Obesity: An Epidemic in America 15 Jul 2004

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Obesity An Epidemic in America15 Jul 2004

• Kevin deWeber, MD, FAAFP
• Family Physician
• Primary Care Sports Medicine

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Objectives

• Review the scope and importance of obesity
• Know how to diagnose obesity and classify its
  severity based on comorbidity
• Know know how to treat each severity class of
  obesity
• Know how to prescribe behavioral modification,
  diet, exercise, medications and surgical
  treatments for obesity

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Body Mass Index (BMI) is the global method of
determining overweight/obesityBMI
wt/ht²(kg/m²)(lbs/in²)x704.5
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Definitions

• Normal BMI 18 - 24.9
• Overweight 25 -29.9
• Obese 30
• Class I 30 - 34.9
• Class II 35 - 39.9
• Class III 40

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Etiology of obesity

• Too much food intake
• Insufficient energy output
• Not enough exercise
• Low resting metabolic rate
• Genetic predisposition
• Environment favoring weight gain
• Psychological stressors

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Evidence review for etiologyPublic Health Nutr
2004 Feb7(1A)123-46

• Convincing evidence as risk factors
• Sedentary lifestyle
• High intake of energy-dense, micronutrient-poor
  foods
• Probable risk factors
• Sugar-sweetened soft drinks and fruit juices
• Adverse social and economic conditions

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Obesity is associated with increased risk of
co-morbid conditions

• Hypertension
• Dyslipidemia
• Diabetes mellitus
• Coronary artery dz.
• Cerebrovascular dz.
• OVERALL MORTALITY HIGHER!

• Gallbladder dz.
• Sleep apnea
• Osteoarthritis
• Gout
• Cancers
• Colon
• Breast
• Prostate
• Uterus
• Cervix

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The scope of Obesity

• Two thirds of American adults are overweight!
• 31 are obese!
• The prevalence is increasing!
• Consumes 7 of national health care budget
• HCPs only counsel about 40 of obese patients

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Goals of treatment

• Get patients to look like models?
• NOT
• Get patients to their ideal body weight?
• NOT practical usually
• Get patients to lose 5-10 of body weight?
• HOPEFULLY
• Get patients to exercise and reduce their
  mortality risk?
• DEFINITELY!

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Set reasonable expectations

• Gradually develop regular exercise
• Gradually develop more healthy eating
• Shoot for losing 5-10 of body weight first

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Why the not-so-lofty goals?

• Rarely do obese patient achieve IBW
• Falling short leaves patients disappointed and
  highly susceptible to re-gain of lost weight
• Health can be achieved WHILE still obese
• Healthy Obesity concept

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Healthy Obesity

• Physically-fit obese patients have LOWER
  mortality rates than unfit normal-weight persons!
• Being thin doesnt guarantee being healthy
• Being fat doesnt HAVE to be unhealthy
• Physical activity and cardiovascular fitness are
  much more predictive of health than body weight

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Relative risk of all-cause mortality
Obese UNfit
Normal UNfit
Obese FIT
Normal FIT
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Relative risk of cardiovascular disease
Obese UNfit
Normal UNfit
Obese FIT
Normal FIT
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Despite the protection against cardiovascular dz.
and all-cause mortality that cardio-respiratory
fitness incurs, obesity still has its problems.

• Osteoarthritis
• Decreased quality of life
• Social discrimination
• Functional limitations

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Risk-stratifying obese patients

• RISK FACTORS
• Age (men45, W55)
• HTN
• LDL 160
• HDL
• Impaired fasting glucose
• FH of premature CAD
• Osteoarthritis
• Gallstones
• Stress incontinence
• Smoking

• HIGH RISK
• Coronary artery dz
• Sleep apnea
• Type 2 diabetes

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Choosing treatments

• Determine BMI
• Determine of risk factors
• Determine treatment options based on combination
  of the above

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Summary of Obesity Treatment
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The single BEST method of treatment for
obesityis...
EXERCISE
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Goals of treatment

• Get patients to look like models?
• NOT
• Get patients to their ideal body weight?
• NOT practical usually
• Get patients to lose 5-10 of body weight?
• HOPEFULLY
• Get patients to exercise and reduce their
  mortality risk?
• DEFINITELY!

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Relative risk of all-cause mortality
Obese UNfit
Normal UNfit
Obese FIT
Normal FIT
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Treating obesity demands a multi-faceted approach
with chronic monitoring

• 1. Increased exercise
• 2. Decreased caloric intake
• 3. Behavioral modification
• 4. /- Pharmacotherapy
• 5. /- Surgery

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Single vs. Combined Treatment

• Diet alone significant short-term weight loss,
  poor weight loss maintenance
• Exercise alone slight weight loss, good weight
  loss maintenance
• Diet PLUS Exercise more weight loss AND weight
  loss maintenance
• Behavioral modification techniques are needed to
  increase diet/exercise effectiveness

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1. Increased exercise

• Exercise regularly
• 150 minutes of moderate-intensity per week
• 30 min 5 days a week
• Start with brisk walking
• Work up to 300 min a week
• 60 min 5 days a week
• Better weight loss maintenance

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Facts on exercise in obesity tx.

• Exercise alone only leads to slight wt loss but
  marked reduction in mortality
• Aerobic exercise during wt loss lessens loss of
  FFM
• Resistance exercise during wt loss preserves FFM
  and may help maintain wt loss
• Any type of exercise helps maintain wt loss, but
  duration must be 300 minutes a week
• Compliance may be better with multiple short-bout
  sessions

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How good is exercise alone for weight loss?

• Not very effective
• 11 studies
• 5 found no change in weight w/ Exercise alone
• 6 showed slight weight loss w/ Exercise alone
• 1-2 kg

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What kind of exercise is best for obesity
treatment?

• Aerobic exercise is necessary
• Resistance exercise alone does not lead to weight
  loss
• Best approach may be a combination of aerobic AND
  resistance training
• Preserves fat-free mass, strength, endurance
• Maintains weight loss best

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Kraemer WJ et al. Influence of exercise training
on physiological and performance changes with
weight loss in men. Med Sci Sports Exer 1999
Sep31(9)1320-9.
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What is the effect of exercise intensity on
weight loss?

• Not much, as long as it is moderate to high
• However, high-intensity aerobics leads to
• Better preservation of muscle mass
• Greater LDL reduction
• Better strength and endurance

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Intermittent vs. continuous exercise for weight
loss

• Probably equal efficacy
• Encourage use of Pedometers
• Goal 10,000 steps a day
• Less for older pts, those w chronic dz
• More for children

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What role does exercise have in weight loss
maintenance?

• A HUGE role
• Best with 300 min/week

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Prevalence of leisure-time physical activity
among overweight adults--United States, 1998.

• Two thirds of overweight persons trying to lose
  weight reported using physical activity as a
  strategy for wt loss
• However, only 1/5 reported being active at
  recommended levels (30 min/day,most days).
• MMWR 2000 Apr49(15)326-30.

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Counseling patients to increase exercise

• Use the 5 As of counseling\
• Address the agenda
• Assess
• Knowledge, beliefs, concerns, feelings, stage of
  change
• Advise
• Personalized exercise recommendations
• Assist
• Provide support, identify barriers and resources
• Arrange follow-up

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Tailor counseling to the patients stage of change

• Pre-contemplation - not remotely interested
• Contemplation - considering wt loss
• Preparation - starting to make small changes
• Action - meeting behavior change criteria
• Maintenance - steady behavior over time

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Example Counseling a Pre-contemplator

• Provide handout on health benefits of weight loss
  and exercise
• Discuss barriers to exercise

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Example Counseling a patient in preparation
phase

• Give specific advice on Frequency, Intensity,
  Time and Type of exercise (FITT)

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Specific Exercise RecommendationsFITT

• Frequency 3-5 days a week
• Intensity 55-90 of max heart rate
• Time 30-60 minutes
• Gradually work up to this
• Start with brisk walking 10 min
• Work up to 60 min
• Type aerobic, resistance
• NHLBI, ACSM

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Follow-up after initial counseling

• See patient two weeks later and every month
• Ask about progress
• Encourage!
• Ask about barriers
• Discuss remedies
• Weigh patient
• Follow cholesterol, blood sugar, BP, etc.

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2. Decreased caloric intake

• 500 - 1000 kcal/day less than usual
• Lose 1-2 lbs/week
• Women 1000 - 1200 kcal/day total diet
• Men 1200 - 1500 kcal/day total diet
• National Heart, Lung, and Blood Institute.
  Clinical guidelines on the identification,
  evaluation, and treatment of overweight and
  obesity in adults the evidence report. 1998.

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Step I DietA low-fat, low-calorie diet

• Fat
• Protein about 15 of total calories
• Carbohydrate 55 of total calories
• Cholesterol
• Saturated Fatty Acids 8-10 of total cal
• NaCl
• Fiber 20-30 gm

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Step I Diet success

• 8 wt loss over 6 months

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What about Low-carb diets?

• Range from 20-90 gm carbs/day
• Atkins start 20 gm/d, go up from there
• Otherwise, eat what you want
• Induces lipolysis ketosis minor side effects
• 2003 meta-analysis wt loss was a/w
• Longer diet duration
• Restriction of calorie intake but not
  specifically carbs
• No adverse efx on LDL, HDL, fasting glucose BP

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5 RCTs on low-carb vs low-fat diet in 2003/2004

• Low-carb diets show greater wt loss at 6 mos
• 4-6 more body wt, or 4-5 more kg
• One study 12 mos no significant difference in wt
  loss
• Low-carb showed better lipid profiles
• Lower TG
• Higher HDL
• Same reduction in LDL
• Same improvement in insulin sensitivity

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How do low-carb diets work?

• Am J Clin Nutr 2004 May79(5)899S
• Reviewed wt loss studies and examined calorie
  intake and expenditure
• Wt loss was related to ENERGY BALANCE, not
  macronutrient type
• CONCLUSION Low-carb diets may influence satiety
• Research needed

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Zone Diet

• 40 carbs, 30 protein, 30 fat calorie
  distribution
• Promoted to reduce insulinglucagon ratio leading
  to balanced eicosanoid ratio, leading to
• reduced chronic dz, autoimmune dz, fatigue
• enhanced wt gain, longevity, mental performance
• Literature review little scientific basis
• J Am Coll Nutr 2003 Feb22(1)9-17

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South Beach Diet

• No carbs for 2 weeks
• Tho not a low-carb diet
• Reintroduce only low-glycemic-index carbs
• Certain fruits, veggies, whole grains
• Heavy on healthy meats, esp. fish
• No saturated fats more healthy monounsaturated
  fats
• Certain nuts, olive oil
• Theoretically sound, but LACKS SCIENTIFIC
  CREDIBILITY

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3. Behavioral Modification

• Self-monitoring
• Stimulus control
• Body image and self-esteem counseling
• Stress management
• Social support

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Self-monitoring

• One of the MOST HELPFUL TOOLS IN OBESITY
  MANAGEMENT
• Observation and recording of behaviors
• Total calorie intake, fat grams consumed, food
  groups used, situations that promote overeating,
  amount/intensity of exercise, weight, body
  composition, etc.
• Provides patient objective feedback so
  improvements can be made

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Stimulus control

• Identifying and modifying the environmental cues
  that are a/w overeating and inactivity
• Laying workout clothes on bed to increase
  likelihood of exercise the next AM
• Eating only at kitchen table
• Avoiding situations where overeating common

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Body image and self-esteem counseling

• Many obese pts have poor self-esteem
• Negative thoughts lead to poor compliance
• Many have unrealistic wt loss expectations
• Ideal body wt vs. 5-10
• Distorted body image
• 20 of obese pts wont exercise because they feel
  too fat

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Stress management

• Stress is a primary predictor of relapse and
  overeating
• Management techniques are VERY effective in
  obesity treatment
• Refer to mental health professionals if not
  skilled yourself

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Social support Those with it have more success

• Friends
• Family
• Community-based groups
• Health clubs, education courses, Weight Watchers
• Church-related activities

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Behavior modification strategies, extended
treatment, and physical activity are excellent
predictors of weight loss during
treatment.Foreyt JP, Goodrick GK. Evidence for
success of behavior modification in weight loss
and control. Annals of Internal Medicine
1993119698-701.
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Behavioral strategies of individuals who have
maintained long-term weight losses.

• Phone survey of 238 pts who lost 10 body wt
  Factors that correlated with maintenance
• Higher levels of exercise, especially strenuous
• More behavioral strategies to control dietary fat
  intake
• Greater frequency of self-weighing
• McGuire MT et al. Obes Res 1999 Jul7(4)334-41.

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Successful weight loss maintenance Ann Rev
Nutr 200121323-41.

• Data from National Weight Control Registry
• 3500 pts who have maintained 30lb wt loss over
  1 yr
• Common characteristics
• Low-cal diet (1380 kcal/day) low in fat (24)
• Frequently monitor their weight (daily to wkly)
• 80 eat breakfast daily
• Do an average of 60 min moderate exercise daily

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Weight loss with self-help compared with a
structured commercial program A randomized
trialJAMA 20032891792.

• Weight Watchers vs self-help
• One year
• WW 4.3 kg
• SH 1.3 kg
• Two years
• WW 2.9 kg
• SH 0

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Evans Army HospitalsLEAN program

• Lifestyle, Exercise And Nutrition
• 4-week Gastric Bypass program
• 8-week full program

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Gastric Bypass Program

• PCM referral to Nutrition Care
• 45-minute outpatient appointment with dietitian
  to enroll in program
• Nutrition history questionnaire
• Personal Wellness Profile, fitness assessment,
  gym orientation (Wellness Center)
• Weight loss contract
• Information on gastric bypass support group
• Lipid panel

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Gastric Bypass Program (cont.)

• 4-week class offered monthly
• 45 minutes of education
• 45 minutes of physical activity in the Wellness
  Center gym
• Topics
• Exercise Basics
• Nutrition 101
• Gastric Bypass Diet
• Diet Progression Following Surgery

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8-Week LEAN Program

• Referral from PCM
• 45 minute initial appointment with RD
• 8 weeks of classroom instruction and exercise
  sessions at the Wellness Center
• 4 months of individual f/u with RD
• Book Cooper Clinic Solution to the
• Diet Revolution

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Cooper Clinic Solution to theDiet Revolution

• Behavioral modification techniques
• Traditional low-fat diet high in fiber, fruits
  and vegetables
• Emphasis on exercise

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4. Pharmacologic therapy

• Candidates
• BMI 27-29.9 and 1 risk factor
• BMI 30
• Never use as sole therapy!!
• Low-to-moderate effectiveness
• Poor long-term maintenance of wt loss
• Agents approved by FDA for long-term use
• Sibutramine
• Orlistat

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Sibutramine

• Blocks reuptake of norepi and serotonin
• Appetite suppressant, ? thermogenic
• Side-effects
• small increases in BP, HR
• Headache, insomnia
• Cost 80/month

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Meta-analysis of sibutramine trialsArch Intern
Med, May 2004

• 29 RPC trials reviewed
• 3 months 2.8 kg more wt loss than placebo
• 12 months 4.5 kg more wt loss than placebo
• 2 yrs one trial w significant difference
• Improved HDL, TG, HbA1c
• ? long-term risk-benefit ratio
• No evidence of reduction in obesity-associated
  morbidity or mortality

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Orlistat

• Decreases fat absorption by inhibiting lipase in
  intestine
• Side-effects mostly GI
• Oily spotting, flatus, fecal urgency/incontinence
• Worse after fat ingestion
• Multi-vit with A/D/E/K recommended
• Cost 130/month

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Meta-analysis of orlistat trialsObes Rev, Feb
2004

• 23 trials RPC trials reviewed
• 3 mos 1.8 kg more wt loss
• 6 mos 9.8 vs 6.5
• 1-2 yrs 3.2 kg more wt loss
• 4 yrs 2.8 kg more wt loss
• Significant increase in pts achieving 5-10 wt
  loss
• Improved cardiovascular risk factor profiles
• Slt lower BP
• Lower TC, LDL, HbA1C
• ? Cost-effectiveness

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Surgical therapybariatric surgery

• For high-risk patients who have failed
  non-surgical therapy
• BMI 35-39.9 with at least 1 risk factor
• BMI 40
• Produces the most wt loss and longest maintenance
  of all treatment methods
• Significantly decreases mortality rate
• Techniques
• gastric bypass
• vertical banded gastroplasty (stomach stapling)

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Roux-en-Y gastric bypass

• Much earlier satiety
• Sweets can cause cramps and hypoglycemia
• Mortality 0-0.4
• 93 success in reducing BMI
• M-vit, Fe, Ca supplements needed

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Vertical banded gastroplasty

• Less popular now
• Restriction sometimes too tight, too loose
• Vomiting common
• 39 success in reaching BMI
• M-vit, Ca supplements needed

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Laparoscopic adjustable gastric band

• Up-and-coming
• Band tension adjustable via port
• Mixed study results

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Long-term benefits of surgery

• 83 of diabetics become euglycemic
• Dyslipidemia practically eliminated
• Sleep apnea markedly improved
• 60 of Htn patients come off meds

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Summary of treatment based on BMI and risk

• BMI 25-30, no RF advise wt loss
• BMI 27-29.9, 2 RF treat, /- meds
• BMI 30-35 treat, /- meds
• BMI 35-39.9, no RF treat, /- meds
• BMI 35-39.9, RF treat /- meds consider
  surgery
• BMI 40 treat /- meds consider surgery

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Summary of Obesity Treatment
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Review pearls

• BMI 30 defines obesity
• Risk-stratify patients based on co-morbidity
• Combined treatment with exercise, diet and
  behavior modification is most effective
• Set a reasonable goal of 5-10 wt loss
• Start exercise slowly emphasize benefits even if
  it doesnt result in wt loss
• Follow-up frequently and monitor
• Consider meds/surgery for high-risk patients

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Questions?