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Obesity Treatment: What Is a “Staged Approach” & What Does it Mean for Clinicians? Nancy F. Krebs, MD, MS University of Colorado Denver School of Medicine.

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Presentation on theme: "Obesity Treatment: What Is a “Staged Approach” & What Does it Mean for Clinicians? Nancy F. Krebs, MD, MS University of Colorado Denver School of Medicine."— Presentation transcript:

1 Obesity Treatment: What Is a “Staged Approach” & What Does it Mean for Clinicians? Nancy F. Krebs, MD, MS University of Colorado Denver School of Medicine Department of Pediatrics American Academy of Pediatrics: NCE09

2 Conflict of Interest Disclosure u Nothing to declare

3 Objectives u Describe recommendations of Expert Committee –Terminology –Definitions & categorization of severity –“Staged Approach” to treatment u Outcomes of aggressive dietary treatments u Realistic expectations/approaches

4 2007 Expert Committee Recommendations on Childhood & Adolescent Overweight & Obesity u Sponsors: AMA, CDC, HRSA u 16 organizations represented on EC: AAP, ADA, APSA, NAASO, NMA, et al u 3 Writing Groups/Sections: –Assessment –Prevention –Treatment u Evidence-based reviews u Summary: Sarah Barlow, MD

5 Expert Committee Recommendations ‘07 u Terminology u Diet and physical activity assessment, prevention and treatment of obesity u Staged approach to treatment, tailored to severity & age

6 Terminology & Definitions

7 “Overweight” “Obese” Changing Language & Definitions 2007 Expert Committee: “Overweight” - 85-95th BMI % for age “Obese” - > 95th BMI % for age No change in cut-points  no change in prevalence

8 Rationale for Change in Terminology u Obesity: excess adiposity u Overweight denotes high LBM or adiposity, more appropriate for 85-95 th % BMI range u AROW & OW terminology misunderstood & frequently mis-used by parents & providers u Continuity with adult BMI cut-points u [Stigmatization legitimate concern]: different language for patients/families (excess weight, high BMI etc)

9 Definitions: New Category

10 Trends in Childhood Overweight: Increasing Severity u Onset overweight < 8 yr & persisting into adulthood  adult BMI 41 u Childhood onset of overweight may account for disproportionate burden of severe adult obesity (BMI > 40) US Children Increased skewness at upper end of BMI distribution (US: 4% > 99th%) Greatest risk for adverse health outcomes at highest BMI Flegal & Troiano, ‘00

11 “Obese” Characterizing “Severe Obesity” > 95% = “Obese” 97 th % BMI highest on chart (BMI > 40 – bariatric surgery) (BMI 40)

12 Characterizing Severe Obesity BMI ≥ 99% (~ 3 Z)… Strongly associated w/ co-morbidities Excess adiposity Persistence Influence therapy “Severe Obesity” (BMI ≥ 99%) (BMI 40)

13 Staged Approach to Obesity Treatment

14 WHO? Single Approach Unlikely to be Ideal 4 yo, BMI=95%2 yo, BMI > 99%16 yo, BMI > 40

15 Treatment Overview: Goals u Behavioral goals and parenting skills u Self esteem and self efficacy u BMI velocity, weight loss targets & BMI % u Reduce co-morbidities

16 Treatment Overview: Staged Approach u Prevention Plus u Structured Weight Management u Comprehensive, Multidisciplinary Intervention u Tertiary Care Intervention

17 Stage 1: “Prevention Plus” u Family visits with physician/health care professional u Lifestyle/behavioral recommendations u Motivational interviewing – negotiate change; involve pts in decision making u Small changes, specific, lifestyle targets for  u Setting: Primary Care “If no improvement after 3-6 mo, advance to Stage 2”

18 Stage 1: “Prevention Plus” u Everyone starts here u Lifestyle changes: Diet + Physical Activity u Evidence: – Sugar sweetened beverages – Eating out – (excess portion sizes) – Reduce sedentary time (screen) u Jointly set the agenda u Follow-up – 1-2 mo; progressive Rx as needed

19 Stage 2: “Structured Weight Management” u Stage 1 rec’s + more structure & support u Individual or group follow-up u ± visits with a dietitian, exercise therapist or counselor u ↑ monitoring (pt/family, provider), goal setting and rewards u Frequency: monthly or individualized per family needs, risk factors u Setting: Primary care +, schools/community? “If no improvement after 3-6 mo, pt should advance to Stage 3”

20 Stage 3: “Comprehensive, Multidisciplinary” u ↑ intensity, frequency, support u Structured behavioral program, diet & PA goals; more prescriptive u Multidisciplinary obesity care team: –Behaviorist, dietitian, exercise specialist –MD – assess/Rx co-morbidities u ↑ Frequency: e.g. weekly group sessions for 8-12 weeks with follow up u Setting: ? Schools, Community, Clinical

21 Stage 4: “Tertiary Care Intervention” u Who: BMI > 95% w/ signif. co-morbidities, w/o success in Stages 1-3, or BMI > 99% u Multi-disciplinary team, subspecialists –Identify, manage co-morbidities u Structured interventions: –Medications - sibutramine, orlistat –Structured diets: High Protein / Low Carb; very low calorie –Physiotherapy –Weight control surgery - gastric bypass, banding u Setting: Tertiary care referral centers; ?in-patient

22 Severe Obesity: How bad?

23 Bogalusa Heart Study u Cross-sectional (10,099) & longitudinal data (2,392) - children & adolescents u Compared accuracy of BMI cut-points for: –# adverse risk factors –Excess adiposity –Risk for adult obesity [Freedman et al, J Peds, 2007]

24 Prevalence of multiple risk factors according to BMI percentile No. Risk Factors BMI%≥1 ≥2 ≥3 ≥4 < 2525510 85-94 a 511951 ≥ 95 b 7039185 99 c 84593311 % w/ excess adiposity: a 13%, b 65%, c 94% Obesity in Adults:100% 99P ; 88% 99P BMI ≥ 35 Freedman et al, J Peds, 2007

25 How common? u US: BMI ≥ 97 th % 2005-2006, 2-19 yr: – Overall: 11.3% – White: 9.6 – Blacks 15.9 – Mex-Amer 15.5(Ogden CL, JAMA, 2008) u Denver Children’s Hospital in-pt admissions, ‘07: – BMI > 40:2.3% – BMI ≥ 99 th %4.3% (ED: 12%)

26 Implications for Treatment Stage 4: Structured interventions(Medications) Structured Diets (Physiotherapy)(Surgery)

27 Diet: Intensive Approaches u High Protein/Low Carbohydrate –Used historically for severe obesity –Aka “Protein Sparing Modified Fast” – Very low calorie (< 1000 kcal/d) u Studies without comparison group u Concerns about safety u Limited long-term follow-up

28 Rationale for “Low Carb” – Protein [Sparing] Modified Fast u High protein (& low carb) proposed to minimize loss of lean body mass w/ weight loss u Satiety ± euphoria u Better metabolic tolerance in face of insulin resistance? [CHO  insulin   “fat burning,”  hypoglycemia] u Faster weight loss – “jump start” u Unrestricted in calories; restricted in choices

29 Low Carb Diet - Adolescents Methods: u Randomized, nonblinded study x 12 wk u 16 – low carb (20  40 g/d); 14 – low fat (< 30%) u Overweight (BMI > 95 th %); mean BMI 35 u Outcomes: weight, lipids Sondike et al, J Peds, 2003

30 Low Carb Diet - Adolescents Results after 12 wk intervention: u Low Carb lost > 2x more weight: - 9.9 vs - 4.1 kg (p < 0.05) u Dietary Intake (subgroup): LC: 1830 kcalLF: 1100 (p=0.03) u Lipids: LC:  TG (p=0.07) LF:  LDL (p=0.01) Sondike et al, J Peds, 2003

31 High Protein/Low Carb Diet: Denver Adolescents u Severely overweight (  175% IBW; BMI ~ 40) u Hi protein/low carb (HPLC) vs Low Fat (LF) diet –HPLC: CHO 20 g/d (ketones x BID) u Monitor weight, lipids, GTT, body composition u Intervention x 12 wk; f/u at 24 & 36 wk u n = 46: HPLC 24; LF 22 Krebs et al, submitted, 2009

32 Low Carb Diet – Denver Adolescents u Weight: Low Carb lost more weight - 9.0 kg vs - 5.6 kg (p < 0.06) u Body composition: both lost fat; HPLC not protein sparing u Lipids: improvements for both groups, no difference by diet, except ↓ TG HPLC u CHO metabolism: both groups improved u No adverse effects of HPLC Krebs et al, submitted, 2009

33 “Family Based Treatment” Severe Obesity u 192, 8-12 yr olds, avg BMI 99.2% u Randomized to intervention vs usual care u 0-6 mo –Family based, behavioral weight control –20 group meetings »adults & children separately »joint coaching for self monitoring + weekly goal setting u 6-12 mo: 6 “booster sessions” (3 grp + 3 phone) u 12-18 mo: no contact [Kalarchian, Pediatrics, 2009]

34 “Family Based Treatment” Intervention: u Stoplight Eating Plan + daily energy range u Behavioral strategies: ↑ PA, ↓ sedentary u Self monitoring, environmental changes, goal setting, stimulus control, rewards u Adults: set goals & model healthy changes Usual care: u 2 nutrition consultations re Stoplight Eating Plan Kalarchian, Pediatrics, 2009

35 “Family Based Treatment”- Results u 7.6% vs 0.66% decrease in % overweight at 6 mo u Weight change 6 mo : 1.56 kg vs 4.76 (p < 0.001) u BMI change: –6 mo: -0.68 vs + 0. 54 (p < 0.001) –12 mo: + 0.48 vs 1.09 (p = 0.11) –18 mo: +1.50 vs 1.72 (n.s.) u Differences in weight n.s. at 12 & 18 mo u Modest significant improvements in medical outcomes Kalarchian, Pediatrics, 2009

36 Comparison: HPLC vs Family Behavioral u Weight at 6 mo for Treatment Groups –HPLC: - 6.3 kg (-9 kg at 3 mo) –FB: +1.56 u BMI after intervention: – HPLC: - 3.6 (3 mo) – FB: -0.68 (6 mo) FB: Kalarchian et al, Pediatrics, ’09 HPLC: Krebs et al, submitted, ‘09

37 Treatment for Severely Obese u More potent intervention (e.g. HPLC)  greater weight loss & BMI u Both interventions w/ relapse at follow-up u [Severe] obesity is a chronic condition & requires ongoing support/treatment

38 “HPLC Plus” u For severely obese w/ medical or social urgency u In-patient hospitalization x 2-4 weeks –HPLC - BiPAP optimization –PT x bid- Medical mgt –Pt education- Family education/behav mgt –Improved co-morbidities u Regular f/u in out-pt weight mgt clinic u Continued weight loss, ↓ co-morbidities Krebs et al, unpublished

39 Staged Approach: Risks Differ, Interventions Differ, Outcomes Differ  95 th % > 99 th % 85-95 th %

40 Summary: u Expert Committee Recommendations: – Routine assessment of BMI for age – Categorize risk u Match risk w/ intervention u Level 4: consider your setting, options/resources u Potential for better outcomes if more realistic approach

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