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Clinical Diagnosis and Effective Management Strategies.

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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 Summary of studies –We are failing to adequately identify the overweight and mildly obese patient – missed opportunities for early prevention and treatment –We are doing a better job identifying the moderately and severely obese patient presenting with co-morbid conditions, particularly type 2 diabetes, hypertension and hyperlipidemia Identification & Counseling

5 Percent of Patients Receiving PCP Advice by Obesity Classification Simkin-Silverman LR et al. Prev Med 2005;40: Told Overweight: %2 (test for linear trend) – 16.5, p – Gave Weight Loss Advise: %2 (test for linear trend) – 5.5, p – 0.019

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 Recommendation Ann 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 condition –Lack of education, training, and practice organization aimed at evaluating & treating obesity as a chronic illness –Practice barriers –Attitudes of futility, lack of perceived benefit and unrewarding Adapted 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 The Patient Knowledge Attitudes Expectations Demands Motivation Clinician Delivery of Obesity Care Providing Obesity Care The Practice Environment Payment Structure Type of Visit Alternative Demands Availability of Staff Adapted from Jaen et al. J Fam Prac, The Clinician Time Reimbursement Training Interest Type of Visit

10 Developing a Chronic Care Model of Care (A Systems Approach) Put Prevention Into Practice –AHRQ – Improving Chronic Illness Care –http://improvingchroniccare.org –Chronic care training manual –ICIC Improving your practice manual –Tools

11 Provision of Obesity Care Three factors necessary for physicians to intervene –Adequate recognition of obesity as a medical problem –Willingness to provide intervention –Adequate skills or resources to do so Kristeller & Hoerr. Prev Med 1997.

12 Obesity Treatment Guidelines

13 Obesity Treatment Recommendations

14 The Office Visit 1.Measure weight, height, waist circumference and record body mass index (BMI) 2.Categorize obesity classification and risk 3.Take a comprehensive history, physical exam, & lab tests for medical condition 4.Assess need for treatment 5.Broach the subject 6.Assess readiness for treatment The Practical Guide, The Evaluation Process Consists of 6 Action Steps

15 Body Mass Index Chart Height Weight (lbs)

16 BMI-Associated Disease Risk Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults The Evidence Report. Obes Res 1998;6(suppl 2). Additional risks: Large waist circumference (men > 40 in; women > 35 in) Poor aerobic fitness Specific races and ethnic groups ClassificationBMI (kg/m 2 )Risk Underweight< 18.5Increased Normal18.5 – 24.9Normal Overweight25.0 – 29.9Increased Obese I30.0 – 34.9High II35.0 – 39.9Very high III 40Extremely high

17 Relative Risk of CVD Mortality LeanNormalObese Body Fat Category (% Weight as Fat) < 16.7%16.7% – 24.9% 25% Fatness, Fitness, and Cardiovascular Disease Mortality Lee et al. Am J Clin Nutr 1999;69:373. Aerobically fit Unfit

18 Action BMI Ranges for Asian Populations are Lower WHO expert consultation. Lancet 2004;363:157. High to very high risk

19 Cardiovascular – Hypertension – Congestive Heart Failure – Cor Pulmonale – Varicose Veins – Pulmonary Embolism – Coronary Artery Disease Neurologic – Stroke – Idiopathic intracranial hypertension – Meralgia paresthetica Psychological – Depression – Body image disturbance – Stigmatization Respiratory – Dyspnea – Obstructive Sleep Apnea – Hypoventilation Syndrome – Pickwickian Syndrome – Asthma Endocrine – Metabolic Syndrome – Type 2 diabetes – Dyslipidemia – Polycystic ovarian syndrome (PCOS)/androgenicity – Amenorrhea/infertility menstrual disorders Systems Review Kushner and Roth. Endo Metab Clinics N Am 2003.

20 Musculoskeletal –Hyperuricemia and gout –Immobility –Osteoarthritis (knees/hips) –Low back pain –Carpal tunnel syndrome Integument –Striae distensae (stretch marks) –Stasis pigmentation of legs –Cellulitis –Acanthosis nigricans/skin tags –Intertrigo, carbuncles Gastrointestinal –GERD –Non-alcoholic fatty liver disease (NAFLD) –Cholelithiasis –Hernias –Colon cancer Genitourinary –Urinary stress incontinence –Obesity-related glomerulopathy –Kidney stones –Hypogonadism (M) –Breast and uterine cancer –Kidney cancer –Pregnancy complications Systems Review

21 The Metabolic Syndrome Risk FactorDefining Level Abdominal Obesity Men Women Waist Circumference > 102 cm (> 40 in) > 88 cm (> 35 in) Triglycerides 150 mg/dL HDL Cholesterol Men Women < 40 mg/dL < 50 mg/dL Blood Pressure 130 / 85 mm Hg Fasting Glucose 110 mg/dL ATP III, Executive Summary, 2001.

22 Importance of Measuring Waist Circumference: BMI 25 – 29.9 (Overweight) Janssen et al. Arch Intern Med 2002;162: NHANES III. Men (n = 3081)Women (n = 2606) Prevalence, % NI WCHigh WCNI WCHigh WC Hypertension Type 2 DM Hyper-chol High LDL-C Low HDL-C Hyper-TG Metabolic Syndrome

23 Importance of Measuring Waist Circumference: BMI 18.5 – 24.9 (Healthy) Janssen et al. Arch Intern Med 2002;162: NHANES III. Men (n = 3081)Women (n = 2606) Prevalence, % NI WCHigh WCNI WCHigh WC Hypertension Type 2 DM Hyper-chol High LDL-C Low HDL-C Hyper-TG Metabolic Syndrome

24 Subcutaneous Fat Abdominal Muscle Layer Intra- abdominal Fat Visceral Adiposity: The Critical Adipose Depot

25 Classification of Overweight and Obesity by BMI, Waist Circumference and Associated Disease Risks Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in AdultsThe Evidence Report. Obes Res 1998;6(suppl 2). Disease Risk Relative to Normal Weight and Waist Circumference BMI (kg/m 2 ) Obesity Class Men (102 cm) 40 in Women (88 cm) 35 in Men (>102 cm) >40 in Women (>88 cm) >35 in Underweight< Normal18.5 – Overweight25.0 – 29.9IncreasedHigh Obesity30.0 – 34.9IHighVery High 35.0 – 39.9IIVery High Extreme obesity> 40IIIExtremely High

26 Percentage of Men with Metabolic Triad* Classified on Basis of Waist Girth and TG Level Lemieux et al. Circ 2000;102:179. waist < 9090 < waist < 100waist > 100 * Insulin small, dense LDL apo B

27 Metabolic Risk Identified by Hypertriglyceridemic Waist Men Women Insulin Resistance (HOMA) Age Age waist TG Waist = 95 cm M 88 cm F TG = 128 mg/dl Kahn and Valdez. AJCN 2003;78:

28 Despres J-P et al. BMJ 2001;322:716. Subcutaneous adipose tissue Abdominally obese (high waist measurement) Reduced obesity (low waist measurement) High Low Risk of coronary heart disease Visceral adipose tissue ~ 5 – 10% weight loss ~ 30% visceral adipose tissue loss (diet, physical activity, pharmacotherapy) Deteriorated Improved Lipid profile Impaired Improved Insulin sensitivity Insulinemia Glycemia Susceptibility to thrombosis Inflammation markers Impaired Improved Endothelial function

29 Assessing Drug-Induced Causes for Weight Gain Diabetes Treatments Insulin Sulfonylureas Thiazolidinediones Antihistamines (cyproheptadine) β- and alpha-1 adrenergic receptor blockers Chemotherapy agents Tamoxifen Psychiatric/Neuro Anti-psychotics Antidepressants Lithium AEDs Steroid Hormones Corticosteroids Progestational steroids HIV 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 cant 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? Not important Very important How confident are you to that you can get your weight under control? Not confident Very confident

32 Obesity Treatment Pyramid Surgery Pharmacotherapy Lifestyle Modification DietPhysical Activity BMI

33 A Guide to Selecting Treatment The Practical Guide BMI Category Treatment – – – Diet, physical activity, and behavior With co-morbidity ++++ Pharmacotherapy With co-morbidity +++ Surgery With co-morbidity +

34 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.* NHLBI Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults (1998) *Evidence Category A

35 Low calorie diets can reduce total body weight by an average of 8% over 3 to 12 months.* *Evidence Category A NHLBI Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults (1998)

36 U.S. Preventive Services Task Force (USPSTF) Recommendations Fair to good evidence that high-intensity counselingabout 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 Indicated 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 diseases Agents –Phentermine (1973): norepinephrine releasing agent –Sibutramine (1997): serotonin norepinephrine reuptake inhibitor (SNRI) –Orlistat (1999): gastrointestinal lipase inhibitor Pharmacotherapy

38 Additive Effects of Behavior and Meal Replacement Therapy With Pharmacotherapy for Obesity Wadden et al. Arch Intern Med 2001;161: Time (months) Weight Loss (%) Medication, behavior modification and meal replacements * * Medication and behavior modification Medication alone *P < 0.05 vs medication alone

39 Evidence Statement: Appropriate weight loss drugs can augment diet, physical activity and behavior therapy in weight loss.* *Evidence Category B NHLBI Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults (1998)

40 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 NHLBI Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults (1998)

41 Update: Bariatric Surgery Currently Popular Procedures LapBand TM Vertical Banded Gastroplasty Gastric Bypass Biliopancreatic Diversion with Duodenal Switch Restriction Malabsorption

42 Efficacy Outcomes for Weight Reduction Surgeries RYGB = roux-en-y gastric bypass; BPD = biliopancreatic diversion Buchwald et al. JAMA 2004;292:1724. All SurgeriesMean Change Absolute wt loss (kg)39.7 kg BMI decreased14.2 Initial wt loss (%)32.6% ProcedureInitial Wt Loss (%) Gastroplasty24.3% RYGB34.9% BPD39.0%

43 Efficacy for Improvement in Obesity- Related Conditions Disease Diabetes Hyperlipidemia Hypertension Obstructive Sleep Apnea Completely Resolved 76.8% 70% 61.7% 85.7% Resolved or Improved 86% % 83.6% Buchwald et al. JAMA 2004;292:1724

44 Conclusion Obesity is currently under-recognized and under-treated. Physicians need to identify and evaluate the overweight and obese patient at an earlier stage of development Screening begins by measuring BMI, waist circumference and identifying co-morbidities Treatment always includes lifestyle modification. Consideration for pharmacotherapy and surgery is based upon the individual patient

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