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Managing the Obese Patient, With Emphasis on Exercise Kevin deWeber, MD Family Physician Primary Care Sports Medicine USUHS.

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Presentation on theme: "Managing the Obese Patient, With Emphasis on Exercise Kevin deWeber, MD Family Physician Primary Care Sports Medicine USUHS."— Presentation transcript:

1 Managing the Obese Patient, With Emphasis on Exercise Kevin deWeber, MD Family Physician Primary Care Sports Medicine USUHS

2 Objectives Review the benefits of exercise in obesity Discuss the relative benefits of exercise vs. diet in achieving and maintaining weight loss Discuss what types of exercise are most beneficial Learn how to risk-stratify obese patients Learn the components of treatment necessary for weight loss

3 Body Mass Index (BMI) is the global method of determining overweight/obesity BMI = wt/ht² (kg/m²) (lbs/in²)x704.5

4 Definitions Normal: BMI Overweight: Obese: >= 30 –Class I –Class II –Class III >= 40

5 Etiology of obesity Too much food intake Insufficient energy output –Not enough exercise –Low resting metabolic rate Genetic predisposition Environment favoring weight gain Psychological stressors

6 Obesity is associated with increased risk of co-morbid conditions: Hypertension Dyslipidemia Diabetes mellitus Coronary artery dz. Cerebrovascular dz. OVERALL MORTALITY HIGHER! Gallbladder dz. Sleep apnea Osteoarthritis Gout Cancers –Colon –Breast –Prostate –Uterus –Cervix

7 The scope of overweight/obesity 52% of US adults are overweight or obese! –ONE HALF! Prevalence is INCREASING! –30% increase in adults in two decades –>80% increase in children/adolescents!!! Second-leading PREVENTABLE cause of death in the US

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9 “Trends in overweight and physical activity among U.S. mlitary personnel, ” 1995: 50% of military personnel overweight 1998: 54% Physical activity levels were high –67% engaging in regular, vigorous PA. –Levels of PA Increased from CONCLUSION: the increase in Overweight is not due to decreased PA Lindquist CH, Bray RM. Prev Med 2001 Jan;32(1): *

10 “Healthy Obesity” Physically-fit obese patients have LOWER mortality rates than unfit normal-weight persons! –Being thin doesn’t guarantee being healthy –Being fat doesn’t HAVE to be unhealthy Physical activity and cardiovascular fitness are much more predictive of health than body weight

11 Relative risk of all-cause mortality Obese UNfit Normal UNfit Obese FIT Normal FIT

12 Relative risk of cardiovascular disease Obese UNfit Normal UNfit Obese FIT Normal FIT

13 Despite the protection against cardiovascular dz. and all-cause mortality that cardio-respiratory fitness incurs, obesity still has its problems. Osteoarthritis Decreased quality of life Social discrimination Functional limitations

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15 Facts on exercise in obesity tx. Exercise alone only leads to slight wt loss, if any, but marked reduction in mortality Adding moderate/vigorous aerobic exercise to dieting slightly increases wt loss Aerobic exercise during wt loss lessens loss of FFM Resistance exercise during wt loss preserves FFM and may help maintain wt loss Any type of exercise helps maintain wt loss, but duration must be 4-10 hours/week Compliance may be better with multiple short- bout sessions

16 How good is exercise alone for weight loss? Not very effective –11 studies 5 found no change in weight w/ Exercise alone 6 showed slight weight loss w/ Exercise alone –1-2 kg *

17 Ross R et al. Reduction in obesity and related comorbid conditions after diet-induced weight loss or exercise-induced weight loss in men. A randomized, controlled trial. Ann Intern Med 2000 Jul 133(2): *

18 How much does exercise combined with diet add to weight loss? Not very much –15 studies only 4 showed increased weight loss w/ addition of exercise to diet –Exercise may, however, help people pay more attention to their diets

19 “A meta-analysis of the past 25 years of weight loss research using diet, exercise, or diet plus exercise intervention.” Average 15-week treatment –Diet or Diet-plus-exercise program, produces a weight loss of about 11 kg –Miller WC, Koceja DM, Hamilton EJ. Int J Obs Relat Metab Disord 1998 Aug;22(8):825.

20 What is the effect of exercise intensity on weight loss? Not much –as long as it is moderate to high *

21 “Relationship between physical activity and body fat in women.” Irwin ML et al. Presented at 2001 ACSM Conference, Baltimore. 143 women BMI and waist circumference were significantly related to: –Moderate PA –Vigorous PA –Sports/conditioning –Occupation PA –(but not to walking or household/yardwork)

22 Are multiple, short-duration bouts as good as continuous exercise for weight loss? Data inconclusive –Two studies suggest so. –More enjoyable + More accessible = Better compliance –One study suggests no difference

23 Jakicic JM et al. Effects of intermittent exercise and use of home exercise equipment on adherence, weight loss, and fitness in overweight women: a randomized trial. JAMA 1999 Oct;282(16): *

24 “The effects of 18 months of intermittent vs. continuous exercise on aerobic capacity, body weight and composition, and metabolic fitness in previously sedentary, moderately obese females.” Two exercise groups: –continuous (30 min, 3d/wk, 60-75% VO2max) –intermittent (brisk walking 15 min 2x/day, 5d/wk). Weight loss: –continuous group: -2.1% –intermittent group: none Donnelly JE at al. Int J Obes Relat Metab Disord 2000 May;24(5):

25 What is effect of resistance exercise on weight loss? None Some studies even show weight gain However, there may be some other benefits (stay tuned)

26 Does aerobic exercise vs. diet alone alter the composition of weight loss? YES –Diet alone leads to marked reduction in fat free mass (FFM) as well as fat mass –7 of 10 studies: aerobic exercise preserves (FFM) –Differences could be related to degree of obesity Higher BMI --> less FFM lost

27 Does exercise intensity affect body composition? Inadequately studied

28 What is the effect of resistance training on body composition? Definitely preserves, and may even increase, FFM Unclear effect on fat mass –3 studies show more fat mass lost w/ Diet + Resistance vs. Diet alone –3 studies show no difference

29 What role does exercise have in weight loss maintenance? An important role Wing RR. Med Sci Sports Exer 1999 –Review of literature; 6 studies 4 of 8: significant long term differences favoring diet + exercise 4 of 8: trend favoring diet + exercise *

30 “Effects of walking training on weight maintenance after a very-low-energy diet in premenopausal obese women: a randomized controlled trial.” RCT, 82 women, all did 12-wk Diet program to lose wt 40-wk maintenance program randomized to: –Counseling + Walking program –Counseling only At 2 year f/u, –wt regain was 3.5 kg less and waist circ regain 3.8 cm less in the walk group vs. controls. Fogelholm M et al. Arch Intern Med 2000 Jul 24;160(14):

31 “Behavioral strategies of individuals who have maintained long-term weight losses.” Phone survey of 238 pts who lost >10% body wt Factors that correlated with maintenance: –Higher levels of exercise, especially strenuous –More behavioral strategies to control dietary fat intake –Greater frequency of self-weighing McGuire MT et al. Obes Res 1999 Jul;7(4):

32 How much exercise is needed for optimal weight loss maintenance? The more, the better! –210 min/week brisk walking: 40% wt regain –600 min/week brisk walking: 15% retain

33 What type of exercise is best for weight loss maintenance? Either aerobic or resistance ? Both?

34 Resistance exercise DURING weight loss may have a role in long-term maintenance. RCT, 20 kids/adolescents, 2 groups, 12 weeks –Diet-only –Diet + Resistance Exercise Weight loss equal in both groups Fat free mass decreased in diet-only group At one year f/u, wt regain inversely related with fat free mass at 12 wks –Schwingshandl J et al. Effect of an individualised training programme during weight reduction on body composition: a randomised trial. Arch Dis Child 1999 Nov;81(5):426-8.

35 Response of obesity to exercise may have a genetic component. Study of obese patients in France UCP3 gene –Wild C/C genotype: BMI was negatively a/w PA (p=.015). –C-->T polymorphism: BMI not a/w PA –Otabe S et al. A genetic variation in the 5' flanking region of the UCP3 gene is associated with body mass index in humans in interaction with physical activity. Diabetologia 2000 Feb;43(2):245-9.

36 Risk-stratifying obese patients HIGH RISK –Coronary artery dz –Sleep apnea –Type 2 diabetes RISK FACTORS –Age (men>45, W>55) –HTN –LDL > 160 –HDL < 35 –Impaired fasting gluc –FH of premature CAD –Osteoarthritis –Gallstones –Stress incontinence –Smoking

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38 Treating Obese patients

39 The undisputed, #1 BEST method of treatment for obesity is...

40 (there is no one single best method)

41 Treating obesity demands a multi-faceted approach with chronic monitoring 1. Decreased caloric intake 2. Increased exercise 3. Behavioral modification 4. +/- Pharmacotherapy 5. +/- Surgery

42 Behavior modification strategies, extended treatment, and physical activity are excellent predictors of weight loss during treatment. Foreyt JP, Goodrick GK. Evidence for success of behavior modification in weight loss and control. Annals of Internal Medicine 1993;119:

43 Goals of treatment Get patients to look like models? –NOT Get patients to their ideal body weight? –NOT practical usually Get patients to lose 5-10% of body weight? –HOPEFULLY Get patients to exercise and reduce their mortality risk? –DEFINITELY!

44 Set reasonable expectations Gradually develop regular exercise Gradually develop more healthy eating Shoot for losing 5-10% of body weight first

45 Why the not-so-lofty goals? Rarely do obese patients achieve ideal wt Falling short of lofty goals (SO common) leaves patients disappointed and highly susceptible to re-gain of weight lost Health can be achieved WHILE still obese –“Healthy obesity” concept

46 1. Decreased caloric intake kcal/day less than usual –Lose 1-2 lbs/week Women: kcal/day total diet Men: kcal/day total diet National Heart, Lung, and Blood Institute. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: the evidence report

47 2. Increased exercise Exercise regularly –Need to gradually work up to this –Start with brisk walking min, 3-5 days/week –Work up to min, most or all days/week –Aim to expend 1, ,000 kcal/week NHLBI, ACSM

48 What kind of exercise is best for obesity treatment? May be a combination of aerobic AND resistance training *

49 Kraemer WJ et al. Influence of exercise training on physiological and performance changes with weight loss in men. Med Sci Sports Exer 1999 Sep;31(9):

50 Counseling patients to increase exercise (cont.) Use the 5 A’s of counseling:\ –Address the agenda –Assess Knowledge, beliefs, concerns, feelings, stage of change –Advise Personalized exercise recommendations –Assist Provide support, identify barriers and resources –Arrange follow-up

51 Tailor counseling to the patient’s stage of change Pre-contemplation - not remotely interested Contemplation - considering wt loss Preparation - starting to make small changes Action - meeting behavior change criteria Maintenance - steady behavior over time

52 Example: Counseling a Pre-contemplator Provide handout on health benefits of weight loss and exercise Discuss barriers to exercise

53 Example: Counseling a patient in preparation phase Give specific advice on Frequency, Intensity, Time and Type of exercise (FITT)

54 Specific Exercise Recommendations: FITT Frequency: most/all days of week Intensity: 55-90% of max heart rate Time: minutes –Gradually work up to this –Start with brisk walking 10 min, 3-5 days/week –Work up to min, most or all days/week Type: aerobic, resistance NHLBI, ACSM

55 Follow-up after initial counseling See patient two weeks later and every month Ask about progress –Encourage! Ask about barriers –Discuss remedies Weigh patient Follow cholesterol, blood sugar, BP, etc.

56 “Prevalence of leisure-time physical activity among overweight adults-- United States, 1998.” Two thirds of overweight persons trying to lose weight reported using physical activity as a strategy for wt loss However, only 1/5 reported being active at recommended levels (30 min/day,most days). –MMWR 2000 Apr;49(15):

57 3. Behavioral Modification Self-monitoring Stimulus control Body image and self-esteem counseling Stress management Social support

58 Self-monitoring One of the MOST HELPFUL TOOLS IN OBESITY MANAGEMENT Observation and recording of behaviors –Total calorie intake, fat grams consumed, food groups used, situations that promote overeating, amount/intensity of exercise, weight, body composition, etc. Provides patient objective feedback so improvements can be made

59 Stimulus control Identifying and modifying the environmental cues that are a/w overeating and inactivity –Laying workout clothes on bed to increase likelihood of exercise the next AM –Eating only at kitchen table –Avoiding situations where overeating common

60 Body image and self-esteem counseling Many obese pts have poor self-esteem –Negative thoughts lead to poor compliance Many have unrealistic wt loss expectations –Ideal body wt vs. 5-10% Distorted body image –20% of obese pts won’t exercise because they feel too fat

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62 Stress management Stress is a primary predictor of relapse and overeating Management techniques are VERY effective in obesity treatment Refer to mental health professionals if not skilled yourself

63 Social support Those with it have more success Friends Family Community-based groups –Health clubs, education courses, Weight Watchers Church-related activities

64 4. Pharmacological therapy Candidates: –BMI and + risk factor –BMI >=30 Never use as sole therapy!! –Poor effectiveness –Poor long-term maintenance of wt loss Agents approved by FDA for long-term use

65 Sibutramine (Meridia) Blocks reuptake of norepi and serotonin Appetite suppressant, ? thermogenic Proven efficacy, even at one year of tx Improves TC, LDL, TG, HbA1c Side-effects: –Headache, elevated BP, insomnia, constipation, dry mouth Cost: $80/month

66 Orlistat (Xenical) Decreases fat absorption by inhibiting lipase in intestine (not absorbed) Proven efficacy, even long-term Improves TC, LDL, TG, HbA1c, glucose) Side-effects mostly GI: –Oily spotting, flatus, fecal urgency/incontinence Worse after fat ingestion; can lead to less fat eaten –Multi-vit with A/D/E/K recommended Cost: $110/month

67 5. Surgery for obesity For high-risk patients who have failed non- surgical therapy –BMI w/ RF’s –BMI >= 40 Produces longest wt loss maintenance of all treatment methods Significantly decreases mortality rate Techniques: vertical gastric banding, gastric bypass

68 Summary of treatment based on BMI and risk BMI 25-30, no RF: advise wt loss BMI , >= 2 RF: treat, +/- meds BMI 30-35: treat, +/- meds BMI , no RF: treat, +/- meds BMI , + RF: treat; +/- meds; consider surgery BMI >= 40: treat; +/- meds; consider surgery

69 Review pearls BMI > 30 defines obesity Risk-stratify patients based on co-morbidity Combined treatment with exercise, diet and behavior modification is most effective Set a reasonable goal of 5-10% wt loss Start exercise slowly; emphasize benefits even if it doesn’t result in wt loss Follow-up frequently and monitor Consider meds/surgery for high-risk patients

70 Facts on exercise in obesity tx. Exercise alone only leads to slight weight loss, if any, but marked reduction in mortality. Adding moderate/vigorous aerobic exercise to dieting slightly increases weight loss. Aerobic exercise during weight loss lessens loss of FFM. Resistance exercise during weight loss preserves FFM and may help maintain wt loss. Any type of exercise helps maintain weight loss, but duration must be 4-10 hours/week. Compliance may be better with multiple short- bout sessions.

71 Counseling patients to increase exercise Regularly discuss exercise with your patients (obese or not)

72 “A meta-analysis of the past 25 years of weight loss research using diet, exercise, or diet plus exercise intervention.” Average 15-week treatment –Diet or Diet-plus-exercise program, produces a weight loss of about 11 kg Weight loss Maintenance after one year: –Diet only: 6.6 kg loss maintained –Diet-plus-exercise: 8.6 kg loss maintained loss –Miller WC, Koceja DM, Hamilton EJ. Int J Obs Relat Metab Disord 1998 Aug;22(8):825.


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