Diagnosing and Treating Obesity MMA Task Force on Obesity

1
Diagnosing and Treating ObesityMMA 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_at_mnmed.org

2
Obesity Management in an Outpatient Office
Practice
PatientBMI
40
27
31
20
37
33
21
29
3
Establish diagnosisBMI

• BMI weight (kg)/ height (M)2
• Correlates well with direct measures of adiposity
• Overweight child BMI gt85th and lt95th percentile
• Obese child BMI gt 95th percentile
• If child lt 3 years old, use weight for height

4
(No Transcript)
5

• The Wall Street Journal says that this obesity
  epidemic is nonsense. They say that body weight
  has been gradually increasing for a century.

6
Ten Year (approx) Change in US Prevalence
(NHANES) of Obesity and Severe (BMI gt 40) Obesity
35
30
25
20
15
10
5
0
88-94
99-00
7
Prevalence of overweight and obese children in
the USA, 1971-2000
8

• 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.

9
Medical Complications of Obesity
Idiopathic intracranial hypertension
Pulmonary disease abnormal function obstructive
sleep apnea hypoventilation syndrome
Stroke
Cataracts
Nonalcoholic fatty liver disease steatosis steatoh
epatitis cirrhosis
Coronary heart disease Diabetes
Dyslipidemia Hypertension
Severe pancreatitis
Gall bladder disease
Cancer breast, uterus, cervix colon, esophagus,
pancreas kidney, prostate
Gynecologic abnormalities abnormal
menses infertility polycystic ovarian syndrome
Osteoarthritis
Phlebitis venous stasis
Skin
Gout
10
Complications of Childhood obesity
11
Relationship Between Weight Gain in Adulthood and
Risk of Type 2 Diabetes Mellitus
Men Women
Relative Risk
Weight Change (kg)
Willett et al. N Engl J Med 1999341427.
12
Diagnosing the Metabolic Syndrome
Diagnosis is established when ?3 of these risk
factors are present.
Expert Panel on Detection, Evaluation, and
Treatment of High Blood Cholesterol in Adults.
JAMA 20012852486-2497.
13
Increase in Healthcare Costs Among Obese Compared
with Lean (BMI lt25 kg/m2) Patients
Increase in Cost Compared with Lean Subjects ()
BMI 30-34 kg/m2
BMI gt35 kg/m2
HMO Setting Northern California Kaiser
Permanente.
Quesenberry CP Jr et al. Arch Intern Med.
1998158466-472.
14

• Doc, I am fat because my hormones are out of
  whack. I know I dont eat too much. Can you check
  out whats wrong with me and give me a pill to
  fix it..

15
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

16
Selected Medications That Can Cause Weight Gain

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

• Diabetes medications
• Insulin
• Sulfonylureas
• Thiazolidinediones
• Highly active antiretroviral therapy
• Tamoxifen
• Steroid hormones
• Glucocorticoids
• Progestational steroids

SSRIselective serotonin reuptake inhibitor
17

• Yea, I know about balancing food and activity,
  but I dont dont eat that much.
• I dont eat more than other people
• I only eat salads.

18
Discrepancy Between Reported and Actual Energy
Intake and Expenditure
Energy Expenditure
Energy Intake

Kcal/d

Reported
Actual
Reported
Actual
Plt0.05 vs reported.
Lichtman et al. N Engl J Med 19923271893.
19

• My problem is my metabolism is slow. Anything at
  all that I eat turns to fat.

20
Relationship Between Resting Energy Expenditure
and Fat-free Mass
Lean females Obese females
Lean males Obese males
REE (kcal/24 h)
Fat-Free Mass (kg)
REE Resting energy expenditure
Owen. Mayo Clin Proc 198863503.
21

• Any time I try to lose weight, my metabolism
  slows down so much that I cant lose weight.

22
Energy Metabolism Before and After Weight Loss
Mean BMI Reduced from 31 to 23 kg/m2
Resting Energy Expenditure
Total Energy Expenditure


Energy Expenditure (kcal/d)


Before
Predicted
After
Before
Predicted
After
Plt0.05 vs before weight loss
Amatruda et al. J. Clin Invest 1993921236.
23

• So obesity is all genetic. Theres nothing I can
  do.

24
Gene-Environment Interaction in the Pathogenesis
of Obesity
P lt0.0001
Pima Indians
Body Mass Index (kg/m2)
Maycoba, Mexico
Arizona
Ravussin E et al. Diabetes Care 1994171067-1074.
25
Effect of Meal Variety on Energy Intake
Same food at each course Different food at each
course

Energy Intake (kJ)
1
2
3
4
Total
Meal Course
Plt0.001 vs same food at each course.
Rolls et al. Appetite 19845337.
26
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
Dec76(6)1207-13.
27
Diet Energy Density, Independent of Fat Content,
Influences Energy Intake

Energy Content of Food Consumed (k/cal/d)
Weight of Food Consumed (g/d)
Energy Density (kcal/g)
Energy Density (kcal/g)
Plt0.05 versus other 2 groups. Fat content held
constant.
Bell et al. Am J Clin Nutr 199867412.
28
Effects of Fat and Water Content on Energy Density
r20.67
r20.82
Fat Content (g/100 g)
Water Content (g/100 g)
Energy Density (kcal/g)
Energy Density (kcal/g)
Rolls and Bell. Med Clin North Am 200084401.
29
Relationship Between Adiposity and Frequency of
Eating in a Restaurant
Percent Body Fat
Partial r 0.35 P 0.005
McCrory et al. Obes Res 19997564.
30
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
4-5
3-4
2-3
1-2
0-1
gt5
31

• There are too many. We cant treat obesity
  because we would be treating everyone with
  everything.

32
Expert Panel of NHLBI Assessing Obesity - BMI,
Waist Circumference, and Disease Risk
Disease Risk Relative to NormalWeight and Waist
Circumference
Men ?40 inWomen ?35 in
Men gt40 in Women gt35 in
BMI
Category
Underweight Normal Overweight Obesity Extreme
obesity
Increased HighVery high Extremely high
lt18.5 18.5-24.9 25.0-29.9 30.0-34.935.0-39.9 ?40
High Very highVery 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
athttp//www.nhlbi.nih.gov/nhlbi/cardio/obes/pro
f/guidelns/ob_gdlns.htm. Accessed July 31, 1998.
33
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.

34
Expert Panel of NHLBI Therapy Decision

• Therapy is Recommended
• BMI gt 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.

35

• 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.

36
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.

37
Obese Patients Have Unrealistic Weight Loss Goals
Foster et al. J Consult Clin Psychol 19976579.
38
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.

39
Providing Prepackaged Meals Enhances Weight Loss
WeeklyTreatment
Maintenance
Control
Behavior Therapy Self-selected Diet
Weight Change (kg)
Behavior Therapy Food Provision
0
6
12
18
Months
P0.0001 treatment vs control. P0.0002 behavior
therapy self-selected diet vs behavior therapy
food provision.
Jeffery et al. J Consult Clin Psychol
1993611038.
40

• I dont think I need to change what I am eating.
  
• I am going to work out and lose it that way.

41
Physical Activity Alone Results in Minimal Weight
Loss
Stefanick 1998 Stefanick 1998a Anderssen
1995 Hammer 1989 Verity 1989 Rönnemaa 1988 Wood
1988 Wood 1983
Control Group Exercise Group




Weight loss (kg)
Plt0.05 vs control group
Duration of each study ranged from 4 to 12 months.
Wing. Med Sci Sports Exerc 199931(suppl)S547.
42
Relationship Between Physical Activity and
Maintenance of Weight Loss
Plt0.001
Subjects Exercising ()
Not Maintained
Maintained
Weight Loss Pattern
Kayman et al. Am J Clin Nutr 199052800.
43
Considerable Physical Activity is Necessary for
Weight Loss Maintenance
Concomitant Behavior Therapy
Weekly
Biweekly
Monthly
lt150 min/wk
Change in Weight (kg)
gt150 min/wk
Plt0.05
gt200 min/wk
0
6
12
18
Time (months)
Jakicic et al. JAMA 19992821554.
44
Effect of Decreasing Sedentary Activities vs
Increasing Physical Activities on Body Weight in
Children 6-12 Years Old
Increased Physical Activity
Change in Percent Overweight
Decreased Sedentary Activity
0
4
8
12
Time (months)
Epstein et al. Health Psychol 199514109.
45

• This is so hard. Is there any good news?

46
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)

47
Diabetes Development in Diabetes Prevention
Program
48

• Obesity treatment and behavior change are too
  hard. I dont have time to do this in my clinic.

49
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 its 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

50
Five Steps to Facilitate Behavior Change
1
Identify behavior change goal
Review when, where, and how behaviors will be
performed
2
3
Have patient keep record of behavior change
4
Review progress at next treatment visit
Congratulate patient on successes (do not
criticize shortcomings)
5
Wadden and Foster. Med Clin North Am 200084441.
51
Cardinal Behaviors of Successful Long-term Weight
ManagementNational Weight Control Registry Data

• Self-monitoring
• Diet record food intake daily, limit certain
  foods or food quantity
• Weight check body weight gt1 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 kcal/wk
  (eg, walk 4
  miles/d)

Klem et al. Am J Clin Nutr 199766239. McGuire
et al.Int J Obes Relat Metab Disord 199822572.
52
Long-term Weight Loss is Improved with Long-term
Maintenance Therapy
No maintenance tx Maintenance tx
Weight Loss ()
Diet andbehaviormodificationtherapy
P lt0.05
Perri et al. J Consult Clin Psychol 198856529.
53
Assessing Weight Loss Readiness

• Motivation
• Stress level
• Psychiatric issues
• Time availability

Patient seeks weight reduction Free of major life
crises Free of severe depression, substance
abuse, bulimia nervosa Patient can devote 15-30
min/d to weight control for next 26 weeks
YES
NO
Patient Ready?
Prevent weight gain and explore barriers to
weight reduction
Initiate weight loss therapy
54
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

55
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

56

• Isnt there some popular diet I can follow? One
  that makes it easy.

57
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

58

• What about surgery?

59
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

60
Common bariatric operations
61
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?

62
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

63

• I cant lose weight. What am I going to do?

64
When the Patient Cant 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

65

• Why dont I just take a pill?

66
Role of Drugs

• An aid to doing what needs to be done
• Not a program by themselves
• Not infrequently ineffective

67
Mechanisms of Action Sibutramine and Active
Metabolites Block Serotonin and Norepinephrine
Reuptake
MAO
REUPTAKE
Catabolism
Serotonin
Release
MAO
REUPTAKE
Catabolism
Norepinephrine
Release
S sibutramine? norepinephrine, ? serotonin
Adapted from Ryan et al. Obesity Res.
19953(suppl 4)553S-559S.
68
Initial Responders to Sibutramine Can Maintain
Long-term Weight Loss
Weight Loss
Weight Maintenance
Placebo Sibutramine 10-20 mg/d
Body Weight (lb.)
2
0
6
4
10
8
14
12
18
16
20
22
24
Month
Randomization at 6 months in those with gt5
weight loss.
James et al. Lancet 20003562119.
69
Additive Effects of Behavior and Diet Therapy
with Pharmacotherapy for Obesity
Medication alone
Medication and behaviormodification

Weight Change ()

Medication, behaviormodification and meal
replacements
0
2
4
8
12
10
6
Time (months)
Plt0.05 vs medication alone.
Wadden et al. Arch Intern Med 2001161218.
70
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

71
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?

72
Orlistat - Mechanism of Action
Mucosal cell
Lymphatics
Intestinal lumen
TG
GI lipase orlistat
FA
FFA
MG
MG
Bile acids
Micelle
30 not absorbed
73
Orlistat inhibits absorption of approximately 30
of dietary fat
Mean faecal fat (g/day)
Orlistat 120 mg tid
30
25
20
15
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
74
Orlistat Weight Loss and Maintenance Over 2
Years
0
Placebo Orlistat
1
2
3
Plt0.001 vs placebo at 1 and 2 years
4
5
6
Change in Body Weight ()
7
8
9
10
11
12
10
0
10
20
30
40
50
60
70
80
90
110
100
Week
SB single blind DB double blind
Adapted with permission from Sjöström L et al.
Lancet. 1998352167.
75
Gastrointestinal Adverse EventsEpisodes in Year
One
Few withdrawals due to GI adverse
events Gastrointestinal events generally mild and
transient Patients on orlistat should take a
daily multivitamin supplement
76
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

77
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

78
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

79
Phentermine Efficacy
Weight Loss (kg)
Weeks on Diet
80
Phentermine Adverse Effects

• Dry mouth
• Constipation
• Sleep disturbance
• Increased blood pressure

81
Phentermine Safety

• Possibility for dependence
• May increase blood pressure

82
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