sharma

Document Sample
sharma Powered By Docstoc
					      Obesity Management:
         Moving Beyond
     “Eat Less & Move More”

         Arya M Sharma, MD, FRCP(C)
               Professor of Medicine
Research Chair for Obesity Research & Management
                University of Alberta
                 Medical Director
       Capital Health Weight Wise Program
             Edmonton, AB, Canada
       www.ch-weightwisemd.blogspot.com
Four-Fold
increase in
Morbid Obesity
in Canada in 20
Years




Katzmarzyk et al. CMAJ, 2006
Factors Contributing to Obesity

Lifestyle          Psychosocial      Biomedical
• Poor diet        • Depression      • Genetics
• Skipping meals   • Anxiety         • Metabolism
• Sugary soft
                   • Binge eating    • Intrauterine
  drinks
                   • Boredom           growth
• Poor sleep
                   • Social events   • Medications
• Snacking
                   • Low income      • Injury
• Alcohol
• Sedentariness    • Stress          • Mobility issues
• Etc.             • Etc.            • Etc.
Adult Obesity in the Capital Health Region


BMI > 25 ~ 500,000
BMI > 30 ~ 250,000
BMI > 40 ~ 25,000
                                                             Sturgeon
                                                              County        Redwater



                                                     St Albert
                                                                            Ft Sask

                                                                          Strathcona
              Yellowhead                                                     County
             County (East)             Stony Plain
                             Parkland County
                                                                 Edmonton

                                                     Devon
                                                                  Leduc

                                               Leduc County
                Relationship Between BMI and
                 Percent Body Fat in Men and
                           Women
                70
                         Women
                60
                         Men
 Body Fat (%)




                50
                40
                30
                20
                10
                0
                     0   10        20         30             40   50   60
                                 Body Mass Index (kg/m2)
Adapted from: Gallagher et al. Am J Clin Nutr 2000;72:694.
Association of waist-to-hip ratio within BMI
categories with myocardial infarction risk

 OR (95% CI)




               <20   20-23   23.1-25   25.1-27   27.1-29     >30

                             BMI (kg/m2)                        Yusuf S et al.
                                                   Lancet 2005;366:1640-1649
   Health Consequences of Obesity
                   Sedentariness/Overnutrition


Mental                   Mechanical                  Metabolic
- depression             - osteoarthritis            - diabetes
- anxiety                - obstructive sleep apnea   - dyslipidemia
- personality disorder   - reflux disease            - fatty liver
- self esteem            - urinary incontenance      - hypertension
- etc.                   - intertrigo                - cancer
                         - etc.                      - PCOS
                                                     - gall bladder
                                                     - infertility
                                                     - etc.


                Hormones / Adipokines / Inflammation
                                                           Sharma 2006
 Indications for Obesity Treatment

                              Indication for
                             obesity treatment


               Caused
                                Primary
              by obesity?



Symptoms/     Aggravated
                               Secondary
 Condition    by obesity?


                Unrelated
                                Tertiary
               to obesity?

                                      Sharma 2006
Barriers to Weight Management


 Socio-economic?
 Emotional?
 Comorbidities?
 Medications?
 Saboteurs?
 Substance abuse?
 Genetics?

                          Sharma 2005
                 Selected Medications That Can
                       Cause Weight Gain
                                                    Diabetes medications
                 Psychotropic                          – Insulin
                  medications
                                                        – Sulfonylureas
                        –   Tricyclic
                            antidepressants             – Thiazolidinediones
                        –   Monoamine               Highly active antiretroviral
                            oxidase inhibitors
                        –   Specific SSRIs
                                                     therapy
                        –   Atypical                Tamoxifen
                            antipsychotics
                        –   Lithium                 Steroid Hormones
                        –   Specific                    – Glucocorticoids
                            anticonvulsants
                                                        – Progestational
                 -adrenergic receptor                   steriods
                  blockers


                                                                                11/26
SSRI=Selective Serotonin Reuptake Inhibitor.
                 Isn’t Obesity Simple?
                       Genetics


Environmental                              Environmental
Determinants                               Determinants
                +/-                  +/-
    Energy                                 Energy
      In                                    Out



           Energy Regulation is Complex!
                                           Sharma AM 2007
     The Dilemma




Kg



       decades
         Phases of Obesity Treatment

           Phase I                     Phase II
          (Weight Loss)          (Weight-Loss Maintenance)



                          When you stop treatment,
Weight




                          the disease comes back!




         3-6 months                       Indefinitely
Treatment Success


                   Lifestyle (LS) ~ 3-5%


           LS+Pharmacotherapy ~ 5-15%



                 LS+Surgery ~ 20-30%




       Years
                                    Stepped Care Approach to
                                      Obesity Management
                                                                                                Biliopancreatic
                                                                                                    diversion
Degree of Long-Term Weightloss




                                                                         Gastric        Roux-N-Y
                                                                       pacemaker      Gastric Bypass

                                                               Intragastric     Adjustable
                                                                 devices      gastric banding

                                                        Pharmaco-
                                                         therapy
                                          Hypocaloric
                                             diets

                                   Lifestyle
                                 intervention




                                                   Treatment Intensity
                                                                                                          Sharma 2005
      Ingestive Behaviour

          Homeostatic System

   Hunger:                Satiety:
Need for Calories     Sense of “Fullness”



            Hedonic System

  Appetite:               Reward:
Need for Foods        Sense of Pleasure

                                      AM Sharma 08
              Ingestive Behaviour


1. Pattern?                      Regular Meals

              -
                                    Nutritional
        2. Quality?                  Hygiene

                      +
                  3. Quantity?         Portion
                                       Control


                                        Sharma AM 2007
  Characteristics of the ideal
      Anti-Obesity Drug

 Reduce body weight
 Maintain weight loss
 Well tolerated
 Long-term efficacy
 No rebound effect
 Reduce morbidity
 Reduce mortality


                                 Sharma 06
           Anti-Obesity Drug
        Potential Modes of Action
 Energy intake
    – Hunger 
    – Appetite 
    – Satiety 
 Energy metabolism
    – Digestion/Absorption 
    – Metabolism 
    – Partitioning 
 Energy expenditure
    – Metabolic thermogenesis 
    – Non-exercise activity thermogenesis (NEAT) 
    – Exercise thermogenesis 

                                                 Sharma 06
       STORM Mean bodyweight changes during
                                 weight loss and weight maintenance
                                 phases over 2 years

                            Weight loss             Weight maintenance
                  104
                                                                              Control
                  102
Bodyweight (kg)




                  100
                   98
                   96
                   94
                   92
                   90                                                         Sibutramine
                   88
                        0    2     4   6   8   10   12 14    16    18    20   22   24
                                                     Month
       Same diet and exercise for both sibutramine and control
                                                                  James WPT, Lancet 2001
Bariatric Surgery Reduces Mortality
    in Swedish Obese Subjects
              (n=2010 vs. 2037)
     30% Reduction in All Cause Mortality




                        Sjostrom L et al. NEJM 2007;357:741-52
Long-Term Mortality After Gastric Bypass
               Surgery
                                          (n=7928 vs. 7925)

                                          Coronary
                              All Cause    Artery
                              Mortality               Cancer       Diabetes
                                          Disease
% reduced/10,000 person-yrs




                                40%
                                            56%
                                                       60%
                                                                     92%

                                                     Adams TD, et al. NEJM 2004;357:753
                     Bariatric Surgery
              Effect on Cardiovascular Risk
             A Systematic Review and Meta-Analysis of
                          22,090 Patients

              Hypertension   Dyslipidemia    Diabetes     Sleepapnea
% resolved




                 62%
                                 70%
                                               77%
                                                             86%

                                            Buchwald H, et al. JAMA 2004;292:1724
24-Hour Plasma Ghrelin Profiles in Subjects Who
   Underwent Gastric Bypass and in Controls




                       Cummings, D. E. et. al. N Engl J Med 2002;346:1623-1630
        Patient Selection

 Motivation?
 Cognitive skills?
 Mental health?
 Surgical risk?
 Support system?
 Expectations?
 Follow-up?


                            Sharma AM 2007
Referrals to the Adult Bariatric Clinic
  Does your patient have an indication for
   obesity treatment?
  Does your patient have important
   barriers to obesity treatment?
  Is your patient likely to make and
   sustain changes / adhere to treatments?



      Fax Referral to Health LINK
         My Obesity Blog:

www.ch-weightwisemd.blogspot.com
www.obesitynetwork.ca

				
DOCUMENT INFO