 This program was made possible through a grant from the Woodward Endowment for Medical Education at the Penn State Hershey College of Medicine.  COPYRIGHT.

 This program was made possible through a grant from the Woodward Endowment for Medical Education at the Penn State Hershey College of Medicine.  COPYRIGHT  COPYRIGHT © April 13, 2009. All material contained in this program is copyrighted and may not be reproduced without prior written permission from the Pennsylvania State University, College of Medicine, Department of Family & Community Medicine, 500 University Drive, P.O. Box 850, MC H154, Hershey, PA 17033.  Virtual patients depicted in this presentation have provided written consent to include their photographs.

 Author: Michael Flanagan, M.D., Associate Professor, Family and Community Medicine, Penn State College of Medicine  Contributing author: Shawn Bookhammer, CRNP, Penn State School of Nursing Penn State School of Nursing

 Contributing Faculty:  Sharon Falkenstern, Ph.D., CRNP, Penn State University School of Nursing  George Farkas, Ph.D., Professor, Department of Education, University of California, Irvine  Linda Kanzleiter, M.Ps.Sc., D.Ed., Vice-Chair for Education and Outreach, Penn State Hershey College of Medicine  Peter Lewis, M.D., Associate Professor, Family and Community Medicine, Penn State Hershey College of Medicine

 Please see the printed information included with this program for instructions on obtaining CME and Nursing CEU credits for your participation.

 Identify differences between overweight and obesity  Describe the prevalence of overweight and obesity in the United States  Describe the health complications associated with adult overweight and obesity  Describe effective approaches to weight loss  Discuss the various treatments for obesity and when each is appropriate

 Overweight and obesity are terms used to describe weight that is considered greater than is healthy › Both correlate with an increased risk of weight-related diseases and their associated complications. (1)

 Body Mass Index (BMI): A measure describing the relationship between a person’s height and weight. (2) › Calculated by dividing a person's weight (Kg) by the square of the person's height (in meters). (2)

 Overweight: Increased body weight relative to height. Adult BMI between 25-29.9. (2)  Obese: Excessively high body fat relative to lean body mass. Adult BMI of 30 and higher. (2)

a) 25% b) 33% c) 50% d) 66% *2003-2004 National Health and Nutrition Examination Survey (NHANES) (3)

a) From 5 to 20% b) From 10 to 25% c) From 15 to 33% d) From 20 to 50% *2003-2004 NHANES Data (4)

 “ The world’s largest, on-going telephone health survey system, tracking health conditions and risk behaviors in the United States yearly since 1984”. (5)  Data collected monthly in all 50 states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, and Guam. (5)

 BRFSS data are used to track the prevalence of chronic disease risk factors, such as obesity. (6)  BFRSS monitors progress toward state- specific health objectives. (6)  Random telephone surveys on non- institutionalized U.S. citizens > 18 years. (6)

1995 Obesity Trends Among U.S. Adults 1990, 1995, 2005 (BMI  30, or about 30 lbs overweight for 5’4” person) 2005 1990 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30% CDC’s Behavioral Risk Factor Surveillance System (BRFSS) (7)

 From 1995 to 2005, obesity prevalence increased significantly in all states (6)  In 1995 all 50 states had an obesity prevalence <20% (6)  By 2005, only one state, Colorado, had an obesity prevalence <20% (6)

 A Healthy People 2010 objective is to reduce to 15% the proportion of U.S. adults who are obese. (8)  Two-thirds of adults are now overweight or obese, with rate of obesity doubling since 1980. (2)  Among U.S. children, since1980 the rate of obesity has tripled to 16.3 %. (2)

It is estimated that if people keep gaining weight at the current rate, by the year 2015: o 75% of U.S. adults will be overweight or obese o 41% of these will be obese (9)

 Minority and low socioeconomic groups experience disproportionately higher rates of obesity in the U.S. (9)  In contrast, adults and children of higher social class in developing countries experience higher obesity rates because they can better afford available food. (10)

 Result of interaction between genetics and environment  Severe early obesity (< age 10): 7% - single gene mutation (10)  Children of two obese parents more likely to be obese (10)  Obesity attributed to genetics : 6-85% depending on population studied (10) 6-85% depending on population studied (10)

 Leptin (1994). 1 st appetite-controlling hormone described (10)  Several hormones described: regulate appetite, fat storage, insulin resistance  Leptin : Produced by adipose tissue. Stimulates appetite when fat storage is low, suppresses appetite when fat stores are high (10)  Ghrelin : Produced in stomach. Stimulates eating when stomach empty, stop eating when full. (10)

Jason, age 32, is a new patient who scheduled an appointment for help with weight loss. Current weight is 320 lbs. Jason, age 32, is a new patient who scheduled an appointment for help with weight loss. Current weight is 320 lbs. Jason is planning to get married in six months and his fiancée is pressuring him to lose 60 pounds prior to the wedding. Jason is planning to get married in six months and his fiancée is pressuring him to lose 60 pounds prior to the wedding.

 Barriers that obese patients might encounter in seeking medical intervention include: › embarrassment/ shame › lack of medical insurance › medical offices not equipped to handle morbidly obese individuals

 Jason is new to the practice, so it is important to start with a comprehensive history.  What important points from the past medical history should be considered in the overweight patient?

 Elicit Jason’s reasons for seeking medical intervention.  Does he perceive his weight as a problem? If so, why?  Do others perceive his weight as a problem?

 Encourage him to tell his story  Include a nutritional history  Inquire about co-morbid conditions related to obesity: diabetes, hypertension, hyperlipidemia

 Age of onset of weight gain  Previous weight loss attempts  Changes in dietary patterns  History of exercise

 Prior hospitalizations  Current/past medications, allergies  Females: menstruation, contraception, pregnancy or breast feeding?

 Prior surgery  Family history of overweight/ obesity and co-morbid conditions

 Substance Use: smoking, alcohol, drugs  Living situation/walkability of community  Occupation  Supports and stressors

 Has not been to a healthcare provider since starting college.  Only reason for appointment is help with weight loss.  Tried fad diets in past and able to lose up to 40 lbs, but unable to maintain weight loss.

 Weight gain of 90 lbs since starting college.  Requesting medication to lose weight quickly before wedding in six months.  Complaint of bilateral knee pain; relates to old football injuries.

 No significant past medical history except obesity  Overweight since childhood  Obese for seven years  Past surgery: None

 Father: Age 67, hyperlipidemia, colon cancer, and BMI 28.  Mother: Age 65, Type II diabetes, hypertension, and BMI 31.  Younger brother, age 29, BMI of 33.

 Non-smoker, rare alcohol, no drugs  Does not exercise  Diet Hx - No special diet! Eats: › “fast food” 5-7x week › skips breakfast-has morning snack at work › eats minimal vegetables › likes fruit › soda: 1-2 cans/day (non-diet)  Occupation: computer programmer  Fiancée: normal weight

 6 ft 4 in, 320 lbs  Pulse: 86, regular  Temp: 36.8 C  Blood pressure: 142/70 mmHg  BMI: Calculate  Waist circumference =48 inches

 HEENT: Oropharynx normal  Neck: Thyroid not palpable  Lungs: Clear  CV: Normal PMI  Abd: No organomegaly  LE: No edema, venous stasis  Skin: No stria, acanthosis nigricans

 What would be the next step in Jason’s evaluation?

 To diagnose obesity and evaluate a patient’s health status, address three key components: (1) 1)BMI 2)Waist Circumference 3)Risk factors for diseases and conditions associated with obesity

 BMI can be calculated or determined by using a BMI chart (11)  (English) BMI = weight (lbs) x 703/ height squared (in²)  (Metric) BMI = weight (kg)/ height squared (m²)

 BMI Calculators: www.nhlbisupport.com/bmi/ www.nhlbisupport.com/bmi/  BMI Chart: www.freebmicalculator.net/bmi-chart.php www.freebmicalculator.net/bmi-chart.php

 Using Jason’s height and weight, calculate his BMI.  BMI = weight (lbs) x 703/ height squared (in²)  BMI = 320 lbs x 703/ 76 in² = 224960/5776 = 38.9 or 39

 Underweight : BMI <18.5  Normal weight : BMI=18.5-24.9  Overweight : BMI=25.0-29.9  Obese : BMI >30  Morbid Obesity : › BMI ≥ 40 › BMI ≥ 35 with co-morbid conditions › 100 lbs or more above Ideal Body Weight (IBW) (12)

Class I (mild): BMI 30.0 – 34.0 Class II (moderate): BMI 35.0 – 39.9 Class III (severe): BMI ≥40 (10)

 BMI 20-25 kg/m : Little or no increased CV risk unless high visceral fat, or gain of 10 kg since age 18  BMI 25-30 kg/m²: Low CV Risk  BMI 30—35 kg/m²: Moderate CV Risk  BMI 35-40 kg/m²: High CV Risk  BMI >40 kg/m²: Very High CV Risk (13)

Based on Jason’s BMI of 39, into what class would Jason fall?

 Like many Americans, Jason would be considered moderately obese (Class II)  It has been estimated that, at the present increasing rate of obesity, by 2030, 86% of US adults will be overweight or obese (14)  African American women and Mexican American men would be most affected (14)

 Health-care costs related to obesity are also rising  If trends continue, by 2030 annual costs could rise to over $900 billion in U.S. (14)  This would account for 16-18% of total healthcare costs...  …with 1 in 6 health-care dollars spent on obesity-related illness (14)  Currently: Health-care costs related to obesity =$ 61 billion ; physical inactivity =$ 76 billion (2)

While discussing his diagnosis of moderate obesity, Jason questions the reliability of the BMI as an indicator of his body fat percentage

 Body fat percentage correlates with BMI  Body fat percentage is the percent of body mass made up of fat  Example: The body of a 200 lb man with a body fat percentage of 20% means his body consists of 40 lbs of fat

 Body fat percentage can be measured directly with skin calipers or determined via on-line tools.  Body fat calculator available at: www.livestrong.com/tools/body-fat- calculator/

Classification Women (%fat) Men (%fat) Essential Fat 10-122-4 Athletes 14-20 14-206-13 Fitness21-2414-17 Acceptable25-31 18-25 18-25 Obese 32 plus 25 plus American Council on Exercise (15)

 Correlates with body fat  Easy to measure  Non-invasive  Less expensive than other methods  Good sensitivity and specificity  Can be used to track trends  Correlates with CV risk factors and long- term mortality (2)

 Does not take frame size into account (16)  Those with a stockier build may be considered build may be considered overweight, even with overweight, even with minimal body fat (16) minimal body fat (16)

 Patients of African or Polynesian ancestry may have less body fat and leaner muscle mass compared to other groups (2)  Asians may have more weight-related health problems at “healthy” BMIs (2)

BMI is NOT a good predictor of overweight for:  Competitive athletes/ body builders. (Heavy muscle mass may skew results)  Pregnant/ nursing women (They require more fat reserves than others)  Pregnant/ nursing women (They require more fat reserves than others) (16)

 The correlation between BMI and body fat is relatively strong (17)  BMI varies by race, sex, age (17)  At the same BMI: Asians tend to have a higher % body fat and greater waist circumference vs. white Americans (18)  Evidence that Asians may therefore experience health problems at lower BMI’s (18)

 At the same BMI, African Americans have a lower % body fat and smaller waist circumference vs. Caucasians  African Americans tend to have greater bone and muscle mass vs. other ethnic groups (18)  At the same BMI, women will have more body fat than men (17)

Nevertheless, BMI is NOT “CORRECTED” for ethnicity, sex, age or fitness - to allow comparisons across diverse populations (18)

 At the same BMI, older people, on average, will have more body fat than younger people (17)  Highly trained athletes may have a higher BMI may have a higher BMI because of increased because of increased muscle mass rather muscle mass rather than increased body than increased body fat (17, 18) fat (17, 18)

 BMI is only one factor related to risk for disease  To assess the likelihood of developing overweight or obesity-related diseases, National Heart, Lung, and Blood Institute Guidelines also recommend measuring waist circumference (1)

Health risks of overweight and obesity are independently associated with excess abdominal fat (19)

 Fat located in the abdominal region, ”visceral fat”, is associated with a greater health risk than subcutaneous fat, the type you can pinch with your fingers (19)

 Excess abdominal (visceral) fat is reflected by waist circumference  Waist Circumference has largely replaced waist-hip ratio as fat distribution indicator  Excess abdominal fat clinically defined as: › Men: Waist Circumference >40 in › Women: Waist Circumference >35 in (19)

 Waist circumference is measured at the iliac crest (not the umbilicus) (20)

 Locate the top of the right hipbone (right iliac crest) where it intersects an imaginary line dropped vertically from the right axillae (19,20)  Place the measuring tape around the tape around the abdomen at the level abdomen at the level of the iliac crest (19,20) of the iliac crest (19,20)

 The tape should be snug, but should not compress the skin  The tape should be parallel to the floor  Read the measurement at the end of a normal expiration (19,20)

Jason has a waist circumference of 48 inches, putting him at increased risk for developing obesity related illnesses

What co-morbidities are associated with obesity and with increased abdominal fat in men and women?

Obesity is associated with multiple medical problems, most of which improve with weight loss:  Diabetes mellitus  Coronary artery disease  Hypertension  Osteoarthritis  Abnormal blood lipids  Venous stasis/ulcers  Sleep apnea (12)

 Depression  Acid reflux/GERD  Urinary stress incontinence  Gallstones  NASH (fatty liver)  Reduced fertility in females (PCOS) (12)

 Increased risk of Cancer: › Breast (post-menopausal) › Colon › Endometrial › Esophageal › Kidney › Prostate › Lung › Gallbladder › Cervical/ovarian  Low self-esteem/Depression (21)

 Multiple studies demonstrate a reduced life expectancy for obese patients  Range for males and females: › Obese Nonsmokers: 5-7 years lost › Obese Smokers: 13.5 years lost (22)

Jason should be assessed for co-morbidities, including: Jason should be assessed for co-morbidities, including:  Hypertension  Smoking  Hyperlipidemia  Glucose intolerance, Diabetes  CAD  Sleep apnea

o What screening tests/labs would be appropriate for Jason? o Addressing insurance coverage and ability to pay for testing is also advised.

Baseline and diagnostic tests/labs should include: (1)  Electrolytes  Fasting glucose  Liver function tests  Complete blood count  Fasting lipid profile  TSH  ECG

Results of Jason’s labs:  Fasting glucose = 119 (<100)  TSH = 2.3 (0.5-4.0)  CBC = normal  Lipid profile : › Triglycerides = 245 (<150) › HDL = 31 (>40) › LDL = 197 (<100)

 The choice to lose weight should be made jointly between the provider and Jason  The provider will need to assess Jason’s readiness to make behavior changes that will facilitate weight loss

What would be appropriate questions to ask Jason, to determine if he is willing to make the necessary changes?

 What is difficult 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 would you like to get out of this visit regarding your weight?

Initiating changes when patients are not ready often leads to frustration and may hamper future efforts.

 What patients should be excluded from weight loss therapy? (1) › Most pregnant or lactating women › Illnesses where caloric restriction might exacerbate the condition › Active substance abuse or a history of anorexia nervosa/bulimia - should be considered for specialized care

When assessing readiness for weight loss consider:  Motivation for weight loss.  Previous weight loss attempts  Support systems: family, friends, work-site  Insight on medical implications of obesity  Attitude toward physical activity  Time availability  Barriers to success  Financial considerations

Once it is established that Jason is ready to lose weight, the next step is to work with him to establish realistic treatment goals.

 What is a realistic weight loss goal for Jason, who has gained 90 lbs since starting college 14 years ago?  Is it possible for Jason to loose 60 lbs prior to his wedding in six months?

 Primary Goal: Prevent further weight gain and maintain current weight (within 5% of current weight) (23)  Secondary Goal: Identify a realistic weight- loss goal for the patient. Losing 5-15% of initial weight reduces most risks (23)  Tertiary Goal: Maintain weight loss

 Initial Weight Loss Goal: 10% of baseline weight at a rate of 1 to 2 pounds per week for 6 months  Losing and maintaining more than 15% of initial body weight is an extremely good result… even if the patient never reaches their "ideal" weight (1,23,24)

 BMI =27-35: a decrease of 300-500 kcal/day will reduce weight ½-1 lb/week and produce a 10% weight drop in six months  BMI ≥35: a decrease of 500-1000 kcal/day will reduce weight 1-2 lbs/week and produce a 10% weight drop in six months  BMI ≥35: a decrease of 500-1000 kcal/day will reduce weight 1-2 lbs/week and produce a 10% weight drop in six months (1)

 More rapid weight reduction than 1-2 lb/week is usually followed by weight re-gain  Rapid weight reduction increases risk for gallstones and electrolyte abnormalities  Rapid weight reduction increases risk for gallstones and electrolyte abnormalities (1)

 After six months of weight reduction the rate of weight loss usually reaches a plateau  Efforts to maintain weight loss through diet, exercise, and behavioral therapy should continue  Efforts to maintain weight loss through diet, exercise, and behavioral therapy should continue (1)

 Successful Weight Maintenance: › Weight regain of <3 kg (6.6 lb) in two years (1) › Sustained reduction in waist circumference of at least 4 cm (1.6 in) (1)

 For Jason: 10% weight loss = 32 lbs  At the rate of 1 to 2 pounds/week (4 to 8 lb/month) over six months, Jason could safely lose 24-48 lbs  A reasonable goal for Jason to set prior to the wedding would be 32 lbs; less than the 60 lbs he was hoping to lose

 Contributing Factors: › Overweight and obesity result from an energy imbalance over a long period (25) › Energy imbalance: Eating too many calories, and not getting enough physical activity (25)

 Body weight is a result of genes, metabolism, behavior, socioeconomic status, environment, and culture (25)  Behavior and environment are the greatest areas for prevention and treatment interventions (25)

 Obesity has a strong genetic determinant, however, the genetic composition of the population does not change rapidly (25)  The recent marked increase in obesity must be due to non-genetic factors (25)

 American society has evolved into an environment that facilitates weight gain  Only 3 out of 10 Americans achieve the minimum public health goal of 30 minutes of moderate intensity physical exercise on most days of the week (26)

 Food is more available  Grocery stores with greater selection  Pre-packaged foods, fast food restaurants, food at gas stations, and soft drinks are all more accessible  These foods are fast and convenient, but higher in fat, sugar, and calories

 Portion size has also increased  If the body does not burn off the extra calories consumed from the larger portion calorie-dense meals, weight gain occurs  Take the portion-distortion quiz at: http://hp2010.nhlbihin.net/portion/

 Passive entertainment also contributes to being overweight  It is estimated that the average adult spends half of his/her leisure time watching television (27)

 One study* showed that 26% of US children watched four or more hours of T.V. per day (28)  Suggests that the average high school graduate will have spent 15,000 to 18,000 hours watching T.V. vs. 12,000 hours in school (28) *Johns Hopkins University School of Medicine: JAMA (1998;279 (12):938-942, 959-960) *Johns Hopkins University School of Medicine: JAMA (1998;279 (12):938-942, 959-960)

 Despite the benefits of being physically active, most Americans are sedentary (27)  Primary care providers (PCP) serve as a significant resource for obese patients  PCP role: Identify risk factors/prescribe intervention/promote prevention

 Jason has the following risk factors: › Moderate Obesity: BMI=39 (high CV risk) › Waist circumference=48 inches (excess abdominal fat) › High blood pressure: BP=142/70

 High levels of blood cholesterol : › Jason’s lipid levels were:  Triglycerides=245  HDL=31  LDL=197  Family history of diabetes - yes  Obese before age 40 - yes

 Based on the results of labs and characteristics, Jason has metabolic syndrome  Metabolic syndrome is a collection of cardiovascular risk factors that increase the risk of developing diabetes, heart disease, and stroke (29)

 Diagnosed if patient has 3 or more of the following: › Waist circumference: >40 (males) or >35 (females) › Triglycerides: > 150 mg/dl › HDL: <40 mg/dl (males) or <50 mg/dl (females) › Elevated BP : ≥130/85, or taking medication for hypertension. › Fasting glucose: >100, or taking medication for Type-II diabetes (29)

 Prevention of weight gain with lifestyle therapy  Indicated in any patient with a BMI >25 even without complications (1)

 Treatment dictated by risk factors, BMI, waist circumference, and personal preferences  Combination of behavior modification, exercise, diet, and possibly medications  Surgery is reserved for severe obesity unresponsive to other treatments

DIETARY MODIFICATION: The first step for Jason would be to modify his diet

 As overeating leads to an increase in weight, about 75% of the extra energy is stored as fat, and only 25% as lean muscle (23)  Typical weight-loss diets contain less than body’s energy requirements, but more than 800 kcal/day (23)

 A calorie is a unit of energy found in food. It has the same value regardless of source (i.e. carbohydrate, fat, etc.) (25)  Caloric balance refers to balancing the calories consumed (food) with the calories used (body functions, daily activity, exercise) (25)  The goal of any diet is to burn up more calories than are taken in, which results in weight loss (1)

 Weight-loss diets fall into four groups: › Balanced low-calorie diets/ portion-controlled diets › Low-carbohydrate diets › Low-fat diets › Fad diets (diets that involve unusual food combinations or eating certain foods in a particular order) (23)

 Balanced low-calorie / portion-controlled : Produces early weight loss that is maintained  Low-carbohydrate: Shown to be effective for short–term weight loss, but not as effective in long term  Low-fat : Shown to be no better or worse than other diets. High drop-out rates  Fad : (Example: cabbage soup diet) *Study results mixed (23)

 Men lose more weight than women of similar height and weight when dieting because they have more lean body mass and, therefore, use more energy (23)  Older people have a slower metabolism than young people, and thus lose weight at a slower rate (23)

 A diet creating a deficit of 500-1000 kcal/day should be used to achieve weight loss of 1- 2 lb/week  Approximately six-months after diet onset, most patients adapt to the reduced caloric intake  Will require an adjustment of their energy balance if weight loss is to continue (1)

The next step is to increase the amount of Jason’s physical activity

 The belief that physical activity is limited to exercise and sports may discourage people from being active  Exercise does not have to be vigorous to achieve health benefits  Physical activity is any bodily movement that results in an expenditure of energy

*AHA recommendation: Adults 18-64  Moderately intense (3-6 METS) exercise at least 30 minutes five days/week, or  Vigorously intense (>6 METS) aerobic exercise at least 20 minutes three days/week (30)  Exercise above the minimum recommendations provides even greater health benefits (30) *The American Heart Association (AHA) and American College of Sports Medicine (ACSM)

 AHA guidelines also call for weightlifting exercises to work on muscular strength and endurance (30)  Recommendation: 8–10 muscle-strengthening exercises on 2 or more nonconsecutive days/week using the major muscle groups (30)  Repetitions: 8-12 per exercise (30)

 AHA/ACSM: New guidelines for older patients  Applies to all adults aged 65+ years, and adults aged 50–64 with clinically significant chronic conditions or functional limitations that affect movement ability, fitness, or physical activity (30)

 Recommended amount of exercise is the same, but the intensity is reduced for those 65+ (30) › Moderate =5-6/10-point scale; Vigorous = 7-8/10, ↑ to 10-15 reps  Flexibility and balance training have been added for fall prevention: 10 minutes of stretching, 2days/wk, 10-30 sec each, 3-4 reps (30)

Why would Jason not be appropriate for weight loss medication like he requested?

 Drug therapy may be helpful for some obese patients when used in combination with other interventions  The first step should always be a combination of diet, exercise, and behavior modification (31)

 These lifestyle changes should be attempted for six months before considering pharmacological intervention (1)  The decision to initiate drug therapy in overweight patients should be made after careful evaluation of the risks and benefits

Consider pharmacotherapy for Consider pharmacotherapy for :  BMI ≥30 with NO concomitant obesity- related risks/diseases (1,31)  BMI=27-30 with concomitant obesity-related risk factors or diseases (i.e. HTN, Dyslipidemia, CAD, DM-II, Sleep Apnea) (1,31)

 The goals of any weight loss intervention, including drug therapy, must be realistic  It is unrealistic to expect bodyweight to return to normal

With pharmacologic therapy :  During first month of drug therapy: Weight loss should be >2 kg (about 5 lbs or approximately ↓ 1 lb /week) (31)  By 3-6 months: Weight should fall more than 5% below baseline and remain at this level if successful (31)

With pharmacologic therapy :  Weight loss of 10-15% is a very good response (31)  Weight loss >15% is considered an excellent response (31)

FDA-approved pharmacologic options for treating obesity include:  orlistat (Xenical®)  sibutramine (Meridia®)  phentermine  diethylpropion Non-FDA-approved options include:  fluoxetine (Prozac®)  bupropion (Wellbutrin®) (31)

 Inhibits pancreatic lipases, preventing fat from being completely broken down (31)  Increases fecal fat RX dose :  Xenical ® (120 mg TID)  OTC: Alli® (60 mg TID)

 Side effects : cramps, flatus, fecal incontinence, reduced fat-soluble vitamin absorption (A, D, E, B-carotene) (31)  Efficacy : Multiple studies show significant initial (19 lbs) and long-term (8.5-10.2%) weight loss (31)  More efficacious in patients with diabetes (31)

 Inhibits NE, Serotonin, DA reuptake  Reduces food intake via early satiety  Effective in patients with diabetes  RX dose : Meridia ® (10-15 mg daily) (31)

 Side effects : ↑BP  Safety : No evidence it affects heart valves/pulmonary HTN  Average weight loss of 22 lbs after 1 year  Avoid : In CAD, CHF, arrhythmia, CVA (31)

 Phentermine (Adipex-P ®) and Diethylpropion (generic only):  Approved only for short-term use (12 weeks) to achieve weight loss  Dependency potential, withdrawal syndrome, tachycardia, HTN  Limited use (31)

 SSRI approved for depression-NOT obesity  May facilitate short term weight loss  Dose : › 60 mg (higher than usual)  Efficacy : › At 6 months- ↓ 10.5 lbs › At 12 months- ↓ 5.3 lb  Consider initially in depressed, obese patient (31)

 Approved for depression- NOT obesity  Likely works by increasing NE  Limited studies: Has shown significant weight loss over six months and beyond  Safety: Do not use with seizures or eating disorders (31)

 Jason has asked about surgical intervention to assist in achieving his weight loss goals.  When, if ever, would bariatric surgery be appropriate?

 Goals of bariatric surgery : › reduce morbidity and mortality › improve metabolic function (32)  Benefits of bariatric surgery : › Reducing obesity-related co-morbidities › Reducing costs of monthly medication › Reducing sick days › Improving quality of life (32)

Candidates for Bariatric Surgery :  Motivated, informed  BMI >40  Acceptable surgical risk  Failed prior non-surgical weight loss  Also…BMI >35, IF SIGNIFICANT CO-MORBIDITIES (32)

Contraindications to Bariatric Surgery:  Current drug, alcohol abuse  Severe cardiac disease (anesthesia risks)  Untreated depression/ psychosis  Bulima/eating disorders  Severe coagulopathy  Inability to comply with nutritional requirements  Age: >65 or 65 or <18 controversial (32)

 Two types of bariatric surgery: › Malabsorptive procedures shorten the length of the small intestine to reduce the efficiency of nutrient absorption › Restrictive procedures limit caloric intake by reducing the stomach’s capacity (32)

 Roux-en-Y Gastric Bypass is the most common type of bariatric surgery performed in the US  Combination of malabsorptive and restrictive approach (32)  Better than purely restrictive procedures for long-term wt loss

Roux-en-Y Gastric Bypass:  Proximal stomach separated from gastric remnant; attached directly to small bowel (32) (32)

Effectiveness of Roux-en-Y Gastric Bypass :  Performed laparoscopically  Average wt loss after one year: 62-68%  Early weight loss is rapid  Wt loss plateau after 1-2 years: with average two yr wt loss of 50-75%  Sustained wt loss seen up to 16 yrs  Mortality rate: 0.5% at 30 days (32)

 Laparoscopic Adjustable Gastric Banding:  Used extensively Europe/Australia  Approved in US in 2001  Soft silicone band placed around stomach entrance (32)

Laparoscopic Adjustable Gastric Banding:  Band connects to infusion port placed in SQ tissue  Inject saline into SQ port to reduce SQ port to reduce diameter of band diameter of band(32)

Laparoscopic Adjustable Gastric Banding:  Has replaced most other gastric banding procedures  Does not require division of stomach  Lowest mortality rate of all bariatric procedures (0.1% at 30 days)  Band eliminates need for staples  Adjustable band allows for different nutritional needs (i.e. pregnancy)  Reversible (32)

Laparoscopic Adjustable Gastric Banding:  At 3 months: 15-20 % wt reduction (32)  At 1 year: 40-53% wt reduction (32)  At 2 years: 45-75% wt reduction (32)  Weight loss more gradual than Gastric Bypass

 Gastric Bypass : Series of specific dietary transitions (start with liquid diet)  Diet gradually advanced/ ↓ portions (33)  Gastric Banding: Resume normal diet soon after surgery  Initial band placed deflated  Band tightened Q4-6 weeks over 1-2 years (33)

 Gastric Bypass : Nutritional deficiencies are more common due to decreased intake and altered anatomy (33)  Supplement with daily B12, MVI, Vitamin D, Calcium, Iron (if menstruating)  Reduced calcium absorption in duodenum may cause 2° hyperparathyroidism (33)  MONITOR : Ca, Vit D, PTH, CBC, CMP/LFTs  Watch BP (HTN may normalize) (33)

 Bariatric Surgery is covered by 45 state Medicaid plans (2)  The Centers for Medicare and Medicaid Services ruled in February 2006 that it would only cover bariatric surgery in a designated Center of Excellence (34)

 Pennsylvania has 20 bariatric surgery Center of Excellence sites located through the state (35)  Delaware has 2 bariatric surgery Center of Excellence sites, both located in Wilmington  Sites in all states can be accessed at: http://www.surgicalreview.org (35) http://www.surgicalreview.org

 Surgical intervention would not be an option for Jason at this early stage of attempted weight loss

 Weight loss in overweight and obese patients is associated with a significant decrease in obesity-related disease (13)  Studies show that less than half (42%) of obese patients report being advised to lose weight by health care providers (36)

Patient’s with the following characteristics are MORE likely to receive weight-loss advice from health-care providers:  Diabetes  Poor/ fair health  BMI ≥35 kg/m2  Women  Some college education  Residence in Northeast  Increasing age up to 60 (then ↓) (36)

 Healthcare professionals are selective about who they advise to lose weight (36)  Healthcare providers are more likely to advise weight loss when they: › Perceive a weight-related illness (i.e. diabetes) › Believe patient likely to take their advice › Have increased patient contact (36)

 Patients that were told to lose weight by a health-care professional were: › 3x more likely to attempt weight loss (36)  Of these patients, only 56% used diet AND exercise to achieve weight loss (36)

 Expert panels and government guidelines recommend seeking MODEST (i.e. “reasonable) weight reduction - not attaining ideal body weight (24)  Studies indicate patient’s view of reasonable weight loss is not realistic  Patient’s average goal for weight loss program: › 32% reduction (24)  Most patients do not reach expected goals

 Healthcare providers should encourage patients to have reasonable goals for weight loss  Reasonable initial goal for weight loss: 10% reduction from baseline at 1-2 lbs/week for six months (1)  If successful, further weight loss can be attempted after re-assessment (1)

Jason’s Goal: 60-lb weight loss in six months. Is this reasonable? Jason’s Goal: 60-lb weight loss in six months. Is this reasonable?

 At 6’4” and 320 lbs, Jason is >100 lbs. overweight.  He also has significant co-morbid conditions : hypertension, metabolic syndrome  Jason is morbidly obese, even though his BMI is <40.  Ten percent weight reduction, or 32 lbs, would be a reasonable weight loss goal during the six months prior to his wedding

What weight reduction interventions would be appropriate for Jason to address his obesity?

 Behavior modifications, dietary changes, and exercise are all indicated for initial weight loss programs (1)  Lifestyle changes should be attempted for at least six months (1)  Weight loss medication should not be considered until that time  Bariatric surgery should not be considered until Jason’s BMI is >40 kg/m²

 Obesity and overweight are major health problems in the U.S. problems in the U.S.  The prevalence of both is increasing rapidly. rapidly.  The health-care costs of obesity-related illness are rising rapidly illness are rising rapidly  Weight loss can significantly lower the risk of co-morbid obesity-related diseases (1) of co-morbid obesity-related diseases (1)

 Information provided in the primary care setting has been shown to: › Reduce weight › Reduce fat intake › Increase physical activity (36)  Primary care providers are in a unique position to impact positively on the problem of obesity in the U.S.

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 5. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System. Available at: http://www.cdc.gov/brfss/ Accessed October 25, 2008.  6. Centers for Disease Control and Prevention. State-specific prevalence of obesity among adults---United States, 2005. MMWR Morb Mortal Wkly Rep 2006;55(36):985-988.  7. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System. Obesity Trends Among U.S. Adults, BRFSS, 1990, 1995, 2005. Available at (slide #5). Accessed October 31, 2008.  7. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System. Obesity Trends Among U.S. Adults, BRFSS, 1990, 1995, 2005. Available at: http://lwww.saferoutes- wa.org/health/download- center/health%20downloads%20obesity%20map.pdf (slide #5). Accessed October 31, 2008.http://lwww.saferoutes- wa.org/health/download- center/health%20downloads%20obesity%20map.pdf  8. Centers for Disease Control and Prevention. State-specific prevalence of obesity among adults---United States, 2007. MMWR Morb Mortal Wkly Rep 2008;57(28):765-768.

 9. Wang Y, Beydoun M. The Obesity Epidemic in the United States--- Gender, Age, Socioeconomic, Racial/Ethnic, and Geographic Characteristics: A Systematic Review and Meta-Regression Analysis. Johns Hopkins Bloomberg School Of Public Health. 2007:6-28.  10. Centers for Disease Control and Prevention. Defining Obesity and Overweight. Available at: http://www.cdc.gov/nccdphp/dnpa/obesity/defining.htm. Accessed October 25, 2008. http://www.cdc.gov/nccdphp/dnpa/obesity/defining.htm  11. BMI Calculator: BMI Formula. Available at: www.livestrong.com/tools/body-fat-calculator/. Acessed on November 12, 2008. www.livestrong.com/tools/body-fat-calculator/  12. BariatricEdge. Information, symptoms, and treatment. Defining Morbid Obesity. Available at: http://www.bariatricedge.com/dtcf/pages/1_MorbidObesity.htm. Accessed on November 12, 2008. http://www.bariatricedge.com/dtcf/pages/1_MorbidObesity.htm

 13. Bray G. Overview of therapy for obesity in adults. Up-To-Date 2008. Available at: http://www.uptodate.com/patients/content/topic.do?topicKey=~7v7nc.T gz9h_i. Accessed on November 9, 2008. http://www.uptodate.com/patients/content/topic.do?topicKey=~7v7nc.T gz9h_i http://www.uptodate.com/patients/content/topic.do?topicKey=~7v7nc.T gz9h_i  14. Wang Y, Bedoun M, Liang L, et al. Will all Americans Become Overweight or Obese? Estimating the Progression and Cost of the U.S. Obesity Epidemic. Obesity. 2008;16(10):2323-2330.  15. HealthCheck Systems. Understanding your Body Fat Percentage, 2008. Available at: http://www.healthchecksystems.com/bodyfat.htm. Accessed on November 8, 2008. http://www.healthchecksystems.com/bodyfat.htm  16. BMI – Body Mass Index. Available at: http://www.weight.addr.com/BMI1.html. Accessed on November 8, 2008. http://www.weight.addr.com/BMI1.html

 17. Centers for Disease Control and Prevention. About BMI for Adults. Available at: http://www.cdc.gov/nccdphp/dnpa/healthyweight/assessing/bmi/adu lt_BMI/about_adult_BMI.htm. Accessed October 25, 2008.  18. Stevens J. Ethnic-specific revisions of body mass cutoffs to define overweight and obesity in Asians are not warranted. Intl J Obesity. 2003:27, 1297-1299.  19. Harvard Health Publications. Abdominal fat and what to do about it. Harvard Women’s Health Watch 2006. Available at: http://www.health.harvard.edu/newsweek/Abdominal-fat-and-what-to- do-about-it.htm. Accessed on November 8, 2008. http://www.health.harvard.edu/newsweek/Abdominal-fat-and-what-to- do-about-it.htm http://www.health.harvard.edu/newsweek/Abdominal-fat-and-what-to- do-about-it.htm  20. National Institutes of Health, National Heart, Lung, and Blood Institute. The Practical Guide, Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. 2000: No. 00-4084, 1.

 21. Morefocus Group. Obesity and Cancer Statistics: Complex Issues 2008. Available at: http://www.obesityfocused.com/articles/obesity- and-cancer/index.php. Accessed on November 8, 2008. http://www.obesityfocused.com/articles/obesity- and-cancer/index.phphttp://www.obesityfocused.com/articles/obesity- and-cancer/index.php  22. Peeters A, Barendregt J, Willekins F, et al. Obesity in Adulthood and Its Consequences for Life Expectancy: A Life-Table Analysis. Ann Int Med. 2003;38(1):24-32.  23. Bray G. Dietary therapy for obesity. UpToDate. Version 16.2, 2008. Available at: http://www.uptodate.com/patients/content/topic.do?topicKey=~lBbb3I 2srpOU9. Accessed on November 9, 2008. http://www.uptodate.com/patients/content/topic.do?topicKey=~lBbb3I 2srpOU9 http://www.uptodate.com/patients/content/topic.do?topicKey=~lBbb3I 2srpOU9  24. Foster G, Wadden T, Vogt R, et. al. What is a reasonable weight loss? Patients’ expectations and evaluations of obesity treatment outcomes. J Consult Clin Psychol. 1997;65 (1): 79-85.

 25. Centers for Disease Control and Prevention. Overweight and Obesity, Contributing Factors 2008. Available at: http://www.cdc.gov/nccdphp/dnpa/obesity/contributing_factors.htm. Accessed November 9, 2008.  26. CNN.com/Health. Study: Most Americans don’t exercise regularly 2002. Available at: http://archives.cnn.com/2002/HEALTH/04/07/americans.exercise/index. html. Accessed November 9, 2008. http://archives.cnn.com/2002/HEALTH/04/07/americans.exercise/index. html http://archives.cnn.com/2002/HEALTH/04/07/americans.exercise/index. html  27. U.S. Department of Labor. Bureau of Labor Statistics. American Time Use Survey Summary 2008. Available at: http://www.bls.gov/news.release/atus.nr0.htm. Accessed on November 9, 2008. http://www.bls.gov/news.release/atus.nr0.htm  28. Mercola.com. TV Watching, Childhood Obesity Linked. 1998. Available at: http://articles.mercola.com/sites/articles/archive/2008/01/02/tv-and- obesity-in-children.aspx Accessed on November 9,2008. http://articles.mercola.com/sites/articles/archive/2008/01/02/tv-and- obesity-in-children.aspx http://articles.mercola.com/sites/articles/archive/2008/01/02/tv-and- obesity-in-children.aspx

 29. Cleveland Clinic. Metabolic Syndrome. Available at: http://my.clevelandclinic.org/disorders/metabolic_syndrome/hic_metab olic_syndrome.aspx. Accessed on November 17, 2008. http://my.clevelandclinic.org/disorders/metabolic_syndrome/hic_metab olic_syndrome.aspx http://my.clevelandclinic.org/disorders/metabolic_syndrome/hic_metab olic_syndrome.aspx  30. Nelson M, Rejeski W, Blair S, et.al. Physical Activity and Public Health in Older Adults, Recommendation from the American College of Sports Medicine and the American Heart Association. Circulation. 2007;116:1094-1105.  31. Bray G. Drug Therapy of Obesity. UpToDate 2008. Available at: http://www.uptodate.com/online/content/topic.do?topicKey=obesity/57 74&view=print. Accessed on November 9, 2008. http://www.uptodate.com/online/content/topic.do?topicKey=obesity/57 74&view=print http://www.uptodate.com/online/content/topic.do?topicKey=obesity/57 74&view=print  32. Mun E, Tavakkolizadeh. Surgical management of severe obesity. UpToDate 2008. Available at: http://www.uptodate.com/online/content/topic.do?topicKey=obesity/69 16&view=print. Accessed on November 10, 2008. http://www.uptodate.com/online/content/topic.do?topicKey=obesity/69 16&view=print http://www.uptodate.com/online/content/topic.do?topicKey=obesity/69 16&view=print

 33. Boan J, Mun E. Management of patients after bariatric surgery. UpToDate 2008. Available at: http://www.uptodate.com/online/content/topic.do?topicKey=genr_med /32081&view=print. Accessed on November 10, 2008. http://www.uptodate.com/online/content/topic.do?topicKey=genr_med /32081&view=print http://www.uptodate.com/online/content/topic.do?topicKey=genr_med /32081&view=print  34. Bariatric Surgery at The Western Pennsylvania Hospital. West Penn Hospital Receives National Bariatric Surgery Center of Excellence Designation from the American Society for Bariatric Surgery 2006. Available at: http://www.bariatricsurgerypittsburgh.com/news/index.html. Accessed on November 17, 2008. http://www.bariatricsurgerypittsburgh.com/news/index.html  35. Surgical Review Corporation. Locate a Bariatric Surgery Center for Excellence. Available at: http://www.surgicalreview.org/locate.aspx?state=US-PA. Accessed on November 17,2008. http://www.surgicalreview.org/locate.aspx?state=US-PA  36. Galuska D, Will J, Serdula M, Ford E. Are Health Care Professionals Advising Obese Patients to Lose Weight? JAMA. 1999;282(16)1576-1578.  37. Images in this presentation available at: GoogleImages.com. Accessed on November 17,2008.

 This program was made possible through a grant from the Woodward Endowment for Medical Education at the Penn State Hershey College of Medicine.  COPYRIGHT.

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 This program was made possible through a grant from the Woodward Endowment for Medical Education at the Penn State Hershey College of Medicine.  COPYRIGHT.

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Presentation on theme: " This program was made possible through a grant from the Woodward Endowment for Medical Education at the Penn State Hershey College of Medicine.  COPYRIGHT."— Presentation transcript:

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