Obesity the medical practitioner’s essential guide

Robin P. Blackstone

Obesity
The Medical Practitioner’s
Essential Guide

123


Obesity


Robin P. Blackstone

Obesity
The Medical Practitioner’s Essential Guide

123


Robin P. Blackstone
Banner University Medical Center
University of Arizona School
of Medicine – Phoenix
Phoenix, AZ
USA

ISBN 978-3-319-39407-7
DOI 10.1007/978-3-319-39409-1

ISBN 978-3-319-39409-1

(eBook)

Library of Congress Control Number: 2016942485
© Springer International Publishing Switzerland 2016
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The registered company is Springer International Publishing AG Switzerland


Robert N. Pavlich, my father, who should
have lived longer.


Foreword

The world of obesity is still a relatively young world. While some of the treatments
for the disease of obesity have been around for decades, overall, obesity is still a

young disease. Dr. Robin Blackstone phenomenally discusses the current state of
obesity in this book in a very insightful and thoughtful manner. Too often in today’s
literary world, obesity is reduced to statistics, facts, and figures. While these
numbers play an integral role in the discussion of obesity, we often forget that each
number represents a population that on a daily basis faces obstacles such as weight
bias, limited access to care (obesity management and treatment services), oversaturation of harmful and misguided information and more. Dr. Blackstone takes an
in-depth look at these issues and provides readers with a glimpse into the world of
obesity that is often overlooked and ignored.
Weight bias is one of the last acceptable forms of discrimination in today’s
society. Individuals affected by obesity face weight bias in almost all areas of life,
such as employment, education, health care, pop culture, and more. Study after
study shows that weight bias can greatly impact someone’s life and has damaging
effects on their social, mental, and physical well-being. Yet weight bias is still very
prevalent in the world of obesity. We, as a society, need to stand up to weight bias
and put an end to it.
Receiving a diagnosis of obesity can often be a difficult moment for most
individuals. In fact, it is usually not until an individual develops an obesity-related
condition, such as type 2 diabetes, hypertension, or sleep apnea that they would
have had the conversation of weight with their healthcare provider. Even more
troublesome is the extreme limitations on access to care for obesity treatment.
Those battling this disease are often told to “eat less and move more.” And for those
who may be interested in treatment such as behavioral counseling, pharmacotherapy, or bariatric surgery, they will most likely face very limited coverage of obesity
services. Again, this is a clear example of how the world of obesity is so very
different from any other disease state, and Dr. Blackstone clearly recognizes these
differences.

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viii

Foreword

The one place where the world of obesity is most certainly not lacking would be
information. A simple Boolean search for “Obesity and Book” returns more than 51
million hits in a split second. Among the results you will see words like “truth,”
“myth,” “lose,” “guaranteed,” and others. When it comes to searching for information on obesity, information overload is almost a certain fate for any person. In
Dr. Blackstone’s book, she has taken great pride in ensuring that the information she
shares is evidence-based and has stood the test of time. To me, one of the things that
make her book so refreshing is that she knows the world of obesity is an
ever-changing landscape. In fact, she embraces this in a remarkable manner.
As I stated early on, each one of the 93 million Americans affected by obesity is
unique. They are not just simply another number in a statistical fact sheet, and
Dr. Blackstone knows this very important point. While obesity is often reduced to a
scientific level, she recognizes that every person is unique with different struggles in
life.
As President and CEO of the Obesity Action Coalition (OAC), a more than
50,000 member national, nonprofit organization dedicated to helping individuals
affected by obesity, I find Dr. Blackstone’s take on the obesity epidemic refreshing,
enlightening and most of all—human. She has been a pioneer in the field of obesity
treatment and has always advocated for the most important variable in the obesity
epidemic—the patient. I applaud Dr. Blackstone’s efforts and know that she will
continue to pave the way in caring for all individuals affected by the disease of
obesity.
Joseph Nadglowski, Jr.
OAC President and CEO


Preface

As a provider of medical care, regardless of specialty or level of training, 33 % of
your patients are obese and over 60 % are overweight or obese. Within 15 years, it
is projected that 50 % of your patients will be clinically obese. Socially we have
been taught to ignore this fact and try and reach beyond it to interact with the “real
person.” While that is an acceptable, even desirable, approach in a social setting, in
medicine it is devastating. Obesity is the central paradigm of modern disease. It is
the prelude to insulin resistance, high cholesterol, high blood pressure, type 2
diabetes, sleep apnea, and heart disease. If you fail to “see” overweight and obesity
in your patients or to take it into account when treating them, you may stem the tide
of these obesity-related medical problems for a while, but the patient will lose the
battle.
Systematically and with sensitivity, you and your staff must acknowledge the
role overweight and obesity plays in your patients’ health. Helping them to achieve
better health through weight loss and body fat loss will enable you to make all the
other therapies you employ for related disease more effective. It will also strengthen
your relationships with your patients.
This book will educate you about the current state of the science of obesity as a
disease and help you establish a systematic process for recognizing and working
with patients who are overweight or obese. Knowing the facts about the nature of
obesity based upon scientific, peer-reviewed data may require you to suspend your
personal beliefs about obesity. Set aside your preconceived notions, open your
mind, and let us get down to the essential medicine every practitioner should know
for helping this group of patients win this battle.
Robin P. Blackstone

ix


Acknowledgments

With special thanks
Carrie P. Withey, J.D.
Judge Withey helped make the science approachable by providing clarity in the
writing and assistance in copyediting. Her dedication to help people with obesity
and their practitioners understand the material presented was matched by her
superb craftsmanship in creating a professional text. It would have been impossible to complete this project without her help.
Joy C. Bunt, M.D., Ph.D.
Dr. Joy Bunt filtered the content of the rough draft of the book through the lens of
her doctorate in exercise physiology and many years of work with the
NIH/NIDDK section in Phoenix, Arizona working with native peoples affected by
obesity.
Wendy H. Lyons, RN, BSN, MSL
Wendy worked within the healthcare system for many years, starting as a unit
clerk and becoming an RN and the senior Vice President for Community Affairs
for a very large hospital system. She knew first hand the affect and cost of obesity
and provided insight into the writing from this perspective.

xi


Contents

1

2

Epidemiology, Measurement, and Cost of Obesity . . . . . . . .
Obesity in Populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Child and Adolescent Obesity . . . . . . . . . . . . . . . . . . . . . .
Adult Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Obesity Rates Within Minority Groups and Subpopulations . .
Measurement of Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Weight Related Health Indicators (WRHI). . . . . . . . . . . . . .
Surveys of Health Status in the United States . . . . . . . . . . .
Healthcare Costs: The Impact of Obesity
and Obesity-Related Disease . . . . . . . . . . . . . . . . . . . . . . . . .
Social, Future, and Personal Cost of Obesity . . . . . . . . . . . .
Implementing Specific Process for Chapter 1 Recommendations.
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Prejudice, Discrimination, and the Preferred Approach
to the Patient with Obesity . . . . . . . . . . . . . . . . . . . . . . .
The Patient’s Perspective. . . . . . . . . . . . . . . . . . . . . . . . . .
Discrimination, Prejudice, and Weight Stigma . . . . . . . . . . .
Creating a Culture of Safety for the Patient with Obesity .
The Current Healthcare Environment Is Prejudiced
Against People with Obesity . . . . . . . . . . . . . . . . . . . . . . .
Changing the Current Healthcare Environment from Biased
to Blameless . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The Blame Game: Why Blame the Patient for Their Obesity
When We Do not Blame Them for Their Allergies,
High Cholesterol, Hypertension, or Cancer?. . . . . . . . . . . . .
Inability or Unwillingness to Overcome Bias Against Obesity
and Its Effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
How Obesity Bias Negatively Affects Medical Care
and Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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xiv

Contents

The Importance of Communicating the Measurement
and Identification of Obesity of All Patients
Within a Healthcare System. . . . . . . . . . . . . . . . . . . . . . . . .
How to Talk with Your Patient About Obesity—The Preferred
Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The Expression of Empathy. . . . . . . . . . . . . . . . . . . . . . .
The Development of Discrepancy. . . . . . . . . . . . . . . . . . .
Implementing Specific Process for Chapter Two
Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
For Staff and Colleagues . . . . . . . . . . . . . . . . . . . . . . . . .
For Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Physical Environment of the Workplace . . . . . . . . . . . . . .
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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The Biology of Weight Regulation and Genetic ResettingTM . . .
The Canary in the Coal Mine . . . . . . . . . . . . . . . . . . . . . . . . . .
The Pima Story . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Research Results: The NIH/NIDDK and the PIMA. . . . . . . . . .
Fetal Programming . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Application of Research Results to Other Populations . . . . . . . .

Calories in Do Not Equal Calories Out . . . . . . . . . . . . . . . . . . . .
The Brain: The Control Center. . . . . . . . . . . . . . . . . . . . . . . . . .
Neuroanatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Genetic ResettingTM: Setting the Stage for Obesity . . . . . . . . . . . .
The Double Helix—The Human Genome . . . . . . . . . . . . . . . .
Epigenetics and Epigenetic Modification (Genetic ResettingTM) .
Imprinting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Intergenerational Metabolic Programming . . . . . . . . . . . . . . . .
Interactome Networks in Human Disease: Obesity . . . . . . . . . .
The Gut Brain Axis (GBA): Signals from the Gut to the Brain . . .
The Microbiome and Microbiota . . . . . . . . . . . . . . . . . . . . . .
Why Eat? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hormone Signals to the Brain . . . . . . . . . . . . . . . . . . . . . . . .
Taste—Not All in Your Mouth . . . . . . . . . . . . . . . . . . . . . . .
Ghrelin: The “I’m Hungry” Hormone . . . . . . . . . . . . . . . . . . .
Glucagon-Like Peptide-1 (GLP-1) . . . . . . . . . . . . . . . . . . . . .
Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Cognitive Function and Glucose-Related Signaling . . . . . . . . . .
Signaling Through the Nervous System. . . . . . . . . . . . . . . . . . . .
The Sympathetic Nervous System (SNS). . . . . . . . . . . . . . . . .
Parasympathetic Nervous System: The Vagus Nerve. . . . . . . . .
The Second Brain: The Enteric Nervous System (ENS). . . . . . .
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Contents

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5

The Biology of Adipose Tissue. . . . . . . . . . . . . . . . . . . . . . . . .
Adipose Tissue: Energy Storage and Endocrine Signaling . . . . . . .
The Development of Adipose Tissue . . . . . . . . . . . . . . . . . . . . .
The Structure of Adipose Tissue . . . . . . . . . . . . . . . . . . . . . . . .
The Adipocyte . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Brown Adipose Tissue (BAT) . . . . . . . . . . . . . . . . . . . . . . . .
White Adipose Tissue (WAT) . . . . . . . . . . . . . . . . . . . . . . . .
Macrophages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Extracellular Matrix (ECM) . . . . . . . . . . . . . . . . . . . . . . . . . .
Adipose Tissue Blood Flow and Innervation . . . . . . . . . . . . . .
Lipogenesis and Lipolysis: How Fat Is Stored
and How It Is Used For Energy . . . . . . . . . . . . . . . . . . . . . . . . .
The Tipping Point: Inflammation and Adipose Tissue Dysfunction .
Hypoxia and Inflammation in White Adipose Tissue. . . . . . . . . . .
Adipokines: Leptin and Adiponectin . . . . . . . . . . . . . . . . . . . . . .
Leptin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Leptin Resistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Adiponectin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Obesity-Related Diseases and Syndromes: Insulin Resistance,
Type 2 Diabetes Mellitus, Non-alcoholic Fatty Liver Disease,
Cardiovascular Disease, and Metabolic Syndrome . . . . . . . . . . . .
Insulin Resistance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
How to Assess a Patient for Insulin Resistance . . . . . . . . . . . . . .
Mechanisms of Insulin Resistance . . . . . . . . . . . . . . . . . . . . . . .
Inflammation and Insulin Resistance. . . . . . . . . . . . . . . . . . . . . .
Impaired Fasting Glucose (IFG), Impaired Glucose Tolerance (IGT),
and Prediabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Type 2 Diabetes Mellitus (T2DM) . . . . . . . . . . . . . . . . . . . . . . . . .
Metabolic Syndrome. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Non-Alcoholic Fatty Liver Disease (NAFLD), Steatohepatitis (NASH)
and Cirrhosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The Role of Microbiota, Intestinal Dysbiosis,
and Metabolic Endotoxemia in NAFLD . . . . . . . . . . . . . . . . . . .
Obesity-Related Cardiovascular Disease . . . . . . . . . . . . . . . . . . . . .
The Obesity Paradox . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dyslipidemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Atherosclerosis, Coronary Heart Disease (CHD),
and Heart Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Contents

Atrial Fibrillation and Stroke .
Heart Failure . . . . . . . . . . . .
Conclusion . . . . . . . . . . . . . . .
References. . . . . . . . . . . . . . . .
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Obesity-Related Diseases and Syndromes: Cancer,
Endocrine Disease, Pulmonary Disease, Pseudotumor Cerebri,
and Disordered Sleep . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Obesity and Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Mechanisms of Cancer Growth and Promotion in Patients
with Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Obesity and Breast Cancer . . . . . . . . . . . . . . . . . . . . . . . . .
The Challenge of Diagnosing and Treating Cancer
in the Patient with Obesity . . . . . . . . . . . . . . . . . . . . . . . . .
Obesity and Endocrine Disease . . . . . . . . . . . . . . . . . . . . . . . .
Obesity and Thyroid Hormones . . . . . . . . . . . . . . . . . . . . . .
Obesity and Polycystic Ovarian Syndrome . . . . . . . . . . . . . .
Obesity and Infertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Obesity and Pulmonary Disease . . . . . . . . . . . . . . . . . . . . . . . .
Abnormalities of Pulmonary Function . . . . . . . . . . . . . . . . . .
Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Obesity Hyperventilation Syndrome . . . . . . . . . . . . . . . . . . .

Venous Thromboembolic Disease. . . . . . . . . . . . . . . . . . . . .
Obesity and Pseudotumor Cerebrii . . . . . . . . . . . . . . . . . . . . . .
Disordered Sleep . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Circadian Rhythm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Sleep . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Owl or Lark?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Insomnia and Stress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Obstructive Sleep Apnea . . . . . . . . . . . . . . . . . . . . . . . . . . .
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Pediatric Obesity . . . . . . . . . . . . . . . . . . .
Scope of the Epidemic . . . . . . . . . . . . . . . .
Genetic Influence on Childhood Obesity . . . .
Types of Childhood Obesity . . . . . . . . . . . .
Common Obesity . . . . . . . . . . . . . . . . . .
Syndromic Obesity . . . . . . . . . . . . . . . . .
Non-syndromic Obesity . . . . . . . . . . . . .
Clinical Consequences of Childhood Obesity .
Disordered Sleep . . . . . . . . . . . . . . . . . .

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Contents

xvii

Respiratory Problems in Children with Obesity . . . . . .
Gastrointestinal Problems in Children with Obesity . . .
Endocrine Disorders in Children with Obesity . . . . . . .
Clinical Assessment of Children with Overweight/Obesity .
Biobehavioral Susceptibility Model of Child Obesity . . . .
Treatment Recommendations for Children with Obesity . .
Stage 1: Prevention Plus . . . . . . . . . . . . . . . . . . . . . .
Stage 2: Structured Weight Management . . . . . . . . . . .

Stage 3: Comprehensive Multidisciplinary Program . . .
Stage 4: Tertiary Care. . . . . . . . . . . . . . . . . . . . . . . .
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8

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162
162

Fundamentals of Diet, Exercise, and Behavior Modification
Food and Digestion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Digestion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Recommended Mechanics of Eating . . . . . . . . . . . . . . . . .
Calories and Kilocalories. . . . . . . . . . . . . . . . . . . . . . . . .
Macronutrients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Reading a Food Label. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Energy Expenditure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Energy Expenditure: Basal Metabolic Rate (BMR) . . . . . . .
Energy Expenditure: Thermal Effect of Food (TEF) . . . . . .
Energy Expenditure: Thermogenesis
(Exercise and Physical Activity). . . . . . . . . . . . . . . . . . . .
Mental Health in the Bariatric Population . . . . . . . . . . . . . . .
Specific Psychiatric Disorders Related to Obesity:
Depression and Anxiety . . . . . . . . . . . . . . . . . . . . . . . . .
Food Addiction: Science or Silly? . . . . . . . . . . . . . . . . . .
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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The Assessment of the Adult Patient with Overweight
and Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The Health History . . . . . . . . . . . . . . . . . . . . . . . . . . .
Historical Survey of Weight Gain and Loss . . . . . . . .
Family History of Obesity and Related Disease . . . . .
Medications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dietary History . . . . . . . . . . . . . . . . . . . . . . . . . . .
Stress Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Circadian Patterns . . . . . . . . . . . . . . . . . . . . . . . . .
Disordered Sleep Analysis. . . . . . . . . . . . . . . . . . . .
Lifestyle, Cultural, and Occupational Factors . . . . . . .
Physical Activity . . . . . . . . . . . . . . . . . . . . . . . . . .
Obesity-Related Disease . . . . . . . . . . . . . . . . . . . . .

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xviii

Contents

Psychosocial and Psychiatric History . . . . . . . . . . . . .
Surgical History . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Allergies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Review of Systems. . . . . . . . . . . . . . . . . . . . . . . . . .
Physical Assessment of Patients with Obesity
and Related Diseases . . . . . . . . . . . . . . . . . . . . . . . . . .
Anthropometrics. . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pattern of Body Fat Distribution . . . . . . . . . . . . . . . .
Vital Signs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
General Observation . . . . . . . . . . . . . . . . . . . . . . . . .
Head, Eyes, Ears, Nose and Throat. . . . . . . . . . . . . . .
Chest and Breast Exam . . . . . . . . . . . . . . . . . . . . . . .
Abdomen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Extremities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Neurologic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pelvic and Anorectal Exam . . . . . . . . . . . . . . . . . . . .
Skin, Trunk, and Extremities . . . . . . . . . . . . . . . . . . .
Determination of Metabolic Factors . . . . . . . . . . . . . . . .
Resting Metabolic Rate . . . . . . . . . . . . . . . . . . . . . . .
Body Composition Analysis . . . . . . . . . . . . . . . . . . .
Diagnostic Tests for Obesity-Related Disease. . . . . . . .
Conclusion: The Summary Assessment Based on History,
Physical Exam and Diagnostic Testing . . . . . . . . . . . . . .
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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10 Beyond Traditional Management: The Use of Medications
in the Treatment of Obesity . . . . . . . . . . . . . . . . . . . . . . .
The Use of Medications for the Treatment of Other Medical
Problems in Patients with Obesity . . . . . . . . . . . . . . . . . . . .
Medications that Cause Weight Gain . . . . . . . . . . . . . . . .
Medications for Use as Weight Loss Medications. . . . . . . . . .

Historical Perspective of Weight Loss Medications . . . . . . .
Indications for the Use of Prescription Medications
in a Patient with Obesity . . . . . . . . . . . . . . . . . . . . . . . . .
Medications Currently Approved for the Treatment of Obesity.
Phentermine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Lorcaserin (Belviq). . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Liraglutide (Saxenda) . . . . . . . . . . . . . . . . . . . . . . . . . . .
Orlistat (Xenical, Alli) . . . . . . . . . . . . . . . . . . . . . . . . . .
Phentermine/Topiramate (Qnexa, Qsymia) . . . . . . . . . . . . .
Naltrexone SR/Bupropion SR (NB) (CONTRAVE) . . . . . .
Nutraceuticals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Medications as Related to Bariatric Surgery. . . . . . . . . . . . . .
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Contents

xix

11 Bariatric Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
National Accreditation in Metabolic and Bariatric Surgery. . . . .
Indications/Contraindications for Surgery. . . . . . . . . . . . . . . . .
Mechanism of Action of MBS . . . . . . . . . . . . . . . . . . . . . . . .
Epigenetic Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Enteroplasticity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Changes in Reward Pathways . . . . . . . . . . . . . . . . . . . . . .
Changes in Energy Expenditure . . . . . . . . . . . . . . . . . . . . .
Metabolic and Bariatric Surgery: Procedures and Devices . . . . .
Laparoscopic Roux-en Y Gastric Bypass (LRYGB) . . . . . . .
Laparoscopic Sleeve Gastrectomy (LSG). . . . . . . . . . . . . . .
Laparoscopic Adjustable Gastric Band (LAGB) . . . . . . . . . .
Duodenal Switch/Biliopancreatic Diversion (DS/BPD) . . . . .
Gastric Balloon (GB) and the Vagal Blocking
Device (VBLOC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Variability in Response to Metabolic and Bariatric Surgery:
Weight Regain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Cholecystectomy After Metabolic and Bariatric Surgery . . . . . .

Prehabilitation: Preoperative Assessment and Preparation . . . . .
Education and Informed Consent . . . . . . . . . . . . . . . . . . . .
Physical Assessment for Surgery . . . . . . . . . . . . . . . . . . . .
Social and Psychological Health Assessment Prior to Surgery
Enhanced Recovery After Metabolic and Bariatric Surgery . . . .
Preoperative Prehabilitation . . . . . . . . . . . . . . . . . . . . . . . .
Perioperative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Postoperative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Health Maintenance After Metabolic and Bariatric Surgery . . . .
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12 Population Health Management of Obesity . . . . . . . . . .
Barriers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Accurate Measurement of Obesity Is Essential . . . . . . . .
Politicizing Obesity Prevents Action . . . . . . . . . . . . . . .
Prevention Versus Recognition and Treatment
of Existing Disease. . . . . . . . . . . . . . . . . . . . . . . . . . .
The Epidemic of Obesity Is a Social Disease . . . . . . . . . . .
A New Paradigm: Management of Obesity, not Acceptance
of Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Recognition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Measure Every Patient, Every Time . . . . . . . . . . . . . . .
Communicate Level of Risk to Each Patient . . . . . . . . .
Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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xx

Contents

Engagement. . . . . . . . . . . . . . . . . .
Keys to Personal Engagement . . .

Risk Groups in the New Paradigm . .
Measuring Value . . . . . . . . . . . . . .
Population Health and Public Policy .
Conclusion . . . . . . . . . . . . . . . . . .
References. . . . . . . . . . . . . . . . . . .

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Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

327


Chapter 1

Epidemiology, Measurement, and Cost
of Obesity

Key Message
Obesity currently affects 78.6 million people (33 %) in the United States and is

expected to increase to over 50 % of the population by 2030. The epidemic is
fueled by the growing rate of obesity in adolescents of 17 %. Healthcare systems
have the responsibility to provide care to this burgeoning group of people.
Accurate measurement and tracking of a patient’s BMI is critical. As a screening
tool it may identify patients with a BMI of 25 kg/m2 and above who are classified as
overweight and are at risk for progression of weight and obesity-related disease.
Identification of this group of people presents a tremendous opportunity to reverse the
progression of obesity with traditional and less expensive methods of weight loss
and control such as diet and exercise. Patients in the overweight BMI group (25.0–
29.9 kg/m2) have generally not yet experienced amplification of their obesity through
genetic resetting™. Current research proves that keeping a patient in the overweight
range or bringing a patient to a lower BMI from the obese range will stave off
obesity-related disease and save billions of dollars in direct and indirect cost.
This chapter will describe the preferred clinical method of accurately measuring
obesity using Weight Related Health Indicators (WRHI), which should include
BMI, waist circumference, and body fat percentage. The WRHI should be measured and recorded for every patient at every visit and become part of the patient's
ongoing educational and monitoring process. Currently there is no scalable system
in place to cope with the demand for treatment or the cost. The stakes are high. The
annual cost is $305 billion with $190 billion going to the direct cost of treatment of
related disease. A universal platform that employs regular, ongoing measurements
of WRHI for every patient at every health care visit will allow a scalable system to
be put in place to recognize the development of overweight and obesity and to
provide timely opportunities to treat the burgeoning epidemic at its earliest stages.

© Springer International Publishing Switzerland 2016
R.P. Blackstone, Obesity, DOI 10.1007/978-3-319-39409-1_1

1

2

1 Epidemiology, Measurement, and Cost of Obesity

Learning Objectives
1. Summarize the impact of the prevalence rates of obesity in the adult, childhood,
adolescent, and minority populations
2. Describe ways to measure obesity accurately and their relationship to predicting
incidence of disease
3. Implement the Weight Related Health Indicators (WRHI): height, weight, BMI,
BMI for age with Z Score for children/adolescents, waist circumference, and
body fat percentage for all patients seen in the practice
4. Develop an understanding of direct and indirect costs related to obesity
Currently, 30 % of the world’s population is overweight or obese. By 2020, it is
estimated that over 60 % of the world’s population will be overweight or obese.
Estimates suggest that the prevalence of severe obesity in 2030 will be 11 %,
roughly twice the current prevalence [1].
Obesity disproportionately affects minorities, single mothers, and lower
socioeconomic groups. In addition, the rate of obesity within the adolescent age
group is escalating [2].
Obesity occurs on a continuum from “overweight” to “clinically severe obesity.”
The higher a patient’s BMI rises, the higher the risk becomes that the patient will
develop obesity-related diseases. Similarly, the severity of the obesity-related diseases increases as BMI rises. BMI values are clinically related to risk (Table 1.1).
Accurate measurement and tracking of a patient’s BMI is critical as it provides a
screening tool to identify patients with a BMI of 25 kg/m2 and above, who are
classified as overweight and are at risk for progression of weight and obesity-related
disease. Identification of this group of people presents a tremendous opportunity to
reverse the progression of obesity with traditional methods of weight loss and
control such as diet and exercise. This is because patients in the overweight BMI
Table 1.1 Classification of overweight and obesity by body mass index (BMI), waist

circumference, and associated disease risks
BMI
(kg/m2)

Underweight
Normal**
Overweight
Obesity

<18.5
18.5–24.9
25.0–29.9
30.0–34.9
35.0–39.9
! 40.0

Obesity
class

I
II
III

Disease risk* relative to normal weight and waist
circumference
Men 102 cm ( 40 in.)
Men >102 cm (>40 in.)
women 88 cm ( 35 in.) women >88 cm (>35 in.)
–
–

Increased
High
Very high
Extremely high

–
–
High
Very high
Very high
Extremely high

Extreme
obesity
From CDC/NHS Health, United States 2014, Fig. 11, Table 64
*Disease risk for type 2 diabetes, hypertension, and coronary heart disease
**Increased waist circumference can also be a marker for increased risk even in persons of normal
weight. Reprinted from National Institutes of Health and National Heart, Lung, and Blood
Institute, 1998


1 Epidemiology, Measurement, and Cost of Obesity

3

group (25.0–29.9 kg/m2) have generally not yet experienced amplification of the
“genetic reset™.” Current research proves that keeping a patient in the overweight
range or bringing a patient to a lower BMI from the obese range will stave off
obesity-related disease and save billions of dollars in direct and indirect cost [1].
Once a patient gains weight, the environment begins to impact their genes and

changes the way the genes work to control their weight. As the BMI exceeds 30,
their “genetic reset™” generally starts to become apparent as a resistance to weight
loss, and as the patient continues to gain weight they reach a point of no return. The
concept of “genetic reset™” is explained in detail in Chap. 3 The Biology of Weight
Regulation and Genetic Resetting™. Amplification of the genetic reset™ is a
critical tipping point for the patient, because the genetic reset™ greatly
reduces the patient’s ability to reverse or control clinically severe obesity and
its related diseases by traditional methods. In fact, almost the opposite is true:
once the amplification of the genetic reset™ has occurred, the clinically severely
obese patient tends to maintain his or her weight or add additional weight, despite
“normal” eating patterns and concerted attempts at traditional methods of weight
loss. Research shows that the group of patients with a BMI of 40+ has shown the
most rapid growth, and this group has the highest risk for and highest severity of
obesity-related disease [3].
As we examine the epidemiology, the method of measurement and cost of
obesity in this chapter, four statistical terms are necessary to understand the data
presented: incidence, prevalence, QALY, and DALY. Incidence and prevalence are
often used interchangeably, however, they have important distinguishing characteristics in regard to the groups of people included.
INCIDENCE is the number of newly diagnosed cases of a disease divided by the
population at risk. The population-at-risk is all the persons in the population who do
not have the disease at the beginning of the observation period but who are capable
of developing the disease. Incidence answers the question: How many people per
year newly acquire this disease [4]?
PREVALENCE is the number of people in the population with the disease at a
given point in time divided by the total population. Prevalence answers the question: How many people have this disease right now [4]?
QALY (Quality-Adjusted Life Year) measures the value of a specific intervention in economic terms. Health is assigned a value from 1.0 (fully healthy) to 0
(death) multiplied by the time an individual spends in that status (Fig. 1.1). In
general an effective intervention benchmark is $50,000 per QALY [5].
DALY (Disability-Adjusted Life Years) is a health gap measure. The DALY
measures the gap between the current health status caused by a disease in terms of

premature death and disability and the ideal situation that exists when a person lives
to life expectancy free of disease and disability. It is the sum of years of life lost
(YLL) to premature mortality plus years lived with disability (YLD) [6].
These four statistical terms are important to a medical practitioner’s understanding of obesity and obesity-related disease.


4

1 Epidemiology, Measurement, and Cost of Obesity

Fig. 1.1 Quality-adjusted life years (QALY) (from />t050602.pdf)

Obesity in Populations
Child and Adolescent Obesity
Forty years ago if a child was considered to be a little “pudgy,” the prevailing
wisdom among doctors and parents was that the child would “grow out of it,” and
they often did. Times have changed. Experts believe that 110 million children and
adolescents are now affected by obesity [7]. The prevalence of obesity in children
and adolescents is 17 %. Even in early childhood the incidence of obesity is high.
Studies show that for children entering kindergarten 14.9 % are overweight and
another 12.4 % are obese. By eighth grade 17 % are overweight and 20.8 % are
obese. Overweight 5-year olds are more likely to become obese adolescents.
Minority children and children from lower socioeconomic families are disproportionately affected. However, ALL groups between kindergarten and eighth grade
show significant increases in their prevalence of obesity: 65 % in Caucasian children, 50 % in Hispanic children, 120 % in Black children, and 40 % among
children of other races (Asian, Pacific Islander, Native American, and multiracial).
The wealthiest 20 % of families have the lowest prevalence of obesity (7.8 %) than
any other quintiles of socioeconomic status. The two poorest quintiles have a
prevalence of 13.8 and 16.5 % [8].
Despite these sobering statistics, many pediatricians are reluctant to measure and
share BMI information with parents and/or the affected children. The reluctance to

measure and share this clinically relevant data as part of all routine pediatric
examinations is a failure as medical providers to help the family understand and
address any overweight issues that may exist. This reluctance can have devastating
long-term effects because we fail to identify, educate, and help children who have
not yet been genetically reset to favor obesity. They still present as prime candidates


Obesity in Populations

5

to reverse their trend to obesity, particularly when the parents still have the ability to
control their children’s diet and activities. Teaching children the value of weight
maintenance as a part of normal healthy living is essential even if it is a tough
conversation to have with parents and kids. The failure to measure and monitor
every child’s BMI and to encourage and assist the child and the child’s parents in
addressing any overweight issues sets the child up for an uninformed and
defenseless progression to obesity and disease.
The effects of childhood and adolescent obesity are having a negative impact in
many ways. Based on 2013 data, current average life expectancy is 78.8 years in the
United States: 76.4 for men and 81.2 for women [9]. Life expectancy, however, for
future generations is expected to decrease due to the prevalence of childhood obesity
and related disease [10]. In addition, the incidence of obesity rates in adolescents
(17 %) will have a profound impact on the development of talent for future businesses of all types. Obesity stigma often prevents young people from realizing their
full potential. For example, 50 % of applicants to the United States Military fail to
qualify for admission due to high BMI. Indeed, many young people will be disabled
by obesity-related disease at an early age, thereby reducing their productive years of
work. It is estimated that 10 % of children with type 2 diabetes will develop renal
failure by young adulthood [11]. Every study of obesity-related mortality makes
clear that children who are obese have the most years of life to lose.

In subsequent chapters, we will explore in detail the effects of fetal programming
and effects of genetic resetting™ with weight gain on childhood and adolescent
obesity. The epigenetics of obesity are becoming clear: parents who are obese pass
down inheritable physiology to their children. That inheritable physiology is part of
what “resets” the child’s own genetic expression, which in turn predisposes the
child to obesity and type 2 diabetes. Through inheritable epigenetics the incidence
of obesity becomes cyclical and increasingly prevalent with each generation.

Adult Obesity
Although the prevalence of obesity appears to be roughly stable in adults, population
growth is not. This means the overall number of people with overweight, obesity and
related disease is increasing dramatically. The population is estimated to grow from
310 million in 2010 to 439 million in 2030 with a prevalence rate of 42 % for
obesity. It is projected that by 2050, over 157 million people will be obese and
almost as many will be overweight [12]. In addition, the population is becoming
increasingly urbanized with the global urban population growing by 65 million a
year. Urbanization reduces daily energy expenditure by 300–400 calories, which in
turn increases the population’s risk of becoming overweight and obese [13].
Over the past 30 years, the population of overweight and obese adults (BMI of 25
or greater) has increased (Fig. 1.2). In 1980, 28.8 % of men were overweight and/or
obese. By 2013 it was 36.9 %. Similarly, in 1980 29.8 % of women in the U.S. were
overweight and/or obese. By 2013 it was 38 % of women. The World Health


6

1 Epidemiology, Measurement, and Cost of Obesity

Fig. 1.2 a Obesity trends among U.S. adults, BRFSS, 1990 (from />transcripts/t050602.pdf) b Prevalence of self-reported obesity among U.S. adults by state and
territory, BRFSS, 2013 (from />

Obesity in Populations

7

Organization (WHO) estimates that, in the year 2010, overweight and obesity caused
3.4 million deaths (5 %), and resulted in 3.9 % of YLL and 3.8 % of disability
adjusted life years (DALY) worldwide. No country in the world reduced the
prevalence of obesity-related disease between 2000 and 2013. Obesity ranks third
in social burdens created by human beings after smoking and armed violence [14].

Obesity Rates Within Minority Groups and Subpopulations
Statistics bear similarly alarming news for specific subgroups of populations. For
example, groups of young adults age 20–44 years, Black and Hispanic subpopulations and subpopulations with secondary education or less all showed an increase
in their prevalence of obesity and type 2 diabetes [15] (Fig. 1.3).

Native Americans
Native Americans are another such subpopulation. Similar to the increase in the
population at large, the overall population of Native Americans is expected to
experience large growth relative to their current numbers. It is estimated their
populations will increase from 235,000 in 2010 to 918,000 in 2050, with a correlating increase in their rates of obesity and type 2 diabetes [12].

Baby Boomers
The United States has experienced dramatic growth in the number of older people
during this century. As a result, the aging population presents major implications
for national health care needs. By 2030, 25 % of United States residents will be age
65 or older (1 in 5) due to the aging of the “baby boomers” i.e., people born
between 1946 and 1964 [12]. Women represent a significant subgroup within the
baby boomer population. In 2003–2004, the obesity rate among women aged
60 years and older was 31.5 %. Six years later, in 2010–2012 that rate increased to

38.1 % [2].

Gender
When it comes to obesity and type 2 diabetes in general, a gender gap appears to
exist between men and women. Women are more affected by obesity than men in
most countries, but in some countries that gap is more pronounced. In Egypt, for
example, the prevalence of obesity in men is 21 % as compared to Egyptian women
at 45 %. In the United States black women (57.5 %) are far more affected by
obesity than black men (38.1 %) [14].


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1 Epidemiology, Measurement, and Cost of Obesity

Fig. 1.3 a Prevalence of self-reported obesity among hispanic adults, by state, BRFSS, 2011–
2013 (from b Prevalence of self-reported
obesity among non-hispanic black adults, by State, BRFSS, 2011–2013 (from />obesity/data/table-non-hispanic-black.html)