Clinical Diagnosis and Effective Management Strategies

1
Clinical Diagnosis and Effective Management
Strategies
2
What Do We Know About Obesity

• Prevalence continues to rise at alarming rate
  among adults, children and adolescents. Most
  common medical problem seen in primary care
  office.
• Is a major cause of preventable death.
• Causes over 40 medical problems affecting 9 organ
  systems.
• Morbidity and mortality rise with increasing BMI.

3
How Are We Doing as a Medical Profession?
Obesity is under-diagnosed and under-treated
4
Identification Counseling

• Summary of studies
• We are failing to adequately identify the
  overweight and mildly obese patient missed
  opportunities for early prevention and treatment
• We are doing a better job identifying the
  moderately and severely obese patient presenting
  with co-morbid conditions, particularly type 2
  diabetes, hypertension and hyperlipidemia

5
Percent of Patients Receiving PCP Advice by
Obesity Classification
Told Overweight 2 (test for linear trend)
16.5, p 0.001 Gave Weight Loss Advise 2 (test
for linear trend) 5.5, p 0.019
Simkin-Silverman LR et al. Prev Med 20054071-82.
6
Screening for Obesity in Adults

• The U.S. Preventive Services Task Force (USPSTF)
  recommends that clinicians screen all adult
  patients for obesity and offer intensive
  counseling and behavioral interventions to
  promote sustained weight loss for obese adults.
• Grade B Recommendation

Ann Intern Med 2003139930-932.
7
Identification and Treatment of Obesity

• Clinical Inertia
• Failure of the health care providers to initiate
  or intensify therapy when indicated
• Obesity failure to identify the condition
• Lack of education, training, and practice
  organization aimed at evaluating treating
  obesity as a chronic illness
• Practice barriers
• Attitudes of futility, lack of perceived benefit
  and unrewarding

Adapted from Phillips et al. Ann Intern Med 2001.
8
Barriers to Obesity Care

• Counseling is unlikely to be effective without
  understanding the barriers that patients,
  providers, and systems face and applying targeted
  strategies to overcome those behaviors.

Stange et al. Am J Prev Med 2002.
9
Providing Obesity Care
The Patient Knowledge Attitudes Expectations Deman
ds Motivation
The Practice Environment Payment Structure Type
of Visit Alternative Demands Availability of Staff
The Clinician Time Reimbursement Training Interest
Type of Visit
Clinician Delivery of Obesity Care
Adapted from Jaen et al. J Fam Prac, 1994.
10
Developing a Chronic Care Model of Care (A
Systems Approach)

• Put Prevention Into Practice
• AHRQ
• www.ahrq.gov
• Improving Chronic Illness Care
• http//improvingchroniccare.org
• Chronic care training manual
• ICIC Improving your practice manual
• Tools

11
Provision of Obesity Care

• Three factors necessary for physicians to
  intervene
• Adequate recognition of obesity as a medical
  problem
• Willingness to provide intervention
• Adequate skills or resources to do so

Kristeller Hoerr. Prev Med 1997.
12
Obesity Treatment Guidelines
www.nhlbi.nih.gov
www.naaso.org
13
Obesity Treatment Recommendations
14
The Office Visit
The Evaluation Process Consists of 6 Action Steps

• Measure weight, height, waist circumference and
  record body mass index (BMI)
• Categorize obesity classification and risk
• Take a comprehensive history, physical exam,
  lab tests for medical condition
• Assess need for treatment
• Broach the subject
• Assess readiness for treatment

The Practical Guide, 2000.
15
Body Mass Index Chart
Weight (lbs)
Height
16
BMI-Associated Disease Risk
Additional risks Large waist circumference
(men gt 40 in women gt 35 in) Poor aerobic
fitness Specific races and ethnic groups
Clinical Guidelines on the Identification,
Evaluation, and Treatment of Overweight and
Obesity in AdultsThe Evidence Report. Obes Res
19986(suppl 2).
17
Fatness, Fitness, and Cardiovascular Disease
Mortality
8
Aerobically fit
7
Unfit
6
5
Relative Risk of CVD Mortality
4
3
2
1
Lean
Normal
Obese
lt 16.7
16.7 24.9
? 25
Body Fat Category ( Weight as Fat)
Lee et al. Am J Clin Nutr 199969373.
18
Action BMI Ranges forAsian Populations are Lower
High to very high risk
WHO expert consultation. Lancet 2004363157.
19
Systems Review

• Respiratory
• Dyspnea
• Obstructive Sleep Apnea
• Hypoventilation Syndrome
• Pickwickian Syndrome
• Asthma
• Endocrine
• Metabolic Syndrome
• Type 2 diabetes
• Dyslipidemia
• Polycystic ovarian syndrome (PCOS)/androgenicity
• Amenorrhea/infertility menstrual disorders

• Cardiovascular
• Hypertension
• Congestive Heart Failure
• Cor Pulmonale
• Varicose Veins
• Pulmonary Embolism
• Coronary Artery Disease
• Neurologic
• Stroke
• Idiopathic intracranial hypertension
• Meralgia paresthetica
• Psychological
• Depression
• Body image disturbance
• Stigmatization

Kushner and Roth. Endo Metab Clinics N Am 2003.
20
Systems Review

• Gastrointestinal
• GERD
• Non-alcoholic fatty liver disease (NAFLD)
• Cholelithiasis
• Hernias
• Colon cancer
• Genitourinary
• Urinary stress incontinence
• Obesity-related glomerulopathy
• Kidney stones
• Hypogonadism (M)
• Breast and uterine cancer
• Kidney cancer
• Pregnancy complications

• Musculoskeletal
• Hyperuricemia and gout
• Immobility
• Osteoarthritis (knees/hips)
• Low back pain
• Carpal tunnel syndrome
• Integument
• Striae distensae (stretch marks)
• Stasis pigmentation of legs
• Cellulitis
• Acanthosis nigricans/skin tags
• Intertrigo, carbuncles

21
The Metabolic Syndrome
ATP III, Executive Summary, 2001.
22
Importance of Measuring Waist Circumference BMI
25 29.9 (Overweight)
Janssen et al. Arch Intern Med 20021622074-9.
NHANES III.
23
Importance of Measuring Waist Circumference BMI
18.5 24.9 (Healthy)
Janssen et al. Arch Intern Med 20021622074-9.
NHANES III.
24
Visceral AdiposityThe Critical Adipose Depot
25
Classification of Overweight and Obesity by BMI,
Waist Circumference and Associated Disease Risks
Clinical Guidelines on the Identification,
Evaluation, and Treatment of Overweight and
Obesity in AdultsThe Evidence Report. Obes Res
19986(suppl 2).
26
Percentage of Men with Metabolic Triad
Classified on Basis of Waist Girth and TG Level
waist lt 90
90 lt waist lt 100
waist gt 100
Lemieux et al. Circ 2000102179.
27
Metabolic Risk Identified by Hypertriglyceridemic
Waist
waist
TG
waist
TG
waist
TG
waist
TG
Insulin Resistance (HOMA)
Waist 95 cm M 88 cm F TG 128
mg/dl
Men
Men
Women
Women
Age 18-34
Age 55-74
Kahn and Valdez. AJCN 200378928-34.
28
Subcutaneous adipose tissue
5 10 weight loss
Visceral adipose tissue
30 visceral adipose tissue loss (diet,
physical activity, pharmacotherapy)
Lipid profile
Deteriorated Improved
Impaired
Improved ?
? ?
?
Insulin sensitivity Insulinemia Glycemia
Reduced obesity (low waist measurement)
Abdominally obese (high waist measurement)
Susceptibility to thrombosis
? ?
Inflammation markers
? ?
Endothelial function
Impaired
Improved
Risk of coronary heart disease
High
Low
Despres J-P et al. BMJ 2001322716.
29
Assessing Drug-Induced Causes for Weight Gain

• Diabetes Treatments
• Insulin
• Sulfonylureas
• Thiazolidinediones
• Antihistamines (cyproheptadine)
• ß- and alpha-1 adrenergic receptor blockers
• Chemotherapy agents
• Tamoxifen

• Psychiatric/Neuro
• Anti-psychotics
• Antidepressants
• Lithium
• AEDs
• Steroid Hormones
• Corticosteroids
• Progestational steroids
• HIV Protease inhibitors

30
Broaching the Subject Words to Use

• Are you concerned about your weight?
• What is hard about managing your weight?
• How does being overweight affect you?
• What cant you do now that you would like to do
  if you weighed less?
• What kind of help do you need to manage your
  weight?

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How important is it for you to get your weight
under control?
Not important
Very important
2
4
6
7
8
0
1
3
5
9
10
How confident are you to that you can get your
weight under control?
Not confident
Very confident
2
4
6
7
8
0
1
3
5
9
10
32
Obesity Treatment Pyramid
33
A Guide to Selecting Treatment
The Practical Guide. 2000.
34
NHLBI Clinical Guidelines on the Identification,
Evaluation, and Treatment of Overweight and
Obesity in Adults (1998)

• There is strong evidence that combined
  interventions of a low calorie diet, increased
  physical activity, and behavior therapy provide
  the most successful therapy for weight loss and
  weight maintenance.

Evidence Category A
35
NHLBI Clinical Guidelines on the Identification,
Evaluation, and Treatment of Overweight and
Obesity in Adults (1998)

• Low calorie diets can reduce total body weight
  by an average of 8 over 3 to 12 months.

Evidence Category A
36
U.S. Preventive Services Task Force (USPSTF)
Recommendations

• Fair to good evidence that high-intensity
  counselingabout diet, exercise, or bothtogether
  with behavioral interventions aimed at skill
  development, motivation, and support strategies
  produces modest, sustained weight loss (typically
  3 to 5 kg for 1 year) in adults who are obese.

Ann Intern Med 2003139930-932.
37
Pharmacotherapy

• Indicated as an adjunct to diet and physical
  activity for patients with a BMI 30 or 27 who
  also have concomitant obesity-related risk
  factors or diseases
• Agents
• Phentermine (1973) norepinephrine releasing
  agent
• Sibutramine (1997) serotonin norepinephrine
  reuptake inhibitor (SNRI)
• Orlistat (1999) gastrointestinal lipase inhibitor

38
Additive Effects of Behavior and Meal
Replacement Therapy With Pharmacotherapy for
Obesity
0
Medication alone
5
Medication and behavior modification
10

Weight Loss ()
15

Medication, behavior modification and meal
replacements
P lt 0.05 vs medication alone
20
Time (months)
Wadden et al. Arch Intern Med 2001161218.
39
NHLBI Clinical Guidelines on the Identification,
Evaluation, and Treatment of Overweight and
Obesity in Adults (1998)

• Evidence Statement Appropriate weight loss
  drugs can augment diet, physical activity and
  behavior therapy in weight loss.

Evidence Category B
40
NHLBI Clinical Guidelines on the Identification,
Evaluation, and Treatment of Overweight and
Obesity in Adults (1998)

• Evidence Statement Gastrointestinal surgery
  can result in substantial weight loss, and
  therefore is an available weight loss option for
  well-informed and motivated patients with a BMI
  40 or 35, who have comorbid conditions and
  acceptable operative risks.

Evidence Category B
41
Update Bariatric Surgery

• Currently Popular Procedures

Vertical Banded Gastroplasty
Biliopancreatic Diversion with Duodenal Switch
Gastric Bypass
LapBandTM
Restriction
Malabsorption
42
Efficacy Outcomes for Weight Reduction Surgeries
RYGB roux-en-y gastric bypass BPD
biliopancreatic diversion
Buchwald et al. JAMA 20042921724.
43
Efficacy for Improvement in Obesity-Related
Conditions
Completely Resolved 76.8 70 61.7 85.7
Resolved or Improved 86 ----- 78.5 83.6
Disease Diabetes Hyperlipidemia Hypertension O
bstructive Sleep Apnea
Buchwald et al. JAMA 20042921724
44
Conclusion

• Obesity is currently under-recognized and
  under-treated. Physicians need to identify and
  evaluate the overweight and obese patient at an
  earlier stage of development
• Screening begins by measuring BMI, waist
  circumference and identifying co-morbidities
• Treatment always includes lifestyle modification.
  Consideration for pharmacotherapy and surgery is
  based upon the individual patient