1. Management of Obesity in
Women: Current Strategies
Robert Kushner, MD
Professor of Medicine
Northwestern University
Feinberg School of Medicine
Clinical Director, Northwestern
Comprehensive Center on Obesity
rkushner@northwestern.edu

2. Disclosures
• Dr. Kushner has served on the Medical
Advisory Boards for Amylin, Vivus,
Orexigen and Allergan.
• He is the author of Dr. Kushner’s
Personality Type Diet and Counseling
Overweight Adults: The Lifestyle Patterns
Approach and Toolkit

3. Multiple Determinants of Obesity
• Genetics  Health care
• Biology  Economics
• Environment  Ecology
• Society  Diet
• Personal  Physical activity
responsibility  Social networks
• Weight gaining  Stress and emotion
medications

4. Life cycle

5. Weight-Life Events Graph
Your Weight Gain
Your eight Gain
Weight
Time

6. Weight Gain – Life Events Graph:
Childhood and Adolescence

7. Childhood & Adolescent Obesity
• Screen time (TV, computer, video games,
smart phone)
• Less exercise time during school
• Liquid calories (colas, juices)
• More meals eaten away from home
• Snacking
• Parenting and role modeling

8. Portion Sizes out of Control

9. ‘Let’s Move’
• Nationwide campaign targeting childhood
obesity
– Getting parents more informed about nutrition
and exercise
– Improving quality of food in schools
– Making healthy foods more affordable and
accessible for families
– Focusing more on physical education

11. The Pressure of Beauty Ideals

12. The Stigma of Obesity

13. Georgia Billboard Campaign

14. Obesity and Infertility
Relative Risks by BMI at Age 18
Menstrual Cycle Irregularity Primary Ovulatory Infertility
2 4
1.75 3.5
3
1.5
2.5
Relative Relative
Risk 1.25 Risk 2
1 1.5
Reference 1
0.75 Reference
0.5
0.5 0
15 20 25 30 35 15 20 25 30 35
BMI at Age 18 BMI at Age 18
pted from Rich-Edwards et al. Am J Obstet Gynecol. 1994;171:171-177.

15. Weight Gain – Life Events Graph
Pregnancy

16. Weight Gain – Life Events Graph
Pregnancy

17. Weight Gain – Life Events Graph
Pregnancy

19. Consequences of
Maternal Weight Gain
• Postpartum weight • Stillbirth
retention • Shoulder dystocia
• Obstetric • Large baby
complications • Shorter breast feeding
– Gestational • Fetal imprinting
diabetes
– Developmental-
– Hypertension
origins for long-term
– Eclampsia risk
– Caesarean delivery • Offspring obesity

20. Relationship Between Mother’s Weight
and Child’s Risk of Obesity
% Children Obese
Maternal BMI 2-yr olds 3-yr olds 4-yr olds
< 18.5 2.5 4.4 4.7
18.5 – 24.9 6.4 7.5 9.0
25 – 29.9 9.0 12.0 14.5
30 – 30.9 13.9 19.7 22.8
≥ 40 19.4 24.0 28.8
Maternal BMI measured in the first trimester of child’s gestation
Whitaker RC. Pediatrics 2004;114(1): e29-e36

21. (25 – 35
lbs)
(15 – 25
lbs)
(11 – 20
lbs)
JAMA 2009;302:241

23. Weight Gain – Life Events Graph
Midlife

24. Weight Gain – Life Events Graph
Midlife

25. Impairment of Health and
Quality of Life
Women BMI
n=7018 <25 >30
Proportions of subjects, %
Shortness of breath
walking upstairs 18.4 46.4
Chronic low back pain 17.8 24.7
Poor QOL:
 Moderate activities 18.4 36.0
 Bending, kneeling 20.7 48.3
 Walking 1 block 4.5 15.4
Lean et al, Arch Intern Med 1999

26. Prevalence (%) of Comorbidity
Among Women by Obesity Class*
Weight Status Category (%)†
Health Condition Under- Normal Over- Obesity Obesity Obesity
weight weight Class 1 Class 2 Class 3
Type 2 diabetes mellitus 4.76 2.38 7.12 7.24 13.1 19.8
Gallbladder disease 6.42 6.29 11.8 15.99 19.1 23.4
Coronary heart disease 12.0 6.87 11.1 12.56 12.3 19.2
High blood cholesterol 13.3 26.89 45.5 40.37 40.9 36.3
High blood pressure 19.8 23.26 38.7 47.95 54.5 63.1
Osteoarthritis 7.79 5.22 8.51 9.94 10.3 17.1
*N = 7,689.
†
Estimates are weighted to account for the sample design. Weight categories
are based on the NHLBI classification.
(Must A, et al. JAMA. 1999)

27. Relationship Between BMI and
Risk of Type 2 Diabetes Mellitus
100
93.2
90
Age-Adjusted Relative Risk
80
70
■ Men ● Women
60 54.0
50 42.1
40.3
40
27.6
30 21.3
8.1 15.8
20 5.0 11.6
2.9 4.3 2.2 6.7
1.0 1.5 4.4
10 1.0 1.0
0
<22 <23 23-23.9 24-24.9 25-26.9 27-28.9 29-30.9 31-32.9 33-34.9 35+
Body Mass Index (kg/m2)
Chan J, et al. Diabetes Care. 1994;17:961-969.
Colditz G, et al. Ann Intern Med. 1995;122:481-486.

28. Abdominal Obesity Is Associated with
Increased Risk of Developing Diabetes
24
20
Relative Risk
16
12
8
4
0
<71 71–75.9 76–81 81.1–86 86.1–91 91.1–96.3 >96.3
[<27.9 in.] [27.9–29.8 in.] [29.9–31.9 in.] [32–33.9 in.] [34–35.8 in.] [35.9–37.9 in.] [>38 in.]
Waist Circumference (cm)
Carey VJ, et al. Am J Epidemiol. 1997;145:614-619.

30. 20-yr Changes in BMI and Waist
Circumference Among Women
Body Mass Index (BMI) Waist Circumference (cm)
Black
White
Total
Hispanic
Data from NHANES completed during yrs 1976 - 2006
Kramer H, et al. J Diabetes Complications 2010;24:368-74

31. Differentiating Fat Depots

32. Changes in Weight and Body Composition
Through the Menopausal Transition
Lovejoy JC et al. International J Obesity 2008;32:949-58

33. Changes in Hormones and Calories
Through the Menopausal Transition
Lovejoy JC et al. International J Obesity 2008;32:949-58

34. Importance of Measuring Waist
Circumference: BMI 25-29.9 (Overweight)
Men (n=3081) Women (n=2606)
Prevalence, % Nl WC High WC Nl WC High WC
Hypertension 23.0 44.8 12.3 37.5
Type 2 DM 2.7 10.6 1.6 10.0
Hyper-chol 17.2 26.2 19.4 35.2
High LDL-C 19.3 27.2 13.6 26.6
Low HDL-C 35.3 49.0 10.0 15.0
Hyper-TG 21.7 36.3 10.6 21.8
Janssen et al. Arch Intern Med 2002;162:2074-9

35. Abdominal Fat Distribution Increases the
Risk of Coronary Heart Disease
The Iowa Women’s Health Study
2.5
2.0
Relative Risk
1.5
1.0
3 t io
0.5
2 Ra
p
t- Hi tile
0.0 1
a is Ter
3 2 1 W
Body Mass Index Tertile
Folsom AR et al. Arch Intern Med. 2000;160:2117-2128.

36. Gastroesophageal Reflux
and Obese Women
4
Association between body mass index
3.5 and the risk of frequent symptoms of GERD
frequency of GERD symptoms
Multivariate odds ratio for
3
P < 0.001 ● ● 2.93 (2.24-3.85)
2.92
2.5
● (2.35-3.62)
2 ● 2.43 (1.96-3.01)
2.20 (1.81-2.66)
1.5
●1.38 (1.13-1.67)
1 ●
● 0.67 (0.48-0.93)
0.5
0
<20.0 20.0-22.4 22.5-24.9 25.0-27.4 27.5-29.9 30.0-34.9 ≥35
Body mass index
n = 2306 women with symptoms
of heartburn, acid regurgitation, or both
Jacobson BC, et al. N Engl J Med. 2006;354:2340-2348.

37. Obesity and Cancer Mortality
Women
Uterus (≥40) 6.25
Kidney (≥40) 4.75
Cervix (≥35) 3.20
Pancreas (≥40) 2.76
Esophagus (≥30) 1.88*
Type of All other cancers (≥40) 2.51
cancer Gallbladder (≥30) 2.13
(highest
Breast (≥40) 2.12
BMI
Non-Hodgkin lymphoma (≥35) 2.51*
category)
All cancers (≥40) 2.64*
Liver (≥35) 1.68
Ovary (≥35) 1.51
Colon and rectum (≥40) 1.46
Multiple myeloma (≥35) 1.44
0 1 2 3 4 5 6 7
P≤.05, *relative risk for women who never smoked Relative Risk
For each relative risk, the comparison was between
women in the highest BMI category and men in the reference category (BMI 18.5 to 24.9)
Calle EE et al. N Engl J Med. 2003;348:1625-1638.

38. Current Approaches
to Treating Obesity
● Diet, exercise, and behavioral therapy continue to
be the mainstays of obesity treatment
● There is limited pharmacotherapy available. When
possible, use weight-losing medications when
treating co-morbidities
● A 5 – 10% weight loss improves many of the
obesity-related metabolic
● Active weight loss and maintenance of lost weight
requires ongoing support and use of resources

39. Macronutrients To Address
Individual Risk Factors
 Waist circumference Caloric Reduction
 Blood pressure DASH
Metabolic  Blood glucose Carbohydrate
controlled
Syndrome
 Triglycerides
 HDL-cholesterol Mediterranean,
TLC
 LDL-cholesterol
Insulin resistance Mediterranean
 Thrombotic risk Omega–3 Fatty acids

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

41. Summary
• There are multiple events in a woman’s
life that predispose her to weight gain
• The reasons for weight gain at each time
point differ – a combination of changing
biology, hormonal status and life events
• It is important to implement preventive and
treatment strategies to halt further weight
gain and the development of ill health

42. Thank you!