Obesity Management: Moving Beyond

1
Obesity ManagementMoving Beyond Eat Less
Move More
Arya M Sharma, MD, FRCP(C) Professor of
Medicine Research Chair for Obesity Research
Management University of AlbertaMedical
DirectorCapital Health Weight Wise
Program Edmonton, AB, Canada www.ch-weightwisemd.b
logspot.com
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Objectives

• Discuss environmental, psychosocial and
  biomedical causes of obesity
• Lay the conceptual framework for obesity
  diagnosis and management
• Briefly discuss treatment options, their role and
  efficacy

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Four-Fold increase in Morbid Obesity in Canada in
20 Years
Katzmarzyk et al. CMAJ, 2006
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Factors Contributing to Obesity

• Lifestyle
• Poor diet
• Skipping meals
• Sugary soft drinks
• Poor sleep
• Snacking
• Alcohol
• Sedentariness
• Etc.

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Adult Obesity in the Capital Health Region

• BMI gt 25 500,000
• BMI gt 30 250,000
• BMI gt 40 25,000

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Relationship Between BMI and Percent Body Fat in
Men and Women
Women Men
Body Fat ()
0
10
30
40
60
20
50
Body Mass Index (kg/m2)
Adapted from Gallagher et al. Am J Clin Nutr
200072694.
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Association of waist-to-hip ratio within
BMI categories with myocardial infarction risk
OR (95 CI)
lt20
20-23
23.1-25
25.1-27
27.1-29
gt30
BMI (kg/m2)
Yusuf S et al. Lancet 20053661640-1649
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Health Consequences of Obesity

• Metabolic
• diabetes
• dyslipidemia
• fatty liver
• hypertension
• cancer
• PCOS
• gall bladder
• infertility
• etc.

• Mechanical
• osteoarthritis
• obstructive sleep apnea
• reflux disease
• urinary incontenance
• intertrigo
• etc.

• Mental
• depression
• anxiety
• personality disorder
• self esteem
• etc.

Genes?
Sharma 2006
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Indications for Obesity Treatment
Indication for obesity treatment
Symptoms/Condition
Sharma 2006
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Barriers to Weight Management

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

Sharma 2005
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Selected Medications That Can Cause Weight Gain

• Diabetes medications
• Insulin
• Sulfonylureas
• Thiazolidinediones
• Highly active antiretroviral therapy
• Tamoxifen
• Steroid Hormones
• Glucocorticoids
• Progestational steriods

• Psychotropic medications
• Tricyclic antidepressants
• Monoamine oxidase inhibitors
• Specific SSRIs
• Atypical antipsychotics
• Lithium
• Specific anticonvulsants
• ?-adrenergic receptor blockers

11/26
SSRISelective Serotonin Reuptake Inhibitor.
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Isnt Obesity Simple?
Genetics
Environmental Determinants
Environmental Determinants
Energy Regulation is Complex!
Sharma AM 2007
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The Dilemma
Kg
decades
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Phases of Obesity Treatment
Phase I (Weight Loss)
Weight
3-6 months
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Treatment Success
Lifestyle (LS) 3-5
LSPharmacotherapy 5-15
Change in Weight
LSSurgery 20-30
Years
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Stepped Care Approach to Obesity Management
Biliopancreatic diversion
Gastric pacemaker
Roux-N-Y Gastric Bypass
Intragastric devices
Adjustable gastric banding
Pharmaco-therapy
Degree of Long-Term Weightloss
Hypocaloric diets
Lifestyle intervention
Treatment Intensity
Sharma 2005
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(No Transcript)
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Ingestive Behaviour
AM Sharma 08
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Ingestive Behaviour
1. Pattern?
2. Quality?
3. Quantity?
Sharma AM 2007
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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
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Anti-Obesity DrugPotential 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
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STORM Mean bodyweight changes duringweight
loss and weight maintenancephases over 2 years
Weight loss
Weight maintenance
104
Control
102
100
98
Bodyweight (kg)
96
94
92
90
Sibutramine
88
0
12
2
4
6
8
10
14
16
18
20
22
24
Month
Same diet and exercise for both sibutramine and
control
James WPT, Lancet 2001
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Bariatric Surgery Reduces Mortality in Swedish
Obese Subjects(n2010 vs. 2037)
30 Reduction in All Cause Mortality
Sjostrom L et al. NEJM 2007357741-52
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Long-Term Mortality After Gastric Bypass
Surgery(n7928 vs. 7925)
CoronaryArteryDisease
All CauseMortality
Diabetes
Cancer
reduced/10,000 person-yrs
Adams TD, et al. NEJM 2004357753
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Bariatric SurgeryEffect on Cardiovascular RiskA
Systematic Review and Meta-Analysis of 22,090
Patients
Hypertension
Dyslipidemia
Sleepapnea
Diabetes
resolved
Buchwald H, et al. JAMA 20042921724
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24-Hour Plasma Ghrelin Profiles in Subjects Who
Underwent Gastric Bypass and in Controls
Cummings, D. E. et. al. N Engl J Med
20023461623-1630
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Patient Selection

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

Sharma AM 2007
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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
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www.ch-weightwisemd.blogspot.com

• My Obesity Blog

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www.obesitynetwork.ca