1. Pre-test Question 1: Choose the one correct answer 1.Obesity trends in children correlate with declines in milk consumption ** 2.Obesity trends in the mid-west states are lower than other regions 3.Appetite suppressants can help patients lose up to 30% of baseline body weight 4.Lower carb diets are inherently more effective than lower calorie diets

2. Pre-test Question 2: Choose the one correct answer 1.The South Beech Diet advocates a VLCD 2.Biologic pathways for diet intake usually involve regaining of weight to homestasis levels ** 3.Obesity trends in the US have slowed dramatically in the past decade 4.Pharmacotherapy for obesity is indicated for patients with a BMI of 25 or greater with co- morbid conditions

3. Obesity Epidemic in the US: Treatment Spectrum of the Adult Patient Grandview Medical Center Annual Family Practice Review and Reunion Saturday, February 21, 2015 Lawrence E. Mieczkowski, MD Center for Cardiometabolic Treatment & Education Kettering, Ohio

4. Objectives  Describe the growing prevalence and impact of obesity in adults as well as children  Understand the pathophysiology of obesity and its relationship to diabetes and other co-morbid condition  Obtain a better grasp of the lifestyle treatment options, benefits of pharmacologic therapy, and when to recommend gastric bypass surgery for patients with obesity

5. 2000 Obesity Trends* Among U.S. Adults BRFSS, 1990, 2000, 2010 (*BMI 30, or about 30 lbs. overweight for 5’4” person) 2010 1990 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

6. Generation XXL

7. Prevention of obesity in US adults must start with childhood  The lower the BMI of a child at kindergarten entrance, the lower the risk of obesity by 8 th grade.  An obese child at age 7 has a 47% risk of being obese at 8 th grade.  A Black or Hispanic girl born today has a 50% chance of becoming a Type II Diabetic.

8. Rapid Increases in Obesity Among U.S. Youth NHANES 1963-2008 National Health Examination Surveys II (ages 6-11) and III (ages 12-17). National Health and Nutrition Examination Surveys I, II, III and 1999-2008. www.cdc.gov/nchs/data/hestat/obesity_child_07_08/obesity_child_07_08.htm.

9. Beverage Intake Among Adolescents Aged 11-18, 1965-1996 SOURCE: Cavadini C et al. Arch Dis Child 2000;83:18-24 (based on USDA surveys) 0 200 400 600 800 1000 1200 1400 1600 1965197719891996 Per capita grams consumed per day BoysGirls (Soft drinks, diet soft drinks, and fruit drinks)

10. Active Transportation by Youth has Decreased Mode for Trips to School – National Personal Transportation Survey McDonald NC. Am J Prev Med 2007;32:509.

11. Increased TV Viewing Increases Childhood Obesity Prevalence  $1.6 billion/year spent on marketing of foods and beverages to youth $745 million on television  Television viewing associated with consumption of foods advertised on television  70% children 8-18 years and 30% children <3 year old have TVs in their rooms NHES: National Household Education Surveys. NLSY: National Longitudinal Survey of Youth.

12. Shifts in Dietary patterns in the United States  Relative prices of more healthful foods (fresh fruits and veggies) have increased faster than prices for less healthful foods (2 medium pizzas for $10.99).  Increased portion size: Biggie Fries, The Big Gulp  Increased consumption of processed foods typically higher in sodium  Increase in vending machines with pop schools and a la carte foods

14. Adult BMI Chart 5'4" Height Weight (lbs) 5'2 " 5'0" 5'10" 5'8" 5'6" 6'0" 6'2" 120130150160170180 190200210220230240250 140 260270280290300 6'4"

15. The Pathophysiology of Obesity Impacts Clinical Management 1. Aronne LJ et al. Clin Cornerstone. 2009;9:9-29. 2. Ochner CN et al. Physiol Behav. 2013;120:106-113. Clinical Treatment 1  Obesity is a chronic, progressive disease – Treatment must be long-term – Lifestyle modification alone may only be effective short term  For patients with difficulty achieving and maintaining weight loss, pharmacotherapy is recommended Pathophysiology  A complex, multifactorial disease 1  Biological changes: 2 – Resist weight loss – Predispose patients to weight regain

16. Why is Obesity a Difficult Disease to Treat?

18. Obesity and Mortality Risk Bray GA, et al. Diabetes Metab Rev. 1988;4:653-679.

19. Actual Causes of Death in the United States, 1990 Source: McGinnis JM, Foege WH. JAMA 1993;270:2207-12. 400,000 300,000 100,000 90,000 30,000 20,000 TobaccoDiet/ActivityAlcoholMicrobial agents Sexual behavior Illicit use of drugs

20. What are your patients doing about obesity? 29% of men and 44% of women trying to lose weight About 20% of report restricting calories or increasing physical activity

21. Goal  Learn how to work with obese patients in a manner that is effective, minimizes physician frustration, shows respect for the patient and maintains good communication

22. Case Study: CAD and Type II DM S: Ms. X is a 45 year old who was diagnosed with diabetes at the time of her admission for chest pain. Cath showed obstructive CAD. She had 2 coronary stents placed in her LAD. She is currently taking Metformin 2000 mg daily, Januvia 100 and 12 units of Lantus at night. She says that she checks her BS several times daily, and they are always in the upper 100s and lower 200s. She takes Lisinopril 10 mg, Atorvastatin 40 mg, ASA 81 mg, Clopidogrel 75 mg and Prozac 40 mg. She has lost 15 lbs. since her diagnosis, approximately 3 months ago, but has not lost any weight recently. Smokes 1ppd. O: Current weight is 235#. Height is 5’4”. BMI 40.5.

23.  Assuming you want to address her obesity, how would you proceed?

24. The Good Old 4-A Technique  ASK  ADVISE  ASSIST  ARRANGE

25. ASK Assess readiness to change “I would like to discuss your weight and its impact on your health” If ready, assess previous and current efforts and obstacles Weight Watchers, Jenny Craig, etc.

26. When asked, she acknowledges how her weight has been a life-long problem. She expresses her frustration that she has not been to lose weight or regains what she has lost. She is supposed to be on a 1500 calorie diet, but she has never really counted calories, so she is not sure what she is actually consuming. She is not able to identify any single foods that she eats frequently that she thinks are bad for her. She drinks 2% milk, and apparently has 3-4 glasses daily. She was unaware that this is actually high fat milk. She often eats only 1 or 2 meals daily. She would like to exercise but doesn’t find the time or energy to get out and walk.

27. Readiness to Change  Precontemplation (not interested)  Contemplation (6 months)  Preparation (within a month)  Action (working on it)  Maintenance

28. Obstacles  Unaware of current intake  Unaware of high calorie foods: ½ gallon whole milk=1200 cal  Doesn’t like exercise or dieting  Doesn’t feel poorly most days, giving her the feedback that nothing bad happens if she is not compliant.

29. ADVISE Give personalized advice:  her risks of overweight  benefits to her of controlling weight

30. ASSIST How to assist depends on Stage of Readiness to Change!!!

31. Assist (Readiness Stage: Preparation) Provide educational materials Test Motivation: Give diet diary (3-7 day) Decrease obstacles  Inform of support programs available in the community  Counsel or refer as needed for counseling

32. Treating Obesity Without Frustration  Assess readiness to change  Assess barriers to change  Use appropriate tools to assess motivation  Address obstacles creatively  Determine whether referral is appropriate and to whom patient should be referred  Frequent follow-up for patients in preparation, action, or maintenance

33. Pearls for Treating Kids  Self-monitoring is one of most helpful tools. Have them record physical activity and diet on daily basis, weight every 2-4 weeks. Review when patients come back and give praise where appropriate.  Work on stimulus control  Set limits on screen time (2 hrs/ day). No TV while eating.  Remove snacks from view. Put out fruits and vegetables.  Regular meal times including breakfast.  Fist size portions only.  Consider Metformin for puberty age children  Check for underlying thyroid dysfunction

34. Dietary and Pharmcologic Treatment for Obesity

35. AHA Guidelines for Healthy Diets  Protein: 15-20% of calories not excessive (50-100g/d) proportional to carbohydrate and fat  Carbohydrates: ~55% of calories Minimum of 100g/d  Fat: ~30% of calories, <10% sat fat  Protein foods should not contribute excess total fat, sat fat or cholesterol  Diet should provide adequate nutrients and support dietary compliance St. Jeor ST, etal. Circulation 104:1869-74, 2001.

36. A particular food or nutrient causes weight loss. Usually low in calories. May lead to protein calorie malnutrition leading to breakdown of lean muscle mass. Right for your type Beverly Hills Fit for Life Grapefruit Diet Cabbage diet Low calorie, generally levels of 1200 or less. Jenny Craig Weight Watchers Slim Fast Richard Simmons Limit carbohydrates; increase protein and sometimes fat. Atkin’s Diet South Beach Sugar Busters Protein Power Carbohydrate Addict’s diet DescriptionDiets

37. Categorization of Diets by CHO and Fat Dean Ornish Diet<10% Fat Pritikin Diet<15% Fat Weight Watchers, Jenny Craig, DASH diet, Food Guide Pyramid 55-60% CHO <30% Fat The Zone Diet40% CHO 30% Fat Carbohydrate Addicts Diet< 30% CHO Atkins (20-60g CHO), Protein Power (<60g CHO), VLCD-protein sparing modified fast < 20% CHO Riley RE. Clinics in Sports Medicine. 18(3):691-701, 1999.

38. High Protein: Effects  Diuresis (limited to 1 st week)  Mobilization of glycogen stores – cause weight loss of ~ 1 kg  Generation of ketones  Reductions in caloric content  Appetite suppression from ketosis  No studies have demonstrated advantages of ketotic diet Denke M. Am J Cardiology 88(1):59-61, 2001. St.Jeor ST, et al. Circulation 104:1869-1874, 2001.

39. High protein: Metabolic effects  Ketosis  dehydration, constipation and kidney stones  fatigue  ??? alter cognitive functioning  High Saturated Fat  Increases in LDL-C and TC  Low Fruits, Vegetables and Grains  Deficient in micronutrients (Vitamin B, calcium, K) and phytochemicals  Increases in serum uric acid Denke M. Am J Cardiology 88(1):59-61, 2001. St.Jeor ST, et al. Circulation 104:1869-1874, 2001. Westman EC. Et al. Am J Med. 113(1): 30-6, 2002.

41. South Beach Diet Phase 1: 2 weeks. Most should see a weight loss of between 8 – 13 pounds. Most restrictive. Phase 2: Until reach goal weight. Weight loss 1-2 pounds per week. Foods that were restricted in re-introduced into the diet. Phase 3: for life. Restrictions: avoid highly processed food that contains ‘bad’ carbs and ‘bad’ fats and try and stick to the food that contains the ‘good’ ones.

42. Structure  Studies suggest that adding structure to dietary recommendations improves weight loss in the behavioral treatment of obesity.  Structure reduces the effort required for adherence, and eliminates much of the decision making, temptation, and guesswork involved in making healthy food choices.

43. Weight Watchers  Practical advice  Group techniques  Food variety  Moderate protein, low fat  Limits refined sugars and EtOH  Stresses activity  Groups  Very structured  Weekly fees

44. Structured Meal Plans  Providing patients with structured meal plans and grocery lists produced just as great a weight loss at 6 months (13.7%) as did providing them with portion-controlled servings of food (13.5%).  The findings of this study indicate that specifying what foods and what amounts patients should eat improves weight loss, but that providing the food has no additional effect.

45. Protein – Sparing Modified Fast (Optifast, Medifast)  Calorie intake usually <900/d  Minimize loss of lean body mass by having 70- 90g/d protein  LCD = ~800 cal/d  VLCD = <800 cal/d  Usually liquid  Medical supervision needed

46. Maintenance  After losing 10% of their weight or more with 6 months of treatment, patients typically regain approximately one half of that weight within 1 year and return to their baseline weight within 5 years if they receive no further treatment

47. Pharmacotherapy Multiple national groups advocate pharmacotherapy with BMI > 30 and > 27 with co-morbid conditions  FDA-approved pharmacotherapy can be helpful adjunct for treatment of obesity  Consider if lifestyle changes do not promote weight loss after 6 months  Net average loss attributable to drugs 5-10%, usually within first 6 months

48. Appetite Suppressant Obesity Drugs  Noradrenergic ( Schedule IV, 12-week use )  Phentermine (Adipex)  Selective Serotonergic (Schedule IV, no time limits on use )  Lorcaserin (Belviq)  Combination (Schedule IV, no time limits on use)  Phentermine/Topiramate (Qysmia)  Combination ( Non schedule, no time limits on use )  Bupropion/Naltrexone (Contrave)

49. Conclusions  Childhood and adult obesity continues on with minimal improvement in past 4-5 years  Morbidity and costs of obesity will drain health care dollars and contribute to declining tax base  Dietary and lifestyle changes in childhood and adolescence may slow rate of obesity in adulthood  Structured lower-carb, lower calorie diets are effective on the short-term  Appetite suppressants proven effective in short- term and may be needed for long-term maintenance of weight loss