Transcript ATP III: The Metabolic Syndrome Diagnosis is established

Assessment and Management of
Obesity
Cheryl A. Gibson, Ph.D.
Department of Internal Medicine
Susan Carlson, Ph.D.
Department of Dietetics and Nutrition
Objectives
• Upon completion of this session, you will be
able to:
– Determine a patient’s level of obesity by
calculating the BMI
– Assess a patient’s risk status associated with
obesity by analyzing the BMI, waist
circumference, and co-morbidities
– Assess a patient’s readiness to lose weight
– Be able to work with a patient to develop a
personalized strategy to address their
overweight/obesity
Epidemiology: Obesity/Overweight
• In last 2 decades, prevalence increased by 50-100%
among adults, and 3-fold among children and
adolescents
• 62% of US pop. are overweight, of these, 30% are
obese
• Higher in specific subgroups
– i.e., African American women have an 80% and 50%
prevalence of overweight and obesity, respectively
• 29% of US adults report no regular physical activity
Clinical Evaluation of Overweight and
Obesity --- Assessment
• Determine severity of patient’s obesity
– Overweight and obesity are classified by BMI
– Calculated with the formula:
– Weight (kg) / height squared (m2) OR
– [weight (pounds)/height squared
(inches2)] * 703
Classifying Obesity by Body Mass Index
• Classifying obesity by BMI units replaces previous
weight-height terminology such as percent ideal or
desirable body weight
Desirable or healthy weight: BMI = 18.5 to 25 kg/m2
Overweight: BMI = 25 to 29.9 kg/m2
Obesity: BMI ≥ 30 kg/m2
Obesity Trends Among U.S. Adults Between
1985 and 2000
Source of the data:
• The data shown in these maps were collected
through CDC’s Behavioral Risk Factor Surveillance
System (BRFSS). Each year, state health
departments use standard procedures to collect
data through a series of monthly telephone
interviews with U.S. adults
Clinical Evaluation of Overweight and
Obesity
• Assess patient’s obesity-related risk status
– Waist circumference
– Distribution of adipose tissue is an important
consideration in addition to BMI
– Measured by placing a measuring tape in a
horizontal plane at the level of the iliac crest
without compressing the skin
Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight
and Obesity in Adults: The Evidence Report. NIH Publication 98-4083.
Measurement of Waist Circumference
Waist Circumference
• Independent risk factor for type 2 diabetes and
cardiovascular disease
Excess abdominal fat
Men: Waist circumference > 40 inches (102 cm)
Women: Waist circumference > 35 inches (88 cm)
Weigh Your Patient’s Health Risks
Classification of Overweight and Obesity
BMI
(kg/m2)
Obesity
Class
Disease Risk
(Relative to Normal Weight and
Waist Circumference)
M ≤ 40 in
F ≤ 35 in
> 40 in
> 35 in
< 18.5
---
---
Normal
18.5 – 24.9
---
---
Overweight
25.0 – 29.9
Increased
High
Obesity
30.0 – 34.9
35.0 – 39.9
I
II
High
Very High
Very High
Very High
Extreme
Obesity
≥ 40
III
Extremely
High
Extremely
High
Underweight
ATP III: The Metabolic Syndrome
Diagnosis is established when 3 of these risk factors are present.
Risk Factor
Defining Level
Abdominal obesity
(Waist circumference†)
Men
>102 cm (>40 in)
Women
>88 cm (>35 in)
TG
150 mg/dL
HDL-C
Men
<40 mg/dL
Women
<50 mg/dL
Blood pressure
130/85 mm Hg
Fasting glucose
110 mg/dL
*Abdominal obesity is more highly correlated with metabolic risk factors than is BMI.
†Some men develop metabolic risk factors when circumference is only marginally
increased.
Expert Panel on Detection, Evaluation, and Treatment of
High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
TM
© 2002, Professional Postgraduate Services®
www.lipidhealth.org
NHANES III: Age-Specific Prevalence
of the Metabolic Syndrome
50
45
40
Men
Women
35
30
%
25
20
15
10
5
0
20-29
30-39
40-49
50-59
60-69
70
Age (y)
Data are presented as percentage (SE).
Ford ES et al. JAMA. 2002;287:356-359.
®
© 2002 Thomson Professional Postgraduate Services®
www.lipidhealth.org
Metabolic syndrome: Treatment
• The safest, most effective and preferred way to reduce
insulin resistance in overweight and obese people is
weight loss and increased physical activity (AHA, 2004)
• Other steps for managing the metabolic syndrome are also
important for patients and their doctors:
– Routinely monitor body weight (especially the index for
central obesity), blood glucose, lipoproteins and blood
pressure.
– Treat individual risk factors (hyperlipidemia, hypertension
and high blood glucose) according to established
guidelines.
– Carefully choose anti-hypertensive drugs because different
agents have different effects on insulin sensitivity.
Other Co-morbid Conditions
• Obstructive Sleep Apnea
– Often overlooked in obese patients
– Symptoms:
• Very loud snoring
• Cessation of breathing followed by a loud clearing
breath
• Nighttime awakening
• Daytime fatigue with episodes of sleepiness at
inappropriate times
• Morning headaches
Medical History
• History is important for evaluating risk and
deciding upon treatment. Questions should
address:
– Age of onset of obesity
– Minimum weight as an adult
– Events associated with weight gain
– Recent weight loss attempts
– Previous weight-loss modalities (successful
and unsuccessful)
– Complications of the above modalities
Drug-induced Weight Gain
• Although most common causes for overweight
and obesity are excessive caloric intake and lack
of physical activity, medication history should be
taken also
– Uncover possible drug-induced weight gain
– Other medications, which might be interfering
with weight loss
Drug-induced Weight Gain
– Drugs used to treat the following problems have
been shown to cause weight gain or make weight
loss more difficult
 Depression
 Schizophrenia
 Mood disorders
 Seizures
 Hypertension
Contraindications to Treatment of
Overweight and Obesity
• Active cancer
• Any severe illness
• Pregnancy
• Eating disorders
• Medical or psychiatric illnesses must be stable
before weight reduction begins
• Patients with cholelithiasis and osteoporosis
should be warned that these conditions might be
aggravated by weight loss
NIH Guidelines for Obesity Treatment
• Aim for 5-10% sustained weight loss (>1 yr.) for best
long-term effect
• Weight loss maintenance difficult
– Longitudinal registries illustrate 10-20% adherence
(+/- 10 lbs. of total weight loss)
– Tough, but important task!
• 3500 calorie deficit for 1 lb. weight loss
– i.e., 500 calorie deficit per day for 1 lb. weight loss
per week
NIH guidelines for obesity treatment, cont’d.
• Creating an energy deficit
– Restrict energy intake: maintain, on average,
1000-1200 kcal/day for women, 1200-1600
kcal/day for men
– Increase energy expenditure: at least 150
minutes of moderate/vigorous physical activity
per week, i.e., brisk walking, biking, jogging,
swimming
– On average, 10 minutes of vigorous activity
expends about 100 calories
Treatment Plan
– Based on clinical evaluation of patient’s level
of obesity and risk factors
– Primary Targets for Treatment
– Overweight patients with a BMI > 25 plus
at least 2 concomitant risk factors
– Obese patients with a BMI > 30,
regardless of complications
Treatment Modalities
• Physical Activity
• Behavioral Therapy
• Diet
• Pharmacotherapy
• Surgery
Goals of Non-surgical Therapies
• Reduce body weight
– Initial weight loss of 10% of body weight over
6 months (recommended target)
– Recommended rate of weight loss is 1 – 2
pounds each week
– Even modest weight may reduce visceral fat
and improve co-morbid conditions
• Maintain a lower body weight for the long-term
• Prevention of further weight gain is the minimum
goal
Multifaceted Approach
• Lifestyle approach (dietary therapy, PA, behavioral
therapy)
• Strong evidence supports multifaceted approach
– far more effective for wt loss and maintenance than
any single approach alone
• Lifestyle interventions should be attempted for at least
6 months before considering pharmacotherapy
Dietary Therapy
• Goal
– Reduce patients’ daily calorie intake to below
maintenance level
– Reduction of 500 to 1,000 kcal/day will achieve
weight loss of 1 to 2 lbs/week
– Women 1,000 to 1,200 calories/day
– Men 1,200 to 1,600 calories/day
Portion Control
• Important factor in patients’ effort to lose and maintain
weight
– Portion sizes for many foods are much bigger now
– Many people misjudge portion sizes
1 bagel = 4-6 slices of bread
1 muffin = 800 calories
16 oz steak = 1625 calories
(65% of a person’s wt
maintenance calories of 2500)
Source: US Dept Agriculture nutrient analysis
National Weight Control Registry
• National database of > 3000 individuals with average wt loss of 60 lbs maintained
for 5 yrs
 Consumed ~1400 kcal/day (24% fat calories)
 ~400 calories expended/day in PA (walking is the most frequent
PA)
 2/3 of successful weight losers were overweight as children and
60% report family history of obesity
 About 50% lost weight on own without formal program
 Successful weight losers self-monitor
Popular Diets
• Typically emphasize one food (and reduce another)
• Successful for weight loss because they reduce
TOTAL calories
• Higher in protein than RDA (50 gm women, 63 gm
men)
• Studies have shown that  72 gm/day reduces lean
tissue in most patients
– No evidence that carbohydrates contribute to
overweight
– Insulin resistance is reduced by weight loss, no
matter what diet is used to get wt loss results
Formula Diets
• 2 kinds of formula diets
– Very low calorie diets (VLCD)
–  800 calories/day
– Meal replacements
– Liquid or solid
– Can be bought over the counter
Very Low Calorie Diets
• Must be physician supervised
– Usually powder form (mixed with water or milk)
– Required vitamins/minerals are contained in 4-5 drinks/day
– Produces a rapid and consistent weight loss
– Rate of weight loss should be restrained for patients with
a history of arrhythmias or MI
Very Low Calorie Diets (VLCDs)
• VLCDs produce greater initial weight loss than
LCDs, which are between 1,000 to 1,500 kcal/day
• VLCDs promoted weight loss of 13 – 23 kg
compared to 9 to 13 kg from LCDs
• However, at 1 yr long term weight loss is not
different from that of LCDs
Source: Clinical guidelines on the identification, evaluation, and treatment of overweight and
obesity in adults. The Evidence Report. NIH Pub #98-4083
Pharmacotherapy
• Useful adjuncts to behavioral therapy
• Can be considered for those with BMI of 30 –
34.9 kg/m2 regardless of co-morbid conditions
• Two FDA approved drugs
– Sibutramine
– Orlistat
Evidence Report Recommendations
• Weight loss drugs may only be used as part of a comprehensive weight loss
program, including dietary therapy and physical activity
– With a BMI of ≥30 with no concomitant obesity-related risk factors or
diseases, and
– With a BMI of ≥ 27 with concomitant obesity-related risk factors or diseases
• Weight loss drugs should never be used without concomitant lifestyle
modifications.
• Continual assessment of drug therapy for efficacy and safety is necessary
– If the drug is efficacious in helping the patient lose and/or maintain weight
loss and there are no serious adverse effects, it can be continued
– If not, the drug should be discontinued
Obesity Pharmacotherapy
• Short term use is not beneficial
• Without lifestyle modification drugs unlikely to be helpful
• Few trials lasting 1 year or longer; attrition rates high
• Net weight loss averages 2-10 kg
• Most weight loss occurs within 6 months
• Weight is frequently regained after therapy is stopped
• Patients expectations ≠ your expectations
• Evaluate risk/benefit ratio before prescribing
– Initial response to therapy appears predictive
• Better drugs are needed
Long-term Pharmacotherapy
Meta-Analysis
Weight Loss
Percent Weight
Loss
≥ 10% weight
loss
Sibutramine
4.3 kg
4.6%
15%
N=929
95%CI: 3.6-4.9
95%CI: 3.8-5.4%
95%CI: 4-27%
Orlistat
2.7 kg
2.9%
12%
N=6021
95%CI: 2.3-3.1
95%CI: 2.3-3.4%
95%CI: 8-16%
Padwal et al. Int J Obesity 2003;27:1437-1446
Weight Loss Surgery
• Option for patients with severe or resistant obesity
• Patients with BMI at least 40 kg/m2 or less severe (BMI
between 35 and 39.9 kg/ m2) if at high risk of comorbid
conditions or weight-induced physical problems
• Must have integrated program that provides guidance
regarding diet, PA, and behavior therapy
Obesity Surgical Procedures
• Two operative approaches
– Vertical banded gastroplasty (VBG)
– Roux-en-Y gastric bypass (RYGB)
• Limit storage capacity of stomach to 30 to 50 cm
• Reduce pouch-emptying rate by creation of a 10mm
diameter anastomotic gastrointestinal stoma
Vertical banded gastroplasty (VBG)
Roux-en-Y gastric bypass (RYGB)
Surgical Procedures
• Average wt loss of approx 50% of excess body
weight
• Maintained in nearly 60% of patients at 5 years
• For VBG patients, no intestinal absorptive
abnormalities
• For RYGB patients, increased risk for micronutrient
deficiencies of vit B12, folate, and calcium
– Patients will need to be placed on long-term
vitamin-mineral supplements
Source: Am Soc Bariatric Surgery
Gastric Bypass Surgery Complications:
14-Year Follow-Up
Vitamin B12
239
39.9%
Readmit for various reasons
229
38.2%
Incisional hernia
143
23.9%
Depression
142
23.7%
Staple line failure
90
15.0%
Gastritis
79
13.2%
Cholecystitis
68
11.4%
Anastomotic problems
59
9.8%
Dehydration, malnutrition
35
5.8%
Dilated pouch
19
3.2%
Source: Pories WJ et al Ann Surg 1995;222:339-352
Summary of Recommendations
Clinical Guidelines
• Measurement of Degree of Overweight and Obesity
to Assess Health Risks
• Goals for Weight Loss
• How to Achieve Weight Loss
• Goals for Weight Loss Maintenance
Diabetes Prevention Program (DPP)
• Reduction of risk of getting type 2 diabetes
– Lifestyle intervention 58%
– Metformin 31%
• Subgroup analyses:
– Lifestyle intervention worked in all groups,
but particularly well in people age 60 and
older (71% reduction in dev of diabetes)
– Metformin worked especially well among
younger (25 to 45 yrs), heavier individuals
with BMI of 36 (50 to 80 lbs overweight)
National Weight Control Registry
• National database of > 3000 individuals who have
maintained at least 30 lb weight loss for at least one year
– Successful weight losers report making substantial changes in
eating and exercise habits to lose weight and maintain their
losses.
– The average registrant has lost approximately 60 lbs and has
maintained that loss for roughly 5 years.
– Two-thirds of these successful weight losers were overweight as
children and 60% report a family history of obesity.
– Approximately 50% of participants lost weight on their own
without any type of formal program or help.
– Walking is the most frequently cited physical activity performed
Weight Loss Counseling in Primary Care Settings
• Improvement Needed
– Recent BRFSS data of over 12,800 obese adults
who were seen by a physician in previous 12
months
– Persons who reported receiving advice to lose
weight were significantly more likely to report trying
to lose weight than those who did not (OR, 2.79;
95% CI, 2.53-3.08).
– Less than half of obese adults report being advised
to lose weight by health care professionals.
Galuska et al. Are health care professionals advising obese
patients to lose weight? JAMA 1999; 282(16)
Readiness to Change
• Initiating Weight Control Efforts
– Determining readiness and motivation are essential
elements of the initial assessment
– Most patients know that they have a weight
problem, and some will bring up the topic
– The way in which the patient is approached can
influence the success of efforts to deal with it
Suggestions for Initiating Discussion
• Determine whether the patient sees the weight
status as a problem for anyone but his or her
doctor
– What do you think about your weight?
– Asking such a question sets the stage for
addressing the patient’s weight as an issue
of mutual concern
Suggestions for Initiating Discussion
• Focus on the health implications of the patient’s
weight
– Narrow the discussion to the health consequences
– Labels matter. “Obesity” may be a clinical label but some
obese patients find it disparaging. Describe the patient’s
weight and health status, not the patient
– “Your weight is in a very unhealthy range” vs “You are
obese”
How should you refer to your patient’s
weight status
• Univ of Penn study 2001
• Relative desirability of different terms that
physicians might use to refer to a patient’s
obesity
– 127 female subjects were asked to imagine
that their doctor said to them: “I want to talk
with you about your _____”
– Had to fill in blank with 11 possible terms
– Desirability of each was rated from 1 (most
desirable) to 5 (least desirable)
How should you refer to your patient’s weight status?
Rank
Term
Score
1
Weight
2.00
2
Body Mass Index
2.96
3
Excess weight
3.08
4
Unhealthy body weight
3.21
5
Weight problem
3.21
6
Unhealthy BMI
3.65
7
Heaviness
4.00
8
Large size
4.27
9
Obesity
4.42
10
Excess fat
4.48
11
Fatness
4.81
•Most preferred
weight (79%)
•Least preferred
fatness (74%)
• 54% selected
obesity as one of
least preferred
ER Didie et al Obes Res 2001
Initiate Discussion
Step One
– Make the most of the patient visit and set an
effective tone for communication
•
Patients who are overweight or obese generally have a
history of dealing with a frustrating and visible problem
•
•
Often experience discrimination and hurtful comments
However, many patients are comfortable
discussing weight with their physician1
Wadden TA, Anderson DA, Porter GD, et al. Arch Fam
Med 2000; 9(9):854-860.
3 Steps to Initiate Discussion
Step Two
– Assess the patient’s motivation/readiness to
lose weight
– Ask the patient if he/she would consider
lifestyle changes to lose weight and
improve health
– Example:
– On a scale of 1 – 10, with 10 being
100% ready to take action, how ready
are you to lose weight?
Assessing Readiness to Change
• If the patient agrees that weight is a problem—seize the
moment to assess readiness to make changes
– Warning—some patients will verbalize a willingness
to change that they do not truly feel
– Careful phrasing of questions may help to avoid this
– Will you try to lose weight?----demands an
affirmative response
– Is there anything you think you can do that
might help your weight situation?---may open
the door to more candid responses
Assessing Readiness to Change
• Remember
– Readiness to change is not an all or nothing matter
– Patient may be willing to eliminate sugared beverages
but not to begin an exercise program
– After establishing the patient’s general patterns of
caloric intake and activity, ask which of them the patient
is willing to address initially
Tips
• Establishing rapport with patients
– Solicit permission to discuss weight issues
– Ask the patient if he/she would be comfortable with
discussing general health including weight
– Ask about the patient’s weight history and how
excess weight has affected his/her life
– Express your concerns about the health risks
associated with excess weight and how this is
affecting the patient
– Review the patient’s BMI, waist circumference,
and other associated health risks
Tips
• Ask the patient about previous attempts to lose
weight. What were the most successful and least
successful?
• Ask about the patient’s physical activity level and
attitude toward exercise
• Ask the patient about the level of support he/she can
expect from family and friends
• Ask about potential barriers to success
3 Steps to Initiate Discussion (continued)
Step Three
• Build a partnership with the patient
– Set goals for behavior change together with
the patient
– Recent study showed that most overweight
patients would like assistance with weight
management (e.g., dietary and physical
activity advice) and setting realistic goals*
*Potter WB, Vu JD, Croughan-Minihane M. J
Fam Pract 2001; 50(6): 513-8.
Tips
• Ask what the patient’s weight goals are
• Explain that even a small weight loss of 5 – 10 % of
initial weight can lower health risks
• Select 2 or 3 measurable, achievable goals and
discuss steps needed to achieve them
• Provide and discuss patient handouts and/or refer
patient to dietitian or exercise specialist
Summary
• Step One
– Make the most of the patient visit and set an
effective tone for communication
• Step Two
– Assess the patient’s motivation/readiness to
lose weight
• Step Three
– Build a partnership with the patient by setting
goals for behavior change together
Review Case Studies
Do You Know How Food Portions Have
Changed in 20 Years?
National Heart, Lung, and Blood Institute
Obesity Education Initiative
BAGEL
20 Years Ago
140 calories
3-inch diameter
Today
How many calories
are in this bagel?
BAGEL
20 Years Ago
140 calories
3-inch diameter
Today
350 calories
6-inch diameter
Calorie Difference: 210 calories
Maintaining a Healthy Weight is a Balancing Act
Calories In = Calories Out
How long will you have to rake leaves in order to burn
the extra 210 calories?*
*Based on 130-pound person
Calories In = Calories Out
If you rake the leaves for 50 minutes you will burn the
extra 210 calories.*
*Based on 130-pound person
CHEESEBURGER
20 Years Ago
333 calories
Today
How many calories are in
today’s cheeseburger?
CHEESEBURGER
20 Years Ago
Today
333 calories
590 calories
Calorie Difference: 257 calories
Maintaining a Healthy Weight is a Balancing Act
Calories In = Calories Out
How long will you have to lift weights in
order to burn the extra 257 calories?*
*Based on 130-pound person
Calories In = Calories Out
If you lift weights for 1 hour and 30 minutes,
you will burn approximately 257 calories.*
*Based on 130-pound person
SODA
20 Years Ago
85 Calories
6.5 ounces
Today
How many calories are in
today’s portion?
SODA
20 Years Ago
85 Calories
6.5 ounces
Today
250 Calories
20 ounces
Calorie Difference: 165 Calories
Maintaining a Healthy Weight is a Balancing Act
Calories In = Calories Out
How long will you have to work in the garden to burn
those extra calories?*
*Based on 160-pound person
Calories In = Calories Out
If you work in the garden for 35 minutes,
you will burn approximately 165 calories.*
*Based on 160-pound person
Thank you for participating in
Portion Distortion!
For more information about Maintaining a Healthy Weight
visit www.nhlbi.nih.gov