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© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. * For Best Viewing: Open in Slide Show Mode Click on icon or From the View menu, select the Slide Show option * To help you as you prepare a talk, we have included the relevant text from ITC in the notes pages of each slide
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. in the clinic Obesity
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. What health problems are associated with overweight and obesity? Metabolic effects Prediabetes and type 2 diabetes, dyslipidemia Hypertension, CAD, stroke, CHD, AF, venous stasis, DVT, PE Cancer (colorectal, postmenopausal breast, endometrial) GERD, erosive gastritis, cholelithiasis, nonalcoholic FLD Nephrolithiasis, proteinuria, CKD Genitourinary PCOS, infertility, pregnancy complications (women) Benign prostatic hypertrophy, ED (men) Neurologic: Migraine, pseudotumor cerebri Greater severity of influenza; skin and soft tissue infections
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. Mechanical effects Obstructive sleep apnea Restrictive lung disease Osteoarthritis Low back pain Psychosocial effects Depression and anxiety Social stigmatization
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. What is the evidence that intentional weight loss improves health outcomes? Look AHEAD trial (n = 5145) Weight loss: 8.6% of starting weight at 1y, 6.15% at 4y Better mood, health-related QOL, physical & sexual function Less sleep apnea, less need for meds for CVD risk factors Improved reduced urinary incontinence Swedish Obese Subjects (SOS) study (n = 4047) Bariatric surgery for severe obesity Weight loss 15–25% of initial weight at 10y post-surgery 29% reduction in all-cause mortality
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. CLINICAL BOTTOM LINE: Health Consequences… Obesity increases risk for many chronic medical conditions Moderate to severe (BMI≥35): increases risk for mortality Modest weight loss (5-10% of initial weight): reduces burden of comorbid disease in patients with overweight and obesity Larger weight loss (15–30%): may reduce mortality
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. Should clinicians screen patients for overweight or obesity? U.S. Preventive Services Task Force recommends: Screen all adult patients for obesity and offer intensive, multi-component behavioral interventions or refer to programs that offer such interventions
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. How can patients prevent obesity? Read food labels and eat smaller portions Eat 5 servings fruits & vegetables daily + fiber (25 g/d) Exercise 45–60 minutes per day Reduce job stress Limit time spent commuting by car Get adequate sleep (6–9 h/night) Review concurrent medications See next slide: medications linked to weight gain Smoking cessation is a priority — even though it may lead to weight gain in 1 st year
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. Medications Associated With Weight Gain Glucocorticoids (prednisone) Insulin, sulfonylureas, thiazolidinediones, meglitinides 1 st -generation antipsychotics (thioridazine) 2 nd -generation antipsychotics (risperidone, olanzapine, clozapine, quetiapine) Neurologic and mood stabilizing agents (carbamazepine, gabapentin, lithium, valproate) Antihistamines (especially cyproheptadine) Antidepressants (paroxetine, citalopram, amitriptyline, nortriptyline, imipramine, mirtazapine) Hormonal agents (especially progestins) Beta-blockers (especially propranolol) Alpha-blockers (especially terazosin)
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. CLINICAL BOTTOM LINE: Screening and Prevention… Screen for obesity Refer for intensive treatment interventions Review medication lists: could changes reduce weight gain? Encourage behaviors that can prevent weight gain
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. How do clinicians diagnose obesity? Overweight: BMI 25–29.9 kg/m2 Class 1 obesity: BMI 30–34.9 kg/m2 Class 2 obesity: BMI 35–39.9 kg/m2 Class 3 obesity: BMI ≥40.0 kg/m2 BMI correlates with total adiposity, morbidity & mortality
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. When might the BMI value be misleading in terms of health risk? East and South Asians Increased diabetes risk at BMI=23 kg/m2 Asia-Oceania criteria different than U.S. Overweight 23.0–24.9 kg/m2; obese ≥25.0 kg/m2 African Americans Disease risk may be lower than whites at same BMI Women ≈12% higher body fat than men Older persons Lost muscle mass ups risk for obesity-associated conditions Elite athletes Elevated weight may be due to increased lean mass
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. When and how should clinicians measure waist circumference? When: measure waist circumference in patients who are Overweight or have class 1 obesity (Waist measurement doesn’t add additional risk information if BMI <25 kg/m2 or ≥35 kg/m2) How: measure over iliac crests in a horizontal plane after patient exhales following a normal breath Elevated waist circumference: ≥35in women; ≥40in men Central adiposity correlates well with visceral adiposity Risk: diabetes, hypertension, nonalcoholic fatty liver disease
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. What elements of the history and physical exam are important in patients with obesity? Rule out secondary causes of obesity (uncommon) TBI + hypothalamic injury: can cause weight gain Rare genetic syndromes: can cause obesity in adults Review patient’s medication list (slide 10) Include weight history at 5-y to 10-y intervals Life events associated with significant weight gain Previous weight loss attempts Successful efforts and reasons for recidivism Medical history and review of systems: focus on major comorbid conditions (slides 1 and 2)
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. Is a family history of obesity important? Family history of obesity suggests genetic component Particularly severe obesity Genetic polymorphisms more common than genetic abnormalities responsible for rare syndromes Genetics accounts for ≈40–70% of variability in BMI Genetic factors alone doesn’t explain U.S. rise in obesity Obesity and related diseases respond to lifestyle changes Even if genetic predisposition suspected
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. What laboratory tests or other evaluations should be done in patients with obesity? Routine laboratory studies Fasting glucose and/or hemoglobin A1c TSH, liver-associated enzymes, and fasting lipids Optional tests depend H&P exam and initial blood test EKG, ECHO Overnight sleep study Right upper quadrant ultrasound (fatty liver) Transvaginal ultrasound (ovarian cysts) Tests to assess HPA axis for suspected hypothalamic obesity (uncommon)
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. Use BMI + waist circumference to assess adiposity and body composition Bioelectrical impedance analysis: not more accurate CT or MRI: quantify central and visceral adiposity, but both expensive + CT exposes patient to radiation DEXA: accurate estimate of body composition Estimate energy requirements Resting metabolic rate + level of physical activity Harris-Benedict equation: weight, height, demographic factors, and level of physical activity
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. CLINICAL BOTTOM LINE: Diagnosis… Use BMI to diagnose obesity Combine with other patient characteristics to assess risk Measure waist circumference if BMI 25–34.9 kg/m2 Abdominal obesity increases health risk Focus history and physical exam on Weight-related conditions Weight trajectory Previous weight loss attempts Screen for diabetes, nonalcoholic fatty liver disease, thyroid dysfunction, dyslipidemia
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. How should clinicians counsel patients about their weight? Weight is a sensitive subject for many patients Say “weight” or “weight problem”, not “obesity” Ask “Could we talk about your weight today?” Let patients discuss their concerns If BMI >25: recommend lifestyle modifications If BMI >30 (≥27 with comorbid condition): consider weight loss medications If BMI ≥40 (>35 with comorbid condition): consider surgery 5-10% weight loss improves comorbid conditions Patients often think must be ≥25% to be successful
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. Try the 5A approach Assess (assess weight and risk factors) Advise (advise weight loss, personalize the recommendation to the patient) Agree (agree on a target for behavior change) Assist (assist with a referral) Arrange (arrange follow-up)
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. What are the lifestyle modifications for obesity? Diet ( 500-1000 kcal/d energy deficit, ≈1–2 lbs/wk weight loss) Physical activity Behavior modification Goal-setting, record-keeping Recommend high-intensity lifestyle modification program Weekly individual / group treatment sessions (16-26 weeks) Mean weight loss ≈6-9% of initial weight More effective than lower-intensity programs
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. What dietary strategies are used in lifestyle modification? Calorie restriction Easier to reduce food intake by 500-1000 kcal/d than increase energy expenditure by equivalent amount More weight loss via diet changes than physical activity Main diet types: low-fat, low-carb, meal-replacement diets Very-low-calorie diets not recommended Physical activity Important component of weight management Particularly important in maintaining weight loss in adults
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. Which diet is best for long-term weight loss? Any calorie reduction diet leads to weight loss No matter the macronutrient content of given diet Higher protein diets vs lower fat diets: similar weight loss Having good support aids sustained weight loss Calorie-deficit diet following federal dietary guidelines Initial choice for most patients 50–60% of calories from complex carbohydrate Emphasis on “healthy” foods (vegetables, nuts, fish)
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. What is the role of exercise in weight loss and maintenance? Regular exercise is critical for overall health More important to maintain weight loss than to reduce Adds 1-3 kg weight loss if combined with diet program Aerobic exercise + resistance training may have additional health benefits beyond either type alone
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. How can clinicians assess readiness for weight loss? Little evidence exists to guide clinicians Practical approach Patient monitors food intake + physical activity for ≥1 week Consensus: patients should be Committed to monitoring food intake Committed to physical activity Be free of untreated major depression Not in the middle of a major life event
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. What makes maintaining weight loss so difficult? What improves long-term results? Physiologic basis for regain After substantial loss: hunger-stimulating hormones remain elevated, satiety-mediating hormones remain depressed Obese persons who lose weight may burn fewer calories than never-obese persons with same lean body mass Behaviors associated with weight loss maintenance Participation in structured weight management program Physical activity ≥60 mins/d most days of the week Monitoring body weight frequently Eating a reduced-calorie diet Recording food intake periodically
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. When is pharmacotherapy indicated for treatment of obesity? When BMI ≥30 Or ≥27 with significant weight-related condition Screen carefully for contraindications to medications Combine with structured lifestyle modification program Doubles the weight loss achieved
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. Phentermine Approved for short-term use only ≈12 wks Sympathomimetic: ensure increases in BP, pulse don’t occur Phentermine-topiramate Lower dose than either monotherapy (reduces side effects) Category X in pregnancy (topiramate) Produces most weight loss (8–11% of initial weight) Lorcaserin 5HT2C receptor agonist: helps regulate appetite Avoids serotonin agonism in heart (“fen-phen” mechanism) Use caution in patients receiving SSRIs and SNRIs Orlistat Available prescription (120mg 3x/d) and OTC (60mg 3x/d) Reduces absorption of fat from GI tract Modest weight loss (3-4% > placebo, similar to lorcaserin)
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. Should weight loss medications be taken long-term? Patients tend to regain weight if medications stopped Long-term pharmacotherapy needed for most patients Consider treatment every other month, rather than continuously (no loss of efficacy) Don’t interpret plateau as medication no longer working Medications approved for chronic use have been subjected to rigorous safety testing
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. When is surgery indicated for treatment of obesity? Bariatric surgery: when BMI ≥40 Or ≥35 kg/m2 + ≥1 serious weight-related comorbid condition Or ≥30 + type 2 diabetes (laparoscopic gastric banding only) 3 most common surgeries: adjustable gastric banding, Roux-en-Y gastric bypass, sleeve gastrectomy Weight loss often ameliorates comorbid conditions Prior to surgery Try lifestyle modifications and pharmacotherapy Preop psychological evaluation for appropriateness Inform patient of potential risks and need for long-term monitoring of weight and nutritional status
© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. CLINICAL BOTTOM LINE: Treatment… Discuss weight with patients, using appropriate language Advise record-keeping on food intake, physical activity Suggest calorie-deficit diet Recognize physiologic factors play role in weight regain Pharmacotherapy Appropriate for selected patients Monitor for side effects Bariatric surgery Most effective and most high-risk treatment Improves and occasionally cures comorbid conditions May reduce mortality from excess weight
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