1. David D. Griffin, MD, FACC CHI St. Vincent Heart Clinic Arkansas Jack Stephens Heart Institute Little Rock, AR April 25, 2015

2. Overweight and Obesity (The Problem) Estimated 69% of adults overweight or obese, with 35% obese (NHANES) Severe Obesity (BMI > 40) is over 6% World wide epidemic effecting adults, adolescents and children Associated with multiple health risks (DM, HTN, Dyslipidemia, Heart Disease, Stroke, OSA, Gallbladder disease, Osteoarthritis and some types of Cancer) Associated with increased all cause and CVD mortality

3. Obesity & Mortality

4. Rel Risk Disease Increase Weight

5. BMI Symptomatic Gallstones AGA

6. Obesity and Health Care (The Cost) Compared to Normal-Weight Individuals -Incur 46% higher inpatient costs -27% more physician visits and outpatient costs -80% higher spending on Rx Drugs

7. Screening for Obesity Obtain Height and Weight to calculate BMI at routine health examinations Obtain Waist Circumference if BMI 25-35 Kg/m^2

8. BMI Classification UnderweightBMI <18.5 Kg/m^2 Normal WeightBMI 18.5-24.9 Kg/m^2 OverweightBMI 25-29.9 Kg/m^2 ObesityBMI >30 Kg/m^2 -Class I BMI 30-34.9 Kg/m^2 -Class II BMI 35-39.9 Kg/m^2 -Class III BMI >40 Kg/m^2 ***limitations (over and underestimation of “fatness”) but BMI better than body weight alone

9. Waist Circumference Waist Circumference is a measure of abdominal obesity, providing additional risk assessment to BMI (taken horizontal to the floor at the iliac crest) Man > 40 inches (102 cm) Woman > 35 inches (88 cm)

10. Evaluation of the Obese Patient History and Physical Fasting Blood Sugar and Hgb A1c Thyroid functions (TSH) Liver Enzymes Fasting Lipid Profile Evaluate Risk for CVD, OSA and Osteoarthritis

11. Etiology of Obesity Most Common (Non-Medical) -Sedentary Lifestyle and increased caloric intake Less Common (Medical) -Hypothyroidism -Cushing’s Syndrome -Polycystic Ovary Syndrome

12. Candidates for Weight Loss Intervention BMI > 30 BMI 24.9-29.9 with one CVD risk factor -(HTN, DM, Dyslipidemia) or -OSA or -Symptomatic Osteoarthritis

13. Treatment Options Lifestyle intervention -Diet -Exercise -Behavioral Modification Consideration for some patients that fail Lifestyle change -Pharmacologic Therapy -Bariatric Surgery

14. Goals of Therapy Initial Goal should not be unrealistic -Most patients have a goal of 30% Loss of 5-7% of body weight at 6 months is realistic Weight loss exceeding 15% is considered excellent ***If modest weight loss is associated with an improvement in CV and other risk factors, then therapy has been successful

15. Energy Expenditure Approximately 22 kcal/kg is required to maintain a kilogram of body weight in a normal adult. A deficit of 500 kcal/day should result in an initial weight loss of approximately 1 lb/week. ***After 3-6 months of weight loss, energy expenditure adaptations occur, which slows further weight loss.

16. Dietary Therapy Balanced Low-Calorie Low-Fat Low-Calorie Moderate-Fat Low-Calorie Low-Carbohydrate Diets Mediterranean Diet

17. Comparison of Diets If adhered to, all diets will result in weight loss Low-Carbohydrate diets are associate with greater short- term weight loss, but long term superiority over other diets has not been established. No clear benefit of one diet over another for reducing long term CV risk (adherence is key) ***Consider tailoring a diet that is most palatable to the patient in hopes of improving adherence

18. Physical Activity Reduces (MI, Stroke, Colon Cancer, BP, Anxiety, Depression) Results in stronger muscles, joints and bones Decreases all cause and CV Mortality

19. Physical Activity and Weight Exercise alone only modestly improves weight loss and should be combined with diet therapy. Brisk walking >30 minutes daily (5-7 days/week) to prevent weight gain and improve CV health 30 minute daily walk is equivalent to approximately 150 Kcal of energy expenditure Physical exercise and activity are important to prevent weight regain (may require >60 minutes of activity/day)

20. Pharmacologic Therapy Indicated for patients with BMI > 30 -Or BMI 25-29.9 with comorbidities that fail diet/exercise Drugs that alter fat digestion (Orlistat) Serotonin Agonists (Lorcaserin) Sympathomimetic Drugs (Phentermine, Diethylpropion, Benzphetamine, Phendimetrazine) Antidepressants (Bupropion) Antiepileptic Drugs (Topiramate, Zonisamide) Diabetes Drugs (Metformin, Pramlintide, Exenatide, Liraglutide) Combination Drugs (Phentermine-topiramate, Bupropion- naltrexone)

21. Weight Loss With Orlistat

22. Weight Loss with Phentermine

23. Therapies that Should be used with Caution or Avoided hCG-Human Chorionic Gonadotropin---ineffective Many Dietary Suppliments (Chitosan, Guar gum, Calcium suppliments)---ineffective Liposuction (does not improve insulin sensitivity or CV risk factors---HTN, Dyslipidemia, or plasma glucose levels) Sympathomimetic Drugs---(Use with caution, avoid in patients with CVD, HTN, Arrhythmias) Compounded Diet Pills---Avoid (amphetamines, etc) -Emagrece Sim (aka, Brazillian diet pill) -Herbathin

24. Bariatric Surgery Indicated in patients that: -Have failed previous non-surgical weight loss -Have a BMI > 40 Kg/m^2 -Are well informed and motivated -Have acceptable risk for surgery *BMI >35 kg/m^2 who have serious comorbidities (DM/OSA/Severe OA)

25. Roux en Y gastric bypass

26. Adjustable gastric band

27. Sleeve gastrectomy

28. Thank You