Transcript Physical Activity and Weight Management

Physical Activity and
Weight Management
Julie Hagel, Pharm.D.
September 24, 2003
U.S. Obesity Statistics
 127 million adults: overweight or obese
 2nd leading cause of preventable death
 Responsible for 5-7% of annual national
health care expenditure
 $117 billion in healthcare costs: includes
direct and indirect costs
U.S. Obesity Statistics
 43.6% women, 28.8% men attempt
weight loss
 $30 billion spent annually on weight loss
products
A need and an opportunity
National Institutes of
Health (NIH) notes
that few healthcare
providers play a role
in management of
obesity
Barrier or Benefit?
 No 3rd-party
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coverage
Who has time /
space?
Scope of practice?
Costs
Competition
Pathophysiology of Obesity
 Chronic medical condition
 Energy intake exceeds energy
expenditure
 Factors involved
 Genetic
and physiological
 Environmental
 Cultural and socioeconomic
Health Consequences
of Obesity
 Hypertension
 Degenerative joint
 Dyslipidemias
 Type 2 diabetes
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 Cardiovascular
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disease
 Stroke
 Gallstones
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disease
Sleep apnea
Respiratory disease
Some types of
cancer
Hyperuricemia/gout
Getting started……
 NHLBI Obesity Education Initiative
 Treatment
of overweight or obese person
is two step process
Assessment
 Management
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 Requires lifelong effort!
Assessment:Weight & Obesity
 Body Mass Index (BMI)
 Waist circumference
 Risk factors
 Readiness to lose weight
Assessment: BMI
Body Mass Index:
Wt in Kg
Ht in meters squared
or
Weight in Lb x 703
Ht in inches squared
BMI
BMI Ranges
 Normal: 18.5 to 24.9
 Overweight: 25.0 to 29.9
 Class I obesity: 30.0 to 34.9
 Class II obesity: 35.0 to 39.9
 Class III obesity: 40.0 or greater
(extreme obesity)
Assessment: Waist
Circumference
 Regardless of weight or calculated BMI,
waist circumference marks increased
risk
 Men:
>40 inches
 Women: >35 inches
 Measure right above the upper hip bone
at the top of the iliac crest with tape
measure parallel to floor
Fat Distribution
 Apple
 Android
shape, typically in males
 Fat store seen in abdomen
 Pear
 Gynecoid
shape, typically in females
 Fat store seen in buttocks, hips, thighs
Assessment: Risk Factors
 Very high absolute risk
 Established coronary heart disease
 Other atherosclerotic diseases
 Type 2 diabetes
 Sleep apnea
 Increased risk
 Osteoarthritis, gallstones, stress
incontinence, gynecological abnormalities
Assessment: Risk Factors
 High absolute risk if three or more of the
following:
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Hypertension
Cigarette smoking
High LDL cholesterol
Low HDL cholesterol
Impaired fasting glucose
Family history of early cardiovascular disease
Age
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Male > 45
Female > 55
Assessment: Readiness
 Motivation
 Previous attempts
 Potential barriers
 Support system
Assessment: Tools
 Scale and Height
measurement
 Calculator or Chart
 On-line calculator
(Search engine:
“BMI Calculator”)
 Tape measure
Weighing In
 Can be performed by patient for self-
monitoring
 Recommend
once weekly
 Scale in pharmacy
 Document
patient progress
Body Fat Analysis
 Normal range
 Men: 12-15% (>25% indicator for obesity)
 Women: 20-25% (>30% indicator for obesity)
 Measuring techniques
 Hydrostatic weighing- mainly used in research
 Bioimpedance
 Near-infrared spectroscopy
 Body fat calipers
Management
 Goals
 Reduce
and maintain body weight
 Prevent future weight gain
 Promote healthy lifestyle
Therapies
 Must be individualized
 Can include:
 Dietary therapy
 Physical activity
 Behavior therapy
 Combination of above
 Pharmacotherapy-eligible high risk patients
 Surgery- extreme obesity
It doesn’t happen overnight….
 NHLBI guidelines
 Initial
goal: 10 percent reduction in body
weight
 Weight should be lost at rate of 1-2 pounds
per week
 Consequences associated with losing
weight too fast
Dietary Therapy
 Modify diet to achieve a decrease is
caloric intake
 Must adopt long term nutritional
adjustments
 Avoid very low calorie (<800 kcal /day)
content diets
 Ensure that all daily recommended
dietary allowances are met
Key Counseling Points
 Learn energy values of different foods
 Read and understand nutrition labels
 Monitor food consumption
 Reduce
portion size
 Use dietary recall or food diary
 Use new habits with food purchasing
and preparation
Physical Activity
 Has direct and indirect benefits
 Crucial for weight maintenance
 Evaluation before starting
 Recommendation is 60 minutes of
moderate intensity most days of week
 Build activity level slowly over period of
time
Key Counseling Points
 Keep track of physical activity and chart
weekly progress
 Effects of increased activity add up;
small increases = benefit
 Step counters may help motivate
 Reduce sedentary time
 Build physical activity into each day
Behavior Therapy
 Strategies to provide tools for
overcoming barriers
 Consider
attitude and past history
 Develop partnership with patient
 Set realistic goals
Behavior Modification
Techniques
 Self-monitoring
 Stimulus control
 Stress management
 Relapse prevention
 Social support
Pharmacotherapy
 May be used as adjunctive therapy in
 BMI
> 30
 BMI > 27 + risk factors
 Continue diet, physical activity and
behavior therapy
Pharmacologic Interventions
 Agents approved for short term use only
 Phentermine, diethylpropion,
benzamphetamine
 Increase NE in brain
 Usually prescribed 8-12 weeks
 Contraindications: hypertension, advanced
arteriosclerosis, cardiovascular disease,
hyperthyroidism, glaucoma, agitated
states, history of drug abuse, patients
taking MAOI, tricyclic antidepressants
Pharmacologic Interventions
 Serotonergic Agents
 Inhibits reuptake serotonin + NE + dopamine in
brain
 sibutramine (Meridia®); dosed once daily with or
without food
 Induces feeling of satiety
 Adverse effects include dry mouth, constipation,
headache, insomnia
 Contraindicated in cardiovascular disease, past
history of stroke
 Caution: Hypertension- monitor BP early
Pharmacologic Interventions
 Pancreatic Lipase Inhibitor
 Blocks
digestion of ~30% dietary fat
 orlistat (Xenical®); dosed 3 times daily
during or up to 1 hour after meal (with fat)
 GI side effects
 Can minimize GI side effects with a low fat
(<30% fat) high fiber diet
Pharmacologic Interventions
 OTC weight loss medications
 No FDA approved OTC ingredients
 Many products that claim to promote
weight loss
 Ephedra
Currently under FDA investigation
 Stimulant properties: potential to cause
increased blood pressure, MI, stroke, seizures,
especially in high doses
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Surgery
 Reserved for patients in whom other
treatments have failed AND who have
clinically severe obesity
Now what do you do?
 Behavioral approaches:
 Develop a therapeutic relationship
 Determine patient readiness
 Partner with patient / facilitate “buddies”
 Goal: Increase energy expenditure through
planned and unplanned physical activity and
decrease energy intake
Three levels of management
 Level I
 Entry level
 Educate patients re:
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health risks of obesity and
health benefits of increased physical activity and weight
loss
Distribute literature
Offer Digi-Walkers®, exercise bands, etc.
Get to know the weight loss drugs & community
resources very well
Three levels of management
 Level II
 Add all or some of the following:
 Medical quality scale and height tape/bar
 Assess health risks: BMI and waist circumference
 Referral relationships w/ other providers
 Incorporate weight management strategies into
disease management programs (e.g. HTN/DM)
 Documentation system
 Marketing
Three levels of management
 Level III
 Health-oriented weight loss and physical activity
improvement as a focal point of pharmacy practice
 Pharmacist is facilitator, motivator, educator
 Dedicated assessment room and classroom
 Program fee: primarily private pay
 Small group or individual counseling
 Marketing of screenings and classes
Useful Resources
 www.nhlbi.nih.gov/about/oei/
Obesity Education Initiative
 www.obesity.org
American Obesity Association
 www.d.umn.edu/student/loon/soc/phys/par-
q.html
Physical Activity Readiness Questionnaire (PAR-Q)
Conclusion
 Obesity is recognized as a disease
 Obesity and lack of physical activity
present significant health risks
 Few providers are involved in weight
management
 A screening and management program
is a viable pharmacy practice option