1. Section 1 Review

2. Pulmonary disease abnormal function obstructive sleep apnea hypoventilation syndrome Nonalcoholic fatty liver disease steatosissteatohepatitiscirrhosis Coronary heart disease Diabetes Diabetes Dyslipidemia Dyslipidemia Hypertension Hypertension Gynecologic abnormalities abnormal menses infertility polycystic ovarian syndrome Osteoarthritis Skin Gall bladder disease Cancer breast, uterus, cervix colon, esophagus, pancreas kidney, prostate Phlebitis venous stasis Gout Medical Complications of Obesity Idiopathic intracranial hypertension Stroke Cataracts Severe pancreatitis

3. Complications of Childhood obesity

4. Relationship Between Weight Gain in Adulthood and Risk of Type 2 Diabetes Mellitus Relative Risk Weight Change (kg) Willett et al. N Engl J Med 1999;341:427. -10-505101520MenWomen

5. Diagnosing the Metabolic Syndrome Diagnosis is established when 3 of these risk factors are present. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA 2001;285:2486-2497. Risk FactorDefining Level Abdominal obesity (Waist circumference) Men Women >102 cm (>40 in) >88 cm (>35 in) TG  150 mg/dL HDL-C Men Women <40 mg/dL <50 mg/dL Blood pressure  130/  85 mm Hg Fasting glucose  110 mg/dL

6. Increase in Healthcare Costs Among Obese Compared with Lean (BMI <25 kg/m2) Patients* Increase in Cost Compared with Lean Subjects (%) BMI 30-34 kg/m 2 BMI >35 kg/m 2 Quesenberry CP Jr et al. Arch Intern Med. 1998;158:466-472. *HMO Setting: Northern California Kaiser Permanente. Healthcare visits Pharmacy Laboratory tests All outpatient services All inpatient services Total healthcare

7. “Doc, I am fat because my hormones are out of whack. I know I don’t eat too much. Can you check out what’s wrong with me and give me a pill to fix it..”

8. Hormonal Causes of Obesity Cushings Syndrome (glucocorticoid excess) Most treatments for Diabetes Mellitus type 2 NOT Hypothyroidism Very few (less than 1%) of patients are obese due to hormonal problems, but a substantial number are obese in part due to diabetes treatment or treatment with glucocorticoids

9. Selected Medications That Can Cause Weight Gain Psychotropic medications –Tricyclic antidepressants –Monoamine oxidase inhibitors –Specific SSRIs –Atypical antipsychotics –Lithium –Specific anticonvulsants  -adrenergic receptor blockers SSRI=selective serotonin reuptake inhibitor Diabetes medications – Insulin – Sulfonylureas – Thiazolidinediones Highly active antiretroviral therapy Tamoxifen Steroid hormones – Glucocorticoids – Progestational steroids

10. “ Yea, I know about balancing food and activity, but I don’t don’t eat that much.” “I don’t eat more than other people” “I only eat salads.”

11. Discrepancy Between Reported and Actual Energy Intake and Expenditure Kcal/d Reported *P<0.05 vs reported. Lichtman et al. N Engl J Med 1992;327:1893. Energy Intake ActualReportedActual Energy Expenditure * *

12. “My problem is my metabolism is slow. Anything at all that I eat turns to fat.”

13. Relationship Between Resting Energy Expenditure and Fat-free Mass REE = Resting energy expenditure Fat-Free Mass (kg) REE (kcal/24 h) Owen. Mayo Clin Proc 1988;63:503. 309010004050607080 Lean females Obese females Lean males Obese males

14. “Any time I try to lose weight, my metabolism slows down so much that I can’t lose weight.”

15. Energy Metabolism Before and After Weight Loss Energy Expenditure (kcal/d) Before *P<0.05 vs before weight loss Amatruda et al. J. Clin Invest 1993;92:1236. Predicted Mean BMI Reduced from 31 to 23 kg/m 2 AfterBeforePredictedAfter Resting Energy Expenditure Total Energy Expenditure * * * *

16. “So obesity is all genetic. There’s nothing I can do.”

17. Gene-Environment Interaction in the Pathogenesis of Obesity Body Mass Index (kg/m 2 ) Ravussin E et al. Diabetes Care 1994;17:1067-1074. Pima Indians Maycoba, MexicoArizona P <0.0001

18. Effect of Portion Size on Energy Intake 500 Amount Consumed (g) Amount of Macaroni and Cheese Served (g) Rolls et al. Am J Clin Nutr. 2000 Dec;76(6):1207-13. 6257501000

19. Relationship Between Adiposity and Frequency of Eating in a Restaurant Percent Body Fat McCrory et al. Obes Res 1999;7:564. Log Restaurant Food Consumption per Month 0.81.01.21.31.51.41.10.9 Partial r = 0.35; P = 0.005

20. Prevalence of Obesity by Hours of TV per Day: NHES Youth Aged 12-17 in 1967-70 and NLSY Youth Aged 10-15 in 1990 4-53-42-31-20-1>5

21. “There are too many. We can’t treat obesity because we would be treating everyone with everything.”

22. Expert Panel of NHLBI: Assessing Obesity - BMI, Waist Circumference, and Disease Risk *An increased waist circumference can denote increased disease risk even in persons of normal weight. BMI Men  40 in Women  35 in UnderweightNormal*OverweightObesity Extreme obesity ——Increased High Very high Extremely high <18.518.5-24.925.0-29.9 30.0-34.9 35.0-39.9  40 Category Men >40 in Women >35 in ——High Very high Very high Extremely high Disease Risk Relative to Normal Weight and Waist Circumference Adapted from Clinical guidelines. National Heart, Lung, and Blood Institute Web site. Available at: http://www.nhlbi.nih.gov/nhlbi/cardio/obes/prof/guidelns/ob_gdlns.htm. Accessed July 31, 1998.

23. Expert Panel of NHLBI: Overall Risk of Obesity Evaluate the potential presence of other risk factors. Some conditions associated with obesity put patients at high risk for subsequent mortality, and will require aggressive modification. Other obesity associated conditions are less lethal, but still require treatment. Among the risks to consider are: coronary heart disease, other atherosclerotic diseases, type 2 diabetes mellitus, sleep apnea, gynecological abnormalities, osteoarthritis, gallstones, stress incontinence, hypertension, cigarette smoking, hyperlipidemia, and family history of early coronary disease.

24. Expert Panel of NHLBI: Therapy Decision Therapy is Recommended: –BMI > 30 –BMI 25 - 29.9, a dangerous waist circumference and 2 or more risk factors. Individuals at lesser risk should be counseled about useful lifestyle changes if they are ready for a change.

25. “So what can we do? There are all these diets and pills on the TV, but nothing seems to work very well. Is there anything that actually helps.”

26. NHLBI Expert Panel: Goals of Therapy Reduce body weight and maintain a lower body weight for the long term. An initial weight loss target of 10% of body weight, lost over six months is recommended and will be medically significant. The rate of weight loss should be 1 -2 pounds each week. Evidence indicates that greater rates of weight loss do not achieve better long- term results. After the first six months of weight loss therapy, the priority should be weight maintenance through combined changes in diet, physical activity, and behavior.

27. Obese Patients Have Unrealistic Weight Loss Goals OutcomeWeight (lbs)% Reduction Initial2180 Dream13538 Happy15031 Acceptable16325 Disappointed18017 Foster et al. J Consult Clin Psychol 1997;65:79.

28. NHLBI Expert Panel: Changes in “Lifestyle” or Priorities Food “Diets” chosen should be long-term Reduced 500 to 1000 from baseline in calories Targeting 30% or less of calories as fat Individualized. Activity Activity is most useful in maintaining weight loss Goal of 30 minutes of moderate activity every day Increase everyday activity by taking the stairs, etc.

29. Providing Prepackaged Meals Enhances Weight Loss Weight Change (kg) Jeffery et al. J Consult Clin Psychol 1993;61:1038. P=0.0001 treatment vs control. P=0.0002 behavior therapy + self-selected diet vs behavior therapy + food provision. Months 061218 Maintenance Weekly Treatment Control Behavior Therapy + Self-selected Diet Behavior Therapy + Food Provision

30. “I don’t think I need to change what I am eating. I am going to work out and lose it that way.”

31. Physical Activity Alone Results in Minimal Weight Loss Wing. Med Sci Sports Exerc 1999;31(suppl):S547. *P<0.05 vs control group Duration of each study ranged from 4 to 12 months. Stefanick 1998 Stefanick 1998a Anderssen 1995 Hammer 1989 Verity 1989 Rönnemaa 1988 Wood 1988 Wood 1983 Weight loss (kg) Control Group Exercise Group * * * *

32. Relationship Between Physical Activity and Maintenance of Weight Loss Not Maintained Subjects Exercising (%) P<0.001 Kayman et al. Am J Clin Nutr 1990;52:800. Weight Loss Pattern Maintained

33. Considerable Physical Activity is Necessary for Weight Loss Maintenance Jakicic et al. JAMA 1999;282:1554. Change in Weight (kg) Time (months) 061218 WeeklyBiweeklyMonthly Concomitant Behavior Therapy *P<0.05 <150 min/wk >150 min/wk >200 min/wk

34. Effect of Decreasing Sedentary Activities vs Increasing Physical Activities on Body Weight in Children 6-12 Years Old 0 Time (months) Decreased Sedentary Activity Change in Percent Overweight Increased Physical Activity Epstein et al. Health Psychol 1995;14:109. 4812

35. “This is so hard. Is there any good news?”

36. Diabetes Prevention Program (DPP) Hypothesis: Can diabetes be delayed or prevented by addressing risk factors: impaired glucose tolerance, overweight and sedentary life - using lifestyle changes or metformin? 3234 pts of mean age 51, BMI 34, 68% women, 45% minorities and impaired glucose tolerance were randomized to 3 groups at 27 US centers: –Usual care (control) –Metformin 850 mg BID –Lifestyle intervention – Goal of 7% weight loss by Food Pyramid, NCEP 1 diet Goal of 150 min/wk moderate activity (brisk walking)

37. Diabetes Development in Diabetes Prevention Program

38. “Obesity treatment and behavior change are too hard. I don’t have time to do this in my clinic.”

39. Practical Behavior Change Physicians make a difference Repetition and follow-up are most useful Likely better to do with 2-5 minutes repeatedly than with an hour at once Education can be done in pieces Let them know that you know it’s hard and that the environment is against them Encourage patients to find their own goals (motivational interviewing techniques) but encourage specificity - go beyond “watch what I eat”

40. Review when, where, and how behaviors will be performed Identify behavior change goal Have patient keep record of behavior change Review progress at next treatment visit Five Steps to Facilitate Behavior Change Wadden and Foster. Med Clin North Am 2000;84:441. 1 2 5 3 4 Congratulate patient on successes (do not criticize shortcomings)

41. Cardinal Behaviors of Successful Long-term Weight Management National Weight Control Registry Data Self-monitoring: –Diet: record food intake daily, limit certain foods or food quantity –Weight: check body weight >1 x/wk Low-calorie, low-fat diet: –Total energy intake: 1300-1400 kcal/d –Energy intake from fat: 20%-25% Eat breakfast daily Regular physical activity: 2500-3000 kcal/wk (eg, walk 4 miles/d) Klem et al. Am J Clin Nutr 1997;66:239. McGuire et al.Int J Obes Relat Metab Disord 1998;22:572.

42. Long-term Weight Loss is Improved with Long- term Maintenance Therapy Weight Loss (%) Perri et al. J Consult Clin Psychol 1988;56:529. 0123456789101112 Time (mo) 1314151617 P <0.05 No maintenance tx Maintenance tx Diet and behavior modification therapy

43. Assessing Weight Loss Readiness Motivation: Stress level: Psychiatric issues: Time availability: Patient seeks weight reduction Free of major life crises Free of severe depression, substance abuse, bulimia nervosa Patient can devote 15-30 min/d to weight control for next 26 weeks Patient Ready? Prevent weight gain and explore barriers to weight reduction Initiate weight loss therapy YESNO

44. Prevention Breastfeeding when possible Plotting BMI at each visit Anticipatory guidance: 5-2-1-0 –“5 a day” fruits and vegetables –Less than 2 hr/day of screen time –At least 1 hour of moderate activity each day –No sweet drinks