Transcript Sharma 2005
Obesity Management: Moving Beyond “Eat Less & Move More” Arya M Sharma, MD, FRCP(C) Professor of Medicine Research Chair for Obesity Research & Management University of Alberta Medical Director Capital Health Weight Wise Program Edmonton, AB, Canada www.ch-weightwisemd.blogspot.com Four-Fold increase in Morbid Obesity in Canada in 20 Years Katzmarzyk et al. CMAJ, 2006 Factors Contributing to Obesity Lifestyle • Poor diet • Skipping meals • Sugary soft drinks • Poor sleep • Snacking • Alcohol • Sedentariness • Etc. Psychosocial • Depression • Anxiety • Binge eating • Boredom • Social events • Low income • Stress • Etc. Biomedical • Genetics • Metabolism • Intrauterine growth • Medications • Injury • Mobility issues • Etc. Adult Obesity in the Capital Health Region BMI > 25 ~ 500,000 BMI > 30 ~ 250,000 BMI > 40 ~ 25,000 Sturgeon County Redwater St Albert Ft Sask Yellowhead County (East) Strathcona County Stony Plain Parkland County Edmonton Devon Leduc Leduc County Relationship Between BMI and Percent Body Fat in Men and Women 70 Women Body Fat (%) 60 Men 50 40 30 20 10 0 0 10 20 30 40 Body Mass Index (kg/m2) Adapted from: Gallagher et al. Am J Clin Nutr 2000;72:694. 50 60 OR (95% CI) Association of waist-to-hip ratio within BMI categories with myocardial infarction risk <20 20-23 23.1-25 25.1-27 BMI (kg/m2) 27.1-29 >30 Yusuf S et al. Lancet 2005;366:1640-1649 Health Consequences of Obesity Sedentariness/Overnutrition Mental - depression - anxiety - personality disorder - self esteem - etc. Mechanical - osteoarthritis - obstructive sleep apnea - reflux disease - urinary incontenance - intertrigo - etc. Metabolic - diabetes - dyslipidemia - fatty liver - hypertension - cancer - PCOS - gall bladder - infertility - etc. Hormones / Adipokines / Inflammation Sharma 2006 Indications for Obesity Treatment Indication for obesity treatment Symptoms/ Condition Caused by obesity? Primary Aggravated by obesity? Secondary Unrelated to obesity? Tertiary Sharma 2006 Barriers to Weight Management Socio-economic? Emotional? Comorbidities? Medications? Saboteurs? Substance abuse? Genetics? Sharma 2005 Selected Medications That Can Cause Weight Gain – – – – – – Insulin Psychotropic medications – Tricyclic antidepressants Monoamine oxidase inhibitors Specific SSRIs Atypical antipsychotics Lithium Specific anticonvulsants -adrenergic receptor blockers SSRI=Selective Serotonin Reuptake Inhibitor. Diabetes medications – Sulfonylureas – Thiazolidinediones Highly active antiretroviral therapy Tamoxifen Steroid Hormones – Glucocorticoids – Progestational steriods 11/26 Isn’t Obesity Simple? Genetics Environmental Determinants Energy In +/- +/- Environmental Determinants Energy Out Energy Regulation is Complex! Sharma AM 2007 The Dilemma Kg decades Phases of Obesity Treatment Phase I Phase II (Weight Loss) (Weight-Loss Maintenance) Weight When you stop treatment, the disease comes back! 3-6 months Indefinitely Treatment Success Lifestyle (LS) ~ 3-5% LS+Pharmacotherapy ~ 5-15% LS+Surgery ~ 20-30% Years Degree of Long-Term Weightloss Stepped Care Approach to Obesity Management Biliopancreatic diversion Gastric pacemaker Intragastric devices Roux-N-Y Gastric Bypass Adjustable gastric banding Pharmacotherapy Hypocaloric diets Lifestyle intervention Treatment Intensity Sharma 2005 Ingestive Behaviour Homeostatic System Hunger: Need for Calories Satiety: Sense of “Fullness” Hedonic System Appetite: Need for Foods Reward: Sense of Pleasure AM Sharma 08 Ingestive Behaviour 1. Pattern? Regular Meals Nutritional Hygiene 2. Quality? + 3. Quantity? Portion Control Sharma AM 2007 Characteristics of the ideal Anti-Obesity Drug Reduce body weight Maintain weight loss Well tolerated Long-term efficacy No rebound effect Reduce morbidity Reduce mortality Sharma 06 Anti-Obesity Drug Potential Modes of Action Energy intake – Hunger – Appetite – Satiety Energy metabolism – Digestion/Absorption – Metabolism – Partitioning Energy expenditure – Metabolic thermogenesis – Non-exercise activity thermogenesis (NEAT) – Exercise thermogenesis Sharma 06 STORM Mean bodyweight changes during weight loss and weight maintenance phases over 2 years Weight loss 104 Weight maintenance Control Bodyweight (kg) 102 100 98 96 94 92 90 88 Sibutramine 0 2 4 6 8 10 12 14 Month 16 18 20 22 24 Same diet and exercise for both sibutramine and control James WPT, Lancet 2001 Bariatric Surgery Reduces Mortality in Swedish Obese Subjects (n=2010 vs. 2037) 30% Reduction in All Cause Mortality Sjostrom L et al. NEJM 2007;357:741-52 Long-Term Mortality After Gastric Bypass Surgery (n=7928 vs. 7925) % reduced/10,000 person-yrs All Cause Mortality 40% Coronary Artery Disease Cancer Diabetes 56% 60% 92% Adams TD, et al. NEJM 2004;357:753 Bariatric Surgery Effect on Cardiovascular Risk A Systematic Review and Meta-Analysis of 22,090 Patients Dyslipidemia Diabetes Sleepapnea % resolved Hypertension 62% 70% 77% 86% Buchwald H, et al. JAMA 2004;292:1724 24-Hour Plasma Ghrelin Profiles in Subjects Who Underwent Gastric Bypass and in Controls Cummings, D. E. et. al. N Engl J Med 2002;346:1623-1630 Patient Selection Motivation? Cognitive skills? Mental health? Surgical risk? Support system? Expectations? Follow-up? Sharma AM 2007 Referrals to the Adult Bariatric Clinic Does your patient have an indication for obesity treatment? Does your patient have important barriers to obesity treatment? Is your patient likely to make and sustain changes / adhere to treatments? Fax Referral to Health LINK My Obesity Blog: www.ch-weightwisemd.blogspot.com www.obesitynetwork.ca