Current Obesity Management in Primary Care

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Current Obesity Management in Primary Care

• Eileen L. Seeholzer, M.D., M.S.
• Asst. Professor
• Case Western University School of Medicine
• Department of Medicine
• MetroHealth Medical Center

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Obesity Defined  

•  Traditionally defined as a weight 20 greater
  than ideal body weight
•   Severe obesity or morbid obesity is defined
  traditionally defined as a weight 100 greater
  than ideal body weight

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Fat Distribution

• Upper-body obesity or abdominal obesity or
  androgenic obesity An independent risk factor
  for diabetes mellitus, cardiovascular disease,
  hypertension, arthritis, menstrual irregularities
  and gallbladder disease
• (Diabetes mellitus is thirty times higher in
  highest waist-to-hip ratio (whr)compared to
  lowest quartile whr)

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Clinical Guidelines on the Identification,
Evaluation and Treatment of overweight and
Obesity in Adults NIH NHLBI 1998
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Body Mass Index Chart
Weight (lb)
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Scope of the problem in the U.S.

• The prevalence of obesity in the United States is
  between 30 and 35 (Women 34)
• Overweight and obesity prevalence is 64.5
• Obesity rates are highest in lowest socioeconomic
  levels and in minorities and women. Rates of
  obesity often 50

Flegal et al. JAMA October 9, 2002 Vol 288,
no. 14
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Scope of the problem in the U.S.

• The prevalence of obesity has risen steeply in
  the last 20 years and continues to rise,
  especially in children, adolescents, and young
  adults
•  More than 78 million Americans are estimated to
  be obese and more the 8 million Americans are
  estimated to be severely obese

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Increased Risk for Adult Obesity

• Gender/Ethnicity Women, blacks, Hispanics and
  Native Americans
• Family History
• Childhood Obesity
• In lower socioeconomic status
• Sedentary lifestyle
• Increased time-spent watching TV

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Local Public Health Data

• The Behavior Risk Factor Survey
• a survey of 40,000 people conducted annually
  by the Centers for Disease Control. Subjects are
  asked about their weight and activity levels. Of
  forty thousand subjects 2,700 of the subjects
  live in Ohio 350 live in Cuyahoga County

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Local Public Health Data

• Obesity rates in Ohio rose from 25 in 1988 to
  35 in 1995
• ? Figures for Cuyahoga County are similar.
• ? 1995 obesity rate for African Americans of 48
  in Cuyahoga County
• ? Obesity is linked strongly to sedentary
  lifestyle. Forty percent of Ohio subjects
  reported a sedentary lifestyle

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Associated Medical Problems

• Cardiovascular HTN, cardiomyopathy, sudden
  death, CHF
• Endocrine DM, dyslipidemia, hypothyroidism
• Pulmonary OSA, disordered sleep, asthma
• GI GERD, cholelithiasis, NAFLD/NASH
• Oncologic Breast, colon, cervical, prostate
• Neurologic CVA, idiopathic intracranial
  hypertension, meralgia paresthetica

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Associated Medical Problems

• Renal Proteinuria/glomerulosclerosis, CRF
• Dermatologic intertrigo, venous stasis,
  cellulitis, hidradenitis suppurativa, acanthosis
  nigricans
• Psychiatric depression, binge eating disorder,
  night eating syndrome
• GU stress incontinence, PCOS, infertility,
  pregnancy risk
• Rheumatologic DJD- knee, hip, low back pain
• General fatigue, pain, disability, lower socio-
  economic status, poorer quality of life

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Obesity associated Increased Risks in Pregnancy

• Gestational Diabetes
• Hypertension
• Disordered breathing/Obstructive Sleep Apnea
• Cesarean section rate (RR1.5-1.8)
• Congenital heart defects (OR 1.4-2.0)
• Spina Bifida (OR 3.5)
• Omphalocele (OR 3.3)
• Increased levels of leptin, crp and tnf-alpha

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Birth Weight and Obesity

• LBW and ((4000gm)OR 1.53 increased gestational DM risk
• LBW associated with increased overweight
  adolescence
• Prolonged breast feeding associated with lower
  rates of adult obesity

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Metabolic Syndrome

• Three or more of the following present
• Abdominal obesity(102cm M/88cm F)
• Elevated triglycerides (150mg/dl)
• Low HDL (women)
• Hypertension
• High fasting blood sugar

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Metabolic Syndrome

• High risk and high cost constellation of medical
  problems
• U.S. prevalence overall is about 23
• Prevalence by BMI 6 of normal weight adults,
  60 moderately obese

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Metabolic Syndrome Impact on Mortality
Without metabolic syndrome With metabolic syndrome


Mortality Rate ()
P Isomaa B et al. Diabetes Care. 200124683-689.
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Nature/Nurture

• Genetics are estimated to explain about 30-40 of
  BMI variance
• Certain groups highly susceptible(Pima Indians,
  Samoans)
• Environmental factors are estimated to explain
  about 60- 70 of BMI variance

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Neuroendocrine Environment

• Leptin/Leptin receptor resistance (at VMH)
• TNF-a, IL-6, adiponectin (aconitase theory
  decreased cellular ATP,increased FFA and glucose,
  Wlodek, et. Al. 2003)
• CRP
• Dopamine, serotonin, norepinephrine
• Low growth hormone levels observed
• Higher cortisol levels sometimes seen

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Ghrelin and Peptide YY

• Ghrelin is orexigenic (hunger signal) secreted
  by stomach and duodenum serum level rise before
  and fall after meals
• Ghrelin levels increase with dieting, but
  decrease with gastric bypass
• PYY (satiety signal) secreted post-prandially by
  distal small bowel and colon decreases appetite
  and food consumption
• PYY decreases ghrelin levels
• Ghrelin acts on growth hormone secretagogue
  receptors to increase growth hormone

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National Weight Loss Registry

• Cohort 784 in initial cohort(629 female)
• Eligible subjects had maintained 13.6kg loss for
  over a year (avg. loss 28kg)
• FINDINGS
• Food strategy
• High levels of physical exercise
• Weight maintenance method
• Later study found maintenance less difficult with
  time

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Impact of Weight Loss on Risk Factors
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1. Wing RR et al. Arch Intern Med.
19871471749-1753. 2. Mertens IL, Van Gaal LF.
Obes Res. 20008270-278. 3. Blackburn G. Obes
Res. 19953 (Suppl 2)211S-216S. 4. Ditschunheit
HH et al. Eur J Clin Nutr. 200256264-270.
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Obesity Treatment Pyramid
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Non-Pharmacologic Treatments

• Weight loss goals 5-15 considered achievable
  and will improve health
• Components of Basic Program
• Diet Recommendations
• Exercise Recommendations
• Behavior Therapy
• Regular f/u in maintenance phase

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Short-term Obesity Therapy Does Not Result in
Long-term Weight Loss
Diet alone Behavior therapy Combined therapy
Change in Weight (kg)
5-yearFollow-up
1-yearFollow-up
End ofTreatment
Baseline
Wadden et al. Int J. Obes 198913 (Suppl 2) 39.
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Long-term Weight Loss is Improved with Long-term
Maintenance Therapy
No maintenance tx Maintenance tx
Weight Loss ()
Diet andbehaviormodificationtherapy
P Perri et al. J Consult Clin Psychol 198856529.
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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
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Results from Non-pharmacologic Programs

• Patient overwhelmingly regain the weight.
• Behavior therapy and exercise key to weight loss
  maintenance
• This therapy only addresses external environment
  and not biologic environment

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• Is it reasonable for an obese individual to exert
  continuous control over both biologic factors and
  environmental factors to successfully maintain
  weight loss?

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Pharmacologic Treatments

• Older meds increased noradrenergic output (i.e.
  phenteramine, diethylproprion) or increased
  serotonin release(dexfenfluramine Redux)
  withdrawn from market
• Sibutramine (Meridia) inhibits norepinephrine
  and serotonin reuptake. It induces 4-12
  decreases in weight. A longer term study showed
  5 reduction

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Pharmacologic Treatments

• Orlistat (Xenical) decreases fat absorption. It
  induces 5-13 decreases in weight and may have
  the benefit of a food avoidance behavioral
  mechanism. Losses of 3-5 observed long-term
• Ephedrine/caffeine over the counter supplements
  may induce 5-10 losses - not reliable
  ingredients and risk of arrhythmia/cardiac events

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• Pharmacotherapy helps maintain weight loss best
  in combination with behavioral, diet and exercise
  interventions

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Other Agents

• Topiramate (Topamax)- anticonvulsant. Mechanism
  for weight loss unknown. Doses of 64-384mg given.
  Weight loss at higher doses about 4 higher than
  placebo group(n385) (24 week)
• Bupropion (Wellbutrin) norepinephrine reuptake
  inhibitor and antidepressant. Weight loss found
  to be 5 higher in treatment group 400mg (24
  week) (n327)

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Experimental Agents - Phase 3

• SR141716 (Rimonabant) - blocks a cannabinoid
  receptor in then central nervous system that
  stimulates hunger when activated
• Recombinant human variant ciliary neurotrophic
  factor or CNTF (Axokine) - Binds to the CNTF
  receptor and activates signaling pathways in
  neurons of an appetite-control center in the
  hypothalamus
• Vastag, JAMA 4/9/2003

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Medications That May Promote Weight Gain

• Antipsychotics risperidone, clonazepine,
  olanzepin
• Antidepressants Tri-cyclics, SSRI
• Antiepileptics valproic acid, gabapentin,
  carbemazepine
• Lithium
• DM treatments Sulfonylureas, insulin
• Progestin steroids
• Cortisone
• Antihistamines
• Beta blockers

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Surgical Treatment

• In U.S, 40,000 done in 2001, estimated 80,000
  done in 2002
• NIH criteria - BMI40 or BMI35 with 2 medically
  important comorbid conditions
• Age not a contraindication
• Presurgical evaluation extensive
• Goal is to lose 50 of excess weight and improve
  comorbid conditions

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Surgical Outcomes

• Weight nadir 12-24 months
• BMI reduction 12 months after surgery of 16.4,
  at 24 months 13.3
• Vertical banded gastroplasty only 38 meet
  weight loss goal
• RGB - 5yr post-op excess weight loss 50-60 and
  75-89 successful at losing 50 excess weight
  (57 in super-obese)

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Predictors of Better Surgical Outcomes

• Age
• Employment
• Marital status
• Social support
• Female gender
• Diet compliance
• Appt compliance
• Preoperative weight loss
• Tobacco cessation
• Knowledge of eating rules

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Predictors of poorer Surgical outcomes

• Psychiatric admission history
• MMPI psychopathology
• Public assistance
• Negative life events
• Snacking
• Codependency
• Childhood abuse
• Denial of disease
• Black ethnicity
• Prior bariatric procedure

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Improvement in Comorbid Conditions s/p Gastric
Bypass

• Cures 85 of Diabetes Mellitus
• Cures 50-66 Hypertension
• Cures 85 hyperlipidemia
• Cures 89 gerd(lap-band)
• LVH regression seen after a year
• Improved fertility
• Pregnancy safer fewer complications compared to
  obese counterparts watch vitamins
• Depression decreases
• Increase in work and decreased disability/assistan
  ce

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Common longer-term Complications after Gastric
Bypass

• Dumping syndrome
• Nutritional deficiencies iron 20-50, B-12
  26-70, folate 9-35
• Higher rates of nutritional deficiencies in
  biliopancreatic diversion
• Rarely can have neuropathy or protein deficiency

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Screening For Obesity in Adults

• The USPSTF recommends that clinicians screen
  all adult patients for obesity and offer
  intensive counseling and behavioral interventions
  to promote sustained weight loss for adults
• December, 2003

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Office Assessment

• Assess BMI and if possible waist circumference
• Assess for co-morbid conditions and other risk
  factors (smoking, family history)
• Assess patients willingness to lose weight
• If ready take diet and activity history and set
  goals.

Based on the Assessment, Classification and
Treatment (ACT) tool. Clinical Guidelines on the
Identification, Evaluation and Treatment of
overweight and Obesity in Adults NIH NHLBI 1998
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Office Assessment

• Follow progress frequently with goal
  re-assessment for at least 6 months consider
  dietary or other referrals
• If BMI 30 consider medications
• If BMI 40, or 35 with risk factors, consider
  surgical assessment

Based on the Assessment, Classification and
Treatment (ACT) tool. Clinical Guidelines on the
Identification, Evaluation and Treatment of
overweight and Obesity in Adults NIH NHLBI 1998
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Weight Management Clinic

• Currently two ½ days weekly likely to expand
• This clinic is for obese patients (BMI30) who
  are READY to commit to lifestyle changes to
  maintain weight loss.

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Weight Management Clinic

• Evaluation for gastric bypass appropriateness/rea
  diness
• Medical management of co-morbid problems through
  weight loss
• Evaluation for pharmacologic treatment
• Pre-operative gastric bypass evaluation
• Post-operative gastric bypass follow-up for
  medical problems and adherence to diet and
  exercise recommendations

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Obesity Treatment Guidelines
The Practical Guidecan be found at
NHLBI web sitewww.nhlbi.nih.gov NAASO web
sitewww.naaso.org
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Obesity-Related ResourcesProfessional
Associations

• North American Association for the Study of
  Obesity (NAASO)
• American Academy of Family Physicians (AAFP)
• American College of Sports Medicine (ACSM)
• American Diabetes Association (ADA)
• American Dietetic Association (ADA)
• American Gastroenterological Association (AGA)
• American Heart Association (AOA)
• American Obesity Association (AOA)
• American Society for Bariatric Surgery (ASBS)

www.naaso.org www.aafp.org www.acsm.org www.diabe
tes.org www.eatright.org www.gastro.org www.americ
anheart.org www.obesity.org www.asbs.org
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Obesity-Related ResourcesGovernment Organizations

• Centers for Disease Control (CDC) Obesity and
  Overweight
• Centers for Disease Control (CDC) Prevalence
  data and growth charts
• National Institutes of Health (NIH)
• National Institutes of Diabetes Digestive
  Kidney Diseases (NIDDK) Weight-Control
  Information Network (WIN)
• National Institutes of Diabetes Digestive
  Kidney Diseases (NIDDK) Weight Loss and
  Control
• National Library of Medicine, MEDLINE Plus

www.cdc.gov/nccdphp/dnpa/obesity/
index.htm www.cdc.gov/nchs/nhanes.htm www.nih.gov
www.niddk.nih.gov/health/nutrit/win.htm www.nid
dk.nih.gov/health/nutrit/nutrit.
htm www.nlm.nih.gov/medlineplus/obesity.html