Presentation on theme: "Clinical Diagnosis and Effective Management Strategies"— Presentation transcript:
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 studiesWe are failing to adequately identify the overweight and mildly obese patient – missed opportunities for early prevention and treatmentWe 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 – 0.001Gave Weight Loss Advise: %2 (test for linear trend) – 5.5, p – 0.019Simkin-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 RecommendationAnn 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 conditionLack of education, training, and practice organization aimed at evaluating & treating obesity as a chronic illnessPractice barriersAttitudes of futility, lack of perceived benefit and unrewardingAdapted 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 PatientKnowledgeAttitudesExpectationsDemandsMotivationThe ClinicianTimeReimbursementTrainingInterestType of VisitThe PracticeEnvironmentPayment StructureType of VisitAlternative DemandsAvailability ofStaffClinician DeliveryofObesity CareAdapted from Jaen et al. J Fam Prac, 1994.
10 Developing a Chronic Care Model of Care (A Systems Approach) Put Prevention Into PracticeAHRQImproving Chronic Illness CareChronic care training manualICIC Improving your practice manualTools
11 Provision of Obesity Care Three factors necessary for physicians to interveneAdequate recognition of obesity as a medical problemWillingness to provide interventionAdequate skills or resources to do soKristeller & Hoerr. Prev Med 1997.
14 Consists of 6 Action Steps The Office VisitThe Evaluation ProcessConsists of 6 Action StepsMeasure weight, height, waist circumference and record body mass index (BMI)Categorize obesity classification and riskTake a comprehensive history, physical exam, & lab tests for medical conditionAssess need for treatmentBroach the subjectAssess readiness for treatmentThe Practical Guide, 2000.
15 Body Mass Index Chart Weight (lbs) Height 120 130 140 150 160 170 180 1902002102202302402502602702802903005’0”232527293133353739414345474951535557595’2”2224263840424446485’4”2128343650525’6”19325’8”1820305’10”176’0”166’2”156’4”Height
16 BMI-Associated Disease Risk ClassificationBMI (kg/m2)RiskUnderweight< 18.5IncreasedNormal18.5 – 24.9Overweight25.0 – 29.9ObeseI30.0 – 34.9HighII35.0 – 39.9Very highIII≥ 40Extremely highAdditional risks:Large waist circumference (men > 40 in; women > 35 in)Poor aerobic fitnessSpecific races and ethnic groupsClinical 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 Mortality 8Aerobically fit7Unfit65Relative Risk of CVD Mortality4321LeanNormalObese< 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 riskWHO expert consultation. Lancet 2004;363:157.
19 Systems Review Respiratory Cardiovascular Endocrine Neurologic HypertensionCongestive Heart FailureCor PulmonaleVaricose VeinsPulmonary EmbolismCoronary Artery DiseaseNeurologicStrokeIdiopathic intracranial hypertensionMeralgia parestheticaPsychologicalDepressionBody image disturbanceStigmatizationRespiratoryDyspneaObstructive Sleep ApneaHypoventilation SyndromePickwickian SyndromeAsthmaEndocrineMetabolic SyndromeType 2 diabetesDyslipidemiaPolycystic ovarian syndrome (PCOS)/androgenicityAmenorrhea/infertility menstrual disordersKushner and Roth. Endo Metab Clinics N Am 2003.12
20 Systems Review Gastrointestinal Musculoskeletal Integument GERDNon-alcoholic fatty liver disease (NAFLD)CholelithiasisHerniasColon cancerGenitourinaryUrinary stress incontinenceObesity-related glomerulopathyKidney stonesHypogonadism (M)Breast and uterine cancerKidney cancerPregnancy complicationsMusculoskeletalHyperuricemia and goutImmobilityOsteoarthritis (knees/hips)Low back painCarpal tunnel syndromeIntegumentStriae distensae (stretch marks)Stasis pigmentation of legsCellulitisAcanthosis nigricans/skin tagsIntertrigo, carbuncles12
21 The Metabolic Syndrome Risk FactorDefining LevelAbdominal ObesityMenWomenWaist Circumference> 102 cm (> 40 in)> 88 cm (> 35 in)Triglycerides≥ 150 mg/dLHDL Cholesterol< 40 mg/dL< 50 mg/dLBlood Pressure≥ 130 / ≥ 85 mm HgFasting Glucose≥ 110 mg/dLATP 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 WCHigh WCHypertension23.044.812.337.5Type 2 DM2.710.61.610.0Hyper-chol188.8.131.525.2High LDL-C19.327.213.626.6Low HDL-C35.349.015.0Hyper-TG21.736.321.8Metabolic Syndrome11.329.03.616.3Janssen 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 WCHigh WCHypertension15.661.211.642.9Type 2 DM1.910.61.87.5Hyper-chol11.921.911.432.1High LDL-C14.029.38.823.9Low HDL-C15.06.713.1Hyper-TG9.412.44.520.7Metabolic Syndrome184.108.40.2062.8Janssen et al. Arch Intern Med 2002;162: NHANES III.
25 Disease Risk Relative to Normal Weight and Waist Circumference Classification of Overweight and Obesity by BMI, Waist Circumference and Associated Disease RisksDisease Risk Relative to NormalWeight and Waist CircumferenceBMI(kg/m2)Obesity ClassMen (≤102 cm) ≤40 inWomen (≤88 cm) ≤35 inMen (>102 cm) >40 inWomen (>88 cm) >35 inUnderweight< 18.5--Normal18.5 – 24.9Overweight25.0 – 29.9IncreasedHighObesity30.0 – 34.9IVery High35.0 – 39.9IIExtreme obesity> 40IIIExtremely HighClinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity inAdults—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*Insulinsmall, dense LDLapo Bwaist < 9090 < waist < 100waist > 100Lemieux et al. Circ 2000;102:179.
27 Metabolic Risk Identified by “Hypertriglyceridemic Waist” TGwaistTGwaistTGwaistTGInsulin Resistance (HOMA)Waist = 95 cm M88 cm FTG = 128 mg/dlMenWomenMenWomenAge 18-34Age 55-74Kahn and Valdez. AJCN 2003;78:
28 Risk of coronary heart disease High Low Subcutaneous adipose tissue~ 5 – 10% weight lossVisceral adipose tissue~ 30% visceral adipose tissue loss (diet, physical activity, pharmacotherapy)Lipid profileDeteriorated ImprovedImpaired Improved↑ ↑Insulin sensitivityInsulinemiaGlycemiaAbdominally obese (high waist measurement)Reduced obesity (low waist measurement)Susceptibility to thrombosis↑ ↓Inflammation markers↑ ↓Endothelial functionImpaired ImprovedRisk of coronary heart diseaseHigh LowDespres J-P et al. BMJ 2001;322:716.
29 Assessing Drug-Induced Causes for Weight Gain Diabetes TreatmentsInsulinSulfonylureasThiazolidinedionesAntihistamines (cyproheptadine)β- and alpha-1 adrenergic receptor blockersChemotherapy agentsTamoxifenPsychiatric/NeuroAnti-psychoticsAntidepressantsLithiumAEDsSteroid HormonesCorticosteroidsProgestational steroidsHIV 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? NotimportantVeryimportant12345678910How confident are you to that you can get your weight under control?NotconfidentVeryconfident12345678910
33 A Guide to Selecting Treatment BMI CategoryTreatment27 – 29.930 – 34.935 – 39.9≥ 40Diet, physical activity, and behaviorWithco-morbidity+PharmacotherapySurgeryThe 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 PharmacotherapyIndicated 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 diseasesAgentsPhentermine (1973): norepinephrine releasing agentSibutramine (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 alone5Medication and behavior modification10*Weight Loss (%)15*Medication, behaviormodification andmeal replacements*P < 0.05 vs medication alone2024681012Time (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 ProceduresVertical BandedGastroplastyBiliopancreatic Diversionwith Duodenal SwitchGastric BypassLapBandTMRestrictionMalabsorption
42 Efficacy Outcomes for Weight Reduction Surgeries All SurgeriesMean ChangeAbsolute wt loss (kg)39.7 kgBMI decreased14.2Initial wt loss (%)32.6%ProcedureInitial Wt Loss (%)Gastroplasty24.3%RYGB34.9%BPD39.0%RYGB = roux-en-y gastric bypass; BPD = biliopancreatic diversionBuchwald et al. JAMA 2004;292:1724.
43 Efficacy for Improvement in Obesity-Related Conditions CompletelyResolved76.8%70%61.7%85.7%Resolved orImproved86%-----78.5%83.6%DiseaseDiabetesHyperlipidemiaHypertensionObstructive SleepApneaBuchwald et al. JAMA 2004;292:1724
44 ConclusionObesity is currently under-recognized and under-treated. Physicians need to identify and evaluate the overweight and obese patient at an earlier stage of developmentScreening begins by measuring BMI, waist circumference and identifying co-morbiditiesTreatment always includes lifestyle modification. Consideration for pharmacotherapy and surgery is based upon the individual patient