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Weight Management Clinic

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1 Weight Management Clinic
Program Orientation Amy Rothberg, MD, PhD, Andrew Kraftson, MD, Charles Burant, MD, PhD Christine Fowler, RD, MS and Gina Neshewat, MPH

2 This is the UM Weight Management Clinic Schedule of Visits.
2

3 The visits are more frequent during the first 3 months of the program
The visits are more frequent during the first 3 months of the program. Thereafter, the visits to the physician are quarterly (every 12 weeks) and monthly to the dietician. 3

4 Research Program Component
There are research programs offered by UM These programs are separate from the clinical program, but can be helpful to add important information to help you manage your health Participation is voluntary

5 The Scope of Obesity

6 Obesity Rates: United States
Who are the fattest Americans? Obesity is especially common in the South. It has 10 out of the 11 states with the highest obesity rates, including Mississippi along with Alabama and Tennessee, which tied for second place. Michigan is the only state in the top 11 that is not in the South. Where is obesity most common in the US?

7 Obesity Rates: United States
Obesity is especially common in the South. It has 10 out of the 11 states with the highest obesity rates, including Mississippi along with Alabama and Tennessee, which tied for second place. Who are the fattest Americans? Obesity is especially common in the South. It has 10 out of the 11 states with the highest obesity rates, including Mississippi along with Alabama and Tennessee, which tied for second place. Michigan is the only state in the top 11 that is not in the South.

8 Obesity Rates: United States
Who are the fattest Americans? Obesity is especially common in the South. It has 10 out of the 11 states with the highest obesity rates, including Mississippi along with Alabama and Tennessee, which tied for second place. Michigan is the only state in the top 11 that is not in the South. Michigan is the only state in the top 11 that is not in the South.

9 The prevalence of overweight and obesity changed little between the early 1960s and Findings from the and National Health and Nutrition Examination Surveys, showed substantial increases in overweight among adults.

10 The upward trend in weight since 1980 reflects primarily an increase in the percentage of adults years of age who are obese. In , 67% of adults in that age group were overweight (includes obese); 34% of adults years of age were obese (age-adjusted).

11 Since , the percentage of adults who were overweight but not obese has remained steady at 32%-34% (age-adjusted). Criteria for overweight: BMI value of 27.8 or greater for men and 27.3 or greater for women. Criteria for obese is BMI greater than 30.

12 Diet-Induced Thermogenesis
Energy Homeostasis Body Weight Increase Decrease Energy Intake Ingestion of: Protein Fat Carbohydrate Energy Expenditure Physical Activity Diet-Induced Thermogenesis Basal Metabolic Rate Body weight is determined by the balance between the calories we consume and the calories we expend (aka: “burn”).

13 Overnutrition, Type 2 Diabetes and CVD
Primary Metabolic Disturbance Intermediate Vascular Disease Risk Factor Intravascular Pathology Clinical Event Insulin Resistance Hypertension Dyslipidemia Atherosclerosis Hypercoagulability Over-Nutrition Hyperglycemia Coronary arteries Carotid arteries Cerebral arteries Aorta Peripheral arteries CVD Hyperinsulinemia Inflammation Impaired Fibrinolysis Endothelial Dysfunction What are the consequences of too much weight? Overnutrition leads to a number of metabolic problems that lead to diseases such as diabetes and heart disease. Modified from Despres JP, Lemieux I. Nature. 2006;444:881-7.

14 Growth in Caloric and CHO Intake
There has been a substantial growth in our intake with greater intake of carbohydrates. Between 1974 and 2000, men have increased their caloric consumption by 7% and women by as much as 22%. 7% increase in men and 22% increase in women MMWR. 2005;53:80-82.

15 Growth in Caloric and CHO Intake
Caloric Intake (kcal/day) Years 1971 – 1974 1999 – 2000 Change Men 2450 2618 (+) 168 Women 1542 1877 (+) 335 There has been a substantial growth in our intake with greater intake of carbohydrates. Between 1974 and 2000, men have increased their caloric consumption by 7% and women by as much as 22%. MMWR. 2005;53:80-82.

16 Growth in Vehicle Miles Traveled Growth in “Overweight”
These charts illustrate the parallel trend between growth in Vehicle Miles of Travel and the growth in the percent of overweight Americans. The majority of health problems associated with behavioral change caused by the built environment are, unfortunately, more extreme; they include obesity, early onset diabetes, heart failure, respiratory failure, and some forms of cancer. Growth in Vehicle Miles Traveled Growth in “Overweight” VMT BMI >30 kg/m2 20000 70 18000 65 60 16000 55 14000 50 12000 45 40 10000 35 8000 30 1969 1977 1983 1990 1995 2001 1969 1977 1983 1990 1995 2001 Growth Trend for Annual Household Vehicle Miles of Travel (VMT) Growth Trend for Percentage of Americans “Overweight” (50% Overall Growth) (40% Overall Growth) Source: National Household Travel Survey.

17 But Other Things Are Changing as Well…
Keith SW, et al. Int J Obes. 2006;30:

18 But Other Things Are Changing as Well…
Other factors in our environment have contributed to this rise in overweight/obesity. The light blue line is the Adult Obesity prevalence which has been rising, but steeply increased at the end of the 1970s. But Other Things Are Changing as Well… Keith SW, et al. Int J Obes. 2006;30:

19 But Other Things Are Changing as Well…
In parallel with that climb was the average rise in our home temperature setting (yellow), the number of prescriptions written in the millions for antidepressants (pink), and time spent awake (time at jobs) (green). But Other Things Are Changing as Well… Keith SW, et al. Int J Obes. 2006;30:

20 Short term regulation of feeding
Food intake is a complex process. The amount and type of food ingested is determined by: Genes Environmental setting Experience

21 Short term regulation of feeding
Short term regulation of feeding is governed by: Taste perception Meal size, caloric density Environmental setting Signals emanating from GI system and energy stores are received and integrated by diverse neuronal circuits in the hypothalamus and brainstem.

22 “Caloric density” as a concept
Think of foods in terms of calories per pound 2450 It is possible that the volume of food consumed and its energy density could affect intake through differential stimulation of gastrc and postgastric compartments. The stomach is sensitive to cure related to volume and that manipulation of gastric distension affects food intake. 1000 490 Tortillas Tortilla chips Fresh corn

23 “Caloric density” as a concept
Think of foods in terms of calories per pound 490 2450 1000 The volume of food consumed and its energy density affect intake through differential stimulation of gastric and post-gastric compartments. The stomach is sensitive to cues related to volume and that manipulation of gastric distension affects food intake. It is possible that the volume of food consumed and its energy density could affect intake through differential stimulation of gastrc and postgastric compartments. The stomach is sensitive to cure related to volume and that manipulation of gastric distension affects food intake.

24 “Caloric density” as a concept
Think of foods in terms of calories per pound 490 2450 1000 The lower in caloric density, the greater the volume and the fewer the number of calories. Fresh corn has far fewer calories than a similar serving size of tortillas (made from corn) and Tostito’s® (a product of corn).

25 Gut Peptides - Satiety Signals
Our sense of hunger and fullness are determined by complex interactions between a number of peptides (proteins) and hormones (such as leptin, PYY, CCK, ghrelin, and insulin) that relay signals from our gut to our brain . We are studying these signals and processes. Mountjoy, Kyiv 2003

26 As you may know, our eating patterns are affected by more than the caloric and nutritional value of food. The emotional and pleasurable aspects of feeding affect food intake. It will come as no surprise, then, that the brain (particularly parts of the brain called the hypothalamus and the brainstem) has a central role in coordinating the many nutrient, hormonal, and behavioral signals to regulate food intake, metabolism, and ultimately body weight.

27 These central circuits and neuro-peptides have a pivotal role in triggering hunger and food search, initiating satiety and generating responses to peripheral adiposity (fat) signals. There are additional brain/central nervous system regions that participate in regulating appetitive behavior by mediating the motivational, cognitive, and emotional components of food intake. Gaining a better understanding of the brain’s role in weight is one of our goals.

28 Randomized, Clinical Trials to Prevent Diabetes by Lifestyle Modification
The UM Weight Management Clinic program has modeled itself after large epidemiological trials of lifestyle intervention. We have summarized data from some of these studies:

29 Randomized, Clinical Trials to Prevent Diabetes by Lifestyle Modification
Study* # Patients Baseline BMI (kg/m2) Duration of intervention (years) Lifestyle goals Weight loss at 1 year (kg) Risk Reduction (95% CI) DaQing Study (1997) 530 26 6 Weight loss + maintenance of a health diet + exercise NR 42% Finnish Diabetes Prevention Study (2001) 522 31 4 5% weight loss on low-fat, high-fiber diet + 30 min exercise per day 58% Diabetes Prevention Program (2002) 2161 34 3 7% weight loss min exercise per week 7 *All study populations had impaired glucose tolerance Nature Clinical Practice 2008; 4:

30 Randomized, Clinical Trials to Prevent Diabetes by Lifestyle Modification
Study* # Patients Baseline BMI (kg/m2) Duration of intervention (years) Lifestyle goals Weight loss at 1 year (kg) Risk Reduction (95% CI) DaQing Study (1997) 530 26 6 Weight loss + maintenance of a health diet + exercise NR 42% Finnish Diabetes Prevention Study (2001) 522 31 4 5% weight loss on low-fat, high-fiber diet + 30 min exercise per day 58% Diabetes Prevention Program (2002) 2161 34 3 7% weight loss min exercise per week 7 These two trials split a large group of individuals at high risk for diabetes into two groups: usual care intensive lifestyle intervention = eating a low calorie diet of 1,500 calories per day and exercising 150 minutes per week. *All study populations had impaired glucose tolerance Nature Clinical Practice 2008; 4:

31 Randomized, Clinical Trials to Prevent Diabetes by Lifestyle Modification
Study* # Patients Baseline BMI (kg/m2) Duration of intervention (years) Lifestyle goals Weight loss at 1 year (kg) Risk Reduction (95% CI) DaQing Study (1997) 530 26 6 Weight loss + maintenance of a health diet + exercise NR 42% Finnish Diabetes Prevention Study (2001) 522 31 4 5% weight loss on low-fat, high-fiber diet + 30 min exercise per day 58% Diabetes Prevention Program (2002) 2161 34 3 7% weight loss min exercise per week 7 Those that achieved a 5-7% weight loss from baseline weight reduced their risk of progression to diabetes by 58%. This is better than any study that used medications as the primary treatment. *All study populations had impaired glucose tolerance Nature Clinical Practice 2008; 4:

32 Randomized, Clinical Trials to Prevent Diabetes by Lifestyle Modification
Study* # Patients Baseline BMI (kg/m2) Duration of intervention (years) Lifestyle goals Weight loss at 1 year (kg) Risk Reduction (95% CI) DaQing Study (1997) 530 26 6 Weight loss + maintenance of a health diet + exercise NR 42% Finnish Diabetes Prevention Study (2001) 522 31 4 5% weight loss on low-fat, high-fiber diet + 30 min exercise per day 58% Diabetes Prevention Program (2002) 2161 34 3 7% weight loss min exercise per week 7 Lifestyle change continues to be reasonable, rational and feasible approach to weight management and risk reduction of chronic diseases. *All study populations had impaired glucose tolerance Nature Clinical Practice 2008; 4:

33 Weight Management Clinic
Goal: Identify strategies that will result in long-term weight management for obese individuals, using the latest research and clinical strategies. We are dedicated to educating, motivating, and empowering individuals to make healthy lifestyle choices!

34 Comprehensive Adult Weight Management Clinic Personalized Weight Management Program
Multidisciplinary approach to weight loss and weight maintenance Intensive induction phase Advice regarding activity/exercise/conditioning Individual one-on-one sessions Focus on prevention of weight regain Behavioral Nutritional Pharmacological

35 Stepped Obesity Treatment Regimen
What happens at the first visit to the physician? Your health and weight history is reviewed. A physical exam is performed. Your current medication list is examined. The research is reviewed and your consent to participate is obtained (if you are interested).

36 1 Change medication regimen Eliminate ‘weight positive’ medications
Substitute weight neutral or weight negative medications 1

37 2 Initiate caloric restriction
Initial very-low-calorie diet (VLCD )(800 cals/day) or low-calorie-diet (LCD) ( cals/day): Meal substitution/replacement Dietary counseling: One-on-one with RD Initial emphasis on calories and caloric density, not fuel 2 The meal replacement diet will not start until you meet formally with the program’s dietician.

38 3 Exercise prescription Individual preference/Get moving
Bouts of activity v. all at once 3

39 Research Component (“phenotyping”)
Integral to the understanding of obesity Examination of gene-gene interactions and gene-environmental interactions- a systems biology approach Identifying the factors that predict success for weight loss and maintenance of weight loss – key to changing our treatment paradigms Examining potential novel therapeutic targets Participation is VOLUNTARY

40 Procedures

41 Mixed Meal Tolerance Testing:
3 hour dynamic test examining hormone excursions (insulin, glucose, and fat hormones) in response to nutrients. Metabolomics is the analysis of metabolites performed to generate a specific fingerprint of a current metabolic state at any given time point. It allows characterization of the dynamic changes of the metabolic pattern of person in response to nutrients. Genetic Analysis identifying obesity and obesity-related genes

42 Oral Glucose Tolerance Test:
2 hour test to diagnose diabetes*. Resting and exercise tests to determine your resting metabolic rate and exercise capacity/fit-ness Questionnaires regarding overall health and impact of weight on emotional and physical well-being *1/3rd of the participants in the program have undiagnosed Type 2 diabetes mellitus.

43 DXA-measures body composition including fat free mass, fat mass and bone density

44 Bod Pod-alternative method to measure fat free mass and fat mass

45 Resting Energy Expenditure-measures the fuel the body burns at rest (the number of calories burned at rest)

46 V02 max-Exercise capacity is highly predictive of disease risk, longevity and may predict the ability to lose weight. Graded exercise test done on a treadmill.

47 SenseWear Triaxial Accelerometer
Products for Medical Professionals SenseWear Triaxial Accelerometer Movement/motion sensor Worn for 7 days at intervals: Baseline (prior to diet) 5% weight loss from baseline 10% weight loss from baseline 15% weight loss from baseline 6 months, 12 months and 24 months

48 Re-Phenotyping: You will have the option to repeat the testing after the initial 15% weight loss goal is achieved.

49 Sweet Taste Study II Procedure Contact
Questionnaire Tasting sugar water at various concentrations Medical record review and linkage to your research data Compensation: $16 gift card for each research clinic visit Location: Clinics at Domino’s Farms Contact Keiko Asao, Phone , Please find the information in your package. You can turn in the completed response sheet now or mail it.

50 Weight Maintenance by Sex
Weight (kg) Number of Weeks in Program

51 The University of Michigan’s Weight Management Clinic (WMC) Program:
Overview

52 Program Design Highly structured to make weight loss easier and more successful. Shakes and soups replace meals and snacks. Support provided through individual appointments with physician and dietitians. Daily physical activity aids in weight loss.

53 12 weeks…

54 Very Low Calorie Diet (VLCD) Phase
Initial 12 weeks: 800 calories per day Foods Allowed: HMR 800 Shakes HMR 70+ Shakes if Lactose Intolerant HMR Chicken Soup

55 Meal Replacement Prescription
Personalized for you Average prescription: HMR Shakes + 1 HMR Chicken Soup Concept: “More is Better” but “Stay in the Box”

56 Why use a Very-Low Calorie Diet (VLCD)?
Short term only: initial 12 weeks Medically supervised, guaranteed weight loss Divorce yourself from unhealthy food habits by making meals “decision free” Learn nutrition information, lifestyle and behavioral skills

57 Meal Replacements Enhance Initial and Long-term Weight Loss
15 10 5 Time (mo) Phase 2 Phase 1* MR-2 2 4 6 8 12 18 24 30 36 45 51 MR-1 Percentage Weight Loss CF *1200–1500 kcal/d diet prescription. CF=conventional foods. MR-2=replacements for 2 meals, 2 snacks daily. MR-1=replacements for 1 meal, 1 snack daily. . Ditschuneit et al. Am J Clin Nutr 1999;69:198. Fletchner-Mors et al. Obes Res 2000;8:399

58 Why VLCD with HMR? HMR is a national healthcare company specializing in weight loss and weight management. HMR is a leading provider of meal replacement system in clinics and hospitals throughout the country.

59 Weight Maintenance Phase
Following 15% weight loss, food is reintroduced. An individualized diet plan is designed and implemented. Maintenance calorie amount is calculated and personalized.

60 Can people with diabetes use HMR shakes?
Yes. HMR is frequently recommended by doctors for their patients with diabetes because of the foods' nutritional formulation and low calories. Your medication(s) will be monitored by our physicians, and dosage may change throughout the program.

61 Can I use HMR shakes if I have food allergies?
HMR products are generally well tolerated by most people. Some of our products, however, contain common allergens such as dairy, eggs, wheat, soy and peanuts. Please let us know if you have any allergies prior to beginning the shake regime, or if any GI discomfort occurs.

62 I’m lactose intolerant. Is there lactose in HMR?
Most of the HMR Shakes contain lactose. However, people who are lactose-intolerant can use HMR shakes by taking a Lactaid® tablet. -or- HMR 70 Plus shakes are lactose-free + or

63 Shake Preparation Blender Instructions:
Pour 6 oz. cold water into a blender. Begin mixing on lowest speed. While blender is on, add 1 packet HMR shake mix and blend for 10 seconds. Add 2 ice cubes, 1 at a time (replace blender cover in between) Continue to blend on low speed for 1 – 1 ½ mins. until ice is crushed & shake is smooth

64 Meal Replacement Prescription:
Add non-caloric flavorings for variety: Spices or seasonings Extracts Diet soda Sugar free pudding or Jell-O mix Sugar free Crystal light Sugar free coffee syrup

65 Costs of HMR: You are responsible for purchasing the product (~$2-3 per shake or ~$12/day.)

66 Ordering HMR: Some easy ways to find HMR are:
Saint Joseph Mercy Health System: Ellen Thompson Women’s Health Center 5320 Elliot Drive, Ypsilanti, MI 48197 Phone: Fax: HMR program website: and follow instructions from “order online” link

67 Physical Activity Daily exercise is tracked
Active lifestyle is encouraged Further recommendations will be based on the individual

68 Questions or concerns? Please contact:
Christine Fowler, RD: Gina Neshewat, MPH: Andrew Kraftson, MD: Amy Rothberg, MD, PhD: When sending an , please “cc” everyone so the whole team is able to assist. Thank you! Need to set up your first nutrition visit or reschedule? Please call:

69 Thank you!


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