Transcript Templates For Richard - Johns Hopkins Medicine

The Global Obesity Pandemic
JHI Partners Forum
October 2, 2012
Richard R. Rubin, PhD
Professor, Medicine and Pediatrics
The Johns Hopkins University School of Medicine
[email protected]
Obesity Pandemic Key Points
•
•
•
•
Prevalence
Causes
Medical consequences
Financial consequences
BMI Chart
WHO Fact sheet N°311, September 2006, http://www.who.int/mediacentre/factsheets/fs311/en/index.html
Almost 70% of the U.S. population are either overweight or obese
Obese
Overweight
U.S. adult population overweight or obese
Percentage, age 20-74
70
65
• Obesity levels in the
60
55
50
45
•
40
35
30
•
25
20
15
10
5
U.S. have more than
doubled since 1980,
and currently ~1/3 of
adults are obese
In contrast, the
percentage of
overweight adults
has changed little
over the past 40 yrs
Just 33% of adults in
the U.S. are of
normal/under weight,
down from 55%
which held steady
between 1960 and
1980
0
1966
1976
1986
1996
2006
6
Source:CDC/National Center for Health Statistics, National Health Exam Survey
Portion Sizes 20 Years Ago to Today
Drivers of the Obesity Pandemic
Swinburn et al. The Lancet 2011;378:804-814.
Obesity Prevalence in U.S Children 2-19 Years 1999-2010
Age-Adjusted Relative Risk
Relationship Between BMI
and Risk of Type 2 Diabetes
93.2
100
Men
Women
75
54.0
50
42.1
40.3
27.6
21.3
25
1.0
2.9
1.0
<22
<23
4.3
1.0
5.0
1.5
8.1
2.2
15.8
4.4
6.7
11.6
0
23-23.9 24-24.9 25-26.9 27-28.9 29-30.9 31-32.9 33-34.9
Body Mass index (kg/m2)
Chan J et al. Diabetes Care 1994;17:961.
Colditz G et al. Ann Intern Med 1995;122:481.
35+
Sample data suggest that obese adults can incur close to twice
the annual health care costs of normal weight adults
Normal weight
Healthcare costs
Obese
by BMI*
7,555
$/capita, 2007
6,120
*91%
*55%
4,675
3,950
BMI <25
*18%
30-34* *35-39 *40+
Weighted average cost of
the obese is $5,500
* For the U.S. adult population (ages 20-64)
Source: McKinsey analysis; D2Hawkeye database of ~20,000 people with biometric data, National Bureau of Economic Research, 2007 census data for population by
age
1
5
Medical Management of
Obesity
Kimberly Gudzune, MD, MPH
Assistant Professor of Medicine
Johns Hopkins Digestive Weight Loss Center
Johns Hopkins International Partners Forum
October 2, 2012
Objectives
• Eligibility for obesity treatment
• Description of medical management of
obesity
• Review of new weight loss medications
coming on the market
•
•
•
•
•
Weight is more than about
looking good…
Heart disease
Diabetes
Cancer
Gall stones
Fatty liver
•
•
•
•
•
Lung disease
Infertility
Arthritis
Incontinence
Disability
Decreased quality of life!
Increased risk of early death!
Shorter life span!
WHO IS ELIGIBLE FOR
OBESITY TREATMENT?
Estimating Obesity
• Measuring body fat requires specialized equipment
• Patients typically identified in the clinical setting using
body mass index (BMI)
Weight (kg)
Height (m)2
• NIH and WHO have categorized BMI based on
increased risk of cardiovascular (CVD) and other
diseases
BMI Classification of Obesity
Normal weight
BMI 18.5-24.9 kg/m2
5’ 11” man @
5’ 4” woman @
Overweight
BMI 25.0-29.9 kg/m2
5’ 11” man @ 179 lbs
5’ 4” woman @ 146 lbs
Class I obesity
BMI 30.0-34.9 kg/m2
5’ 11” man @ 215 lbs
5’ 4” woman @ 175 lbs
Class II obesity
BMI 35.0-39.9 kg/m2
5’ 11” man @
5’ 4” woman @
Class III obesity
BMI≥40 kg/m2
5’ 11” man @ 287 lbs
5’ 4” woman @ 233 lbs
Fat Distribution
• Increased visceral fat in
the abdomen is linked with
greater CVD disease risk
• Assessed by a proxy
measure -- waist
circumference
– >40” in men
– >35” in women
From http://www.nhlbi.nih.gov/guidelines/obesity/e_txtbk/txgd/4142.htm
CVD Risk Assessment
Waist Circumference
Normal
High
Overweight
Increased
High
Class I obesity
High
Very High
Class II obesity
Very High
Very High
Class III obesity
Extremely High
Extremely High
Obesity-related Comorbidities
•
•
•
•
•
•
Hypertension
Heart disease
Dyslipidemia
Pre-diabetes
Diabetes mellitus
Gastroesophageal
reflux disease
•
•
•
•
Fatty liver
Back pain
Arthritis
Polycystic ovarian
syndrome
• Infertility
• Incontience
WHAT SERVICES
ENCOMPASS THE MEDICAL
MANAGEMENT OF OBESITY?
Integrated Weight Management
Model
Medical
Care
Nutrition
Exercise
Behavioral
Care
Modified from Kushner & Pendarvis 1999
Medical Care
• Weight evaluation and
management performed by
a physician
– Primary care physician
– Weight management
specialist
• Physician counseling can be
more effective if the 5A’s or
motivational interviewing
used
Medical Care
• Role of the physician includes
evaluation and management of:
– Goal setting
– Secondary causes of obesity
– Co-morbidities associated with weight gain
– Medications associated with weight gain
– Candidacy for use of anti-obesity
medications
Goal Setting
• Initial goal for weight loss is to achieve a
“healthier weight”
– 5-10% loss of initial body weight
• Accomplishable for most people
• Typically leads to improvement in blood
pressure, blood sugar, and other obesityrelated diseases
– Goal rate of 1-2 lbs lost per week
• Accomplishable for most people
• Safe
• Less risk of weight regain
Secondary Causes of Obesity
Common
• Hypothyroidism
• Polycystic ovarian
syndrome (PCOS)
Rare
• Cushing syndrome
• Hypothalamic obesity
syndromes
• Melanocortin-4 mutations
• Leptin deficiency
Co-morbid Conditions
Cardiovascular
• Hypertension
• Coronary heart disease
Pulmonary
• Asthma
• Obstructive Sleep Apnea
Metabolic
• Diabetes mellitus
• Dyslipidemia
• Metabolic syndrome
• Gout
Gastrointestinal
• GERD
• Gallbladder disease
• Fatty liver
Co-morbid Conditions
Musculoskeletal
• Osteoarthritis
• Back pain
Reproductive/GU
• PCOS
• Infertility
• Incontinence
Cancer
• Colorectal cancer
• Prostate cancer
• Endometrial cancer
• Cervical cancer
• Breast cancer
• Ovarian cancer
• Pancreatic cancer
Medications Associated with Weight Gain
Disease
Type of
Medication
How they cause weight
gain
Examples
High Blood
Pressure
Betablockers1
-Reduced resting energy
expenditure & thermogenesis
-Increased tiredness
-Reduced exercise tolerance
-Increased insulin resistance
Metoprolol
Atenolol
Carvedilol
Allergies
Antihistamines2
-Increased appetite
Diphenhydramine
-Impaired glucose tolerance
-Increased truncal fat
Prednisone
AntiCorticoinflammatory steroids2-3
From: 1. Sharma et al 2001
2. Malone 2005
3. Cheskin 1999
Medications Associated with Weight Gain
Disease
Type of
Medication
How they cause weight
gain
Examples
Diabetes
mellitus
Sulfonylureas
-Anabolic effects
-Increased appetite
-Fluid retention
Glyburide
Glipizide
Glimepiride
Diabetes
mellitus
Thiazolidinediones
(TZDs)
-Increased adipogenesis
-Fluid retention
-Increased appetite
Pioglitazone
Rosiglitazone
Diabetes
mellitus
Insulin
-Anabolic effects
-Increased appetite
-Fluid retention
From Mitri & Hamdy 2009
Medications Associated with Weight Gain
Disease
Type of
Medication
How they cause weight
gain
Examples
Depression Selective
Serotonin
Reuptake
Inhibitors
(SSRIs)
-Increased appetite
-Increased food cravings
Fluoxetine
Sertraline
Paroxetine
Depression Tricyclic
Antidepressants
(TCAs)
-Increased appetite
Amitriptyline
Nortriptyline
Schizophrenia
-Increased appetite and
binge eating
Olanzipine
Quetiapine
Risperidone
From Malone 2005
Atypical
Antipsychotics
Nutrition
• Nutrition evaluation
and diet plan
– Trained physician
– Registered dietician
– Certified nutrition
specialist
Nutrition
• Assessment of dietary habits
• Tailor dietary recommendations to individual
patient needs
• Work with physician to address diet and
medication changes as needed given comorbid condition profile
• Address patient nutrition education and skill
deficiencies
One-Year Changes in Body Weight By Diet Group
and By Adherence Level
Copyright restrictions may apply.
Dansinger, M. L. et al. JAMA 2005;293:43-53.
Exercise
• Physical activity
evaluation
performed by an
exercise
physiologist or
personal trainer
Exercise
• Role of the exercise physiologist
and/or personal trainer includes:
– Assessment of exercise tolerance,
metabolic fitness, and cardiovascular risk
– Create an individualized exercise
prescription
WHAT NEW WEIGHT LOSS
MEDICATIONS WILL BE
AVAILABLE?
Criteria for Medication Use
Element
Criteria
Body Mass Index
≥30 kg/m2
≥27 kg/m2 + an obesity-related condition
• High blood pressure
• High cholesterol
• Pre-diabetes or diabetes
Prior attempt at
lifestyle change
Unable to achieve a goal of 1 lb of weight loss per week
during a 6 month period of diet and exercise changes
Any medication must be combined with
diet and exercise changes to be effective
Patient Counseling
• Expected weight loss
• Potential side effects and risks
• Interactions with other medications
Medication selected should be tailored to
best suit each individual patient
QSYMIA
• Combination of
phentermine and
topiramate
• Works by suppressing
the appetite
• Patients lost between
11-24 lbs at 12 months
QSYMIA
• Common side effects
include tingling,
dizziness, increased
heart rate, and
depressed mood.
• May not be a good
choice if you have
heart, liver or kidney
disease
• Causes birth defects
BELVIQ
• New medication that
targets a special
Serotonin
neurotransmitter
receptor
• Works by suppressing
the appetite
• Patients lost 10-12 lbs
at 12 months
BELVIQ
• Common side effects
include headache,
dizziness, nausea,
drowsiness
• May not be a good
choice if you have
heart, liver, or kidney
disease
What current medication
options do I have?
ALLI (orlistat)
• Works by blocking
absorption of fat
• Common side effects
include abdominal
cramping, bloating,
diarrhea
• May not be a good choice
if you have
gastrointestinal issues or
liver disease
ADIPEX (phentermine)
• Works by suppressing the
appetite
• Common side effects
include headache,
dizziness, nausea
• May not be a good choice
if you have heart, liver, or
kidney disease
Digestive Weight Loss Center
2360 W. Joppa Rd, Suite 200
Lutherville, MD 21093
410-583-LOSE
http://www.hopkinsmedicine.org/digestive_weight_loss_center/index.html
Behavioral Lifestyle Interventions for Obesity:
The Foundation for Change
Janelle W. Coughlin, Ph.D.
Johns Hopkins School of Medicine
Department of Psychiatry and Behavioral Sciences
Johns Hopkins Medicine International Partners Forum
October 2, 2012
Objectives
 To describe important components of behavioral lifestyle
interventions for obesity
 To summarize outcomes achieved with behavioral lifestyle
interventions for obesity
 To highlight recent innovative developments in behavioral
lifestyle interventions for obesity
Obesity Treatment Pyramid
Surgery
BMI
Pharmacotherapy
Lifestyle Modification
Diet
Physical Activity
Dietary Approaches to Lifestyle
Modification
 Calorie Deficit
 ~1200-2000 kcal/d
 Dietary Approaches:
 Low-fat
 Low-carbohydrate
 Mediterranean
 Low-glycemic load
 Portion-controlled
diets
Increasing Physical Activity
 > 180 m/wk MVPA for weight loss
 Must also include caloric restriction
 Associated with a number of health improvements, independent
of weight loss
 Critical for long-term weight loss maintenance
 ~ 60 m/d MVPA
 Can be performed in short bouts
 Increasing other lifestyle activities is also effective
 > 2000 steps for weight loss; > 6000 to avoid regain
Behavioral Strategies
•Self-monitoring
 Increase self-efficacy and social support
•Goal Setting
•Stimulus control
•Problem solving
•Cognitive
restructuring
•Relapse Prevention
 Motivational Interviewing
Weight Loss Maintenance
 Patients gain ~ 1/3 of
 There is significant
their lost weight in the
year following treatment
 Nearly half of
participants return to
their original weight
within 5 years
 1:6 adults accomplish >
1 yr of maintaining >
10% of IBW
evidence that weight loss
maintenance
interventions can
decrease the chance of
weight regain
 Regular ongoing contact
following initial weight
loss is perhaps the most
successful method of
preventing weight regain
Study Design
Phase I
N=1685
Behavioral weight loss intervention
Phase I
6
months
Weight loss ≥4 kg
Yes
Phase II
30
months
No
No further
contact
Phase II
Randomization
N=1032
Self-directed
control group
Personal
Contact
Interactive
Technology
Data collection prior to Phase I, at randomization, then every 6 months
Change from initial weight
Weight change, kg
0
-2.9
-2
-3.3
-4.2
-4
-6
-8
-10
-6
0
6
12
18
24
30
Months after Randomization
Self-directed
Interactive technology
Svetkey et al., 2008
Personal Contact
 Remote/Telephone-delivered
 Technology-Based
 PCP-Enhanced or Promoted
Design
Randomization
Control
Remote
In-Person
Baseline
6 Mo
12 Mo
= Measured weights and other outcomes
24 Mo
Interventions
Mode of Delivery
Coach
Coach support
Study website
Physician Roles
Remote
In-Person
Telephone only
Group meetings
Individual meetings
Telephone
Hopkins
Healthways
Case management
Educational modules
Self-monitoring tools
Tailored emails
Supportive
Review weight progress reports
Weight change, kg
2
0
-0.8
-2
-4.3*
-4.6*
-4
-6
-8
0
6
12
24
Months after Randomization
Control
Appel et al, NEJM 2011;365:1959-68
Remote
In-Person
*P <0.001 (vs control
Does lifestyle modification enhance the effects of
weight loss medications and surgery?
Surgery
BMI
Pharmacotherapy
Lifestyle Modification
Diet
Physical Activity
Thank You
Wadden et al., (March, 2012). Circulation