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Camilo Toro Restrepo

on 11 December 2013

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Transcript of Obesity

-Surgery is generally considered a last resort option, an option that approximately 40,000 people in the U.S. choose to do each year.
-There are many different types of Bariatric Surgery (Gastric Banding, Gastric Bypass, Gastric Sleeve) that can be performed, but the cost of the procedures are usually between $20,000 to $25,000.
- The National Institute of Health recommends that the procedure only be carried out if the patient has a BMI over 40, or a BMI over 35 in conjunction with another disorder brought on by obesity such as cirrhosis.
- Surgery consistently outperforms dieting and exercise. A Canadian Task Force on Preventative Health Care found that over 2 -5 years average wieght loss was between 17kg and 46kg.
Obesity: Disease or Disorder?
Doctors as choice architects
A study by the National Center for Biotechnology Information concluded that physicians with normal BMI more frequently report discussing compared to overweight/obese physicians (Bleich, Bennett and Lisa Cooper). Physicians with normal BMI had greater confidence in their ability to provide diet (53% vs. 37%) and exercise counseling (56%vs.38%). Only a third of doctors of physicians reported very good/ good obesity related training in medical school or residency.
Obesity Epedemic
15% of world population is obese
6 other countries are 20%+ obese: Mexico, UK, Slovakia, Greece, Australia, New Zealand
Globally, more than 1 billion overweight adults, at least 300 million of them obese
78.5 million American adults obese
35.7% US adults
32 million children in US obese
17% of kids under 18
Percentages for men & women are the same
Higher obesity rates in adults 60+
Body Mass Index
A weight-to-height ratio, calculated by dividing one's weight in kilograms by the square of one's height in meters
Short Term:

Difficulty sleeping
Back or joint pain.

On the average dieters lose 8.5 kg of weight, within 3 to 12 months of starting.
Low calorie diets are more effective in the long run when calorie consumption is tapered off slowly
This leads to gradual weight loss and increases the likelihood that the dieter will maintain the weight loss.
Low calorie diets usually involve the person consuming approximately 1200 kcal per day. Very low calorie diets have the patients consuming only 800 kcal per day!

ROI Curves for BMI Calculations
Long term
High blood pressure
High cholesterol levels
Increase risk of coronary heart disease, stroke, type 2 diabetes, all leading causes of preventable death

low self esteem
feeling isolated in society
Lack of energy balance (caloric energy)
Energy ≠ energy out
Poor diet
Lack of exercise

Social and Environmental
Family resemblances in body weight
Thrifty genotype hypothesis
Proteins involved in food intake regulation and energy homeostasis
Other medical causes
Cushing's syndrome
Polycystic ovarian syndrome (PCOS)
Causes of Obesity
No official definition:
Center for Disease Control: 'An adult who has a BMI of 30 or higher is considered obese"
NIH: "The condition of having too much body fat, as determined by BMI"
Obesity Society: "An excess of body fat sufficiently large to cause reduced health or longeit"
Natural Library of Medicine: "Obesity means having too much body fat. It is not the same as being overweight, which means weighing too much. A person may be overweight from extra muscle, bone, or water, as well as from having too much fat"
Should it be considered a disease?

Arguments for:
The decision to intervene needs to be based on the holistic profile of an individual, not an arbitrary cut-point
30% of "obese" (defined by BMI) are not actually obese--people might be overtreated because their B.M.I. was above a line designating them as having a disease, even though they were healthy.
Declaring it a disease would define one-third of Americans as being ill and could lead to more reliance on costly drugs and surgery rather than lifestyle changes.
Labeling it as a disease is a way of excluding it from everyday life, your decision don't make a difference to your condition.
Arguments against:
U.S. Preventive Services Task Force (USPSTF) first began to recommend “screening all adults for obesity. Clinicians should "offer or refer patients with a body mass index (BMI) of 30 kg/m2 or higher to intensive, multicomponent behavioral interventions.”
Many authoritative bodies, such as the AMA, the Obesity Society, the FDA, the IRS, and National Institutes for Health already consider it a disease
It would focus more attention on obesity
This could increase the amount of research dollars allocated towards obesity for research
Could fuel more policy changes
Help improve reimbursement and services for obesity counseling and education
Economic Costs
Direct costs – outpatient and inpatient services, lab and radiological tests, and drug therapy.
Indirect Costs - include resources lost due to a health condition.
Value of Lost Work – obese people tend to miss work more often leading to lower productivity and lost wages.
Insurance – employers pay higher premiums and more workers compensation for obese workers than non-obese workers.
Wages – obesity correlated with lower wages and lower household income.
Obesity cost per person - in 2006 the medical expenses for obese patients were 42% higher than those those of normal weight. A study by Cawley & Meyerhoefer found the percentage increase to be closer to 150%.
Each month Social Security pays out $77 million in obesity disability claims.
As a percentage of medical costs, obesity related medical issues have been rising. In 1998 it constituted about 6% of costs, in 2006 it was 10%.
-Exercise has proven to be more effective in the short run than in the long run
-On average people lose 2 to 3 kg within the first 6 months.
- Exercise is much more effective as a preventative measure against obesity.

Public Policy Responses
Behavioral economic model and responses:
Behavioral theory: points to human self-control problems, impatience, and asymmetrical information--David Cutler's potato theory and discounting (Cutler, 2003)
policy makers should impose extra "costs" on consuming food or behavior likely to lead to obesity.
A value added tax on food expenditures or a calorie-based food tax.
Consumer should be better informed about characteristics of foods like calorie counts.
Cass Sunstein, author of Nudge, argues that public schools and private companies should offer students and employees smaller portion sizes because we eat with System 1 thinking
- Weight loss drugs, or anorectic, drugs work by suppressing ones appetite, however, there are also those that work by blocking the absorption of fat.
- Phentermine and orlistat are drugs that have proven able to treat obesity in the long term.
- The mechanism by which these drugs suppress appetite is the nonadrenergic mechanism. It works by releasing norepinephrine which subsequently interact with hypothalamic beta adrenergic receptors.
Other Ways to Diagnose
skin-fold thickness
waist circumference
Body Fat Percentage
Classical economic model and responses:
Neoclassical theory of obesity: some humans make the rational decision to be obese: for some, the cost of obesity is less than the cost of maintaining slenderness or a normal weight (Philipson and Posner 1999).
Policy-makers shouldn't just tax factors that cause obesity but rather obesity itself.
Richard Posner argues that we should relax legal limitations on "weight discrimination" by private group insurers and employers.
Gary Becker, an economist at University of Chicago, argues that individuals proposes that Medicare and Medicaid should penalize obese citizens because they are more expensive to treat.
Food Costs and Less Calories Expenditure
Economists first law of demand: a decrease in price of food will causes consumption to increase.
CPI data indicates that since 1980, food prices have decreased at an average real annual rate of .4%. This compounds to an overall decrease in 14%.
Substitution effect: According to Putnum and Allshouse, two economists at the USDA, the price of fresh fruits and vegetables, fish, and dairy products increased by 118%, 77%, and 56%, respectively, whereas sugar and sweets, fats and oils, and carbonated beverages (54)
Reductions in the price of energy-dense food and an increase in the practice of marginal cost pricing (ie: supersizing) have resulted in an increase in the amount consumed at each meal
Technology has decreased the presence of manual labor According to diaries presented by John Robinson and Geoffrey Godbey report that energy expenditures fell from 1.69 to 1.57 kcal/min from 1960 to 1980 but has remained virtually constant since.
Rising wages, a mixed bag: A rise in wages will presumably result in more hours worked which could lead to an increase in restaurant and prepackaged foods. But, it could lead to an increase in the purchasing of fresh food or exercise products
Horn Effect
Works Cited
Obesity U.S. Trends
The Horn Effect is the tendency of an individual to think lowly of a person as a whole based on one negative impression. It is essentially the opposite of the Halo Effect.
- This bias has applications in the medical field especially when we look at relationships between doctor and patient.
- For instance, we know that patients with overweight doctors, have higher obesity rates than patients with doctors of relatively normal weight.
- One possible conclusion we can draw from this is that patients view their own doctors as unhealthy and are less likely to listen to their advice when addressing their own weight issues.
-The patients allow that one attribute to effect their overall view of the doctor, including his or her own abilities to treat patients.
Martin, Pamela D., Dr., Valerie H. Myers, Dr., and Phillip J. Brantley, Dr. Effectiveness of Interventions for Overweight and Obesity in Adults. Rep. no. 153. Baton Rouge: Pennington Biomedical Research Center, 2004. Print.
Children Adolescents Adults

U.S Obesity Trends Among Adults
Miriam Webster's definition of a disease: an illness that affects a person, animal, or plant : a condition that prevents the body or mind from working normally.
In Robert Aronowitz's article "when do symptoms become a disease?", Aronwitz writes that, "social influences have largey determined when symptoms become a disease."
Other Public Policy Response
Mass media campaigns
Preventive education in schools along with systematic changes such as fitness programs and nutritional reforms
Taxes to encourage healthy food and beverages
Community design and zoning
Menu labeling
1. Prevent further weight gain
2. Reduce body weight
3. Maintain long term weight loss
4. Decrease health related risk factors
5. Decrease affect of comorbidities
Precontemplation, Contemplation, Motivation, and Reinforcement
What is the prevalence?
What are the causes?
How do you define Obesity?
How do you diagnose obesity?
What are the consequences?
What are the treatments?
What are the public policy responses to obesity?
Should obesity be considered a disease?
The Five A's for evaluation and treatment of obesity:
Assess: Severity of obesity with BMI, waist circumference
Advise: Appropriateness of various treatment
Agree: Come to a consensus with your patient, do not discuss if the patient is not ready
Assist: Provide a diet plan, web resources, and behavior modification guide
Arrange: Follow up appointments and referral to a registered dietician
Doctors and framing
Components of assessing a patient's willpower and readiness:
Agenda setting--"Would you mind if I talk about your weight?--Asking permission emphasizes patient's autonomy
Exploration--"Are you interested in being more active?" "Why are you more open now to exercise than you were before", "How interested are you in getting fit?"--Assesses sources and degree of motivation and value of changing
Providing information--"Obesity can lead to health risks but there are many options available to help you"-- conveys hope
Listening and summarizing--"What do you think about hat idea?"-- identifies sources of ambivalence
"Adult Obesity Facts." Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 16 Aug. 2013. Web.
"Obesity - Symptoms ." Obesity. N.p., n.d.
"Screening for Obesity in Children and Adolescents: US Preventive Services Task Force Recommendation Statement." Screening for Obesity in Children and Adolescents: US Preventive Services Task Force Recommendation Statement. The American Academy of Pediatrics, 2010.
Baum, Charles L., and Shin-Yi Chou. "The Socio-Economic Causes of Obesity." NBER. N.p., Sept. 2011. Web.
Nestle, Marion, PhD MPH, and Michael F. Jacobson, PhD. "Halting the Obesity Epidemic: A Public Health Policy Approach." Http://www.ncbi.nlm.nih.gov/. N.p., Jan. 2000. Web.
Reeder, Bruce A., MD, MHSc, FRCPC, and Peter T. Katzmarzyk, PhD. "Canadian Task Force on Preventive Health Care." Canadian Task Force on Preventive Health Care. N.p., Mar. 2004. Web.

"Harvard School of Public Health » Obesity Prevention Source » Adult Obesity." Obesity Prevention Source. N.p., n.d. Web.
1 out of 3 adults
1 out of 6 children
Sensitivity and Specificity for skinfold thickness test was .65 and .95
Largely caused by personal, environment, and economic factors, not by inevitable medical conditions
As a group, we decided that obesity should not be labeled is a disease, primarily because it conveys a sense of fatalism and lack of sense of control.
We also agreed upon several public policy responses. We do think obese individuals that are Class II obese and up (BMI of 35 and higher) should pay extra Medicare fees. We applaud efforts by local and federal governments which mandate the disclosure of calorie counts. However, we do not think that governments should ban unhealthy products but rather should impose a VAT tax on processed foods. We do not think that more educating campaigns gear towards adults would have a significant, but public schools should take more steps to promote a healthy lifestyle
Behavioral treatment
The USPSTF found that intensive behavioral
treatments (defined as >25 hours of doctor to patient
meetings) was highly effective. "Most of the higher-intensity behavioral interventions included multiple behavioral management activities, such as group sessions, individual sessions, setting weight-loss goals, improving diet or nutrition, physical activity sessions, addressing barriers to change, active use of self-monitoring, and strategizing how to maintain lifestyle changes." (USPSTF, 2012)
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