Managing the Obese Patient, With Emphasis on Exercise

1
Managing the Obese Patient,With Emphasis on
Exercise

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

2
Objectives

• Review the benefits of exercise in obesity
• Discuss the relative benefits of exercise vs.
  diet in achieving and maintaining weight loss
• Discuss what types of exercise are most
  beneficial
• Learn how to risk-stratify obese patients
• Learn the components of treatment necessary for
  weight loss

3
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 gt 30
• Class I 30 - 34.9
• Class II 35 - 39.9
• Class III gt 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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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 overweight/obesity

• 52 of US adults are overweight or obese!
• ONE HALF!
• Prevalence is INCREASING!
• 30 increase in adults in two decades
• gt80 increase in children/adolescents!!!
• Second-leading PREVENTABLE cause of death in the
  US

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Trends in overweight and physical activity among
U.S. mlitary personnel, 1995-1998.

• 1995 50 of military personnel overweight
• 1998 54
• Physical activity levels were high
• 67 engaging in regular, vigorous PA.
• Levels of PA Increased from 1995-1998
• CONCLUSION the increase in Overweight is not
  due to decreased PA
• Lindquist CH, Bray RM. Prev Med 2001
  Jan32(1)57-65.

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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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Facts on exercise in obesity tx.

• Exercise alone only leads to slight wt loss, if
  any, but marked reduction in mortality
• Adding moderate/vigorous aerobic exercise to
  dieting slightly increases wt loss
• 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 4-10 hours/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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Ross R et al. Reduction in obesity and related
comorbid conditions after diet-induced weight
loss or exercise-induced weight loss in men. A
randomized, controlled trial. Ann Intern Med
2000 Jul 133(2)92-103

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How much does exercise combined with diet add to
weight loss?

• Not very much
• 15 studies
• only 4 showed increased weight loss w/ addition
  of exercise to diet
• Exercise may, however, help people pay more
  attention to their diets

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A meta-analysis of the past 25 years of weight
loss research using diet, exercise, or diet plus
exercise intervention.

• Average 15-week treatment
• Diet or Diet-plus-exercise program, produces a
  weight loss of about 11 kg
• Miller WC, Koceja DM, Hamilton EJ. Int J Obs
  Relat Metab Disord 1998 Aug22(8)825.

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What is the effect of exercise intensity on
weight loss?

• Not much
• as long as it is moderate to high

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Relationship between physical activity and body
fat in women.

• Irwin ML et al. Presented at 2001 ACSM
  Conference, Baltimore.
• 143 women
• BMI and waist circumference were significantly
  related to
• Moderate PA
• Vigorous PA
• Sports/conditioning
• Occupation PA
• (but not to walking or household/yardwork)

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Are multiple, short-duration bouts as good as
continuous exercise for weight loss?

• Data inconclusive
• Two studies suggest so.
• More enjoyable More accessible Better
  compliance
• One study suggests no difference

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Jakicic JM et al. Effects of intermittent
exercise and use of home exercise equipment on
adherence, weight loss, and fitness in overweight
women a randomized trial. JAMA 1999
Oct282(16)1554-60.

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The effects of 18 months of intermittent vs.
continuous exercise on aerobic capacity, body
weight and composition, and metabolic fitness in
previously sedentary, moderately obese females.

• Two exercise groups
• continuous (30 min, 3d/wk, 60-75 VO2max)
• intermittent (brisk walking 15 min 2x/day,
  5d/wk).
• Weight loss
• continuous group -2.1
• intermittent group none
• Donnelly JE at al. Int J Obes Relat Metab Disord
  2000 May24(5)566-72.

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What is effect of resistance exercise on weight
loss?

• None
• Some studies even show weight gain
• However, there may be some other benefits (stay
  tuned)

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Does aerobic exercise vs. diet alone alter the
composition of weight loss?

• YES
• Diet alone leads to marked reduction in fat free
  mass (FFM) as well as fat mass
• 7 of 10 studies aerobic exercise preserves (FFM)
• Differences could be related to degree of obesity
• Higher BMI --gt less FFM lost

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Does exercise intensity affect body composition?

• Inadequately studied

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What is the effect of resistance training on body
composition?

• Definitely preserves, and may even increase, FFM
• Unclear effect on fat mass
• 3 studies show more fat mass lost w/ Diet
  Resistance vs. Diet alone
• 3 studies show no difference

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What role does exercise have in weight loss
maintenance?

• An important role
• Wing RR. Med Sci Sports Exer 1999
• Review of literature 6 studies
• 4 of 8 significant long term differences
  favoring diet exercise
• 4 of 8 trend favoring diet exercise

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Effects of walking training on weight
maintenance after a very-low-energy diet in
premenopausal obese women a randomized
controlled trial.

• RCT, 82 women, all did 12-wk Diet program to lose
  wt
• 40-wk maintenance program randomized to
• Counseling Walking program
• Counseling only
• At 2 year f/u,
• wt regain was 3.5 kg less and waist circ regain
  3.8 cm less in the walk group vs. controls.
• Fogelholm M et al. Arch Intern Med 2000 Jul
  24160(14)2177-84.

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Behavioral strategies of individuals who have
maintained long-term weight losses.

• Phone survey of 238 pts who lost gt10 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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How much exercise is needed for optimal weight
loss maintenance?

• The more, the better!
• 210 min/week brisk walking 40 wt regain
• 600 min/week brisk walking 15 retain

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What type of exercise is best for weight loss
maintenance?

• Either aerobic or resistance
• ? Both?

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Resistance exercise DURING weight loss may have a
role in long-term maintenance.

• RCT, 20 kids/adolescents, 2 groups, 12 weeks
• Diet-only
• Diet Resistance Exercise
• Weight loss equal in both groups
• Fat free mass decreased in diet-only group
• At one year f/u, wt regain inversely related with
  fat free mass at 12 wks
• Schwingshandl J et al. Effect of an
  individualised training programme during weight
  reduction on body composition a randomised
  trial. Arch Dis Child 1999 Nov81(5)426-8.

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Response of obesity to exercise may have a
genetic component.

• Study of obese patients in France
• UCP3 gene
• Wild C/C genotype BMI was negatively a/w PA
  (p.015).
• C--gtT polymorphism BMI not a/w PA
• Otabe S et al. A genetic variation in the 5'
  flanking region of the UCP3 gene is associated
  with body mass index in humans in interaction
  with physical activity. Diabetologia 2000
  Feb43(2)245-9.

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Risk-stratifying obese patients

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

• RISK FACTORS
• Age (mengt45, Wgt55)
• HTN
• LDL gt 160
• HDL lt 35
• Impaired fasting gluc
• FH of premature CAD
• Osteoarthritis
• Gallstones
• Stress incontinence
• Smoking

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Treating Obese patients
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The undisputed, 1 BEST method of treatment for
obesityis...
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(there is no one single best method)
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Treating obesity demands a multi-faceted approach
with chronic monitoring

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

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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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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 patients achieve ideal wt
• Falling short of lofty goals (SO common) leaves
  patients disappointed and highly susceptible to
  re-gain of weight lost
• Health can be achieved WHILE still obese
• Healthy obesity concept

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1. 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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2. Increased exercise

• Exercise regularly
• Need to gradually work up to this
• Start with brisk walking 10-45 min, 3-5 days/week
• Work up to 60-80 min, most or all days/week
• Aim to expend 1,000 - 2,000 kcal/week
• NHLBI, ACSM

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What kind of exercise is best for obesity
treatment?

• May be a combination of aerobic AND resistance
  training

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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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Counseling patients to increase exercise (cont.)

• 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 most/all days of week
• Intensity 55-90 of max heart rate
• Time 30-80 minutes
• Gradually work up to this
• Start with brisk walking 10 min, 3-5 days/week
• Work up to 60-80 min, most or all days/week
• 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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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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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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4. Pharmacological therapy

• Candidates
• BMI 27-29.9 and risk factor
• BMI gt30
• Never use as sole therapy!!
• Poor effectiveness
• Poor long-term maintenance of wt loss
• Agents approved by FDA for long-term use

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Sibutramine (Meridia)

• Blocks reuptake of norepi and serotonin
• Appetite suppressant, ? thermogenic
• Proven efficacy, even at one year of tx
• Improves TC, LDL, TG, HbA1c
• Side-effects
• Headache, elevated BP, insomnia, constipation,
  dry mouth
• Cost 80/month

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Orlistat (Xenical)

• Decreases fat absorption by inhibiting lipase in
  intestine (not absorbed)
• Proven efficacy, even long-term
• Improves TC, LDL, TG, HbA1c, glucose)
• Side-effects mostly GI
• Oily spotting, flatus, fecal urgency/incontinence
• Worse after fat ingestion can lead to less fat
  eaten
• Multi-vit with A/D/E/K recommended
• Cost 110/month

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5. Surgery for obesity

• For high-risk patients who have failed
  non-surgical therapy
• BMI 35-39.9 w/ RFs
• BMI gt 40
• Produces longest wt loss maintenance of all
  treatment methods
• Significantly decreases mortality rate
• Techniques vertical gastric banding, gastric
  bypass

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Summary of treatment based on BMI and risk

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

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Review pearls

• BMI gt 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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Facts on exercise in obesity tx.

• Exercise alone only leads to slight weight loss,
  if any, but marked reduction in mortality.
• Adding moderate/vigorous aerobic exercise to
  dieting slightly increases weight loss.
• Aerobic exercise during weight loss lessens loss
  of FFM.
• Resistance exercise during weight loss preserves
  FFM and may help maintain wt loss.
• Any type of exercise helps maintain weight loss,
  but duration must be 4-10 hours/week.
• Compliance may be better with multiple short-bout
  sessions.

71
Counseling patients to increase exercise

• Regularly discuss exercise with your patients
  (obese or not)

72
A meta-analysis of the past 25 years of weight
loss research using diet, exercise, or diet plus
exercise intervention.

• Average 15-week treatment
• Diet or Diet-plus-exercise program, produces a
  weight loss of about 11 kg
• Weight loss Maintenance after one year
• Diet only 6.6 kg loss maintained
• Diet-plus-exercise 8.6 kg loss maintained loss
• Miller WC, Koceja DM, Hamilton EJ. Int J Obs
  Relat Metab Disord 1998 Aug22(8)825.