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  1. 1. Principles of Weight Management by R.Daniel Braun,MD Indiana U. School of Medicine
  2. 2. Goals of Obesity Therapy <ul><li>Old goal: Reduction to “Ideal” Weight </li></ul><ul><li>Most significantly obese individuals can not achieve “Ideal” weight. </li></ul><ul><li>Most cannot maintain large weight loss. </li></ul><ul><li>Frustrating to patients and physicians </li></ul>
  3. 3. Goals of Obesity Therapy <ul><li>New Goal: Reduction to a HEALTHIER Body Weight </li></ul><ul><li>Weight loss of as little as 5-15% of initial weight improves many Obesity-related co-morbidities </li></ul><ul><li>Most patients can achieve and maintain weight losses of 10-15% of initial weight </li></ul>
  4. 4. Long Term Behavioral Rx Study Maximum Loss Loss last Treatment visit Perri 14% @ wk 20 13% @ wk 72 Viegener 9% @ wk 26 9% @ wk 52 Wadden 14% @ wk 52 12% @ wk 78 Wing 13% @ wk 26 10% @ wk 52
  5. 5. Long Term Pharmacotherapy Study Maximum Loss Loss last Treatment visit Andersen 15% @ wk 26 11% @ wk 52 Finer 12% @ wk 8 17% @ wk 34 14% @ wk 52 Guy-Grand 11% @ wk 34 10% @ wk 52 Weintraub 16% @ wk 34 15% @ wk 54 11% @ wk 156
  6. 6. Challenges in Weight Management <ul><li>To facilitate patient and provider acceptance of modest weight loss goals </li></ul><ul><li>To develop treatment models for long term care </li></ul><ul><li>To demonstrate the benefits of weight management </li></ul>
  7. 7. Definition of Overweight <ul><li>Body Mass Index wt(Kg)/ht(m) 2 or wt(lb)/ht(in) 2 X 70 3 </li></ul><ul><li>BMI < 27 = Normal weight BMI 27-30 = Overweight BMI 31-39 = Obese BMI >39 = Morbidly Obese </li></ul>
  8. 8. Scope of Problem <ul><li>300,000 Excess deaths per year due to Obesity </li></ul><ul><li>51 % of Population in U.S has BMI>30 </li></ul><ul><li>58% of Females in U.S. have BMI>30 </li></ul>
  9. 9. Phenotype of Obese 1. Family is more likely to be overweight. 2. Poorer fitness than the lean, and lesser tendency to exercise. 3. Age group at onset: infant, teen, or adult 4. Immigrants or those becoming westernized in their own natural surroundings tend to become overweight. 5. Many efforts and failures to lose weight. Many excuses for not being able to change habits or weight. 6. Overeating (binge eating) typically under stress.
  10. 10. Goals of Treatment <ul><li>Induce and maintain weight loss </li></ul><ul><li>Reduce obesity related co-morbidities </li></ul><ul><li>Help patients adopt a healthy lifestyle </li></ul><ul><li>Improve patient satisfaction with outcome. </li></ul>
  11. 11. Benefits of Weight Loss <ul><li>Decreased glucose </li></ul><ul><li>Decreased insulin </li></ul><ul><li>Decreased triglycerides </li></ul><ul><li>Decreased LDL Cholesterol </li></ul><ul><li>Decreased blood pressure </li></ul><ul><li>Decreased uric acid </li></ul><ul><li>Increased HDL Cholesterol </li></ul><ul><li>Improved quality of life </li></ul>
  12. 12. Phases of Treatment <ul><li>Patient evaluation </li></ul><ul><li>Treatment decision and selection </li></ul><ul><li>Goal setting </li></ul><ul><li>Induction of weight loss </li></ul><ul><li>Maintenance of weight loss </li></ul><ul><li>Long term weight management </li></ul>
  13. 13. Patient Evaluation <ul><li>Medical History and physical Ekg, blood chemistry panel, waist and hip circumferences </li></ul><ul><li>Behavioral Mood, social support, psychopathology Patient readiness, stress, time availability </li></ul>
  14. 14. Treatment Decision and Selection BMI Category Health Risked based on BMI <25 Minimal 25>27 Low 27<30 Moderate 30<35 High 35<40 Very High >40 Extremely High Presence of a co-morbid condition or other risk factor jumps patient to next level of risk based on BMI. Shapeup America
  15. 15. Treatment Decision and Selection Health Risk Treatment Options Minimal & Low Healthful eating &/or moderate deficit diet, Increased physical activity Lifestyle change Moderate All of above plus low calorie diet High & Very High All of above plus pharmacotherapy or very low calorie diet (VLCD) Extremely High All of above plus surgical intervention
  16. 16. Goal Setting Dream Weight What you would like to weigh. Happy Weight A weight you would be happy with. Acceptable Weight Less than above but “OK” Disappointed Less than current, but more than Weight above.
  17. 17. Goal Setting 60 women mean age 40 years, BMI of 36.3 Current Weight 99.1 kg Dream Weight 61.4 kg (-38%) Happy Weight 68 kg (-31%) Acceptable Weight 74 kg (-25%) Disappointed Weight 82 kg (-17%)
  18. 18. Goal Setting Weight Goal % Achieving Dream Weight 0% Happy Weight 9% Acceptable Weight 24% Disappointed Weight 20% Less than Disappointed 47% Foster et.al. J Consult Clin Psychol, 1996
  19. 19. Induction of Weight Loss <ul><li>Identify Components of Treatment (Diet, activity, lifestyle modification, Pharmacotherapy, etc. </li></ul><ul><li>Provide overview of course of initial treatment including duration, schedule of visits, and probable results </li></ul><ul><li>Identify treatment provider’s and patient’s responsibilities for behavior change </li></ul>
  20. 20. Maintenance of Weight Loss <ul><li>Break maintenance into “semesters” and schedule regular visits </li></ul><ul><li>Identify diet, activity, and life style goals for each visit </li></ul><ul><li>Increase social support and new activities </li></ul><ul><li>Provide “lapse” counseling as needed </li></ul>
  21. 21. Long-Term Weight Control <ul><li>Establish weight and health criteria and a schedule for monitoring them </li></ul><ul><li>Determine when treatment should be re-initiated and approach to be used </li></ul><ul><li>Alleviate patients shame and guilt concerning weight regain </li></ul>
  22. 22. Predictors of Weight Loss <ul><li>Body Weight </li></ul><ul><li>Resting Metabolic Rate </li></ul><ul><li>Self Efficacy (Says Yes I can do that) </li></ul><ul><li>Good Attendance </li></ul><ul><li>Early Weight Loss </li></ul>
  23. 23. Predictors of Greater Weight Loss <ul><li>Longer Treatment </li></ul><ul><li>Pharmacotherapy </li></ul><ul><li>Supervised Physical Activity </li></ul><ul><li>Lifestyle Modification </li></ul>
  24. 24. Characteristic of Weight Loss Maintainers <ul><li>Exercises Regularly </li></ul><ul><li>Monitors weight Regularly (Daily even) </li></ul><ul><li>Eats Low fat diet tailored to food preferences </li></ul><ul><li>Has problem focused coping skills </li></ul><ul><li>Monitors fat intake periodically (Food diary esp when weight starts up) </li></ul><ul><li>Takes medication on regular basis </li></ul>
  25. 25. Caloric Energy Balance <ul><li>Body weight remains same when: Caloric Intake = Caloric Expenditure </li></ul><ul><li>Intake (we all know about that </li></ul><ul><li>Expenditure 1.Resting Metabolic Rate=(60-70%) Expenditure 2.Thermic Effect of Food= (5-10%) Expenditure 3.Physical Activity = rest of Expenditure </li></ul>
  26. 26. Diet <ul><li>Careful Training in : Selection of lower fat foods Modified food guide pyramid Increase fruits & vegetables Lower fat preparation techniques Estimation of portion size </li></ul>
  27. 27. _diet <ul><li>Moderate deficit (- 500 Kcal/day) 1200-1500 for women & 1400-2000 for men </li></ul><ul><li>Low calorie (- 800-1200 Kcal/ day) </li></ul><ul><li>Very low calory diet (VLCD) (< 800 Kcal/ day) </li></ul>
  28. 28. Energy Deficit Calculation <ul><li>Calculate REE (Resting Energy Expenditure) REE = {9.99 * Wt.(Kg)} + {6.25 * Ht. (Cm.)} - {4.92 * Age} =Kcal/day </li></ul><ul><li>Multiply REE by activity factor (AF) AF = 1.6 for males and 1.5 for females </li></ul><ul><li>Subtract 500 from Result. This = recommended caloric intake and will result in loss of 1 pound per week. </li></ul>
  29. 29. Exercise <ul><li>Not enough by itself </li></ul><ul><li>Hard to Succeed without it </li></ul><ul><li>30 min/day (3-7 days/week) </li></ul>
  30. 30. Behavior Modification <ul><li>Identify barriers to changing eating and exercise patterns </li></ul><ul><li>Once identified, change and modify those barriers </li></ul><ul><li>Involves identifying reasons for inappropriate eating and exercise and changing them </li></ul>
  31. 31. Pharmacologic Management of Obesity <ul><li>Goal: To help obese patients achieve a reduction in food intake and a higher level of energy expenditure, not for 3 months or 3 years, but for a lifetime. </li></ul>
  32. 32. History of Obesity Pharmacotherapy <ul><li>1930’s Scolex </li></ul><ul><li>1950’s Amphetamines Sold by MD’s </li></ul><ul><li>1960’s Phenethylamines Amphetamine-like agents (Not addictive) </li></ul><ul><li>1970’s Drug abuse transformation Controlled Substances act </li></ul><ul><li>1980’s Market dried up (Stigma) </li></ul><ul><li>1990’s Introduction of New Agents Break three month barrier </li></ul>
  33. 33. Leptin <ul><li>Protein produced by the ob gene </li></ul><ul><li>Obese humans have higher concentrations than non obese counterparts NEJM 1996;334:292-295 </li></ul><ul><li>Phase I clinical trials began late 1996 </li></ul>
  34. 34. Sibutramine <ul><li>Developed as Antidepressant & Obesity Inhibits monoamine reuptake Lacks anticholinergic activity No diabetic problem exacerbation </li></ul><ul><li>Phase I & II trials Adv. Effects Insomnia,irritability, tachycardia HTN in Afro.-Amer. (3-4Torr in whites & 20Torr in Afro.-Amer. </li></ul>
  35. 35. Orlistat/Hydrolipistatin <ul><li>Potent gut irreversible lipase inhibitor Pancreatic lipase divides FFA from glycerol </li></ul><ul><li>Reduces triglyceride and cholesterol absorption Eliminated in feces </li></ul><ul><li>Lowers Cholesterol (4-11%) & LDL (5-10%) </li></ul><ul><li>Not dependant on amt fat or fiber ingested </li></ul><ul><li>120 mg TID [ac, during, or pc] </li></ul>
  36. 36. Cholecystokinin-8 Agonists <ul><li>Sulfated carboxy-terminal of cholecystokinin </li></ul><ul><li>CCK-8released in response to food intake </li></ul><ul><li>Generates satiety signal </li></ul><ul><li>CCK-8 is a peptide. Cannot be given orally or IV </li></ul><ul><li>Agonists block endogenous CCK-8 breakdown by tripeptidyl peptidase II (TPPII) </li></ul><ul><li>Duration of action too short for efficacy; looking for other analogues </li></ul>
  37. 37. Initial Weight Loss Response Predicts Long Term Response <ul><li>Those who lose 4# in 1st 4 weeks (78%) Mean weight loss = 22 # 60% lost 10% of initial weight </li></ul><ul><li>Those who do not lose 4# in 1st 4 weeks Mean weight loss = 6 # Only 10% lost 10% of initial weight </li></ul>
  38. 38. For Those Who Don’t Lose Weight <ul><li>Reassess: Understanding and compliance with diet. physical activity, and drug regimen Accuracy of weight recordings Possible Fluid retention (salt intake, etc) Changes in medical condition Motivation for change Social and personal stress Is the provider of health care the root of the problem ? </li></ul>
  39. 39. For Those Who Don’t Lose Weight and There is no Cause Except Noncompliance with Diet & Exercise <ul><li>Consider changing medication </li></ul><ul><li>consider referral to: Dietitian Behavioral counselor Exercise professional Weight Watchers </li></ul><ul><li>Reconsider goal: i.e. simple maintenance or a rest from weight loss efforts </li></ul><ul><li>Discuss surgical options if medically or psychologically indicated </li></ul>
  40. 40. Obesity Surgery <ul><li>Vertical Banded Gastroplasty 238 patients averaging 245% of IBW lost to average of 140% of IBW After 6 years averaged 150% of IBW </li></ul>Am.J Surg 1989;157:150-155