Clinical Diagnosis and Effective Management Strategies

What Do We Know About Obesity Prevalence continues to rise at alarming rate among adults, children and adolescents. Most common medical problem seen in primary care office. Is a major cause of preventable death. Causes over 40 medical problems affecting 9 organ systems. Morbidity and mortality rise with increasing BMI.

How Are We Doing as a Medical Profession? Obesity is under-diagnosed and under-treated

Identification & Counseling Summary of studies We are failing to adequately identify the overweight and mildly obese patient – missed opportunities for early prevention and treatment We are doing a better job identifying the moderately and severely obese patient presenting with co-morbid conditions, particularly type 2 diabetes, hypertension and hyperlipidemia

Percent of Patients Receiving PCP Advice by Obesity Classification Told Overweight: %2 (test for linear trend) – 16.5, p – 0.001 Gave Weight Loss Advise: %2 (test for linear trend) – 5.5, p – 0.019 Simkin-Silverman LR et al. Prev Med 2005;40:71-82.

Screening for Obesity in Adults The U.S. Preventive Services Task Force (USPSTF) recommends that clinicians screen all adult patients for obesity and offer intensive counseling and behavioral interventions to promote sustained weight loss for obese adults. Grade B Recommendation Ann Intern Med 2003;139:930-932.

Identification and Treatment of Obesity Clinical Inertia “Failure of the health care providers to initiate or intensify therapy when indicated” Obesity – failure to identify the condition Lack of education, training, and practice organization aimed at evaluating & treating obesity as a chronic illness Practice barriers Attitudes of futility, lack of perceived benefit and unrewarding Adapted from Phillips et al. Ann Intern Med 2001.

Barriers to Obesity Care “Counseling is unlikely to be effective without understanding the barriers that patients, providers, and systems face and applying targeted strategies to overcome those behaviors.” Stange et al. Am J Prev Med 2002.

Providing Obesity Care The Patient Knowledge Attitudes Expectations Demands Motivation The Clinician Time Reimbursement Training Interest Type of Visit The Practice Environment Payment Structure Type of Visit Alternative Demands Availability of Staff Clinician Delivery of Obesity Care Adapted from Jaen et al. J Fam Prac, 1994.

Developing a Chronic Care Model of Care (A Systems Approach) Put Prevention Into Practice AHRQ www.ahrq.gov Improving Chronic Illness Care http://improvingchroniccare.org Chronic care training manual ICIC Improving your practice manual Tools

Provision of Obesity Care Three factors necessary for physicians to intervene Adequate recognition of obesity as a medical problem Willingness to provide intervention Adequate skills or resources to do so Kristeller & Hoerr. Prev Med 1997.

Obesity Treatment Guidelines www.nhlbi.nih.gov www.naaso.org

Obesity Treatment Recommendations

Consists of 6 Action Steps The Office Visit The Evaluation Process Consists of 6 Action Steps Measure weight, height, waist circumference and record body mass index (BMI) Categorize obesity classification and risk Take a comprehensive history, physical exam, & lab tests for medical condition Assess need for treatment Broach the subject Assess readiness for treatment The Practical Guide, 2000.

Body Mass Index Chart Weight (lbs) Height 120 130 140 150 160 170 180 190 200 210 220 230 240 250 260 270 280 290 300 5’0” 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 5’2” 22 24 26 38 40 42 44 46 48 5’4” 21 28 34 36 50 52 5’6” 19 32 5’8” 18 20 30 5’10” 17 6’0” 16 6’2” 15 6’4” Height

BMI-Associated Disease Risk Classification BMI (kg/m2) Risk Underweight < 18.5 Increased Normal 18.5 – 24.9 Overweight 25.0 – 29.9 Obese I 30.0 – 34.9 High II 35.0 – 39.9 Very high III ≥ 40 Extremely high Additional risks: Large waist circumference (men > 40 in; women > 35 in) Poor aerobic fitness Specific races and ethnic groups Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults—The Evidence Report. Obes Res 1998;6(suppl 2).

Fatness, Fitness, and Cardiovascular Disease Mortality 8 Aerobically fit 7 Unfit 6 5 Relative Risk of CVD Mortality 4 3 2 1 Lean Normal Obese < 16.7% 16.7% – 24.9%  25% Body Fat Category (% Weight as Fat) Lee et al. Am J Clin Nutr 1999;69:373.

Action BMI Ranges for Asian Populations are Lower High to very high risk WHO expert consultation. Lancet 2004;363:157.

Systems Review Respiratory Cardiovascular Endocrine Neurologic Hypertension Congestive Heart Failure Cor Pulmonale Varicose Veins Pulmonary Embolism Coronary Artery Disease Neurologic Stroke Idiopathic intracranial hypertension Meralgia paresthetica Psychological Depression Body image disturbance Stigmatization Respiratory Dyspnea Obstructive Sleep Apnea Hypoventilation Syndrome Pickwickian Syndrome Asthma Endocrine Metabolic Syndrome Type 2 diabetes Dyslipidemia Polycystic ovarian syndrome (PCOS)/androgenicity Amenorrhea/infertility menstrual disorders Kushner and Roth. Endo Metab Clinics N Am 2003. 12

Systems Review Gastrointestinal Musculoskeletal Integument GERD Non-alcoholic fatty liver disease (NAFLD) Cholelithiasis Hernias Colon cancer Genitourinary Urinary stress incontinence Obesity-related glomerulopathy Kidney stones Hypogonadism (M) Breast and uterine cancer Kidney cancer Pregnancy complications Musculoskeletal Hyperuricemia and gout Immobility Osteoarthritis (knees/hips) Low back pain Carpal tunnel syndrome Integument Striae distensae (stretch marks) Stasis pigmentation of legs Cellulitis Acanthosis nigricans/skin tags Intertrigo, carbuncles 12

The Metabolic Syndrome Risk Factor Defining Level Abdominal Obesity Men Women Waist Circumference > 102 cm (> 40 in) > 88 cm (> 35 in) Triglycerides ≥ 150 mg/dL HDL Cholesterol < 40 mg/dL < 50 mg/dL Blood Pressure ≥ 130 / ≥ 85 mm Hg Fasting Glucose ≥ 110 mg/dL ATP III, Executive Summary, 2001.

Importance of Measuring Waist Circumference: BMI 25 – 29 Importance of Measuring Waist Circumference: BMI 25 – 29.9 (Overweight) Men (n = 3081) Women (n = 2606) Prevalence, % NI WC High WC Hypertension 23.0 44.8 12.3 37.5 Type 2 DM 2.7 10.6 1.6 10.0 Hyper-chol 17.2 26.2 19.4 35.2 High LDL-C 19.3 27.2 13.6 26.6 Low HDL-C 35.3 49.0 15.0 Hyper-TG 21.7 36.3 21.8 Metabolic Syndrome 11.3 29.0 3.6 16.3 Janssen et al. Arch Intern Med 2002;162:2074-9. NHANES III.

Importance of Measuring Waist Circumference: BMI 18.5 – 24.9 (Healthy) Men (n = 3081) Women (n = 2606) Prevalence, % NI WC High WC Hypertension 15.6 61.2 11.6 42.9 Type 2 DM 1.9 10.6 1.8 7.5 Hyper-chol 11.9 21.9 11.4 32.1 High LDL-C 14.0 29.3 8.8 23.9 Low HDL-C 15.0 6.7 13.1 Hyper-TG 9.4 12.4 4.5 20.7 Metabolic Syndrome 5.7 9.7 2.9 12.8 Janssen et al. Arch Intern Med 2002;162:2074-9. NHANES III.

Visceral Adiposity: The Critical Adipose Depot Subcutaneous Fat Abdominal Muscle Layer Intra-abdominal Fat

Disease Risk Relative to Normal Weight and Waist Circumference Classification of Overweight and Obesity by BMI, Waist Circumference and Associated Disease Risks Disease Risk Relative to Normal Weight and Waist Circumference BMI (kg/m2) Obesity Class Men (≤102 cm) ≤40 in Women (≤88 cm) ≤35 in Men (>102 cm) >40 in Women (>88 cm) >35 in Underweight < 18.5 -- Normal 18.5 – 24.9 Overweight 25.0 – 29.9 Increased High Obesity 30.0 – 34.9 I Very High 35.0 – 39.9 II Extreme obesity > 40 III Extremely High Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults—The Evidence Report. Obes Res 1998;6(suppl 2).

Percentage of Men with Metabolic Triad Percentage of Men with Metabolic Triad* Classified on Basis of Waist Girth and TG Level * Insulin small, dense LDL apo B waist < 90 90 < waist < 100 waist > 100 Lemieux et al. Circ 2000;102:179.

Metabolic Risk Identified by “Hypertriglyceridemic Waist” TG waist TG waist TG waist TG Insulin Resistance (HOMA) Waist = 95 cm M 88 cm F TG = 128 mg/dl Men Women Men Women Age 18-34 Age 55-74 Kahn and Valdez. AJCN 2003;78:928-34.

Risk of coronary heart disease High Low Subcutaneous adipose tissue ~ 5 – 10% weight loss Visceral adipose tissue ~ 30% visceral adipose tissue loss (diet, physical activity, pharmacotherapy) Lipid profile Deteriorated Improved Impaired Improved ↑ ↑ Insulin sensitivity Insulinemia Glycemia Abdominally obese (high waist measurement) Reduced obesity (low waist measurement) Susceptibility to thrombosis ↑ ↓ Inflammation markers ↑ ↓ Endothelial function Impaired Improved Risk of coronary heart disease High Low Despres J-P et al. BMJ 2001;322:716.

Assessing Drug-Induced Causes for Weight Gain Diabetes Treatments Insulin Sulfonylureas Thiazolidinediones Antihistamines (cyproheptadine) β- and alpha-1 adrenergic receptor blockers Chemotherapy agents Tamoxifen Psychiatric/Neuro Anti-psychotics Antidepressants Lithium AEDs Steroid Hormones Corticosteroids Progestational steroids HIV Protease inhibitors

Broaching the Subject: Words to Use “Are you concerned about your weight?” “What is hard about managing your weight?” “How does being overweight affect you?” “What can’t you do now that you would like to do if you weighed less?” “What kind of help do you need to manage your weight?”

How important is it for you to get your weight under control? Not important Very important 1 2 3 4 5 6 7 8 9 10 How confident are you to that you can get your weight under control? Not confident Very confident 1 2 3 4 5 6 7 8 9 10

Obesity Treatment Pyramid Surgery Pharmacotherapy Lifestyle Modification Diet Physical Activity BMI  40 35 30 25

A Guide to Selecting Treatment BMI Category Treatment 25 - 26.9 27 – 29.9 30 – 34.9 35 – 39.9 ≥ 40 Diet, physical activity, and behavior With co-morbidity + Pharmacotherapy Surgery The Practical Guide. 2000.

NHLBI Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults (1998) “There is strong evidence that combined interventions of a low calorie diet, increased physical activity, and behavior therapy provide the most successful therapy for weight loss and weight maintenance.”* *Evidence Category A

NHLBI Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults (1998) “Low calorie diets can reduce total body weight by an average of 8% over 3 to 12 months.”* *Evidence Category A

U.S. Preventive Services Task Force (USPSTF) Recommendations Fair to good evidence that high-intensity counseling—about diet, exercise, or both—together with behavioral interventions aimed at skill development, motivation, and support strategies produces modest, sustained weight loss (typically 3 to 5 kg for ≥ 1 year) in adults who are obese. Ann Intern Med 2003;139:930-932.

Pharmacotherapy Indicated as an adjunct to diet and physical activity for patients with a BMI ≥ 30 or ≥ 27 who also have concomitant obesity-related risk factors or diseases Agents Phentermine (1973): norepinephrine releasing agent Sibutramine (1997): serotonin norepinephrine reuptake inhibitor (SNRI) Orlistat (1999): gastrointestinal lipase inhibitor

Additive Effects of Behavior and Meal Replacement Therapy With Pharmacotherapy for Obesity Medication alone 5 Medication and behavior modification 10 * Weight Loss (%) 15 * Medication, behavior modification and meal replacements *P < 0.05 vs medication alone 20 2 4 6 8 10 12 Time (months) Wadden et al. Arch Intern Med 2001;161:218.

NHLBI Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults (1998) “Evidence Statement: Appropriate weight loss drugs can augment diet, physical activity and behavior therapy in weight loss.”* *Evidence Category B

NHLBI Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults (1998) “Evidence Statement: Gastrointestinal surgery can result in substantial weight loss, and therefore is an available weight loss option for well-informed and motivated patients with a BMI ≥ 40 or ≥ 35, who have comorbid conditions and acceptable operative risks.”* *Evidence Category B

Update: Bariatric Surgery Currently Popular Procedures Vertical Banded Gastroplasty Biliopancreatic Diversion with Duodenal Switch Gastric Bypass LapBandTM Restriction Malabsorption

Efficacy Outcomes for Weight Reduction Surgeries All Surgeries Mean Change Absolute wt loss (kg) 39.7 kg BMI decreased 14.2 Initial wt loss (%) 32.6% Procedure Initial Wt Loss (%) Gastroplasty 24.3% RYGB 34.9% BPD 39.0% RYGB = roux-en-y gastric bypass; BPD = biliopancreatic diversion Buchwald et al. JAMA 2004;292:1724.

Efficacy for Improvement in Obesity-Related Conditions Completely Resolved 76.8% 70% 61.7% 85.7% Resolved or Improved 86% ----- 78.5% 83.6% Disease Diabetes Hyperlipidemia Hypertension Obstructive Sleep Apnea Buchwald et al. JAMA 2004;292:1724

Conclusion Obesity is currently under-recognized and under-treated. Physicians need to identify and evaluate the overweight and obese patient at an earlier stage of development Screening begins by measuring BMI, waist circumference and identifying co-morbidities Treatment always includes lifestyle modification. Consideration for pharmacotherapy and surgery is based upon the individual patient