Transcript Progression of vessel damage. A 62 yo male comes into your

Screening and Management of
Obesity
Ray Plodkowski, MD
Chief Endocrinology and Metabolism
VA Sierra Nevada Health Care System, Reno and
Medical Director: University of Nevada School of Medicine
Division of Endocrinology, Nutrition, and Metabolism Weight Loss Clinic
(775)848-4206
Body Mass Index (BMI)
The clinical standard for
weight-for-height estimations
Body wt (in kg) / [Ht (in meters)]2
or
Body Wt (in lb) / [Ht (in in]2 X 703.1
WHAT IS YOUR BODY MASS INDEX?
Chart from CDC: For
Adults, aged 20 years and
older
BMI Clinical Guidelines*
Classification
BMI (kg/m2)
Underweight
< 18.5
Normal Weight
19 - 24.9
Overweight
25 - 29.9
Class I Obesity (Mild)
30 -34.9
Class II Obesity (Moderate)
35 - 39.9
Class III Obesity (Extreme)
 40
_______________________________________
*NHLBI /NIDDK, NIH. Clinical Guidelines on the Identification, Evaluation, and Treatment of
Overweight and Obesity in Adults. The Evidence Report. NIH Publication No. 98-4083, Sept. 1998
Why Body Mass Index (BMI)?
Wt (kg)/Ht (m2)
•
•
•
•
New definitions for overweight and obesity
Related to health risk (morbidity & mortality)
Simple, inexpensive, noninvasive
Nomograms available
Limitations of BMI







Does not distinguish between high weights due to large muscle
mass or edema
Can misclassify muscular persons as being overly fat
Does not reveal differences in fat distribution (visceral vs.
subcutaneous)
Does not differentiate between men and women
Is not accurate when height is compromised (kyphosis, scoliosis)
Should not be used for children < 2 years of age
Clinical judgment needed (frail elderly, etc.)
Obesity Trends* Among U.S. Adults
BRFSS, 1985
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
Obesity Trends* Among U.S. Adults
BRFSS, 1986
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
Obesity Trends* Among U.S. Adults
BRFSS, 1987
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4”
person)
No Data
<10%
10%–14%
Obesity Trends* Among U.S. Adults
BRFSS, 1988
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
Obesity Trends* Among U.S. Adults
BRFSS, 1989
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
Obesity Trends* Among U.S. Adults
BRFSS, 1990
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
Obesity Trends* Among U.S. Adults
BRFSS, 1992
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
Obesity Trends* Among U.S. Adults
BRFSS, 1993
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
Obesity Trends* Among U.S. Adults
BRFSS, 1994
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
Obesity Trends* Among U.S. Adults
BRFSS, 1995
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
Obesity Trends* Among U.S. Adults
BRFSS, 1996
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
Obesity Trends* Among U.S. Adults
BRFSS, 1997
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
≥20%
Obesity Trends* Among U.S. Adults
BRFSS, 1998
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
≥20%
Obesity Trends* Among U.S. Adults
BRFSS, 1999
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
≥20%
Obesity Trends* Among U.S. Adults
BRFSS, 2000
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
≥20%
Obesity Trends* Among U.S. Adults
BRFSS, 2001
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
≥25%
Obesity Trends* Among U.S. Adults
BRFSS, 2002
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
≥25%
Obesity Trends* Among U.S. Adults
BRFSS, 2003
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
≥25%
Obesity Trends* Among U.S. Adults
BRFSS, 2004
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
≥25%
Obesity Trends* Among U.S. Adults
BRFSS, 2005
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
Obesity Trends* Among U.S. Adults
BRFSS, 2006
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
Obesity Trends* Among U.S. Adults
BRFSS, 2007
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
Obesity Trends* Among U.S. Adults
BRFSS, 2008
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
Age-adjusted percentage of adults aged ≥20 years who are obese, 2007
MMWR 58:1259-1263, 2009
Age-adjusted percentage of adults aged ≥20 years with diagnosed diabetes, 2007
MMWR 58:1259-1263, 2009
Why is the Epidemic Occurring?
• Energy Balance: Intake vs. Output
Prevalence of Overweight and
Obesity Among US Adults
BMI=kg/m2
80
Overweight or obese
Overweight
Obese
(BMI 25.0)
(BMI 25.0-29.9)
(BMI 30.0)
64
60
Increased
100% in
20 years
56
47
% 40
34
33
32
31
23
20
15
0
NHANES II
1976-1980
(n=11,207)
NHANES III
1988-1994
(n=14,468)
NHANES †
1999-2000
(n=3601)
US Bureau of the Census estimates using the
age groups 20-34, 35-44, 45-54, 55-64, and
65-74 years
†Flegal KM et al. JAMA. 2002;288:1723-1727.
Environment
• Abundance of palatable, calorie-dense food
• Number of calories expended in physical
activity is insufficient to offset consumption
– Mechanization limits physical activity
– Sedentary daily routines consisting of:
• sitting at work
• sitting in traffic
• sitting in front of a television or a computer monitor for
most of their waking hours
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
SPAGHETTI AND MEATBALLS
20 Years Ago
500 calories
1 cup spaghetti with
sauce and 3 small
meatballs
Today
How many calories
do you think are in
today's portion of
spaghetti and
meatballs?
SPAGHETTI AND MEATBALLS
20 Years Ago
Today
500 calories
1,025 calories
1 cup spaghetti with
2 cups of pasta with
sauce and 3 small
sauce and 3 large
meatballs
meatballs
Calorie Difference: 525 calories
Maintaining a Healthy Weight is a Balancing Act
Calories In = Calories Out
How long will you have to houseclean in
order to burn the extra 525 calories?*
*Based on 130-pound person
Calories In = Calories Out
If you houseclean for 2 hours and 35 minutes,
you will burn approximately 525 calories.*
*Based on 130-pound person
Intake vs Output
• Walking = 5 kcal/minute
• 100 kcalories = a mile (walking at 3 MPH)
• Burger King Whopper = 640 calories(kcal)
To walk off a Whopper 640/5 = 128 minutes (6 miles)
• Subway 6” Turkey Sub (no cheese, no mayo) = 289 kcal
To walk off a Turkey Sub 289/5 = 57 minutes (3 miles)
Calorie Dense Food
Breakfast:
Blackberry Green Tea Frappuccino®
12 Grain Bran Muffin
560 (kcal)
400 (Kcal)
Lunch:
Double Quarter-Pounder with Cheese
Chocolate Shake 32 fl. oz.
Super Size Fries
760 (kcal)
1150 (kcal)
610 (kcal)
Dinner:
¼ white meat chicken (breast and thigh)
Mashed Potatoes (8oz)
Coca-Cola
330 (kcal)
210 (kcal)
140 (kcal)
Total:
3600 (kcal)
Intake vs Output
Extreme High Activity: Mountain Climbing
10.0 kcal/minute
To Burn off
3600(kcal) = 6 hours of
Mountain climbing
Intake vs Output
Extreme High Activity: Mountain Climbing
10.0 kcal/minute
To Burn off “Super-sized”
meal: 3600(kcal)
= 6 hours of
mountain climbing
(or 36 miles of walking!!)
Health Risks of Obesity
OBESITY is a Gateway Disease
As BMI Increases:
– LDL increases
– HDL decreases
– Blood Pressure Increases
– Cardiovascular events increase
– Dysmetabolic Syndrome
– Type 2 Diabetes
– Cancers (breast, colon, gallbladder, uterine)
NHANES III and
Hubert HB et al. Circulation
1983;67:968-977.
NHANES III Prevalence of Hypertension*
According to BMI
BMI <25
BMI 25-<27
BMI 27-<30
BMI >30
50
41.9
37.8
Percent
40
32.7
27.7
27
30
22.1
20
15.2
14.9
10
0
Men
*Defined as mean systolic blood pressure 140 mm Hg, mean
diastolic 90 mm Hg, or currently taking antihypertensive medication.
Brown C et al. Body Mass Index and the Prevalence of
Hypertension and Dyslipidemia. Obes Res. 2000; 8:605619.
Women
26 -Year Incidence of Coronary Heart Disease
in Men
<50 years
50+ years
Incidence/1,000
600
500
440
400
300
200
366
333
350
255
177
100
0
<25
25-<30
30+
BMI Levels
Adapted from Hubert HB et al. Circulation 1983;67:968-977.
Metropolitan Relative Weight of 110 is a BMI of approximately
25.
26 -Year Incidence of Coronary Heart Disease in
Women
<50 years
50+ years
Incidence/1,000
500
400
292
268
300
223
179
200
119
100
76
0
<25
25-<30
30+
BMI Levels
Adapted from Hubert HB et al. Circulation 1983;67:968-977.
Metropolitan Relative Weight of 110 is a BMI of approximately 25.
Obesity and Diabetes Risk
Incidence of New Cases
per 1,000 Person-Years
100
80
60
40
20
0
<20
20-25
25-30
30-35
35-40
>40
BMI Levels
Knowler WC et al. Am J Epidemiol 1981;113:144-156.
Cholescystectomy
20
25
30
35
40
BMI
Relationship between BMI and crude percentage of women reporting
medical problems, surgical procedures, symptoms, and health care utilization.
Brown WJ et al. Int J Obes 1998;22:520-528.
Hysterectomy
20
25
30
BMI
Brown WJ et al. Int J Obes 1998;22:520-528.
35
40
Back Pain
20
25
30
35
40
BMI
Brown WJ et al. Int J Obes 1998;22:520-528.
Constant Tiredness
20
25
30
BMI
Brown WJ et al. Int J Obes 1998;22:520-528.
35
40
Other Risks
•
•
•
•
•
Congestive Heart Failure
Stroke
Osteoarthritis
Sleep Apnea
Cancer (Colon, Breast, Endometrial,
Gallbladder)
Primary Care
Obesity Evaluation
Appropriate Office Environment
for Obese Patients
• Waiting room chairs without arms or a larger bench seat
with arms
• Step stools next to examination tables
• Large gowns and blood pressure cuffs
• Scale that can weigh extremely obese patients, located
in a private area
• Appropriate obesity educational materials, handouts, and
treatment protocols
• Empathetic, respectful, and supportive office staff
Slide Source:
Obesityonline.org
Medical History
•
•
•
•
•
•
Elicit risk factors and symptoms of the
manifestations of obesity:
Dysmetabolic syndrome
Type 2 diabetes
Cardiovascular disease (and angina)
Sleep apnea
Gallstones
Potential Pregnancy
Family and Social Histories
• Identify support networks and cultural factors
– May influence the patient’s ability to participate in a
weight management program
• Other household members with obesity
– May impact the ability for the patient to modify his or
her lifestyle and diet.
• Dietary changes
– Easier to implement if the other members of the family
also adopt healthier nutrition habits.
Assessing Weight Loss Readiness
• Motivation:
• Stress level:
• Psychiatric issues:
• Time availability:
YES
Initiate weight loss
therapy
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
Patient Ready?
NO
Prevent weight gain
and explore barriers to
weight reduction
Slide Source:
Obesityonline.org
Medical Causes of Obesity
• Hypothyroidism
• Cushing's syndrome
• Depression (Beck’s depression inventory)
Beck AT. The Beck Depression Inventory. San
Antonio, TX: The Psychological Corporation; 1987.
Beck AT, Steer RA, Garbin MG. Psychometric
properties of the Beck Inventory: Twenty-five years
of evaluation. Clin Psychol Rev. 1988;8:77-100.
Psychiatric History
• Comfort Eating (in response to negative emotions)
• Boredom
• Sadness and Depression
• Anger
•
•
•
•
Anorexia
Bulimia
Binge eating
Addictions: Smoking
Selected Medications That Can
Cause Weight Gain

Diabetes medications
– Insulin
– Sulfonylureas
– Thiazolidinediones

Highly active antiretroviral
therapy

Tamoxifen

Steroid hormones
– Glucocorticoids
– Progestational steroids
Selected Medications That Can
Cause Weight Gain
• Psychotropic medications
– Tricyclic antidepressants
– Monoamine oxidase
inhibitors
– Specific SSRIs
– Atypical antipsychotics
clozapine (Clozaril) 4.4 kg gain*
olanzapine (Zyprexa) 4.2 kg*
risperidone (Resperdal) 2.1 kg*
Paxil, Prozac
– Lithium
– Specific anticonvulsants
• -adrenergic receptor blockers
*Allison DB et al. Am J
Psychiatry 1999
Nov;156(11):1686-96
Exercise History
•
•
•
•
Exercise habits
Physical activity patterns
Limitations
Preferences
Physical Exam and
Measurements
– Blood Pressure
– Waist circumference (Non-Stretchable Tape)
– Height (wall-mounted stadiometer)
– Weight (Balance Beam Scale)
– Calculate BMI: weight (kg)/height (m2)
– Body Composition (by bio-impedence)
– Attention to gallbladder
– “The Usual”
Laboratory Assessment
•
•
•
•
•
•
TSH (optional Free T4)
CBC
Chem 20
Fasting Lipid Panel
Pregnancy test
Optional
– 24hr urine cortisol if Cushing’s suspected
Obesity Treatment
Lifestyle therapy
(diet, physical activity, and behavioral therapy)
is the cornerstone of obesity treatment
NIH Guide to Selecting Obesity
Treatment
Lifestyle
Therapy*
Pharmaco
therapy
Surgery
25-26.9
With
Comorbid.
Treatment
BMI Category
27-29.9
30-34.9 35-39.9
>40
With
Comorbid.
YES
YES
YES
With
Comorbid.
YES
YES
YES
With
Comorbid.
YES
*Lifestyle therapy: diet, physical activity, and behavioral therapy.
•Consider pharmacotherapy only if a patient has not lost 1 pound per week after
6 months of combined lifestyle therapy.
Goals of Weight
Management/Treatment
• Prevent further weight gain
(minimum goal).
• Reduce body weight.
• Maintain a lower body
weight over long term.
Target Weight: Realistic Goals
•
Substitute “healthier weight” for ideal or
landmark weight.
•
Accept slow, incremental progress to goal.
— Short-term goal: 5 to 10 percent loss,
1 to 2 lb per week.
— Interim goal: Maintenance.
— Long-term goal: Additional weight loss,
if desired, and long-term weight
maintenance.
Increase Physical Activity
• Most important in preventing weight regain
• Health benefits independent of weight loss
• Start slowly and increase gradually
— Can be single session or intermittent
— Start with walking 30 minutes 3 days/week
— Increase to 45 minutes 5 or more
days/week
— Encourage increased “lifestyle” activities
Behavior Therapy
Implementation of strategies, based on learning
principles, that provide tools for overcoming
barriers to compliance with diet or physical
activity changes:
• Self-monitoring
• Stress management
• Stimulus control
• Problem-solving
• Contingency management
• Cognitive restructuring
• Social support
Stress Management
Defuse situations that lead to
overeating:
• Coping strategies
• Meditation
• Relaxation techniques
Stimulus Control
Behavior change techniques:
• Learn to shop for healthy foods.
• Keep high-calorie foods out of the
home.
• Limit the times and places of
eating.
Cognitive Restructuring
Rational thoughts designed to replace negative
thoughts:
Instead of. . .
 “I blew my diet this morning by eating
that doughnut.”
Use. . .
 “Well, I ate the doughnut, but I can still
eat in a healthy manner the rest of the
day.”
Determining Daily Calorie Goals
for a Weight Loss Diet
Why Is Energy Balance Important?
• Current practice of weight control utilizes the
following premises for healthy adults:
• Calories in > energy out = weight gain.
• Calories in = energy out = weight
maintenance.
• Calories in < energy out = weight loss.
(3500 kcal deficit is needed for 1 pound weight loss per week)
What is REE?
• Resting energy expenditure (REE)=“burn rate”
• The number of calories the body uses each day
for maintenance of homeostasis.
• Can measure directly or use formulas
– Females: 10 Wt (kg) + 6.25 Ht (cm) - 5 age (y) –161
– Males:
10 Wt (kg) +6.25 Ht (cm) - 5 age (y) +5
*Mifflin-St. Jeor ST et al. Am J Clin Nutr 1990;51-241-7
Case Study
Patient:
• Female
• Age 50 years
• Height = 60”
• Weight= 180 lbs.
• BMI=35
Intake:
3 or 7 Day Food Record shows 2100 kcal/day average intake.
+2100 kcal/d
Output:
1.
REE : - 1400 kcal/d
2.
Physical Activity Factor (Intentional Physical Activity or exercise/wk)
140 min walking (20 min X 7 days) X 5 kcal/min = 700 kcal/week
700 kcal/7 days= - 100 kcal/day average
3.
TEE = REE (1400) X 1.3 = 1800 + Intentional PA (100) = ~1900 kcal/d.
-1900 kcal/d
__________________________________________________________________________________
Total
+200 kcal/d
Recommendation for WEIGHT MAINTENANCE (kcal/d):
To maintain current weight this patient must decrease intake by -200 kcal/day
from the current intake of 2100 kcal/d yielding a 1900 kcal/day diet.
Recommendation for WEIGHT REDUCTION (kcal/d):
To lose 1 pound per week, a 500 kcal per day deficit is needed
In this patient:
(-200 kcal/day deficit to maintain weight)
+ (-500 kcal/day deficit to lose 1 pound per week)
___________________________________________
= -700 kcal/day total deficit needed to lose 1 lb/week
Decrease 2100 KCAL/D intake by -700 kcal/d. = 1400 kcal/d
dietary intake
Questions?
Division of Endocrinology, Nutrition, and
Metabolism Weight Loss Clinic
(775)848-4206