Transcript Obesity Treatment

Obesity Treatment
Factors predispose to obesity
Genetic – familial tendency.
 Sex – women more susceptible .
 Activity – lack of physical activity.
 Psychogenic – emotional deprivation,
depression .
 Social class – poorer classes.
 Alcohol – problem drinking.
 Smoking – cessation smoking.
 Prescribed drugs – tricyclic derivatives.
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Weight Gain: Medications
Disease
Examples
Diabetes
Insulin, sulfonylureas
Depression
Tricyclics
Seizures
Valproic acid, Tegretol
Hypertension
Clonidine, α-blockers, β-blockers
Hormones
Progesterone
Weight Gain: How Does It Happen?
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Energy imbalance
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calories consumed not equal to calories
used
Over a long period of time
 Due to a combination of several factors
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Individual behaviors
 Social interactions
 Environmental factors
 Genetics
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Weight Gain: Energy In
3500 calories = 1 pound
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100 calories extra per day
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= 36,500 extra per year
= 10.4 lbs weight gain
Question: How much is 100 calories?
Answer: Not very much!
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1 glass skim milk, or
1 banana, or
1 slice cheese, or
1 tablespoon butter
Evolving Pathology
More in and less out = weight gain
 More out and less in = weight loss
 Hypothalamus
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control center for hunger and satiety
Endocrine disorder
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where are the hormones?
Leptin
Protein hormone secreted by adipocytes
 Levels correlate with lipid content of cells
 Leptin acts on the hypothalamus to
reduce hunger and to stimulate energy
expenditure
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Ghrelin
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Hormone secreted in the stomach
 Acts on the hypothalamus to stimulate appetite
 Levels peak just before meals and drop
afterward
Bad News for Dieters
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Leptin
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Dieting decreases leptin levels
Reducing metabolism, stimulating appetite
Ghrelin
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Levels in dieters are higher after weight loss
The body steps up ghrelin production in
response to weight loss
The higher the weight loss, the higher the
ghrelin levels
Health Consequences of Obesity
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Major cause of
preventable death
 Increase in mortality
from all causes
 Increase in risk for
these cancers
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Endometrium
Breast
Prostate
Colon
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Increase in risk of:
 Hypertension
 Dyslipidemia
 Diabetes type 2
 Coronary artery
disease
 Stroke
 Gallbladder disease
 Osteoarthritis
 Sleep apnea &
respiratory problems
Assessment
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Assess the patient's readiness and willingness to lose
weight :
 Unfortunately those who are most concerned about
their weights are not necessarily those who are at
the highest health risk.
 Those who are unable or unwilling to embark on a
weight reduction program, but they are willing to
take steps to avoid further weight gain or perhaps
to work on other risk factors such as cigarette
smoking, and they should be encouraged to do so.
 For those not ready to act, the issue should be
deferred and brought up at the next visit
Assessment
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Assess for other risk factors
 Existing high risk disease:
 coronary heart disease; other atherosclerotic diseases;
type 2 diabetes; sleep apnea
 Diseases associated with obesity
 Gynecological problems; osteoarthritis; gallstones; stress
incontinence
 Cardiovascular risk factors (3 or more = high risk)
 Cigarette smoking; Hypertension; LDL >130; HDL <35;
fasting glucose = 110 to 125; family history of premature
CHD; men age > 45; women age > 55
 Other risk factors
 Physical inactivity; elevated serum triglycerides
 Medications associated with obesity
Treatment Approach
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A multi-faceted
approach is best
Diet
 Physical activity
 Behavior change
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“A” Recommendation
Treatment Approach
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Initial goal: 10% weight loss
 Significantly decreases risk factors
Rate of weight loss
 1 to 2 pounds per week
 Reduction of caloric intake 500-1000 per day
Slow weight loss is more stable
 Rapid weight loss is almost always followed by
weight gain
 Rapid weight loss increases risk for gallstones &
electrolyte abnormalities
Treatment Approach
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Aim for 4 - 6 months of weight loss effort
Most people will lose 20 to 25 pounds
After 6 months, weight loss is more difficult
 Ghrelin & Leptin are at work!
 Changes in resting metabolic rate
 Energy requirements decrease as weight
decreases
 Diet adherence wavers
Set goals for weight maintenance for next 6 months,
then reassess.
Dietary Therapy
Weight reduction with dietary treatment
is in order for virtually all patients with a
BMI 25-30 who have comorbidities and
for all patients over BMI 30.
 Strategies of dietary therapy include
teaching about calorie content of
different foods, food composition (fats,
carbohydrates, and proteins), reading
nutrition labels, types of foods to buy,
and how to prepare foods.
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Low-Calorie Step I Diet
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1000 to 1200 kcal/day
for women
1200 to 1600 kcal/day
for men
Adjust for current weight
& activity
 Too hungry?
 increase kcal by
100 - 200/day
 Not losing?
 decrease kcal by
100 - 200/day
How Much is 1200 Calories?
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Could you stick to 1200 per
day?
1 Big Mac (580)
1 SMALL Fries (210)
1 SMALL shake (430)
Low-Calorie Step I Diet
Nutrient
Calories
Total fat
Cholesterol
Protein
Carbohydrate
Sodium
Chloride
Calcium
Fiber
Recommended intake
500 to 1000 kcal/day reduction from
usual
<30% of total calories
<300 mg per day
<15% of total calories
>55% of total calories
<2.4 g sodium, or <6 g sodium chloride
1000 to 1500 mg/day
20 to 30 g/day
Physical Activity
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Physical activity should be an integral part of
weight loss
 Physical activity alone is less successful than a
combined diet & exercise program
 Increased activity alone
does not decrease weight
 Sustained activity does
prevent weight regain
 Reduces risk for heart disease & diabetes
Physical Activity
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Start slowly
 Many obese people live sedentary lives
 Avoid injury
 Early changes can be activities of daily living
 Increase intensity & duration gradually
 Long-term goal
 30 to 45 minutes or more of physical activity
 5 or more days per week
 Burn 1000+ calories per week
Recommend Physical Activity
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What does it take to burn
1000 calories per week?
Gardening
5 hours
Cycling 22 miles
Running
11 miles
Walking
12 miles
Dancing 3 hours
Behavioral Strategies
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Keep a journal of diet & activity
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Set specific goals re: behaviors
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Very powerful intervention!
Eating
Activity
Related behaviors
Track improvement
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Weigh & measure on a regular basis
Cognitive Strategies
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Focus on the goals
Plan meals & activity
Develop reminder systems
Anticipate temptations & plan resistance
Reward yourself
Limit quantities, but do not deprive yourself
Have confidence in your ability to succeed
Do positive self-talk
Pharmacotherapy for Weight
Loss
Adjunct to diet & physical activity
 BMI ≥ 30
 Or, BMI ≥ 27 with other risk factors
 Should not be used for cosmetic weight
loss
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Only for risk reduction
Use only when 6-month trial of diet &
physical activity fails to achieve weight
loss
Pharmacotherapy for Weight
Loss
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These drugs are only modestly effective
2 to 10 kilogram loss
 Most occurs in the first 6 months
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If patient does not lose 2 kilograms in the
first 4 weeks, success is unlikely
 If the first 6 months is successful,
continue medication as long as…
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It is effective in maintaining weight, and
 Adverse effects are not serious
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Pharmacotherapy for Weight
Loss
Drug
Dose
Sibutramin 5/10,/15 mg
e
10 mg po qd to
(Merida) start. May be
increased to 15 mg
or decreased to 5
mg
Orlistat
(Xenical)
120 mg
120 mg po tid
before meals
Action
Adverse
Effects
Nor
epinephrine,
dopamine &
serotonin
reuptake
inhibitor
Increase in
heart rate &
blood pressure
Inhibits
pancreatic
lipase,
decreases fat
absorption
Decrease in
absorption of
fat-soluble
vitamins; soft
stools and anal
leakage
Weight Loss Surgery
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47,000 in 2001; 98,000 in 2003
Types of Obesity Surgery:
1. Restrictive Surgery - uses bands or staples to create food
intake restriction:
 Vertical Banded Gastroplasty (VBG) - is a “pure” restrictive
surgery since it only involves surgically creating a stomach
pouch. VBG uses bands and staples and is the most
frequently performed procedure for obesity surgery.
 Gastric Banding – involves the use of a band to create the
stomach pouch.
 Laparoscopic Gastric Banding (Lap-Band), approved by
the FDA in June 2001, is a less invasive procedure in which
smaller incisions are made to apply the band. The band is
inflatable and can be adjusted over time
Weight Loss Surgery
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2. Combined Restrictive and Malabsorptive
Surgery - is a combination of restrictive surgery
(stomach pouch) with bypass (malabsorptive surgery),
in which the stomach is connected to the jejunum or
ileum of the small intestine, bypassing the duodenum.
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Roux-en-Y Gastric Bypass (RGB) - is the most commonly
performed gastric bypass procedure, and the second most
frequently performed surgery for obesity after VBG. RGB
involves a stomach pouch for food intake restriction. A direct
connection, which is Y-shaped, is made from the ileum or
jejunum to the stomach pouch for malabsorption.
Biliopancreatic Diversion (BPD) - is one of the most complicated
obesity surgery, sometimes involving the removal of a portion
of the stomach. The remaining section of the stomach is
connected to the ileum. BPD successfully promotes weight
loss, but this procedure is typically used for persons with
severe obesity who have a BMI of 50 or more
Weight Loss Surgery
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Indications
100 pounds overweight or more
 Or, BMI > 40
 Or, BMI > 35 and 2 significant comorbidities
 Age 18 to 60
 Documented failure at nonsurgical efforts
 Psychological stability
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Weight Loss Surgery
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Roux-en-Y gastric bypass
 Limits food intake
 Alters digestion
Figure from NIDDK website
Weight Loss Surgery
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Complications of surgery
 Mortality
 <1% mortality in healthy young adults BMI < 50
 2-4% mortality in patients with disease and BMI > 60
 Operative complications
 < 10%
Late complications are uncommon
 Incisional hernias
 Gallstones
 Vitamin B12 & iron deficiency
 Weight loss failure
 Neurologic symptoms in unusual cases
Weight Loss Surgery Outcomes
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Durable weight loss
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One study followed pts for 14 years
Average excess weight loss = 61.2%
 77% with diabetes no longer require
meds
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From Wald meta-analysis in JAMA 2004)
Followup
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Schedule a return visit in 2 to 4 weeks after starting
weight loss plan
 Monitor treatment effectiveness & side effects
Schedule monthly visits for first 3 months
 If making favorable progress
 See more frequently if monitoring medical
complications or chronic disease
Reduce frequency of visits after 6 months
Followup
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Monitor weight, BP, pulse at each visit
Monitor waist size intermittently
Share progress with patient; praise efforts
Share lab results with patient
 Emphasize findings associated with weight
reduction
Focus on medical benefits
 Most weight loss doesn’t reach individual’s ‘ideal’
(cosmetic) goal