Diagnosing and Treating Obesity MMA Task Force on Obesity

Diagnosing and Treating Obesity MMA Task Force on Obesity For information on how to arrange for a presentation on obesity diagnosis and prevention, please contact Lorrie Holmgren, MMA Director of Communications, 612/362-3742 or lholmgren@mnmed.org Slide Source: www.obesityonline.org Obesity Management in an Outpatient Office Practice Patient BMI 40 31 27 20 37 21 33 29 Slide Source: www.obesityonline.org Establish diagnosis:BMI      BMI = weight (kg)/ [height (M)]2 Correlates well with direct measures of adiposity Overweight child: BMI >85th and <95th percentile Obese child: BMI > 95th percentile If child < 3 years old, use weight for height • ―The Wall Street Journal says that this obesity epidemic is nonsense. They say that body weight has been gradually increasing for a century.‖ Ten Year (approx) Change in US Prevalence (NHANES) of Obesity and Severe (BMI > 40) Obesity 35 30 25 20 15 10 5 0 Obesity Severe 88-94 99-00 Prevalence of overweight and obese children in the USA, 1971-2000 30 2-19 yr Overweight 25 Prevalence (%) 20 15 10 2-19 yr Obese 5 0 1971-1974 1976-1980 1988-1994 1999-2000 NHANES data • ―The New England Journal says that obesity is overstated as a problem and that most people have mild to moderate overweight, which is not medically threatening.‖ Medical Complications of Obesity Pulmonary disease abnormal function obstructive sleep apnea hypoventilation syndrome Nonalcoholic fatty liver disease steatosis steatohepatitis cirrhosis Idiopathic intracranial hypertension Stroke Cataracts Coronary heart disease Diabetes Dyslipidemia Hypertension Severe pancreatitis Cancer breast, uterus, cervix colon, esophagus, pancreas kidney, prostate Phlebitis venous stasis Slide Source: www.obesityonline.org Gall bladder disease Gynecologic abnormalities abnormal menses infertility polycystic ovarian syndrome Osteoarthritis Skin Gout Complications of Childhood obesity Relationship Between Weight Gain in Adulthood and Risk of Type 2 Diabetes Mellitus 6 5 Relative Risk Men Women 4 3 2 1 0 -10 -5 0 5 10 Weight Change (kg) 15 20 Slide Source: www.obesityonline.org Willett et al. N Engl J Med 1999;341:427. Diagnosing the Metabolic Syndrome Diagnosis is established when 3 of these risk factors are present. Risk Factor Abdominal obesity (Waist circumference) Men Women TG HDL-C Defining Level >102 cm (>40 in) >88 cm (>35 in) 150 mg/dL <40 mg/dL <50 mg/dL 130/85 mm Hg 110 mg/dL Men Women Blood pressure Fasting glucose Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA 2001;285:2486-2497. Increase in Healthcare Costs Among Obese Compared with Lean (BMI <25 kg/m2) Patients* Healthcare visits Pharmacy Laboratory tests All outpatient services All inpatient services Total healthcare Increase in Cost Compared with Lean Subjects (%) BMI 30-34 kg/m2 BMI >35 kg/m2 *HMO Setting: Northern California Kaiser Permanente. Quesenberry CP Jr et al. Arch Intern Med. 1998;158:466-472. Slide Source: www.obesityonline.org • ―Doc, I am fat because my hormones are out of whack. I know I don’t eat too much. Can you check out what’s wrong with me and give me a pill to fix it..‖ Hormonal Causes of Obesity Cushings Syndrome (glucocorticoid excess) • Most treatments for Diabetes Mellitus type 2 • NOT Hypothyroidism • • Very few (less than 1%) of patients are obese due to hormonal problems, but a substantial number are obese in part due to diabetes treatment or treatment with glucocorticoids Selected Medications That Can Cause Weight Gain  Psychotropic medications – –  Tricyclic antidepressants Monoamine oxidase inhibitors Specific SSRIs Atypical antipsychotics Lithium Specific anticonvulsants    Diabetes medications – Insulin – Sulfonylureas – Thiazolidinediones Highly active antiretroviral therapy Tamoxifen Steroid hormones – Glucocorticoids – Progestational steroids Slide Source: www.obesityonline.org – – – –  -adrenergic receptor blockers SSRI=selective serotonin reuptake inhibitor • ―Yea, I know about balancing food and activity, but I don’t don’t eat that much.‖ • ―I don’t eat more than other people‖ • ―I only eat salads.‖ Discrepancy Between Reported and Actual Energy Intake and Expenditure Energy Intake Energy Expenditure * Kcal/d * Reported Actual Reported Actual Slide Source: www.obesityonline.org *P<0.05 vs reported. Lichtman et al. N Engl J Med 1992;327:1893. • ―My problem is my metabolism is slow. Anything at all that I eat turns to fat.‖ Relationship Between Resting Energy Expenditure and Fat-free Mass 3000 REE (kcal/24 h) Lean females Obese females Lean males Obese males 2000 1000 0 0 30 40 50 60 70 80 90 100 Fat-Free Mass (kg) REE = Resting energy expenditure Owen. Mayo Clin Proc 1988;63:503. Slide Source: www.obesityonline.org • ―Any time I try to lose weight, my metabolism slows down so much that I can’t lose weight.‖ Energy Metabolism Before and After Weight Loss Mean BMI Reduced from 31 to 23 kg/m2 Energy Expenditure (kcal/d) Resting Energy Expenditure Total Energy Expenditure * * * * Before After Predicted Before After Predicted Slide Source: www.obesityonline.org *P<0.05 vs before weight loss Amatruda et al. J. Clin Invest 1993;92:1236. • ―So obesity is all genetic. There’s nothing I can do.‖ Gene-Environment Interaction in the Pathogenesis of Obesity P <0.0001 Body Mass Index (kg/m2) Pima Indians Maycoba, Mexico Ravussin E et al. Diabetes Care 1994;17:1067-1074. Arizona Slide Source: www.obesityonline.org Effect of Meal Variety on Energy Intake Same food at each course Different food at each course Energy Intake (kJ) * 1 2 3 Meal Course 4 Total *P<0.001 vs same food at each course. Rolls et al. Appetite 1984;5:337. Slide Source: www.obesityonline.org Effect of Portion Size on Energy Intake Amount Consumed (g) 500 625 750 1000 Amount of Macaroni and Cheese Served (g) Rolls et al. Am J Clin Nutr. 2000 Dec;76(6):1207-13. Slide Source: www.obesityonline.org Diet Energy Density, Independent of Fat Content, Influences Energy Intake Energy Content of Food Consumed (k/cal/d) * Weight of Food Consumed (g/d) 1.02 1.17 1.34 1.02 1.17 1.34 Energy Density (kcal/g) Bell et al. Am J Clin Nutr 1998;67:412. Energy Density (kcal/g) *P<0.05 versus other 2 groups. Fat content held constant. Slide Source: www.obesityonline.org Effects of Fat and Water Content on Energy Density 100 90 80 70 60 50 40 30 20 10 0 Corn oil Water Content (g/100 g) Fat Content (g/100 g) r2=0.67 Butter Bacon Cheese Lettuce Steak Apple Bread Milk chocolate Pretzels 100 90 80 70 60 50 40 30 20 10 0 Lettuce Apple r2=0.82 Steak Cheese Bread Butter Bacon Milk chocolate Pretzels Corn oil 0 1 2 3 4 5 6 7 8 9 Energy Density (kcal/g) Rolls and Bell. Med Clin North Am 2000;84:401. 0 1 2 3 4 5 6 7 8 9 Energy Density (kcal/g) Slide Source: www.obesityonline.org Relationship Between Adiposity and Frequency of Eating in a Restaurant 55 Percent Body Fat 45 35 25 15 Partial r = 0.35; P = 0.005 5 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 Log Restaurant Food Consumption per Month Slide Source: www.obesityonline.org McCrory et al. Obes Res 1999;7:564. Prevalence of Obesity by Hours of TV per Day: NHES Youth Aged 12-17 in 1967-70 and NLSY Youth Aged 10-15 in 1990 Prevalence (%) 40 35 30 25 20 15 10 5 0 0-1 1-2 2-3 3-4 4-5 >5 NHES 1967-70 NLSY 1990 TV Hours Per Day (Youth Report) • ―There are too many. We can’t treat obesity because we would be treating everyone with everything.‖ Expert Panel of NHLBI: Assessing Obesity - BMI, Waist Circumference, and Disease Risk Disease Risk Relative to Normal Weight and Waist Circumference Men 40 in Men >40 in Women 35 in Women >35 in — — — — Category Underweight Normal* BMI <18.5 18.5-24.9 Overweight Obesity Extreme obesity 25.0-29.9 30.0-34.9 35.0-39.9 40 Increased High Very high High Very high Very high Extremely high Extremely high *An increased waist circumference can denote increased disease risk even in persons of normal weight. Adapted from Clinical guidelines. National Heart, Lung, and Blood Institute Web site. Available at: http://www.nhlbi.nih.gov/nhlbi/cardio/obes/prof/guidelns/ob_gdlns.htm. Accessed July 31, 1998. Expert Panel of NHLBI: Overall Risk of Obesity • • • • Evaluate the potential presence of other risk factors. Some conditions associated with obesity put patients at high risk for subsequent mortality, and will require aggressive modification. Other obesity associated conditions are less lethal, but still require treatment. Among the risks to consider are: coronary heart disease, other atherosclerotic diseases, type 2 diabetes mellitus, sleep apnea, gynecological abnormalities, osteoarthritis, gallstones, stress incontinence, hypertension, cigarette smoking, hyperlipidemia, and family history of early coronary disease. Expert Panel of NHLBI: Therapy Decision • Therapy is Recommended: • BMI > 30 • BMI 25 - 29.9, a dangerous waist circumference and 2 or more risk factors. • Individuals at lesser risk should be counseled about useful lifestyle changes if they are ready for a change. • ―So what can we do? There are all these diets and pills on the TV, but nothing seems to work very well. Is there anything that actually helps.‖ NHLBI Expert Panel: Goals of Therapy • • • • Reduce body weight and maintain a lower body weight for the long term. An initial weight loss target of 10% of body weight, lost over six months is recommended and will be medically significant. The rate of weight loss should be 1 -2 pounds each week. Evidence indicates that greater rates of weight loss do not achieve better long-term results. After the first six months of weight loss therapy, the priority should be weight maintenance through combined changes in diet, physical activity, and behavior. Obese Patients Have Unrealistic Weight Loss Goals Outcome Weight (lbs) % Reduction Initial Dream 218 135 0 38 Happy Acceptable Disappointed 150 163 180 31 25 17 Foster et al. J Consult Clin Psychol 1997;65:79. Slide Source: www.obesityonline.org NHLBI Expert Panel: Changes in ―Lifestyle‖ or Priorities Food • • • • ―Diets‖ chosen should be long-term Reduced 500 to 1000 from baseline in calories Targeting 30% or less of calories as fat Individualized. Activity • • • Activity is most useful in maintaining weight loss Goal of 30 minutes of moderate activity every day Increase everyday activity by taking the stairs, etc. Providing Prepackaged Meals Enhances Weight Loss Weekly Treatment 0 Weight Change (kg) Maintenance -2 -4 -6 -8 -10 -12 0 Control Behavior Therapy + Self-selected Diet Behavior Therapy + Food Provision 6 Months 12 18 P=0.0001 treatment vs control. P=0.0002 behavior therapy + self-selected diet vs behavior therapy + food provision. Jeffery et al. J Consult Clin Psychol 1993;61:1038. Slide Source: www.obesityonline.org ―I don’t think I need to change what I am eating. I am going to work out and lose it that way.‖ Physical Activity Alone Results in Minimal Weight Loss Control Group Stefanick 1998 Exercise Group Stefanick 1998a * * -7.0 -5.0 -3.0 * Anderssen 1995 Hammer 1989 Verity 1989 Rönnemaa 1988 Wood 1988 * -1.0 Wood 1983 1.0 *P<0.05 vs control group Weight loss (kg) Duration of each study ranged from 4 to 12 months. Wing. Med Sci Sports Exerc 1999;31(suppl):S547. Slide Source: www.obesityonline.org Relationship Between Physical Activity and Maintenance of Weight Loss 100 Subjects Exercising (%) P<0.001 80 60 40 20 0 Not Maintained Maintained Weight Loss Pattern Kayman et al. Am J Clin Nutr 1990;52:800. Slide Source: www.obesityonline.org Considerable Physical Activity is Necessary for Weight Loss Maintenance Concomitant Behavior Therapy Weekly Biweekly Monthly <150 min/wk 0 -2 -4 -6 -8 -10 -12 -14 -16 0 Change in Weight (kg) >150 min/wk *P<0.05 >200 min/wk 6 12 Time (months) 18 Slide Source: www.obesityonline.org Jakicic et al. JAMA 1999;282:1554. Effect of Decreasing Sedentary Activities vs Increasing Physical Activities on Body Weight in Children 6-12 Years Old Change in Percent Overweight 0 -5 -10 -15 -20 Decreased Sedentary Activity Increased Physical Activity -25 0 4 Time (months) 8 12 Slide Source: www.obesityonline.org Epstein et al. Health Psychol 1995;14:109. • ―This is so hard. Is there any good news?‖ Diabetes Prevention Program (DPP) • • Hypothesis: Can diabetes be delayed or prevented by addressing risk factors: impaired glucose tolerance, overweight and sedentary life - using lifestyle changes or metformin? 3234 pts of mean age 51, BMI 34, 68% women, 45% minorities and impaired glucose tolerance were randomized to 3 groups at 27 US centers: • Usual care (control) • Metformin 850 mg BID • Lifestyle intervention – • Goal of 7% weight loss by Food Pyramid, NCEP 1 diet • Goal of 150 min/wk moderate activity (brisk walking) Diabetes Development in Diabetes Prevention Program ―Obesity treatment and behavior change are too hard. I don’t have time to do this in my clinic.‖ Practical Behavior Change • • • • • • Physicians make a difference Repetition and follow-up are most useful Likely better to do with 2-5 minutes repeatedly than with an hour at once Education can be done in pieces Let them know that you know it’s hard and that the environment is against them Encourage patients to find their own goals (motivational interviewing techniques) but encourage specificity - go beyond ―watch what I eat‖ Five Steps to Facilitate Behavior Change 1 Identify behavior change goal 2 3 Review when, where, and how behaviors will be performed Have patient keep record of behavior change 4 5 Review progress at next treatment visit Congratulate patient on successes (do not criticize shortcomings) Slide Source: www.obesityonline.org Wadden and Foster. Med Clin North Am 2000;84:441. Cardinal Behaviors of Successful Long-term Weight Management National Weight Control Registry Data  Self-monitoring: – Diet: record food intake daily, limit certain foods or food quantity Weight: check body weight >1 x/wk –  Low-calorie, low-fat diet: – – Total energy intake: 1300-1400 kcal/d Energy intake from fat: 20%-25%  Eat breakfast daily Regular physical activity: 2500-3000 Slide Source: www.obesityonline.org Klem et al. Am J Clin Nutr 1997;66:239. McGuire et al.Int J Obes Relat Metab Disord 1998;22:572.  Long-term Weight Loss is Improved with Long-term Maintenance Therapy 0 -2 -4 -6 -8 -10 -12 -14 -16 -18 Weight Loss (%) No maintenance tx Maintenance tx Diet and behavior modification therapy 0 1 2 3 4 5 6 7 P <0.05 8 9 10 11 12 13 14 15 16 17 Time (mo) Perri et al. J Consult Clin Psychol 1988;56:529. Slide Source: www.obesityonline.org Assessing Weight Loss Readiness   Motivation: Stress level: Patient seeks weight reduction Free of major life crises Free of severe depression,  Psychiatric issues: substance abuse, bulimia nervosa Patient can devote 15-30 min/d to  Time availability: weight control for next 26 weeks YES Patient Ready? NO Initiate weight loss therapy Prevent weight gain and explore barriers to weight reduction Slide Source: www.obesityonline.org Prevention    Breastfeeding when possible Plotting BMI at each visit Anticipatory guidance:  5-2-1-0 “5 a day” fruits and vegetables  Less than 2 hr/day of screen time  At least 1 hour of moderate activity each day  No sweet drinks Appropriate Office Environment for Obese Patients     Waiting room chairs without arms Step stools next to examination tables Large gowns and blood pressure cuffs Scale that can weigh extremely obese patients, located in a private area  Appropriate obesity educational materials, handouts, and treatment protocols Empathetic, respectful, and supportive office staff Slide Source: www.obesityonline.org  • ―Isn’t there some popular diet I can follow? One that makes it easy.‖ Popular Diets • • • Succeed short term because restriction in food choice reduces calories Fail long term because restriction of food choices becomes unacceptable Promote a cycle of euphoria and despair that discourages belief in the possibility of success • ―What about surgery?‖ Role of Surgery • • • • Evidence for long term effectiveness Has serious dangers Is approved by most payers New questions about cost and who should be doing the surgeries Common bariatric operations Who qualifies for surgery? • • BMI greater than 40 BMI greater than 35 with obesity co-morbidity • Attendance in a plausible structured program for some period of time, without sustained and significant degree of weight loss Not impaired psychiatrically? BMI greater than 60? • • Recommendations for bariatric surgery in children         Limit to experienced bariatric surgeons. Ongoing availability of multidisciplinary team. Limited to skeletally mature (F13, M15) children. Pre-operative management by multidisciplinary team for ≥ 6 months BMI ≥ 40 with serious co-morbidities BMI ≥ 50 with less serious co-morbidities Patient assent Avoid pregnancy for one year • ―I can’t lose weight. What am I going to do?‖ When the Patient Can’t Lose Weight • In some patients, weight loss is not achievable. • The goal for these patients should be prevention of further weight gain which would exacerbate disease • Prevention of gain can be a success in some of these individuals • Some people will benefit from weight management programs primarily by prevention of gain, rather than by weight loss • ―Why don’t I just take a pill?‖ Role of Drugs •An aid to ―doing what needs to be done‖ •Not a program by themselves •Not infrequently ineffective Mechanisms of Action: Sibutramine and Active Metabolites Block Serotonin and Norepinephrine Reuptake MAO REUPTAKE S Serotonin Release S MAO S REUPTAKE NorepinephrineRelease S S = sibutramine  = norepinephrine,  = serotonin Adapted from Ryan et al. Obesity Res. 1995;3(suppl 4):553S-559S. Initial Responders to Sibutramine Can Maintain Long-term Weight Loss 230 Weight Loss Weight Maintenance Placebo Sibutramine 10-20 mg/d Body Weight (lb.) 225 220 215 210 205 200 195 0 2 4 6 8 10 12 14 Month 16 18 20 22 24 Randomization at 6 months in those with >5% weight loss. James et al. Lancet 2000:356:2119. Slide Source: www.obesityonline.org Additive Effects of Behavior and Diet Therapy with Pharmacotherapy for Obesity 0 Medication alone Weight Change (%) -5 -10 -15 -20 -25 0 2 4 6 8 Time (months) 10 12 Medication, behavior modification and meal replacements Medication and behavior modification * * *P<0.05 vs medication alone. Wadden et al. Arch Intern Med 2001;161:218. Slide Source: www.obesityonline.org Side Effects of Sibutramine • • • • Hypertension occurs in minority but must be monitored Somnolence and fatigue Mood effects - depression and rebound depression ? GI effects: unsettled stomach, stomach pains, bowel habit alterations Who To consider for Sibutramine • Ready to make long term change • Committed to a program of food and activity choice modification • Needing help to stay with the program • No other serotonergic drugs (prozac etc.) • Complaints of struggling with overwhelming appetite or craving? Orlistat - Mechanism of Action Intestinal lumen TG GI lipase + orlistat Mucosal cell Lymphatics FA FFA MG MG Bile acids Micelle 30% not absorbed Orlistat inhibits absorption of approximately 30% of dietary fat Mean faecal fat (g/day) 30 25 20 15 Orlistat 120 mg tid 10 5 0 -5 -4 -3 -2 -1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Study days Guerciolini, Int J Obesity 1997; 21 (Suppl. 3): S12-23 Orlistat: Weight Loss and Maintenance Over 2 Years Change in Body Weight (%) 0 –1 –2 –3 –4 –5 –6 –7 –8 –9 –10 –11 –12 Placebo Orlistat P<0.001 vs placebo at 1 and 2 years –10 0 10 20 30 40 50 60 70 80 90 100 110 Week SB DB DB Slightly hypocaloric diet SB = single blind; DB = double blind Adapted with permission from Sjöström L et al. Lancet. 1998;352:167. Weight maintenance (eucaloric) diet Gastrointestinal Adverse Events Episodes in Year One One Episode % 17.8 16.8 17.2 14.5 8.7 8.6 5.6 Two Three Episodes Episodes % % 5.9 2.9 4.3 2.8 3.2 1.7 3.6 1.9 2.1 1.1 1.4 0.8 1.7 0.4 Adverse Event Oily Spotting Flatus with Discharge Fecal Urgency Fatty/Oily Stool Oily Evacuation Increased Defecation Fecal Incontinence Few withdrawals due to GI adverse events Gastrointestinal events generally mild and transient Patients on orlistat should take a daily multivitamin supplement Side Effects of Orlistat • Fat malabsorption • Diarrhea - severity generally related to amount of fat eaten • Fecal Incontinence • Abdominal discomforts: bloating, pains, etc. • Mild malabsorption of fat soluble vitamins (like A, E) - which can be overcome by oral supplementation Who To Consider for Orlistat • Ready to make long term change • Committed to a program of food and activity choice modification • Needing help to stay with the program • Those with drugs or conditions that limit sibutramine: depression Rx, serious CV, etc • Willing to tolerate some ―inconvenience‖ Phentermine: Dosage Norepinepherine reuptake inhibitor • Dosage –Short term –Tolerance develops after a few weeks, after which drug should be discontinued • Available Dosage –HCL: 15, 18.75, 30, 37.5 mg –Resin: 15, 30 mg • Recommended Initial Dosage –HCL: 15 or 18.75 mg two hours after breakfast –Resin: 15 mg before breakfast Phentermine: Efficacy Weight Loss (kg) Weeks on Diet Phentermine: Adverse Effects • Dry mouth • Constipation • Sleep disturbance • Increased blood pressure Phentermine: Safety •Possibility for dependence •May increase blood pressure Endogenous cannabinoid blockers -Rimonabont et al. • Likely act on Hedonic/Limbic mechanisms • Weight loss studies appear to be in 10% initial BW range • Animal studies indicate combinations may be effective