1. Physical Activity and Weight Management Julie Hagel, Pharm.D. September 24, 2003

2. U.S. Obesity Statistics 127 million adults: overweight or obese 2 nd leading cause of preventable death Responsible for 5-7% of annual national health care expenditure $117 billion in healthcare costs: includes direct and indirect costs

3. U.S. Obesity Statistics 43.6% women, 28.8% men attempt weight loss $30 billion spent annually on weight loss products

4. A need and an opportunity National Institutes of Health (NIH) notes that few healthcare providers play a role in management of obesity

5. Barrier or Benefit? No 3 rd -party coverage Who has time / space? Scope of practice? Costs Competition

6. Pathophysiology of Obesity Chronic medical condition Energy intake exceeds energy expenditure Factors involved Genetic and physiological Environmental Cultural and socioeconomic

7. Health Consequences of Obesity Hypertension Dyslipidemias Type 2 diabetes Cardiovascular disease Stroke Gallstones Degenerative joint disease Sleep apnea Respiratory disease Some types of cancer Hyperuricemia/gout

8. Getting started…… NHLBI Obesity Education Initiative Treatment of overweight or obese person is two step process Assessment Management Requires lifelong effort!

9. Assessment:Weight & Obesity Body Mass Index (BMI) Waist circumference Risk factors Readiness to lose weight

10. Assessment: BMI Body Mass Index: Wt in Kg Ht in meters squared or Weight in Lb x 703 Ht in inches squared BMI

11. BMI Ranges Normal: 18.5 to 24.9 Overweight: 25.0 to 29.9 Class I obesity: 30.0 to 34.9 Class II obesity: 35.0 to 39.9 Class III obesity: 40.0 or greater (extreme obesity)

12. Assessment: Waist Circumference Regardless of weight or calculated BMI, waist circumference marks increased risk Men: >40 inches Women: >35 inches Measure right above the upper hip bone at the top of the iliac crest with tape measure parallel to floor

13. Fat Distribution Apple Android shape, typically in males Fat store seen in abdomen Pear Gynecoid shape, typically in females Fat store seen in buttocks, hips, thighs

14. Assessment: Risk Factors Very high absolute risk Established coronary heart disease Other atherosclerotic diseases Type 2 diabetes Sleep apnea Increased risk Osteoarthritis, gallstones, stress incontinence, gynecological abnormalities

15. Assessment: Risk Factors High absolute risk if three or more of the following: Hypertension Cigarette smoking High LDL cholesterol Low HDL cholesterol Impaired fasting glucose Family history of early cardiovascular disease Age Male > 45 Female > 55

16. Assessment: Readiness Motivation Previous attempts Potential barriers Support system

17. Assessment: Tools Scale and Height measurement Calculator or Chart On-line calculator (Search engine: “BMI Calculator”) Tape measure

18. Weighing In Can be performed by patient for self- monitoring Recommend once weekly Scale in pharmacy Document patient progress

19. Body Fat Analysis Normal range Men: 12-15% (>25% indicator for obesity) Women: 20-25% (>30% indicator for obesity) Measuring techniques Hydrostatic weighing- mainly used in research Bioimpedance Near-infrared spectroscopy Body fat calipers

20. Management Goals Reduce and maintain body weight Prevent future weight gain Promote healthy lifestyle

21. Therapies Must be individualized Can include: Dietary therapy Physical activity Behavior therapy Combination of above Pharmacotherapy-eligible high risk patients Surgery- extreme obesity

22. It doesn’t happen overnight…. NHLBI guidelines Initial goal: 10 percent reduction in body weight Weight should be lost at rate of 1-2 pounds per week Consequences associated with losing weight too fast

23. Dietary Therapy Modify diet to achieve a decrease is caloric intake Must adopt long term nutritional adjustments Avoid very low calorie (<800 kcal /day) content diets Ensure that all daily recommended dietary allowances are met

24. Key Counseling Points Learn energy values of different foods Read and understand nutrition labels Monitor food consumption Reduce portion size Use dietary recall or food diary Use new habits with food purchasing and preparation

25. Physical Activity Has direct and indirect benefits Crucial for weight maintenance Evaluation before starting Recommendation is 60 minutes of moderate intensity most days of week Build activity level slowly over period of time

26. Key Counseling Points Keep track of physical activity and chart weekly progress Effects of increased activity add up; small increases = benefit Step counters may help motivate Reduce sedentary time Build physical activity into each day

27. Behavior Therapy Strategies to provide tools for overcoming barriers Consider attitude and past history Develop partnership with patient Set realistic goals

28. Behavior Modification Techniques Self-monitoring Stimulus control Stress management Relapse prevention Social support

29. Pharmacotherapy May be used as adjunctive therapy in BMI > 30 BMI > 27 + risk factors Continue diet, physical activity and behavior therapy

30. Pharmacologic Interventions Agents approved for short term use only Phentermine, diethylpropion, benzamphetamine Increase NE in brain Usually prescribed 8-12 weeks Contraindications: hypertension, advanced arteriosclerosis, cardiovascular disease, hyperthyroidism, glaucoma, agitated states, history of drug abuse, patients taking MAOI, tricyclic antidepressants

31. Pharmacologic Interventions Serotonergic Agents Inhibits reuptake serotonin + NE + dopamine in brain sibutramine (Meridia®); dosed once daily with or without food Induces feeling of satiety Adverse effects include dry mouth, constipation, headache, insomnia Contraindicated in cardiovascular disease, past history of stroke Caution: Hypertension- monitor BP early

32. Pharmacologic Interventions Pancreatic Lipase Inhibitor Blocks digestion of ~30% dietary fat orlistat (Xenical®); dosed 3 times daily during or up to 1 hour after meal (with fat) GI side effects Can minimize GI side effects with a low fat (<30% fat) high fiber diet

33. Pharmacologic Interventions OTC weight loss medications No FDA approved OTC ingredients Many products that claim to promote weight loss Ephedra Currently under FDA investigation Stimulant properties: potential to cause increased blood pressure, MI, stroke, seizures, especially in high doses

34. Surgery Reserved for patients in whom other treatments have failed AND who have clinically severe obesity

35. Now what do you do? Behavioral approaches: Develop a therapeutic relationship Determine patient readiness Partner with patient / facilitate “buddies” Goal: Increase energy expenditure through planned and unplanned physical activity and decrease energy intake

36. Three levels of management Level I Entry level Educate patients re: health risks of obesity and health benefits of increased physical activity and weight loss Distribute literature Offer Digi-Walkers®, exercise bands, etc. Get to know the weight loss drugs & community resources very well

37. Three levels of management Level II Add all or some of the following: Medical quality scale and height tape/bar Assess health risks: BMI and waist circumference Referral relationships w/ other providers Incorporate weight management strategies into disease management programs (e.g. HTN/DM) Documentation system Marketing

38. Three levels of management Level III Health-oriented weight loss and physical activity improvement as a focal point of pharmacy practice Pharmacist is facilitator, motivator, educator Dedicated assessment room and classroom Program fee: primarily private pay Small group or individual counseling Marketing of screenings and classes

39. Useful Resources www.nhlbi.nih.gov/about/oei/ Obesity Education Initiative www.obesity.org American Obesity Association www.d.umn.edu/student/loon/soc/phys/par- q.html www.d.umn.edu/student/loon/soc/phys/par- q.html Physical Activity Readiness Questionnaire (PAR-Q)

40. Conclusion Obesity is recognized as a disease Obesity and lack of physical activity present significant health risks Few providers are involved in weight management A screening and management program is a viable pharmacy practice option