2 Weighing the Evidence on Obesity Erika Pierce, PA-C, MMS
3 Learning ObjectivesUpon completion of this activity, participants will be able to:Describe the definition, causes, prevalence and risks associated with obesity;Discuss counseling on lifestyle modification for diet, exercise and behavioral changes as first line approaches;Assess the relative risks and benefits of drug therapy including phentermine, orlistat, phentermine/topiramte and lorcaserin;Analyze clinical trials (Look Ahead and POWER-UP) on multi-component primary care-based interventions;Consider the relative risks and benefits of weight loss surgery for selected patients.
5 Where Are We Going? The Map Obesity as a Disease EpidemicMedical RiskHaving the ConversationLifestyle ModificationsMedications for Weight LossPhentermineOrlistatPhentermine/topiramateLorcaserinWeight Loss Surgery
6 Obesity as a Disease ⅓ adults in U.S. are obese (78 million) ⅓ adults in U.S. are overweightCurrent trends has 45% obese by 2030Annual estimated cost: $150 billion 40% of this cost borne by Medicare & Medicaid
7 Maine Data Adults report 5% less leisure time activity 2000-2010 2011: K-3rd grade students:18.4% obese17% overweightM > F2011: High school students:15.9% overweight12.9% obese
8 Weight Status According to Body Mass Index, Adults Ages 18 years and Older, by Year, Maine,YearHealthy WeightOverweightObesenN%LCLUCL20001,804382,09542.840.245.31,607329,97036.934.539.4911181,31720.318.322.32001898362,37237.942.5888359,86540.037.742.2467178,46019.818.021.62002920370,46140.137.842.4838357,62238.736.541.0499195,03921.119.223.02003912384,77240.838.543.1848366,89738.936.641.2464191,19118.422.120041,281373,24838.036.01,293374,98738.236.2789233,41423.822.025.620051,430381,71739.337.441.31,368365,24537.635.739.5895224,15023.121.524.720061,456388,6651,391367,60837.235.339.1917231,60823.421.925.020072,335361,22334.437.52,482385,29738.436.839.91,670257,67425.724.327.020082,333373,58437.338.82,396365,69635.01,711262,92226.224.927.620092,629347,79134.933.536.42,924381,12938.339.82,120266,30726.825.528.120102,623355,60935.634.137.12,902366,91936.738.12,212276,98727.726.429.0Source: Behavioral Risk Factor Surveillance SystemHealthy weight is a BMI between 18.5 and 25, Overweight is a BMI between 25.1 and 30, Obese is a BMI over 30; based on self-reported height and weight.n = unweighted number of adults (numerator); N = weighted number of adults (weighted numerator)LCL = Lower 95% confidence limit of the weighted percentage; UCL = Upper 95% confidence limit of the weighted percentage. All percentages are weighted to be more representative of the population of Maine and to adjustNA = Not available
9 Maine Data: Healthy Weight YearHealthy WeightnN%LCLUCL20001,804382,09542.840.245.32001898362,37237.942.52002920370,46140.137.842.42003912384,77240.838.543.120041,281373,24838.036.040.020051,430381,71739.337.441.320061,456388,66520072,335361,22334.437.520082,333373,58437.335.738.820092,629347,79134.933.536.420102,623355,60935.634.137.1
10 Maine Data: Overweight YearOverweightnN%LCLUCL20001,607329,97036.934.539.42001888359,86540.037.742.22002838357,62238.736.541.02003848366,89738.936.641.220041,293374,98722.214.171.124051,368365,24537.635.739.520061,391367,60837.235.339.120072,482385,29738.436.839.920082,396365,69635.038.020092,924381,12938.339.820102,902366,91936.738.1
11 Maine Data: Obese Year Obese n N % LCL UCL 2000 911 181,317 20.3 18.3 22.32001467178,46019.818.021.62002499195,03921.119.223.02003464191,19118.422.12004789233,41423.822.025.62005895224,15023.121.524.72006917231,60823.421.925.020071,670257,67425.724.327.020081,711262,92226.224.927.620092,120266,30726.825.528.120102,212276,98727.726.429.0
12 Causes of Obesity We live in a food swamp. Social patterns of physical activityFood consumption↑ portion sizesAdded sugars, fats, calorie dense foods escalatedConsuming more caloriesSedentary lifestyles
13 Screening for Obesity Use BMI Waist circumference > 35 inches for women> 40 inches for men
14 Risk for type 2 diabetes, hypertension, or CVD relative to normal weight and waist circumference BMI (kg/m2)Men ≤ 102 cm (≤ 40 in)Women ≤ 88 cm (≤ 35 in)Men > 102 cm (> 40 in)Women > 88 cm (> 35 in)Underweight< 18.5-Normal*OverweightIncreasedHighClass I ObesityVery HighClass II ObesityClass III Obesity≥ 40.0Extremely High* Increased waist circumference can also be a marker for increased risk even in persons of normal weight.
15 Diagnosis of overweight or obese must prompt stratification of cardiovascular risk
23 Goals Prevent further weight gain Reduce weight Maintain a lower weight over time
24 First Step Screen every patient BMI Waist circumference Determine patient’s level of motivation
25 Determine patient’s level of motivation Stage of ReadinessKey QuestionsNot ReadyRaise AwarenessElicit Change Talk*Advise and EncourageWould you be interested in knowing more about reaching a healthy weight?How can I help?What might need to be different for you to consider a change in the future?UnsureEvaluate AmbivalenceBuild ReadinessWhere does that leave you now?What do you see as your next steps?What are you thinking or feeling at this point?How does being overweight affect you?ReadyStrengthen CommitmentFacilitate Action PlanningWhy is this important to you now?What are your ideas for making this work?What is hard about managing your weight?What might get in the way? How might you work around the barriers?How might you reward yourself along the way?* Elicit Change Talk: Encourage patients to present their own arguments for changing behavior.
35 Weight Loss Medications Can result in weight lossUse as adjunct to calorie reduced dietIncrease physical activitySelected patientsBMI > 30BMI > 27 with comorbid condition
36 FDA Approved Medications PhentermineSibutramine (Meridia)Orlistat (Xenical) (Alli)Lorcaserin (Belviq)Phentermine IR/Topiramate ER (Qsymia)
37 ! CAUTION! Long-term safety No Demonstrated long-term benefits in reducing diabetes, HTN, or cardiovascular risk.
38 Prior Medication Troubles Removed from the MarketNearly all previous prescription diet medications were removed from the market because of dangerous side effects after one or more years of routine use:amphetamines (cardiovascular toxicity, addictionfenfluramine (Pondimin: pulmonary hypertensiondexfenfluramine (Redux: pulmonary hypertension and cardiac valvulopathy)sibutramine (Meridia: cardiovascular toxicity)
39 Common Weight Loss Drugs EfficacyCommon potential side effectsSafetyorlistat(Xenical, Alli)Weight loss:2 kg greater than placebo after 4 years of therapyClinical outcomes:not documentedFlatus, greasy/loose stools or diarrhea, fecal incontinence, and abdominal crampsWorsened by increased dietary fat intakeContraindicated during pregnancy.Malabsorption of fat-soluble vitamins; concurrent use of multivitamin recommendedPatients on warfarin may need to decrease their warfarin dose.lorcaserin(Belviq)3.6 kg greater than placebo after 1 year of therapyNauseaHeadacheDizzinessAvoid use with other serotonergic agents (including most antidepressants, and some muscle relaxants).Concern over increased rate of cardiac valve disease and a possible increase in the risk of breast tumors.phentermine IR/ topiramate ER(Qsymia)kg greater than placebo after 2 years of therapyAnticholinergic symptoms (such as dry mouth and constipation)Irritability, anxiety, insomnia, and depressionIncreased heart rateContraindicated in hyperthyroidism, glaucoma, patients taking MAO inhibitors, pregnancy.Prescribe with a Risk Management Program for women of childbearing age, including monthly pregnancy test.Adjust dose in renal and hepatic impairment.Abuse potential.Discontinuation requires tapering to avoid seizures.
40 Weight Loss at 1 Year for locaserin and phentermine/topiramate
41 Average Retail Costs for Monthly Supplies of Equivalent Doses of Agents*
42 Looking Ahead 5,145 U.S. Adults Overweight or Obese with Diabetes Stopped earlyIntensive lifestyle modification aim3.9% greater weight loss5.3% greater partial or complete remission of DiabetesEnroll higher risk patients
43 !No over-the-counter weight loss supplement is effective for weight loss.Some products contain illegal stimulants or prescription medications. Ask patients about their use of these supplements and counsel them about their risks.
49 SOS: Reduction in Mortality and Cardiovascular Events
50 Bariatric Surgery: Patient Selection BMI ≥40 or BMI ≥35 with weight-related comorbidityPrior attempts at lifestyle modification were unsuccessfulNo contraindications such as binge-eating disorder, substance abuse, depression, psychosis, or anxiety disorderAcceptable surgery risk
51 Bariatric Surgery: Risks and Benefits UncertaintiesRisksWeight loss: rapid and sustainedReduction in HbA1c: elimination of diabetes in some patientsReduction in incidence of diabetesImprovement in other cardiovascular risk factors; hypertension, lipid profileImproved quality of lifeReduction in CV eventsReduction in all-cause mortalityLong-term clinical outcomes in less obese diabetic patients with BMI < 35Prevalence of weight regain over time in routine usePost-surgical complications including increased morbidity and mortality in the short termNutritional and electrolyte deficienciesGI symptoms
52 Tips for ManagementCalculate BMI for all patients. If BMI ≥ 25, discuss the health risks of being overweight or obese.Assess patient’s readiness to modify lifestyle and define success in terms of realistic goals.
53 Tips for ManagementThere is solid evidence that lifestyle interventions can reduce weight:Food intake is the key to weight loss.Exercise can help with weight management and improves health.Counseling in primary care actually works.
54 Tips for ManagementPrescription drugs have some efficacy data but safety concerns limit their use.Weight loss surgery is selected patients can lead to long-term weight loss and decreased risk of diabetes and mortality.