Obesity Exam 1 – Flashcards
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defining obesity in adults
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BMI = weight (kg)/(height^2) (cm) OR weight (in)/(height^2) (in) X 703 - underweight: < 18.5 - normal weight: 18.5-24.9 - overweight: 25-29.9 - obese: ≥ 30 (class 1: 30-34.9; class 2: 35-39.9; class 3: ≥40)
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current trends (of adult obesity)
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1980: no state w/ adult obesity rate about 15% 2016: 22 states have rates about 30% - massive increase - data is collected by the CDC by using the BRFSS - looking at a map, one is able to see places where obesity tends to be more prevalent - new categories have to keep being created because prevalence keeps increasing - obesity rates have risen from 1960s-2005 but stabilized in 2005-2012 - 2/3rds of adults are overweight or obese - since 1970, prevalence of obesity has more than doubled and prevalence of adult diabetes has increased 5X
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defining obesity in children
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- defined in percentiles since children are always growing - underweight: 95th percentile
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current trends (of childhood obesity)
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- similar trends to adults in % of high school students who are obese - childhood obesity rates have tripled since the 1970s/80s - overall, rates have stabilized over the last 10 years - there are race and ethnicity differences; latino (26%) and Black (24%) rates are higher than Whites (13%) - overall, boys and girls ages 2-19 have similar rates (16% vs. 17%); except in ages 2-5 boys have a higher obesity rate than girls (10% vs. 7%); from ages 6-11, girls have a higher obesity rate than boys (18% - more than doubled - vs. 16%) - usually caused by differences in PA or maturation time
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obesity varies by age, race, and gender
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- among obese adults (ages 20+), female rates (36%) are higher than male obesity rates (33%); usually attributed to PA differences and different eating patterns - adults ages 40-59 (40%) have higher obesity rates than adults ages 20-39 (30%) and ages 60+ (35%) - non-hispanic whites (32.6%) compared to hispanics (42.5%) and non-hispanic blacks (47.8%)
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obese prevalence globally
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- 37% world population is overweight/obese - no country has successfully reduced obesity rate in 33 years (since trend was first observed) except for Cuba's "Special Period" - obesity spreading to developing world - 1 billion overweight worldwide - Asia - The Sleeping Giant - they have lower prevalence rates but rates have risen dramatically in last 20 years (important because of the massive # of people in Asia)
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Cuba's "Special Period"
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- 1989: this country lost Soviet Union as trading partner (because the communist party failed) which forced changed in diet and activity for everyone - this affected the entire island - food rationed because of less imports (fewer animal products, fewer carbs, and less fat) - results: 27% of people lost 10% of body weight; obesity decreased from 11.9% to 5.4%; PA increased from 30% active to 67% active; and deaths from CHD (-35%) and type 2 diabetes (-51%) decreased - first instance of sustained negative caloric balance - also accompanied by negative health consequences like increased death from tuberculosis and vitamin deficiency (starvation), and more deaths among elderly and infants
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obesity
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- this is an excess accumulation of stored fat - it is a complex, multifactorial chronic disease with many causes including genetic and environmental contributors that are, in many respects, beyond an individual's ability to choose or control
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weight stigma
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- this is a negative stigmatization of a person's weight - attitudes are often manifested by negative stereotypes - e.g. lazy, sloppy, emotional problems, etc. based on weight - includes: verbal teasing, physical aggression, and social victimization
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weight discrimination
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- this refers to unfair/unequal treatment due to weight - e.g. not getting a job, being fired from a job, denied medical procedures, or denied a bank loan - it is illegal to discriminate against a person for their outward appearance (i.e. gender, race, age, or sexual orientation) - currently, there are no laws that prohibit this - in 2011, ruled that severe obesity could be a disability because it interfered with job performance; would protect these individuals under the Americans with Disabilities Act
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prevalence of weight discrimination
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- this is highly prevalent - comparable to race discrimination in terms of rates - this has increased 66% over the past decade - higher among women, younger adults, heavier individuals, and minorities - occurs in the employment, medical, interpersonal and educational settings - victims of weight bias - doctors are one of the highest sources of bias
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employment setting (for weight discrimination)
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- both employers and coworkers are sources - obese ascribed more negative attributes (lazy, unorganized, or poor hygiene) - discrimination occurs 16Xs more often amongst women - consequences in this setting: receive fewer jobs; receive less pay and fewer promotions; more disciplinary decisions; worse job placement and tasks; more negatively personality ratings; penalized through company benefits
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medical setting (for weight discrimination)
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- doctors, nurses, nutritionists, and med students endorse negative obesity beliefs - 400 doctors ranked obesity behind only drug/alcohol addiction, and mental illness as an attribute of patients they didn't want to see - 50% of PCPs believed obese were "ugly", "awkward", and "non-compliant" - 78% of PCPs believed obese patients lacked the discipline to lose weight (would that physician really give their best effort to that patient) - higher BMI associated with lower respect for patient from physician; this impacts care; there could be less time with patient, less discussion, reluctant to perform preventive screenings, less intervention, and refuse services; results in obese individuals less likely to seek care because no one likes to be disrespected - parents of overweight children report feeling blamed by healthcare professional for child's weight problem
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interpersonal setting (for weight discrimination)
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- peers, family members, spouses, and friends - found to impact romantic relationships - poorer quality relationships and predicted relationship would end sooner - child study (1961) - asked to select child they liked least; overweight child ranked least liked by children; children as young as 3 associate negative feelings with overweight - parents as sources of discrimination: among overweight men and women, incidents of stigma reported for 44% of mothers and 34% of fathers; incidents of overweight children receiving less financial support for college
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gender differences (for weight discrimination)
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- overweight women more likely to report negative stigmatization even at lower weights than men - ideals of attractiveness are different for men and women - e.g. Barbie doll changes
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cultural differences (for weight discrimination)
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- weight bias may vary by ethnicity - lower among African American women, Mexican children, Asian American women and Japanese children - body ideals vary across ethnicity/culture
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educational setting (for weight discrimination)
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- 50% of teachers, nurses, and social workers believe obesity is primarily caused and controlled by behavior - 25% believed obese are less tidy, less likely to succeed, have different personalities, and more family problems (result: teachers not giving 100% effort to overweight child) - P.E. instructor found to believe overweight students possess poorer social, reasoning, physical, and cooperation skills (has negative impact on attitudes towards oneself and negative feelings toward PA)
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consequences of weight bias
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- interpersonal: social isolation, bullying, physical and social abuse, lower likelihood of marrying, and substance abuse - psychosocial: teasing is an overt expression of stigma; leads to anxiety, stress, poor body image, low self-esteem, self-blame, risk of depression, and risky behaviors - quality of life (most important): physical health, psychosocial health, emotional functioning, behavior, and social/general functioning
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causes of weight bias
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these stem from beliefs that: - stigma or shame will motivate behavior change - people are entirely responsible for their own weight both of these are UNTRUE also stems from cultural views: - we value thinness - allow media to portray obese in negative way - blame victims rather than the cause of the disease - evidence suggests that parents transmit beliefs to children these negative stereotypes are unfounded (not supported by any evidence)
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attribution theory
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- this is a belief about weight control - saying that obese individuals are disliked because they are blamed for their condition - greater belief in individual weight control is associated with greater weight bias - compare against other forms of discrimination (age, race) - compare against other forms of disease (cancer)
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common coping mechanisms (for weight discrimination)
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- internalizing social stereotypes: attempt weight loss or turn to food (unhealthy strategies) - assertive coping: confront perpetrator, make formal complaint, join public social group, or assert body image (healthy strategies) - confirmation and compensation: behave in a way consistent with stereotype or compensate through other ways (unhealthy strategy) - self-protection: place less value on comments and people; avoid social interaction (unhealthy strategies)
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changing weight bias
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- reducing weight bias is not the same as discouraging efforts to reduce obesity - start by changing blame attributions (blame the disease and not the victim) - evoking empathy for obese individuals - changing perceived social consensus - holding media accountable for how they portray obese individuals - think about your own attitudes towards or insensitivity towards obese/overweight people - video on efficacy of anti-stigma films; brief intervention effective in reducing weight bias in med students
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measuring weight bias
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- questionnaires are often used to do this - implication association test: identifies feelings individual associates with fatness (good/bad, hard working/lazy)
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complications of obesity
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- increases risks for many chronic diseases such as: type 2 diabetes, cancer, depression, sleep apnea, arthritis, fatty liver or cirrhosis, hypertension, and poor cholesterol - doesn't mean that obesity CAUSES these complications, just increases risk
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views regarding obesity
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- 61% (2012) of US adults believe that personal choice about eating and exercise are responsible for the obesity epidemic - prevailing view that obese individuals lack willpower and discipline and are ultimately responsible for their own conditions
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environmental factors (of obesity)
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- unending over-nutrition and increased sedentary occupations & immobilizing technologies contribute to this - other possible contributors: sleep deprivation, many antidepressants and anti-diabetic drugs, changes in gut bacteria, and metabolic imprinting during gestation
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the genetic/biological contribution to obesity
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- stereotype: obesity is caused solely by behavioral and environmental factors - challenge: substantial genetic contribution to adipose, BMI, and obesity - e.g. monozygotic twins: tend to have similar body compositions when reared together; also looked at when reared separately - counterpoint: gene pool hasn't changed, etc. - concept of obesity sensitivity and obesity resistance on a high fat diet (people are predisposed to be obese - rat study)
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variability of fat gain (during overfeeding in lean humans)
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- 16 non-obese, young adult volunteers overfed by 1000 kcal/day for 8 weeks - weight gain varied 10 fold from 0.4 kg - 4.2 kg - supports concept of obesity prone and obesity resistant humans - Elliot Joslin - "genes load the gun, and lifestyle pulls the trigger"
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the perfect storm (leptin and ghrelin)
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- stereotype: obesity should and can be treated by dietary therapy - challenge: relapse from weight loss after dietary therapy and its biological bias - reproducible evidence of weight cycling (regain in 3-5 y) - conclusion: possible explanations (behavioral or biological) explains why weight maintenance is more difficult than weight loss - leptin (weight hormone) increases with increased fat to increase metabolism - ghrelin (appetite hormone) - increases appetite; levels decrease after eating and increase before meals; it unfortunately increases w/ diet induced weight loss - restricted food intake leads to decreased leptin and increased ghrelin (so one has increased appetite and decreased metabolism so it causes weight regain)
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strategies and behaviors for weight loss maintenance (national weight control registry)
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- the people that are on the national weight control registry tend to have: - very high levels of PA - need good eating habits to work well - primary strategy in 90% of these individuals (healthy eating) - equivalent to 60 min/day of moderately high intensity exercise
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exercise
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- purposeful PA undertaken for health - bodily exertion to develop and maintain fitness - Activities of Daily Living (ADL) are not these; ADLs are spontaneous PA - variations in ADLs possible role in human obesity; sedentary (sitting) behavior is a big contributor - reflections on exercise and ADLs for prevention of obesity (exercise, adherence challenges, and programs that increase ADLs)
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treatment of obesity
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- obesity is incredibly common and difficult to treat - some FDA approved (safe and effective) anti-obesity drugs are just beginning to emerge and can be sold - none of them are a silver bullet (don't work alone) - biologic limitations to weight maintenance during dietary therapy - toxic environment that promotes overeating and sedentary behavior
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bariatric surgery
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- this is a surgery to reduce obesity - when introduced, many complications resulted in deaths - results after 10 years - relatively little relapse
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future medical therapy (for obesity)
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looking ahead: - combo of behavioral and drug therapy - combo of different classes (strength) and mechanisms of drugs - must be safe and relatively free of side effects - lessons from the history of chronic diseases in cardiovascular medicine (e.g. hypertension - FDR)
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types of fat
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- brown (healthy) fat can release energy as heat - white/yellow (unhealthy) fat: can have visceral (around organs) and subcutaneous fat (beneath the skin) - central obesity (includes gluteal fat) - liposuction doesn't improve metabolic abnormalities
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body composition
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- there are numerous ways to measure this; but all ways of measuring have errors - body is composed of water, protein (skeletal muscle and organs), mineral (bone), and faat - the only direct and truly accurate way to measure fat, mineral, and protein content is by using cadavers (everything else is indirect) - measurement concerns: accuracy, precision, and practical problems (such as burden, exclusion of groups that cause bias, and can it be used for community practice or field research?
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accuracy
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this is: how close is the indirect measure is to a direct measure of fat mass or lean mass? - i.e. how does the measurement compare to a cadaver? - establishing this requires a gold standard
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precision
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this is: does the instrument measure the same over time?
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hydrostatic weighing
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- used to be gold standard (not done very much anymore) - not very user friendly: need a lab and many are excluded from it (elderly, overweight, fear of water, etc.) - sources of error: air in the lungs counts as fat because this measures the amount of water you displace; anything other than muscle would be counted as fat (e.g. stuff in GI tract)
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DXA (dual x-ray absorptiometry)
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- this is now considered a gold standard measurement - was initially used to diagnose bone density (osteoporosis) - uses 2 x-ray sources to distinguish fat, lean, & bone mass - requires exposure to x-rays but fairly easy to do (can't have metal though) - takes about 3-5 mins depending on size - fairly user friendly; can't be used by morbidly obese - sources of error: anything in GI tract counts as fat - the results measure many categories - downsides: large machine, x-ray exposure - allows us to measure fat distribution - which is able to show us healthy fat vs. unhealthy fat - visceral fat (in gut & around organs) - subcutaneous fat (under the skin) - android fat (abdominal, more male-patterned distribution) - gynecoid fat (female-patterned distribution; around hips)
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measuring fat distribution
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- the more visceral fat you have ("metabolic obesity fat") you have increased insulin resistance and diabetes, increased hyperlipidemia, and increased pro-inflammatory cytokines - other measurement methods: waist circumference and waist to hip ratio (using tape measure); and MRI or CT scan (best way to see visceral fat) - waist circumference: men = 102 cm (40 in) and women = 88 cm (35 in)
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bod pod
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- this measures air displacement (similar to purpose of hydrostatic weighing) - able to create prediction equations based on air displaced (body density) - not completely user friendly: a lot of "monkey business" because of the special clothing and everything - sources of error: excludes self-conscious people or those who are too large - need to establish norms to be as inclusive as possible
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bioelectrical impedance (BIA)
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- a very up-and-coming technique of measuring - uses electrical currents to estimate body water - assumes about 73% of lean mass is water - assumes that fat tissue has little water (5-10%) - user friendly and appropriate for field use - results are affected by hydration status - dehydration translates to lower muscle mass - affected by food/water in GI tract: more food is translated to more fat (the impulse can't pass through smooth muscle) - single frequency BIA: not very accurate - multi-frequency (segmental) BIA: uses more contact points and can accommodate different body proportions, so more accurate
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strict protocols (for accuracy and precision)
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general considerations for measuring body composition - fasting for specified period of time - measure individual at the same time of day - measure before working out or going in a sauna - wear same clothing when being measured - avoid measuring in unusual circumstances remember that body fat % is instrument specific and each tool measure body fat differently
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skinfold technique
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- this method of measuring has been around for a long time - difficult to trust because of user error (difficult to standardize) - accuracy increases when multiple sites are tested for thickness because can determine distribution - fatness is distributed differently across the body, so only testing one spot is a poor representation of overall fat distribution - measures only subcutaneous fat (not visceral) - low cost, but can be embarrassing
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BMI (as a measuring tool)
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- body mass index as a measuring tool - it overestimates fatness in highly muscled individuals such as athletes - it underestimates fatness in low muscled individuals (can become 'normal weight obesity' where amount of fat % has increased a lot like the elderly or non-exercisers)
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percent fat
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- this is fat mass over (fat mass + lean mass) - the more lean mass, the greater the denominator, and therefore, the lesser the % fat - the opposite of BMI, this underestimates fatness in highly muscled people, and overestimates fatness in low muscled people - overfat vs. over-lean - to the WHO: if women ≥ 35% body fat, they are obese; if men are ≥ 25% body fat, they are obese; it's not clear where this info came from or what instrument was used - ACE and ACSM also have different values for this - isn't a good measure because it isn't standardized between different organizations
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cost of obesity
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- obesity is one of the biggest healthcare cost drivers - adding up to billions of dollars in preventable spending each year - current estimates are at $147 - $210 billion per year in US, and represents about 10% of all medical spending (rising) - half of the money spent was publicly financed (taxes) - majority of spending is generating from treating obesity related diseases
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direct costs (of obesity)
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- these are the costs that result from outpatient and inpatient health services (medical resource uses) - e.g. rehab, intervention, specialist/physician visit - e.g. the visible part of an iceberg
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indirect costs (of obesity)
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- these are the expenses incurred as a result of a health condition - value of lost work (missed days -> money from employer and employee) - obese employees miss more days due to short-term absences, long-term disability, and premature death - presenteeism: may work at less than full capacity - insurance: employers pay higher life insurance premiums and pay out more for workers' compensation for obese employees - wages: obesity is associated with lower wages and income - e.g part of the iceberg you don't see
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absenteeism
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- this is staying away from work due to health reasons
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presenteeism
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- this is when someone is at work but not working at full capacity; associated with health and work/life factors
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cost of obesity (more info)
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- unhealthy workers cost more to employ - severely obese people lose 5.1% days of work and incur $2,000 additional medical costs/year (leads to question of: who would an employer choose to hire?) - health expenditures per person continue to rise - percentage of total healthcare costs attributed to obesity are rising - US spends more on healthcare than any other country (and its not proven that we even give the best care in many medical areas - and, don't have universal healthcare and overall spending would be less if we had it)
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healthcare as part of GDP
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- GDP is the total amount we spend as a country - the portion of GDP we spend on healthcare is growing - this means that there is less to give to infrastructure and state employees - one's health status impacts one's neighbor (in costs)
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insurance
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- the purpose of this is to cover medically related costs - usually shared (costs) by employer and individual - rising obesity rates and medical costs are causing insurance rates to rise - rising insurance costs result in higher premiums for employee or the employer dropping coverage all together - both workers and employers are paying more towards premiums with rising costs (both need to contribute more)
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Medicare
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- this is federal insurance This is the federal social insurance program that guarantees access to health insurance for adults over 65 years and younger people with disability. • Covered 49 Million people in 2010 (83% older adults) • Covers about half of healthcare costs for enrollees • Part A - Funded by 2.9% federal payroll tax (FICA) • Part B - Funded by premiums paid by enrollees
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Medicaid
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- this is federal assistance Social insurance program for low income families and individuals • Covered 50 Million people in 2009 • Funded by state (43%) and federal governments (57%) • Affordable Care Act will expand eligibility and funding for Medicaid in 2014
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federal budget
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- medicare and medicaid make up 23% the federal budget - growing every year (%) due to rising obesity and aging population (baby boomers) - medicare spending: large majority comes from hospital care and physician services; prescription drugs portion is increasing - problem: less than 5% of healthcare costs go to prevention of diseases ("an ounce of prevention is worth a pound of cure" - Ben Franklin)
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drivers of rising healthcare costs
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- increased chronic illness leads to disability - aging population (baby boomers) - rising costs of treatment (prices of drugs, etc. aren't regulated) - nursing homes and long-term care prices - lower food costs - especially those foods that are unhealthy - obese people spend 40% more time disabled than their normal weight counterparts - greater disability translates to higher healthcare spending
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rising drug costs
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- specialty (brand name) drugs are more expensive than generics - this has increased 12.6% - far higher than the inflation rate - generics not available until patent runs out - even generic drug costs rose 100% from 2013-2014 - US drug manufacturers profiting from sick - if a company can make more money, they will - prescription drugs and technology: increasing trends of more people using prescription and more people using multiple prescription drugs - demand for weight loss drugs are rising - lower food prices making weight gain cheap but costs to treat are expensive
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cost of inaction
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- current obesity levels are too high for sustainable good health - stopping the rise in obesity rates would have an economic benefit of $198 billion in the US in 2018 - reducing the obesity rate by just 5% could lead to massive savings, but we are no where close to even stopping the rising rates let alone reducing it
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options for cutting obesity costs (and/or generating revenue)
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- affordable care act - taxing sugar-sweetened beverages - prevention efforts: primary prevention costs less than secondary prevention (treatment); and worksite wellness programs
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sugar sweetened beverages (SSB)
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- trend of less people drinking milk and more people drinking these beverages - 34 states implement sales tax (~5.2%) - too small to impact consumption (if something costs more, you're less likely to buy it) - revenues not earmarked for health programs - excise tax: taxed based on volume/weight proposed for generating revenue - goal is to encourage manufacturers to reformulate products (that way, the public isn't exposed to so many unhealthy beverage choices) - penny tax of one cent per ounce would increase price of a 20 oz drink from $1.50 to $1.70 - estimated that this would result in a 10% reduction of calories from SSB or 20 kcals/person/day
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revenue generation
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- taxes at state level can create additional revenue (better if more than just cities do it) - money generated from taxing SSB could be used specifically for obesity prevention programs such as child nutrition programs or funding uninsured - the penny tax is a controversial tactic - what about freedom to choose? - one would still have the option of SSBs, but it would just cost more
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cognitive function
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- this is a mental process that includes: attention, memory, executive function, producing & understanding language, learning, reasoning, problem solving, and decision making - executive function manages many other cognitive functions
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selective attention
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- a type of attention - ability to focus on certain things while ignoring others
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divided attention
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- a type of attention - ability to actively pay attention to more than one task at a time (e.g. texting and driving)
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top-down attention
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- a type of attention - informed by previous knowledge; only focus on details important to goal (targeted, specific attention)
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bottom-up attention
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- a type of attention - examine small details and piece together to bigger picture (e.g. a puzzle - usually a good problem solver)
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memory
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- this is the process of encoding, storing, and retrieving info - sensory: short duration and lowest capacity (ability to look at an item briefly and recall it) - short-term: short duration and limited capacity (ability to recall for seconds to a minute without rehearsal) - long-term: larger capacity and long duration (ability to recall large amount of info for long periods of time)
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brain anatomy and cognition
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- four lobes of brain: frontal, parietal, temporal, occipital - hippocampus is responsible for memory, spatial navigation (to move in space), and temporal sequencing (piecing together a timeline) - decline of hippocampus activity is partly responsible for symptoms of Alzheimer's Disease - obesity is associated with memory deficit in young and middle-aged adults (usually a less discussed outcome) - high glycemic index foods found to stimulate brain regions associated with addition (similar stimulation to cocaine, nicotine, and alcohol) - addiction feedback loop
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functional magnetic resistance imaging (FMRI)
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- this produces images that show the active areas of brain - obese people put in and cued with images that might trigger a response in the brain - FMRI used to evaluate brain activation in response to food/nonfood logos in healthy weight and obese children - obese children showed less brain activation to food logos in brain area of self control suggesting obese more vulnerable to food advertising - calls into question the ethics of marketing products that contribute to the disease
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obesity paradox
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- obesity plays a bigger role in cognitive function than SES does - obesity is positively associated with cognition for those older than 72 and weight loss associated with poor cognitive performance in old - high BMI negatively associated with risk of death amongst old (higher bone density, lower risk of fractures, less frailty, and higher overall resilience)
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biological mechanisms (linking obesity to poor cog. function)
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- obesity is linked with lower brain volume (4-8% shrinkage) - obesity impairs short-term memory, self-control, planning, memory, movement, and coordination - severe brain degeneration: actual shrinking of the brain - reverse causality? - some evidence that cognitive deficits predict obesity later in life - poorer neurological function in childhood predicted obesity during adulthood - good evidence that increased PA leads to increased cognitive function
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obesity genetics
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- this is a new field of study related to obesity - recent study discovered obesity related gene (FTO), associated with reduced brain volume independent of PA, BMI, diabetes, or CVD
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public health issues
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- research suggests that obesity may be a neurological condition triggered by lifestyle issues - has major impacts on cognitive ability of children and their capacity to learn - has major impacts on mental health (dementia) of older adults (which is a fast growing population)
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obesity increases risk
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"obesity increases risk" of many negative health outcomes: - all causes of death (mortality); high blood pressure; high LDL, low HDL, or high levels of triglycerides (dyslipidemia); type 2 diabetes; coronary heart disease; stroke, gall bladder disease; osteoarthritis; sleep apnea and breathing problems; certain cancers; low quality of life; mental illnesses; and body pain and difficulty with physical function
