1. Clinical Diagnosis and Effective Management Strategies

2. What Do We Know About Obesity
Prevalence continues to rise at alarming rate among adults, children and adolescents. Most common medical problem seen in primary care office.
Is a major cause of preventable death.
Causes over 40 medical problems affecting 9 organ systems.
Morbidity and mortality rise with increasing BMI.

3. How Are We Doing as a Medical Profession?
Obesity is under-diagnosed and under-treated

4. Identification & Counseling
Summary of studies
We are failing to adequately identify the overweight and mildly obese patient – missed opportunities for early prevention and treatment
We are doing a better job identifying the moderately and severely obese patient presenting with co-morbid conditions, particularly type 2 diabetes, hypertension and hyperlipidemia

5. Percent of Patients Receiving PCP Advice by Obesity Classification
Told Overweight: %2 (test for linear trend) – 16.5, p – 0.001
Gave Weight Loss Advise: %2 (test for linear trend) – 5.5, p – 0.019
Simkin-Silverman LR et al. Prev Med 2005;40:71-82.

6. Screening for Obesity in Adults
The U.S. Preventive Services Task Force (USPSTF) recommends that clinicians screen all adult patients for obesity and offer intensive counseling and behavioral interventions to promote sustained weight loss for obese adults.
Grade B Recommendation
Ann Intern Med 2003;139:

7. Identification and Treatment of Obesity
Clinical Inertia
“Failure of the health care providers to initiate or intensify therapy when indicated”
Obesity – failure to identify the condition
Lack of education, training, and practice organization aimed at evaluating & treating obesity as a chronic illness
Practice barriers
Attitudes of futility, lack of perceived benefit and unrewarding
Adapted from Phillips et al. Ann Intern Med 2001.

8. Barriers to Obesity Care
“Counseling is unlikely to be effective without understanding the barriers that patients, providers, and systems face and applying targeted strategies to overcome those behaviors.”
Stange et al. Am J Prev Med 2002.

9. Providing Obesity Care
The Patient
Knowledge
Attitudes
Expectations
Demands
Motivation
The Clinician
Time
Reimbursement
Training
Interest
Type of Visit
The Practice
Environment
Payment Structure
Type of Visit
Alternative Demands
Availability of
Staff
Clinician Delivery of
Obesity Care
Adapted from Jaen et al. J Fam Prac, 1994.

10. Developing a Chronic Care Model of Care (A Systems Approach)
Put Prevention Into Practice
AHRQ
Improving Chronic Illness Care
Chronic care training manual
ICIC Improving your practice manual
Tools

11. Provision of Obesity Care
Three factors necessary for physicians to intervene
Adequate recognition of obesity as a medical problem
Willingness to provide intervention
Adequate skills or resources to do so
Kristeller & Hoerr. Prev Med 1997.

12. Obesity Treatment Guidelines

13. Obesity Treatment Recommendations

14. Consists of 6 Action Steps
The Office Visit
The Evaluation Process
Consists of 6 Action Steps
Measure weight, height, waist circumference and record body mass index (BMI)
Categorize obesity classification and risk
Take a comprehensive history, physical exam, & lab tests for medical condition
Assess need for treatment
Broach the subject
Assess readiness for treatment
The Practical Guide, 2000.

15. Body Mass Index Chart Weight (lbs) Height 120 130 140 150 160 170 180
190
200
210
220
230
240
250
260
270
280
290
300
5’0” 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59
5’2” 22 24 26 38 40 42 44 46 48
5’4” 21 28 34 36 50 52
5’6” 19 32
5’8” 18 20 30
5’10” 17
6’0” 16
6’2” 15
6’4”
Height

16. BMI-Associated Disease Risk
Classification
BMI (kg/m2)
Risk
Underweight
< 18.5
Increased
Normal
18.5 – 24.9
Overweight
25.0 – 29.9
Obese I
30.0 – 34.9
High II
35.0 – 39.9
Very high
III
≥ 40
Extremely high
Additional risks:
Large waist circumference (men > 40 in; women > 35 in)
Poor aerobic fitness
Specific races and ethnic groups
Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults—The Evidence Report. Obes Res 1998;6(suppl 2).

17. Fatness, Fitness, and Cardiovascular Disease Mortality8
Aerobically fit 7
Unfit 6 5
Relative Risk of CVD Mortality 4 3 2 1
Lean
Normal
Obese
< 16.7%
16.7% – 24.9%
 25%
Body Fat Category (% Weight as Fat)
Lee et al. Am J Clin Nutr 1999;69:373.

18. Action BMI Ranges for Asian Populations are Lower
High to very high risk
WHO expert consultation. Lancet 2004;363:157.

19. Systems Review Respiratory Cardiovascular Endocrine Neurologic
Hypertension
Congestive Heart Failure
Cor Pulmonale
Varicose Veins
Pulmonary Embolism
Coronary Artery Disease
Neurologic
Stroke
Idiopathic intracranial hypertension
Meralgia paresthetica
Psychological
Depression
Body image disturbance
Stigmatization
Respiratory
Dyspnea
Obstructive Sleep Apnea
Hypoventilation Syndrome
Pickwickian Syndrome
Asthma
Endocrine
Metabolic Syndrome
Type 2 diabetes
Dyslipidemia
Polycystic ovarian syndrome (PCOS)/androgenicity
Amenorrhea/infertility menstrual disorders
Kushner and Roth. Endo Metab Clinics N Am 2003. 12

20. Systems Review Gastrointestinal Musculoskeletal Integument
GERD
Non-alcoholic fatty liver disease (NAFLD)
Cholelithiasis
Hernias
Colon cancer
Genitourinary
Urinary stress incontinence
Obesity-related glomerulopathy
Kidney stones
Hypogonadism (M)
Breast and uterine cancer
Kidney cancer
Pregnancy complications
Musculoskeletal
Hyperuricemia and gout
Immobility
Osteoarthritis (knees/hips)
Low back pain
Carpal tunnel syndrome
Integument
Striae distensae (stretch marks)
Stasis pigmentation of legs
Cellulitis
Acanthosis nigricans/skin tags
Intertrigo, carbuncles 12

21. The Metabolic Syndrome
Risk Factor
Defining Level
Abdominal Obesity
Men
Women
Waist Circumference
> 102 cm (> 40 in)
> 88 cm (> 35 in)
Triglycerides
≥ 150 mg/dL
HDL Cholesterol
< 40 mg/dL
< 50 mg/dL
Blood Pressure
≥ 130 / ≥ 85 mm Hg
Fasting Glucose
≥ 110 mg/dL
ATP III, Executive Summary, 2001.

22. Importance of Measuring Waist Circumference: BMI 25 – 29
Importance of Measuring Waist Circumference: BMI 25 – 29.9 (Overweight)
Men (n = 3081)
Women (n = 2606)
Prevalence, %
NI WC
High WC
Hypertension
23.0
44.8
12.3
37.5
Type 2 DM
2.7
10.6
1.6
10.0
Hyper-chol
17.2
26.2
19.4
35.2
High LDL-C
19.3
27.2
13.6
26.6
Low HDL-C
35.3
49.0
15.0
Hyper-TG
21.7
36.3
21.8
Metabolic Syndrome
11.3
29.0
3.6
16.3
Janssen et al. Arch Intern Med 2002;162: NHANES III.

23. Importance of Measuring Waist Circumference: BMI 18.5 – 24.9 (Healthy)
Men (n = 3081)
Women (n = 2606)
Prevalence, %
NI WC
High WC
Hypertension
15.6
61.2
11.6
42.9
Type 2 DM
1.9
10.6
1.8
7.5
Hyper-chol
11.9
21.9
11.4
32.1
High LDL-C
14.0
29.3
8.8
23.9
Low HDL-C
15.0
6.7
13.1
Hyper-TG
9.4
12.4
4.5
20.7
Metabolic Syndrome
5.7
9.7
2.9
12.8
Janssen et al. Arch Intern Med 2002;162: NHANES III.

24. Visceral Adiposity: The Critical Adipose Depot
Subcutaneous Fat
Abdominal Muscle Layer
Intra-abdominal Fat

25. Disease Risk Relative to Normal Weight and Waist Circumference
Classification of Overweight and Obesity by BMI, Waist Circumference and Associated Disease Risks
Disease Risk Relative to Normal
Weight and Waist Circumference
BMI
(kg/m2)
Obesity Class
Men (≤102 cm) ≤40 in
Women (≤88 cm) ≤35 in
Men (>102 cm) >40 in
Women (>88 cm) >35 in
Underweight
< 18.5 --
Normal
18.5 – 24.9
Overweight
25.0 – 29.9
Increased
High
Obesity
30.0 – 34.9 I
Very High
35.0 – 39.9 II
Extreme obesity
> 40
III
Extremely High
Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in
Adults—The Evidence Report. Obes Res 1998;6(suppl 2).

26. Percentage of Men with Metabolic Triad
Percentage of Men with Metabolic Triad* Classified on Basis of Waist Girth and TG Level *
Insulin
small, dense LDL
apo B
waist < 90
90 < waist < 100
waist > 100
Lemieux et al. Circ 2000;102:179.

27. Metabolic Risk Identified by “Hypertriglyceridemic Waist”TG
waist TG
waist TG
waist TG
Insulin Resistance (HOMA)
Waist = 95 cm M
88 cm F
TG = 128 mg/dl
Men
Women
Men
Women
Age 18-34
Age 55-74
Kahn and Valdez. AJCN 2003;78:

28. Risk of coronary heart disease High Low
Subcutaneous adipose tissue
~ 5 – 10% weight loss
Visceral adipose tissue
~ 30% visceral adipose tissue loss (diet, physical activity, pharmacotherapy)
Lipid profile
Deteriorated Improved
Impaired Improved
↑ ↑
Insulin sensitivity
Insulinemia
Glycemia
Abdominally obese (high waist measurement)
Reduced obesity (low waist measurement)
Susceptibility to thrombosis
↑ ↓
Inflammation markers
↑ ↓
Endothelial function
Impaired Improved
Risk of coronary heart disease
High Low
Despres J-P et al. BMJ 2001;322:716.

29. Assessing Drug-Induced Causes for Weight Gain
Diabetes Treatments
Insulin
Sulfonylureas
Thiazolidinediones
Antihistamines (cyproheptadine)
β- and alpha-1 adrenergic receptor blockers
Chemotherapy agents
Tamoxifen
Psychiatric/Neuro
Anti-psychotics
Antidepressants
Lithium
AEDs
Steroid Hormones
Corticosteroids
Progestational steroids
HIV Protease inhibitors

30. Broaching the Subject: Words to Use
“Are you concerned about your weight?”
“What is hard about managing your weight?”
“How does being overweight affect you?”
“What can’t you do now that you would like to do if you weighed less?”
“What kind of help do you need to manage your weight?”

31. How important is it for you to get your weight under control?
Not
important
Very
important 1 2 3 4 5 6 7 8 9 10
How confident are you to that you can get your weight under control?
Not
confident
Very
confident 1 2 3 4 5 6 7 8 9 10

32. Obesity Treatment Pyramid
Surgery
Pharmacotherapy
Lifestyle Modification
Diet
Physical Activity
BMI  40 35 30 25

33. A Guide to Selecting Treatment
BMI Category
Treatment
27 – 29.9
30 – 34.9
35 – 39.9
≥ 40
Diet, physical activity, and behavior
With
co-morbidity +
Pharmacotherapy
Surgery
The Practical Guide

34. NHLBI Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults (1998)
“There is strong evidence that combined interventions of a low calorie diet, increased physical activity, and behavior therapy provide the most successful therapy for weight loss and weight maintenance.”*
*Evidence Category A

35. NHLBI Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults (1998)
“Low calorie diets can reduce total body weight by an average of 8% over 3 to 12 months.”*
*Evidence Category A

36. U.S. Preventive Services Task Force (USPSTF) Recommendations
Fair to good evidence that high-intensity counseling—about diet, exercise, or both—together with behavioral interventions aimed at skill development, motivation, and support strategies produces modest, sustained weight loss (typically 3 to 5 kg for ≥ 1 year) in adults who are obese.
Ann Intern Med 2003;139:

37. Pharmacotherapy
Indicated as an adjunct to diet and physical activity for patients with a BMI ≥ 30 or ≥ 27 who also have concomitant obesity-related risk factors or diseases
Agents
Phentermine (1973): norepinephrine releasing agent
Sibutramine (1997): serotonin norepinephrine reuptake inhibitor (SNRI)
Orlistat (1999): gastrointestinal lipase inhibitor

38. Additive Effects of Behavior and Meal Replacement Therapy With Pharmacotherapy for Obesity
Medication alone 5
Medication and behavior modification 10 *
Weight Loss (%) 15 *
Medication, behavior
modification and
meal replacements
*P < 0.05 vs medication alone 20 2 4 6 8 10 12
Time (months)
Wadden et al. Arch Intern Med 2001;161:218.

39. NHLBI Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults (1998)
“Evidence Statement: Appropriate weight loss drugs can augment diet, physical activity and behavior therapy in weight loss.”*
*Evidence Category B

40. NHLBI Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults (1998)
“Evidence Statement: Gastrointestinal surgery can result in substantial weight loss, and therefore is an available weight loss option for well-informed and motivated patients with a BMI ≥ 40 or ≥ 35, who have comorbid conditions and acceptable operative risks.”*
*Evidence Category B

41. Update: Bariatric Surgery
Currently Popular Procedures
Vertical Banded
Gastroplasty
Biliopancreatic Diversion
with Duodenal Switch
Gastric Bypass
LapBandTM
Restriction
Malabsorption

42. Efficacy Outcomes for Weight Reduction Surgeries
All Surgeries
Mean Change
Absolute wt loss (kg)
39.7 kg
BMI decreased
14.2
Initial wt loss (%)
32.6%
Procedure
Initial Wt Loss (%)
Gastroplasty
24.3%
RYGB
34.9%
BPD
39.0%
RYGB = roux-en-y gastric bypass; BPD = biliopancreatic diversion
Buchwald et al. JAMA 2004;292:1724.

43. Efficacy for Improvement in Obesity-Related Conditions
Completely
Resolved
76.8%
70%
61.7%
85.7%
Resolved or
Improved
86%
-----
78.5%
83.6%
Disease
Diabetes
Hyperlipidemia
Hypertension
Obstructive Sleep
Apnea
Buchwald et al. JAMA 2004;292:1724

44. Conclusion
Obesity is currently under-recognized and under-treated. Physicians need to identify and evaluate the overweight and obese patient at an earlier stage of development
Screening begins by measuring BMI, waist circumference and identifying co-morbidities
Treatment always includes lifestyle modification. Consideration for pharmacotherapy and surgery is based upon the individual patient