2. Weighing the Evidence on Obesity
Erika Pierce, PA-C, MMS

3. Learning Objectives
Upon completion of this activity, participants will be able to:
Describe the definition, causes, prevalence and risks associated with obesity;
Discuss counseling on lifestyle modification for diet, exercise and behavioral changes as first line approaches;
Assess the relative risks and benefits of drug therapy including phentermine, orlistat, phentermine/topiramte and lorcaserin;
Analyze clinical trials (Look Ahead and POWER-UP) on multi-component primary care-based interventions;
Consider the relative risks and benefits of weight loss surgery for selected patients.

4. Disclosures
Speaker
Off-label use

5. Where Are We Going? The Map
Obesity as a Disease Epidemic
Medical Risk
Having the Conversation
Lifestyle Modifications
Medications for Weight Loss
Phentermine
Orlistat
Phentermine/topiramate
Lorcaserin
Weight Loss Surgery

6. Obesity as a Disease ⅓ adults in U.S. are obese (78 million)
⅓ adults in U.S. are overweight
Current trends has 45% obese by 2030
Annual estimated cost: $150 billion
 40% of this cost borne by Medicare & Medicaid

7. Maine Data Adults report 5% less leisure time activity 2000-2010
2011: K-3rd grade students:
18.4% obese
17% overweight
M > F
2011: High school students:
15.9% overweight
12.9% obese

8. Weight Status According to Body Mass Index, Adults Ages 18 years and Older, by Year, Maine,
Year
Healthy Weight
Overweight
Obese n N %
LCL
UCL
2000
1,804
382,095
42.8
40.2
45.3
1,607
329,970
36.9
34.5
39.4
911
181,317
20.3
18.3
22.3
2001
898
362,372
37.9
42.5
888
359,865
40.0
37.7
42.2
467
178,460
19.8
18.0
21.6
2002
920
370,461
40.1
37.8
42.4
838
357,622
38.7
36.5
41.0
499
195,039
21.1
19.2
23.0
2003
912
384,772
40.8
38.5
43.1
848
366,897
38.9
36.6
41.2
464
191,191
18.4
22.1
2004
1,281
373,248
38.0
36.0
1,293
374,987
38.2
36.2
789
233,414
23.8
22.0
25.6
2005
1,430
381,717
39.3
37.4
41.3
1,368
365,245
37.6
35.7
39.5
895
224,150
23.1
21.5
24.7
2006
1,456
388,665
1,391
367,608
37.2
35.3
39.1
917
231,608
23.4
21.9
25.0
2007
2,335
361,223
34.4
37.5
2,482
385,297
38.4
36.8
39.9
1,670
257,674
25.7
24.3
27.0
2008
2,333
373,584
37.3
38.8
2,396
365,696
35.0
1,711
262,922
26.2
24.9
27.6
2009
2,629
347,791
34.9
33.5
36.4
2,924
381,129
38.3
39.8
2,120
266,307
26.8
25.5
28.1
2010
2,623
355,609
35.6
34.1
37.1
2,902
366,919
36.7
38.1
2,212
276,987
27.7
26.4
29.0
Source: Behavioral Risk Factor Surveillance System
Healthy weight is a BMI between 18.5 and 25, Overweight is a BMI between 25.1 and 30, Obese is a BMI over 30; based on self-reported height and weight.
n = unweighted number of adults (numerator); N = weighted number of adults (weighted numerator)
LCL = Lower 95% confidence limit of the weighted percentage; UCL = Upper 95% confidence limit of the weighted percentage. All percentages are weighted to be more representative of the population of Maine and to adjust
NA = Not available

9. Maine Data: Healthy Weight
Year
Healthy Weight n N %
LCL
UCL
2000
1,804
382,095
42.8
40.2
45.3
2001
898
362,372
37.9
42.5
2002
920
370,461
40.1
37.8
42.4
2003
912
384,772
40.8
38.5
43.1
2004
1,281
373,248
38.0
36.0
40.0
2005
1,430
381,717
39.3
37.4
41.3
2006
1,456
388,665
2007
2,335
361,223
34.4
37.5
2008
2,333
373,584
37.3
35.7
38.8
2009
2,629
347,791
34.9
33.5
36.4
2010
2,623
355,609
35.6
34.1
37.1

10. Maine Data: Overweight
Year
Overweight n N %
LCL
UCL
2000
1,607
329,970
36.9
34.5
39.4
2001
888
359,865
40.0
37.7
42.2
2002
838
357,622
38.7
36.5
41.0
2003
848
366,897
38.9
36.6
41.2
2004
1,293
374,987
38.2
36.2
40.2
2005
1,368
365,245
37.6
35.7
39.5
2006
1,391
367,608
37.2
35.3
39.1
2007
2,482
385,297
38.4
36.8
39.9
2008
2,396
365,696
35.0
38.0
2009
2,924
381,129
38.3
39.8
2010
2,902
366,919
36.7
38.1

11. Maine Data: Obese Year Obese n N % LCL UCL 2000 911 181,317 20.3 18.3
22.3
2001
467
178,460
19.8
18.0
21.6
2002
499
195,039
21.1
19.2
23.0
2003
464
191,191
18.4
22.1
2004
789
233,414
23.8
22.0
25.6
2005
895
224,150
23.1
21.5
24.7
2006
917
231,608
23.4
21.9
25.0
2007
1,670
257,674
25.7
24.3
27.0
2008
1,711
262,922
26.2
24.9
27.6
2009
2,120
266,307
26.8
25.5
28.1
2010
2,212
276,987
27.7
26.4
29.0

12. Causes of Obesity We live in a food swamp.
Social patterns of physical activity
Food consumption
↑ portion sizes
Added sugars, fats, calorie dense foods escalated
Consuming more calories
Sedentary lifestyles

13. Screening for Obesity Use BMI Waist circumference
> 35 inches for women
> 40 inches for men

14. Risk for type 2 diabetes, hypertension, or CVD relative to normal weight and waist circumference
BMI (kg/m2)
Men ≤ 102 cm (≤ 40 in)
Women ≤ 88 cm (≤ 35 in)
Men > 102 cm (> 40 in)
Women > 88 cm (> 35 in)
Underweight
< 18.5 -
Normal*
Overweight
Increased
High
Class I Obesity
Very High
Class II Obesity
Class III Obesity
≥ 40.0
Extremely High
* Increased waist circumference can also be a marker for increased risk even in persons of normal weight.

15. Diagnosis of overweight or obese must prompt stratification of cardiovascular risk

16. Trends in Obesity

17. Obesity by State

18. 2. Medical Risk

19. Overweight & Obesity Associated with Negative Health Outcomes
HTN
Sleep Apnea
Diabetes
Cancer
Hyperlipidemic
Pro thrombotic States
Cardiovascular Diseases
Musculoskeletal Disease

20. Obesity raises the risk of several major diseases

21. BMI & Mortality

22. 3. Having the Conversation

23. Goals Prevent further weight gain Reduce weight
Maintain a lower weight over time

24. First Step Screen every patient BMI Waist circumference
Determine patient’s level of motivation

25. Determine patient’s level of motivation
Stage of Readiness
Key Questions
Not Ready
Raise Awareness
Elicit Change Talk*
Advise and Encourage
Would you be interested in knowing more about reaching a healthy weight?
How can I help?
What might need to be different for you to consider a change in the future?
Unsure
Evaluate Ambivalence
Build Readiness
Where does that leave you now?
What do you see as your next steps?
What are you thinking or feeling at this point?
How does being overweight affect you?
Ready
Strengthen Commitment
Facilitate Action Planning
Why is this important to you now?
What are your ideas for making this work?
What is hard about managing your weight?
What might get in the way? How might you work around the barriers?
How might you reward yourself along the way?
* Elicit Change Talk: Encourage patients to present their own arguments for changing behavior.

26. 4. Lifestyle Modification

27. Cornerstone of Management
Counseling
Lifestyle modification
Diet
Exercise
Behavioral Changes

28. Do they Work? DPP Trial

29. Do they Work? DPP Trial

30. Counseling in Primary Care Works: The POWER-UP Study

31. Diet Focus on total calorie reduction Actual diet type does not matter
Read more:
p Evidence Document

32. Exercise Important in maintaining lower weight
Modestly effective at achieving weight loss
General health-promoting effects

33. Rx for a Healthier Weight

34. 5. Weight Loss Medications

35. Weight Loss Medications
Can result in weight loss
Use as adjunct to calorie reduced diet
Increase physical activity
Selected patients
BMI > 30
BMI > 27 with comorbid condition

36. FDA Approved Medications
Phentermine
Sibutramine (Meridia)
Orlistat (Xenical) (Alli)
Lorcaserin (Belviq)
Phentermine IR/Topiramate ER (Qsymia)

37. ! CAUTION! Long-term safety
No Demonstrated long-term benefits in reducing diabetes, HTN, or cardiovascular risk.

38. Prior Medication Troubles
Removed from the Market
Nearly all previous prescription diet medications were removed from the market because of dangerous side effects after one or more years of routine use:
amphetamines (cardiovascular toxicity, addiction
fenfluramine (Pondimin: pulmonary hypertension
dexfenfluramine (Redux: pulmonary hypertension and cardiac valvulopathy)
sibutramine (Meridia: cardiovascular toxicity)

39. Common Weight Loss Drugs
Efficacy
Common potential side effects
Safety
orlistat
(Xenical, Alli)
Weight loss:
2 kg greater than placebo after 4 years of therapy
Clinical outcomes:
not documented
Flatus, greasy/loose stools or diarrhea, fecal incontinence, and abdominal cramps
Worsened by increased dietary fat intake
Contraindicated during pregnancy.
Malabsorption of fat-soluble vitamins; concurrent use of multivitamin recommended
Patients on warfarin may need to decrease their warfarin dose.
lorcaserin
(Belviq)
3.6 kg greater than placebo after 1 year of therapy
Nausea
Headache
Dizziness
Avoid use with other serotonergic agents (including most antidepressants, and some muscle relaxants).
Concern over increased rate of cardiac valve disease and a possible increase in the risk of breast tumors.
phentermine IR/ topiramate ER
(Qsymia)
kg greater than placebo after 2 years of therapy
Anticholinergic symptoms (such as dry mouth and constipation)
Irritability, anxiety, insomnia, and depression
Increased heart rate
Contraindicated in hyperthyroidism, glaucoma, patients taking MAO inhibitors, pregnancy.
Prescribe with a Risk Management Program for women of childbearing age, including monthly pregnancy test.
Adjust dose in renal and hepatic impairment.
Abuse potential.
Discontinuation requires tapering to avoid seizures.

40. Weight Loss at 1 Year for locaserin and phentermine/topiramate

41. Average Retail Costs for Monthly Supplies of Equivalent Doses of Agents*

42. Looking Ahead 5,145 U.S. Adults Overweight or Obese with Diabetes
Stopped early
Intensive lifestyle modification aim
3.9% greater weight loss
5.3% greater partial or complete remission of Diabetes
Enroll higher risk patients

43. !
No over-the-counter weight loss supplement is effective for weight loss.
Some products contain illegal stimulants or prescription medications. Ask patients about their use of these supplements and counsel them about their risks.

44. 6. Weight Loss Surgery

45. Useful in Severe Obesity
Produces substantial weight loss
Reduces cardiovascular events & mortality
Can improve or eliminate diabetes
BUT potential for post-operative complications

46. Common Weight Loss Surgeries

47. Swedish Obese Subjects (SOS)
Over 2,000 obese patients (BMI ≥ 34 Men, ≥ 38 Women)
Over 20 years

48. SOS: Weight Loss after Surgery

49. SOS: Reduction in Mortality and Cardiovascular Events

50. Bariatric Surgery: Patient Selection
BMI ≥40 or BMI ≥35 with weight-related comorbidity
Prior attempts at lifestyle modification were unsuccessful
No contraindications such as binge-eating disorder, substance abuse, depression, psychosis, or anxiety disorder
Acceptable surgery risk

51. Bariatric Surgery: Risks and Benefits
Uncertainties
Risks
Weight loss: rapid and sustained
Reduction in HbA1c: elimination of diabetes in some patients
Reduction in incidence of diabetes
Improvement in other cardiovascular risk factors; hypertension, lipid profile
Improved quality of life
Reduction in CV events
Reduction in all-cause mortality
Long-term clinical outcomes in less obese diabetic patients with BMI < 35
Prevalence of weight regain over time in routine use
Post-surgical complications including increased morbidity and mortality in the short term
Nutritional and electrolyte deficiencies
GI symptoms

52. Tips for Management
Calculate BMI for all patients. If BMI ≥ 25, discuss the health risks of being overweight or obese.
Assess patient’s readiness to modify lifestyle and define success in terms of realistic goals.

53. Tips for Management
There is solid evidence that lifestyle interventions can reduce weight:
Food intake is the key to weight loss.
Exercise can help with weight management and improves health.
Counseling in primary care actually works.

54. Tips for Management
Prescription drugs have some efficacy data but safety concerns limit their use.
Weight loss surgery is selected patients can lead to long-term weight loss and decreased risk of diabetes and mortality.

55. Questions?