1. Medical Treatment Options for Obesity Jennifer DeBruler, M.D. Medical Director Advocate Weight Management Board Certified Internal Medicine October 2012

2. Goals for this presentation… Discuss low fat diet, Mediterranean diet, Paleo diet Discuss exercise recommendations for weight loss and mantainence Discuss medication options for treatment of obesity Provide an office tool to help patients loss weight

3. –Dietary Guideline for Americans 2010 US Department of Agriculture www.dietaryguidelines.gov –Decrease saturated fat –Consume >45% from carbohydrate –Once size fits all approach only fits a minority of the population Jeff S. Volek, PhD, RD

4. Re-Examining the Role of Carbohydrate The Low Fat Era The increase in calories during the obesity epidemic was largely due to carbohydrate intake. Jeff S. Volek, PhD, RD

5. Saturated Fat & the Diet Heart Hypothesis We know decreased SFA intake leads to increased carb intake which can lead to metabolic syndrome then diabetes and ultimately heart disease Is it true that increased SFA intake causes increased plasma LDL and heart disease? Jeff S. Volek, PhD, RD

6. What happens to a carbohydrate? Eat Carbohydrate, it goes into blood glucose and is broken down to glycogen and oxidized Too much carbohydrate leads to glycogen and excess carbohydrate fuels lipogenesis (fat synthesis)

7. Plasma Saturated Fat Predicts Heart disease –Br Med J 1982;285993-6 –Am J Epidemiolo. 1995;142: 469-76 –Nut Metab Crdiovasc Dis 2003;13:256-66 –Am Heart J 2008; 156:965-74 Predicts Diabetes –AJCN. 2003; 78:91-8 –Diabetologia. 2005; 48:1999-2005 –AJCN. 2007; 86:189-97 –AJCN. 2010; 92:1214-22

8. Dietary Saturated Fat and Heart Disease 3 Recent Meta-Analyses StudyPooled Cohort Studies Baseline Cohort (n) Follow- Up (yr) Interpretation Skeaff & Miller. Dietary fat and coronary heart disease: summary of evidence from prospective cohort and randomized controlled trials Ann Nutr Metab, 2009. 55(1-3): p. 173-201. 28280,0004-25No association between SFA intake & CHD events/death Jakobsen, et al., Major types of dietary fat and risk of coronary heart disease: a pooled analysis of 11 cohort studies. Am J Clin Nutr, 2009. 89(5): p. 1425-32. 11344,6964-10Increased SFA intake not associated w/CHD events Siri-Tarino et al., Meta-analysis of prospective cohort studies evaluating the association of saturated fat with cardiovascular disease. Am J Clin Nutr, 2010. 91 (3): p. 535- 46. 21347,7475-23No association b/t SFA intake & CVD, CHD or stroke

9. If you decrease SF, it matters what you replace it with. Replacing 5% of SFA with carbohydrates increase coronary events. It increases your relative risk of CAD Jakobsen et al. AJCN, Feb 2011

10. Conclusion When it comes of SFA, you are not what you eat Consumption of carbohydrate at levels that exceed a persons ability to directly oxidize them contributes to increased circulation SFA Instead of telling everyone to restrict dietary saturated fat a more rational and effective strategy would be to focus on ways to help people find their right level of carbohydrate For people with insulin resistance, a low carb lifestyle can have a profoundly beneficial effect on a metabolic risk factors including SFA Jeff S. Volek, PhD, RD

11. Mediterranean Diet Large quantities of minimally processed, fresh, plant-based foods (fruit, vegetables, whole grains, seeds and nuts) Olive oil is principal source of dietary fat Low consumption of red meat and dairy Red Wine in low to moderate amounts with meals 45% Carbohydrate Low glycemic load Minich DM, et al. Nutr Rev Vol 66(8): 429-444.

12. Mediterranean Diet Lyon Diet Heart Study Prospective secondary prevention in 605 subjects for 5 years Subjects randomized to –Mediterranean diet with 40% fat, 45% carbs –ADA Step 1 Diet with 25% fat, 60% carbs –De Lorgeril M. Circulation. 1999; 99: 779-785.

13. Mediterranean Diet Lyon Diet Heart Study Study halted after 27 months due to excess mortality in the AHA Step 1 Diet –Total mortality (cardiac + non-cardiac) 72% (p<0.0001) –Cardiovascular events (MI, CHF, PE) 47% (p<0.0001) –De Lorgeril M. Circulation. 1999; 99: 779-785.

14. Mediterranean Diet Lyon Diet Heart Study The Mediterranean diet dramatically reduced heart attack and overall mortality compared to the AHA diet No change in serum lipids, BP, BMI Key difference: Mediterranean diet modifies inflammation De Lorgeril M. Circulation. 1999; 99: 779-785.

15. Mediterranean Diet Lyon Diet Heart Study Mediterranean diet includes nutrients known to decrease inflammatory mediators (crp, IL-6, WBC) –Omega 3- EFA, DHA-EPA –Gamma Tocopherol –Flavenoids, coumarins anthyrocyanin Med. Diet excludes nutrients that increase inflammatory mediators –Omega 6-EFA, linoleate and arachidonate –Iron –Trans fat: increase CRP –Alpha tocopherol: reduces gamma tocopherol (Vit E)

16. Mediterranean Diet Great for moderately obese, 20-30 pounds overweight Not concerned with rapid weight loss For patients who want to use diet to prevent or treat co-morbids, –e.g. Metabolic syndrome, diabetes, CAD

17. The Paleo Diet Typical food in the Western Diet were virtually unknown in ancestral human diets –Breads, cereals, rice, and pasta –Dairy Products –Added Salt –Refined vegetable oil –Refined sugars, except honey –Processed Meats –Alcohol –Cordain et al. Am J Clin Nutr 2001;71:682-92

18. The Paleo Diet Eat like the cavemen eat –Fresh Veggies –Nuts/Seeds –Healthful Oils –Fresh fruits –Fish/seafood –Grass produced meats

19. The Paleo Diet Typical Hunter-Gatherer Diet –Animal food energy 55% Hunted animal 27.5% Fished animal 27.5% No processed meats No dairy food –Plant food energy 45% No cereal grains Minimally processed fresh fruits, veggies, seeds & nuts –No Processed Foods –Cordain et al. Am J Clin Nutr 2001;71:682-92

20. The Paleo Diet Nutrient differences between: –wild vs. cultivated plant food Smaller More fiber Less sugar Slightly greater minerals Vitamin content similar

21. The Paleo Diet Seems like a lot of cholesterol in this diet? Dietary cholesterol has a minimal influence on serum cholesterol. –Lowering dietary cholesterol from 491 mg (paleo) to 300mg (recommended) drops serum cholesterol by 4.5 mg/dl –Lowering dietary cholesterol from 491 mg (paleo) to 219 mg (food pyramid) drops serum cholesterol by 6 mg/dl –Cutting dietary cholesterol from 491mg to 219 mg would reduce a high cholesterol 240 to 234 or 2.5% –Schonfeld G et al. J Clin Invest 1982;69:1072-80

22. The Paleo Diet High protein diet is more effective than high carbohydrate diet in causing weight loss –After 6 mo – high protein/low fat group had lost average of 19.6 lbs –After 6 mo – high carb/low fat group had lost an average of 11.2 lbs Similar studies have replicated results –Baba NH et al. 1999 –Torbay N et al. 2002 –Johnston CS et al. 2002 –Parker B et al., 2002 –Weigle DS et al, Am J Clin Nutr 2005

23. Exercise Recommendations General Health Benefit –Moderate aerobic exercise 150 min/wk (about 30 minutes 5x/wk) + strength training Prevention of Weight Gain –150-250 minutes per week –150-300 minutes per week Prevention of Weight Regain –200-300 minutes per week –300-420 minutes per week –Donnelly JE. Med Sci Sports Exerc. 2009 –USDHHS. PA Guidelines for Americans. 2008

24. Medical Clearance for Physical Activity ACSM Guidelines for Risk Stratification –Men>45, women>55 w/2 or more risk factors –Risk factors include: FHx of MI in 1 st degree relative M<55, F<65 Smoking in last 6 mo Hypertension Abnormal lipids Impaired Fasting Glucose BMI 30 Sedentary Lifestyle –Plan to exercise at >60% of max, vigorous –Consider Stress testing –Thompson WR, Ed. ACSMs Guidelines for Exercise Testing & Prescription, 2010

25. Medications for Weight Loss Phenylethylamines Sympathomimetic effect Works at the hypothalamus and limbic system Appetite suppressant effect Meta-analysis of phentermine and diethylproprion –3.6 kg additional weight loss at 6 mo for phentermine –3 kg additional weight loss at 6 mo for diethylpropion –Li, A. Ann Intern Med. 2005.

26. Medication for Weight Loss Phenylethylamines Short term adjunct in a regimen of weight reduction involving lifestyle changes in management of adult obesity BMI 30 or 27 with comorbid condition Contraindication – advanced arteriosclerosis, CAD, mod/severe HTN, hyperthyroid, glaucoma, agitated states, history of known drug abuse, pregnancy

27. Medication for Weight Loss Phenylethylamines Adverse Effects –CV: palpitations, tachycardia, primary pulm HTN –CNS: restlessness, dizziness, insomnia, HA –GI: dry mouth, diarrhea, constipation –Endocrine: impotence, change in libido

28. Medication for Weight Loss Orlistat Gastric and pancreatic lipase inhibitor Inhibits uptake of up to 1/3 ingested fat Needs to be used in accordance with low-fat, calorie controlled diet.

29. Medication for Weight Loss Orlistat May be used long-term up 4 yrs for weight loss or for weight loss maintenance in adult obese patients Pediatric indication: 12-16 y/o obese adolescents Should be accompanied by vitamin supplementation Common SE: fecal soiling, dyspepsia, flatulence, vitamin malabsorbtion, elevated liver enzymes Rare SE: severe liver injury Contraindication: cholestasis, malabsorbtion syndrome, liver disease

30. Medication for Weight Loss Metformin Biguanide: reduces hepatic glucose production and improves insulin sensitivity Induces modest weight loss initially Improves fertility in PCOS patient Lost 8 kg more weight over 24 wks than placebo Lee A. Obes Res. 1998

31. Medication for Weight loss GLP-1 Agonists Exenatide, liraglutide Enhances glucose dependent insulin release Suppress inappropriate glucagon release Delays gastric emptying Reduction in food intake directly acting on hypothalamus

32. Medication for Weight Loss GLP-1 Agonist Great medication for DM treatment and weight loss Works synergistically with carbohydrate controlled diet Nausea common, usually self-limited Watch out for pancreatitis

33. Medication for Weight Loss Bupropion Dopamine and norepinephrine reuptake inhibitor Tx major depression, smoking cessation, ADHD Do not use in bulimic patients, may lower seizure threshold

34. Medication for Weight Loss Bupropion Works centrally as an appetite suppressant Only anti-depressant with consistent weight loss effect May blunt weight regain in smoking cessation

35. Medication for Weight Loss Phentermine & topiramate ER (Qsymia) –BMI 30 or 27 with comorbid –Synergistic with Phentermine Increased satiety through reduced GI motility Increased taste aversion Reduced calorie intake –SE: increased HR, paresthesias, metabolic acidosis –TBD when released

36. Medication for Weight Loss Phentermine & topiramate ER (Qsymia) –Caution: women of reproductive age Cleft palate in 1 st trimester Women must be on OCP Avoid with glaucoma Hyperthyroidism MAOIs Studies show 5-10 kg weight loss

37. Medication for Weight Loss Lorcaserin (Belviq) –Activates the seratonin 2C receptor –Works at centrally acting satiety receptors –Caution: Valvular HD, CHF, HTN Men with predisposition to erection more than 4 hrs (sickle cell, MM, Leukemia) or deformed penis –3.7% weight loss, 7kg.

38. Office Tool

39. Thank you