight gain at each time point differ – a combination of changing biology, hormonal status and life events

• It is important to implement preventive and treatment strategies to halt further weight gain and the development of ill health

Thank you!