Pre-test Question 1: Choose the one correct answer

1. Obesity trends in children correlate with declines in milk consumption **

2. Obesity trends in the mid-west states are lower than other regions

3. Appetite suppressants can help patients lose up to 30% of baseline body weight

4. Lower carb diets are inherently more effective than lower calorie diets

Pre-test Question 2: Choose the one correct answer

1. The South Beech Diet advocates a VLCD2. Biologic pathways for diet intake usually involve

regaining of weight to homestasis levels **3. Obesity trends in the US have slowed

dramatically in the past decade4. Pharmacotherapy for obesity is indicated for

patients with a BMI of 25 or greater with co-morbid conditions

Obesity Epidemic in the US:Treatment Spectrum of the Adult

Patient

Grandview Medical CenterAnnual Family Practice Review and Reunion

Saturday, February 21, 2015

Lawrence E. Mieczkowski, MDCenter for Cardiometabolic Treatment & Education

Kettering, Ohio

Objectives

Describe the growing prevalence and impact of obesity in adults as well as children

Understand the pathophysiology of obesity and its relationship to diabetes and other co-morbid condition

Obtain a better grasp of the lifestyle treatment options, benefits of pharmacologic therapy, and when to recommend gastric bypass surgery for patients with obesity

2000

Obesity Trends* Among U.S. AdultsBRFSS, 1990, 2000, 2010

(*BMI 30, or about 30 lbs. overweight for 5’4” person)

2010

1990

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Generation XXL

Prevention of obesity in US adultsmust start with childhood

The lower the BMI of a child at kindergarten entrance, the lower the risk of obesity by 8th grade.

An obese child at age 7 has a 47% risk of being obese at 8th grade.

A Black or Hispanic girl born today has a 50% chance of becoming a Type II Diabetic.

Rapid Increases in Obesity Among U.S. Youth

NHANES 1963-2008

National Health Examination Surveys II (ages 6-11) and III (ages 12-17).National Health and Nutrition Examination Surveys I, II, III and 1999-2008.www.cdc.gov/nchs/data/hestat/obesity_child_07_08/obesity_child_07_08.htm.

Beverage Intake Among Adolescents Aged 11-18, 1965-1996

SOURCE: Cavadini C et al. Arch Dis Child 2000;83:18-24 (based on USDA surveys)

0

200

400

600

800

1000

1200

1400

1600

1965 1977 1989 1996

Per

cap

ita

gra

ms

con

sum

ed p

er d

ay

Boys Girls

(Soft drinks, diet soft drinks, and fruit drinks)

Active Transportation by Youth has Decreased

Mode for Trips to School – National Personal Transportation Survey

McDonald NC. Am J Prev Med 2007;32:509.

Increased TV Viewing Increases Childhood Obesity Prevalence

$1.6 billion/year spent on marketing of foods and beverages to youth

• $745 million on televisionTelevision viewing associated

with consumption of foods advertised on television

70% children 8-18 years and 30% children <3 year old have TVs in their rooms

NHES: National Household Education Surveys.

NLSY: National Longitudinal Survey of Youth.

Shifts in Dietary patterns in the United States

Relative prices of more healthful foods (fresh fruits and veggies) have increased faster than prices for less healthful foods (2 medium pizzas for $10.99).

Increased portion size: Biggie Fries, The Big Gulp

Increased consumption of processed foods typically higher in sodium

Increase in vending machines with pop schools and a la carte foods

Adult BMI Chart

5'45'4""

HeightHeight

Weight (lbs)Weight (lbs)

5'25'2""

5'05'0""

5'105'10""

5'85'8""

5'65'6""

6'06'0""

6'26'2""

120120 130130 150150 160160 170170 180180 190190 200200 210210 220220 230230 240240 250250140140 260260 270270 280280 290290 300300

6'46'4""

The Pathophysiology of Obesity Impacts Clinical Management

1. Aronne LJ et al. Clin Cornerstone. 2009;9:9-29. 2. Ochner CN et al. Physiol Behav. 2013;120:106-113.

Clinical Treatment1

Obesity is a chronic, progressive disease– Treatment must be long-term– Lifestyle modification alone may only be

effective short term For patients with difficulty achieving and

maintaining weight loss, pharmacotherapy is recommended

PathophysiologyA complex, multifactorial disease1

Biological changes:2

– Resist weight loss– Predispose patients to weight regain

Obesity and Mortality Risk

Bray GA, et al. Diabetes Metab Rev. 1988;4:653-679.

Actual Causes of Death in the United States, 1990

Source: McGinnis JM, Foege WH. JAMA 1993;270:2207-12.

400,000

300,000

100,000 90,000

30,000 20,000

Tobacco Diet/Activity Alcohol Microbialagents

Sexualbehavior

Illicit use ofdrugs

What are your patients doing about obesity?

29% of men and 44% of women trying to lose weight

About 20% of report restricting calories or increasing physical activity

Goal

Learn how to work with obese patients in a manner that is effective, minimizes physician frustration, shows respect for the patient and maintains good communication

Case Study: CAD and Type II DM

S: Ms. X is a 45 year old who was diagnosed with diabetes at the time of her admission for chest pain. Cath showed obstructive CAD. She had 2 coronary stents placed in her LAD. She is currently taking Metformin 2000 mg daily, Januvia 100 and 12 units of Lantus at night. She says that she checks her BS several times daily, and they are always in the upper 100s and lower 200s. She takes Lisinopril 10 mg, Atorvastatin 40 mg, ASA 81 mg, Clopidogrel 75 mg and Prozac 40 mg. She has lost 15 lbs. since her diagnosis, approximately 3 months ago, but has not lost any weight recently. Smokes 1ppd.

O: Current weight is 235#. Height is 5’4”. BMI 40.5.

Assuming you want to address her obesity, how would you proceed?

The Good Old 4-A Technique

ASKADVISEASSISTARRANGE

ASK

Assess readiness to change“I would like to discuss your weight and its impact on your health”

If ready, assess previous and current efforts and obstacles Weight Watchers, Jenny Craig, etc.

When asked, she acknowledges how her weight has been a life-long problem. She expresses her frustration that she has not been to lose weight or regains what she has lost.

She is supposed to be on a 1500 calorie diet, but she has never really counted calories, so she is not sure what she is actually consuming.

She is not able to identify any single foods that she eats frequently that she thinks are bad for her. She drinks 2% milk, and apparently has 3-4 glasses daily. She was unaware that this is actually high fat milk. She often eats only 1 or 2 meals daily.

She would like to exercise but doesn’t find the time or energy to get out and walk.

Readiness to Change

Precontemplation (not interested) Contemplation (6 months) Preparation (within a month) Action (working on it) Maintenance

Obstacles

Unaware of current intake Unaware of high calorie foods: ½ gallon whole milk=1200 cal Doesn’t like exercise or dieting Doesn’t feel poorly most days, giving her the feedback that nothing

bad happens if she is not compliant.

ADVISE

Give personalized advice:

her risks of overweight benefits to her of controlling weight

ASSIST

How to assist depends on Stage of Readiness to Change!!!

Assist(Readiness Stage: Preparation)

Provide educational materials Test Motivation: Give diet diary (3-7 day) Decrease obstacles

Inform of support programs available in the community

Counsel or refer as needed for counseling

Treating Obesity Without Frustration

Assess readiness to changeAssess barriers to changeUse appropriate tools to assess motivationAddress obstacles creativelyDetermine whether referral is appropriate and to

whom patient should be referredFrequent follow-up for patients in preparation,

action, or maintenance

Pearls for Treating Kids

Self-monitoring is one of most helpful tools. Have them record physical activity and diet on daily basis, weight every 2-4 weeks. Review when patients come back and give praise where appropriate.

Work on stimulus control Set limits on screen time (2 hrs/ day). No TV while eating. Remove snacks from view. Put out fruits and vegetables. Regular meal times including breakfast. Fist size portions only. Consider Metformin for puberty age children Check for underlying thyroid dysfunction

Dietary and Pharmcologic

Treatment for Obesity

AHA Guidelines for Healthy Diets

Protein: 15-20% of calories not excessive (50-100g/d) proportional to carbohydrate and fat

Carbohydrates: ~55% of calories Minimum of 100g/dFat: ~30% of calories, <10% sat fatProtein foods should not contribute excess total fat, sat fat or cholesterol

Diet should provide adequate nutrients and support dietary compliance

St. Jeor ST, etal. Circulation 104:1869-74, 2001.

A particular food or nutrient causes weight loss. Usually low in calories. May lead to protein calorie malnutrition leading to breakdown of lean muscle mass.

Right for your typeBeverly HillsFit for LifeGrapefruit DietCabbage diet

Low calorie, generally levels of 1200 or less.

Jenny CraigWeight WatchersSlim FastRichard Simmons

Limit carbohydrates; increase protein and sometimes fat.

Atkin’s DietSouth BeachSugar BustersProtein PowerCarbohydrate Addict’s diet

DescriptionDiets

Categorization of Diets by CHO and Fat

Dean Ornish Diet<10% Fat

Pritikin Diet<15% Fat

Weight Watchers, Jenny Craig, DASH diet, Food Guide Pyramid

55-60% CHO <30% Fat

The Zone Diet40% CHO 30% Fat

Carbohydrate Addicts Diet< 30% CHO

Atkins (20-60g CHO), Protein Power (<60g CHO), VLCD-protein sparing modified fast

< 20% CHO

Riley RE. Clinics in Sports Medicine. 18(3):691-701, 1999.

High Protein: Effects

Diuresis (limited to 1st week) Mobilization of glycogen stores – cause weight loss of ~ 1 kg Generation of ketones

Reductions in caloric content Appetite suppression from ketosis No studies have demonstrated advantages of ketotic diet

Denke M. Am J Cardiology 88(1):59-61, 2001.

St.Jeor ST, et al. Circulation 104:1869-1874, 2001.

High protein: Metabolic effects

Ketosis dehydration, constipation and kidney stones fatigue ??? alter cognitive functioning

High Saturated Fat Increases in LDL-C and TC

Low Fruits, Vegetables and Grains Deficient in micronutrients (Vitamin B, calcium, K) and

phytochemicals Increases in serum uric acid

Denke M. Am J Cardiology 88(1):59-61, 2001.

St.Jeor ST, et al. Circulation 104:1869-1874, 2001.

Westman EC. Et al. Am J Med. 113(1): 30-6, 2002.

South Beach Diet

Phase 1: 2 weeks. Most should see a weight loss of between 8 – 13 pounds. Most restrictive.

Phase 2: Until reach goal weight. Weight loss 1-2 pounds per week. Foods that were restricted in re-introduced into the diet.

Phase 3: for life. Restrictions: avoid highly processed food that contains ‘bad’ carbs and ‘bad’ fats and try and stick to the food that contains the ‘good’ ones.

Structure

Studies suggest that adding structure to dietary recommendations improves weight loss in the behavioral treatment of obesity.

Structure reduces the effort required for adherence, and eliminates much of the decision making, temptation, and guesswork involved in making healthy food choices.

Weight Watchers

Practical advice Group techniques Food variety Moderate protein, low

fat Limits refined sugars

and EtOH Stresses activity

Groups Very structured Weekly fees

Structured Meal Plans

Providing patients with structured meal plans and grocery lists produced just as great a weight loss at 6 months (13.7%) as did providing them with portion-controlled servings of food (13.5%).

The findings of this study indicate that specifying what foods and what amounts patients should eat improves weight loss, but that providing the food has no additional effect.

Protein – Sparing Modified Fast (Optifast, Medifast)

Calorie intake usually <900/dMinimize loss of lean body mass by having 70-

90g/d proteinLCD = ~800 cal/dVLCD = <800 cal/dUsually liquidMedical supervision needed

Maintenance

After losing 10% of their weight or more with 6 months of treatment, patients typically regain approximately one half of that weight within 1 year and return to their baseline weight within 5 years if they receive no further treatment

Pharmacotherapy

Multiple national groups advocate pharmacotherapy with BMI > 30 and > 27 with co-morbid conditions

FDA-approved pharmacotherapy can be helpful adjunct for treatment of obesity

Consider if lifestyle changes do not promote weight loss after 6 months

Net average loss attributable to drugs 5-10%, usually within first 6 months

Appetite Suppressant Obesity Drugs

Noradrenergic (Schedule IV, 12-week use) Phentermine (Adipex)

Selective Serotonergic (Schedule IV, no time limits on use) Lorcaserin (Belviq)

Combination (Schedule IV, no time limits on use)

Phentermine/Topiramate (Qysmia) Combination (Non schedule, no time limits on use)

Bupropion/Naltrexone (Contrave)

ConclusionsChildhood and adult obesity continues on with

minimal improvement in past 4-5 yearsMorbidity and costs of obesity will drain health

care dollars and contribute to declining tax baseDietary and lifestyle changes in childhood and

adolescence may slow rate of obesity in adulthoodStructured lower-carb, lower calorie diets are

effective on the short-termAppetite suppressants proven effective in short-

term and may be needed for long-term maintenance of weight loss