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  • Patient can only lose about 10-15% of their body weight. Weight is lost by restricted energy intake, fat cells shrink, reducing expression of leptin (product of the ob gene). Leptin levels fall, metabolic rate decreases, appetite increases, impedes further weight loss. Mouse gene; ob ob gene in adipocytes secretes leptin which is the adipocyte messenger to the brain. There may be mutations of the gene resulting in no production of leptin or a nonfunctioning leptin molecule. Leptin Increases with increased body weight. Possibly indicates leptin resistance? Hypothalamic leptin receptor produced by db gene. Mutations of db; leptin resistance?
  • Self-monitoring includes food diaries, exercise logs, weight/body composition scales Stimulus control includes eating only at the kitchen table w/o watching tv, keeping no snack foods in the house, laying out exercise clothes the night before.
  • Tension reduction techniques may include diaphragmatic breathing, progressive muscle relaxation, meditation.
  • CTobesity.ppt

    1. 1. What is the most common form of malnutrition in the United States? <ul><li>Obesity </li></ul>
    2. 2. What is the most common cause of increased mortality in obese individuals? <ul><li>Coronary artery disease </li></ul><ul><ul><li>Secondary to increased cardiac risk factors </li></ul></ul>
    3. 3. Obesity <ul><li>Strategies for Assessment and Management </li></ul><ul><ul><ul><ul><ul><li>Leanne M. Yanni, MD </li></ul></ul></ul></ul></ul>
    4. 4. A Definition of Obesity <ul><li>A pathologic state characterized by the accumulation of fat in excess of that necessary for optimal body function. </li></ul><ul><li>Primary Care Medicine </li></ul>Obesity is a Chronic Disease
    5. 5. The Four Elements <ul><li>Genetic predisposition </li></ul><ul><ul><li>ob gene and leptin secretion </li></ul></ul><ul><li>Access to calories </li></ul><ul><li>Excessive energy intake </li></ul><ul><li>Insufficient energy output </li></ul><ul><ul><li>Lack of exercise </li></ul></ul><ul><ul><li>Low metabolic rate </li></ul></ul>
    6. 7. Medical Factors <ul><li>Hypothyroidism </li></ul><ul><li>Cushing’s syndrome </li></ul><ul><li>Polycystic Ovarian Syndrome </li></ul><ul><ul><li>Insulin resistance, hirsutism, amenorrhea, polycystic ovaries </li></ul></ul><ul><li>Syndrome X </li></ul><ul><ul><li>Hypertension, hyperlipidemia, insulin resistance </li></ul></ul><ul><li>Kleine-Levin Syndrome </li></ul><ul><ul><li>Periodic hyperphagia and hypersomnia </li></ul></ul>
    7. 8. Metabolic Syndrome <ul><li>NCEP Guidelines </li></ul><ul><li>May 2001 </li></ul><ul><li>Lipid and nonlipid risk factors of metabolic origin </li></ul><ul><ul><li>Insulin Resistance </li></ul></ul><ul><li>Identify the metabolic syndrome </li></ul><ul><ul><li>To reduce underlying causes </li></ul></ul><ul><ul><ul><li>obesity/physical activity </li></ul></ul></ul><ul><ul><li>To treat associated risk factors </li></ul></ul>
    8. 9. Diagnosis with 3 or more of risk determinants <ul><li>Abdominal Obesity </li></ul><ul><li>Triglycerides </li></ul><ul><li>High-density lipoprotein </li></ul><ul><li>Blood pressure </li></ul><ul><li>Fasting glucose </li></ul><ul><li>Waist circumference </li></ul><ul><li>Above 150mg/dL </li></ul><ul><li>Men <40, women <50 </li></ul><ul><li>Above 130/85 </li></ul><ul><li>Above 110 </li></ul>
    9. 10. <ul><li>Fat people are frequently objects of public scorn and malicious ridicule. They are viewed as lacking self-esteem and being slovenly by nature, with insufficient willpower to curtail excessive eating. </li></ul><ul><ul><ul><ul><ul><li>Walter J. Pories </li></ul></ul></ul></ul></ul>
    10. 11. Two Steps for the Primary Care Physician <ul><li>Assessment </li></ul><ul><li>Management </li></ul><ul><ul><li>The 43 year old 5’6” and 248lb </li></ul></ul><ul><ul><li>Sedentary Female </li></ul></ul>
    11. 12. Assessment <ul><li>Eyeball Test </li></ul><ul><li>Body mass index </li></ul><ul><li>Waist circumference </li></ul><ul><li>History </li></ul><ul><li>Overall risk factors </li></ul><ul><li>Motivation for change </li></ul>
    12. 13. “ Eyeball Test”
    13. 14. Body Mass Index The new vital sign! <ul><li>Correlated with total body fat content </li></ul><ul><li>Not accurate in muscular individuals </li></ul><ul><li>Initial assessment and monitoring </li></ul><ul><li>BMI </li></ul><ul><ul><li>weight in lbs/(height in inches) 2 x 704 </li></ul></ul><ul><li>Example </li></ul><ul><ul><li>5’6” 248lb female </li></ul></ul><ul><ul><li>248lbs / (66inches) 2 x 704 = 40 </li></ul></ul>
    14. 15. BMI Chart
    15. 17. Waist Circumference <ul><li>Android obesity or “apple-shaped” </li></ul><ul><li>Higher risk for morbidity and mortality </li></ul><ul><li>High Risk </li></ul><ul><ul><li>Men >102 cm (>40 in) </li></ul></ul><ul><ul><li>Women > 88 cm (>35 in) </li></ul></ul><ul><li>Not accurate if BMI > 35 </li></ul>
    16. 18. History <ul><li>Age of onset of obesity </li></ul><ul><li>Associated circumstances </li></ul><ul><li>Highest and lowest adult weight </li></ul><ul><li>Past dieting attempts </li></ul><ul><li>Current dietary habits </li></ul><ul><li>Current exercise habits </li></ul><ul><li>Stressors </li></ul>
    17. 19. Overall Risk Assessment <ul><li>Current disease - Very high risk </li></ul><ul><ul><li>Cardiovascular disease </li></ul></ul><ul><ul><li>Type II Diabetes </li></ul></ul><ul><ul><li>Sleep apnea </li></ul></ul><ul><li>Comorbidities - Moderate risk </li></ul><ul><ul><li>GERD, OA, Gallstones </li></ul></ul><ul><li>Cardiovascular risk factors </li></ul>Cardiovascular Risk Age Family history of premature CAD Hypertension HDL < 40 Cigarette smoking
    18. 20. Motivation for Change <ul><li>Motivation for weight reduction </li></ul><ul><li>Support system </li></ul><ul><li>Understanding of the “disease” </li></ul><ul><li>Time available for intervention </li></ul><ul><li>Financial considerations </li></ul>
    19. 21. Goals of Management <ul><li>Prevent </li></ul><ul><li>Reduce </li></ul><ul><li>Maintain </li></ul>
    20. 22. Management Options <ul><li>Caloric restriction </li></ul><ul><li>Very low calorie diet (VLCD) </li></ul><ul><li>Behavioral modification </li></ul><ul><li>Exercise </li></ul><ul><li>Drug therapy </li></ul><ul><li>Surgery </li></ul>
    21. 23. Caloric Restriction: Fundamentals <ul><li>Must decrease total calories for weight loss </li></ul><ul><li>Total fat <30% of total calories </li></ul><ul><li>Reduce carbohydrates </li></ul>
    22. 24. Caloric Restriction for Weight Maintenance <ul><li>Calories to maintain weight </li></ul><ul><li>Men: 10-12 calories x weight in pounds </li></ul><ul><li>Women: 8-10 calories x weight in pounds </li></ul><ul><li>Example </li></ul><ul><ul><li>248 pound sedentary female </li></ul></ul><ul><ul><li>248 x 8 = 1984 calories </li></ul></ul>
    23. 25. Caloric Restriction: Weight loss <ul><li>Energy deficit </li></ul><ul><ul><li>500-1000 kcal per day </li></ul></ul><ul><ul><li>1-2 pounds per week </li></ul></ul><ul><li>Example </li></ul><ul><ul><li>1984 calories to maintain weight </li></ul></ul><ul><ul><li>1984 - 500 = 1484 </li></ul></ul><ul><ul><li>1484 calories per day to lose 1 pound per week </li></ul></ul>
    24. 26. Caloric Restriction: Goals <ul><li>Initial goal </li></ul><ul><ul><li>10% of baseline weight over 6-8 months </li></ul></ul><ul><ul><li>248lbs - (248lbs x .10) = 223lbs </li></ul></ul><ul><ul><li>248-223 = 25 lbs </li></ul></ul>
    25. 27. Caloric Restriction: Adjusted body weight <ul><li>Use if > 120% overweight </li></ul><ul><li>Men: (actual wt – IBW) x .38 + IBW </li></ul><ul><li>Women: (actual wt – IBW) x .32 + IBW </li></ul><ul><li>Example </li></ul><ul><ul><li>5’6” 248 pound female </li></ul></ul><ul><ul><li>Ideal body weight = 137lbs </li></ul></ul><ul><ul><li>(248 - 137) x .32 + 137 = 176lbs </li></ul></ul><ul><li>*Ideal body weight obtained from chart </li></ul>
    26. 28. Very low calorie diets <ul><li>“ Supplemented fasts” </li></ul><ul><li>Liquid formula diets 420-800cal/day </li></ul><ul><li>Protein-sparing modified fast </li></ul><ul><li>BMI >30, >50lbs to lose </li></ul><ul><li>Multi-disciplinary to maintain loss </li></ul><ul><ul><li>Nutrition, Behavior, Exercise </li></ul></ul><ul><li>Medical supervision </li></ul><ul><li>Contraindicated with disease </li></ul>
    27. 29. Behavioral Modification 5 Components <ul><li>A systemic method for modifying eating, exercise or other behaviors that may contribute to or maintain obesity. </li></ul><ul><li>Self-monitoring </li></ul><ul><ul><li>Observation and recording of target behaviors </li></ul></ul><ul><ul><li>Purpose: awareness of behaviors and influence </li></ul></ul><ul><ul><li>Research show improved treatment outcomes </li></ul></ul><ul><li>Stimulus control </li></ul><ul><ul><li>Identifying and modifying environmental clues with overeating and inactivity </li></ul></ul>
    28. 30. Behavioral Modification <ul><li>3. Cognitive changes </li></ul><ul><ul><li>Perceptions of themselves and their weight </li></ul></ul><ul><ul><li>Change internal dialogue that undermines ability to successfully lose weight </li></ul></ul><ul><ul><li>Many obese: poor self esteem and distorted body image </li></ul></ul><ul><li>4. Stress Management </li></ul><ul><ul><li>Stress is a predictor of relapse and overeating </li></ul></ul><ul><ul><li>Tension reduction techniques </li></ul></ul><ul><li>5. Social Support </li></ul><ul><ul><li>Including family in the treatment program, participation in community programs, involvement in outside social activities </li></ul></ul>
    29. 31. Does Behavioral Modification Work? <ul><li>Mild to moderate obesity (BMI<30) </li></ul><ul><li>Gradual and moderate weight loss </li></ul><ul><li>Average 1 pound/wk </li></ul><ul><li>Able to maintain 2/3 of weight lost </li></ul><ul><li>Multiple Behavioral Strategies improves outcome </li></ul><ul><li>Used by many weight loss programs </li></ul>
    30. 32. Exercise Strategies <ul><li>Cardiac evaluation if sedentary with risk factors </li></ul><ul><li>Begin with brisk walking 30-45minutes, 3-5x/wk </li></ul><ul><li>Reach 60-80% of age-adjusted max HR </li></ul><ul><ul><li>Formula: 200bpm-age </li></ul></ul><ul><li>Example </li></ul><ul><ul><li>43 year old 248 pound female </li></ul></ul><ul><ul><li>200bpm - 43 = 157bpm max HR </li></ul></ul><ul><ul><li>157 x .60 = 94bpm </li></ul></ul><ul><ul><li>157 x .80 = 126bpm </li></ul></ul><ul><ul><li>Goal: 94 to 126 beats/min </li></ul></ul>
    31. 33. Exercise Effects <ul><li>Can burn 150-225 calories per session </li></ul><ul><li>Modestly contributes to weight loss </li></ul><ul><li>Benefits </li></ul><ul><ul><li>Reduces all-cause mortality </li></ul></ul><ul><ul><li>Decreases abdominal fat </li></ul></ul><ul><ul><li>Increases cardiorespiratory fitness </li></ul></ul><ul><ul><li>Helps prevent weight regain </li></ul></ul>
    32. 34. Drug Therapy <ul><li>At least 6 months of lifestyle modification </li></ul><ul><li>Adjunct if BMI >30 without risk factors </li></ul><ul><li>Adjunct if BMI <30 and 2 comorbidities </li></ul>Agents Noradrenergic Serotonergic Combination Nutrient-partitioning
    33. 35. Noradrenergic Agents
    34. 36. Noradrenergic (amphetamine-like) <ul><li>Hypothalamic central-mediated pathway </li></ul><ul><li>Side effects </li></ul><ul><ul><li>Insomnia, nervousness, nausea, diarrhea, constipation </li></ul></ul><ul><li>Complications </li></ul><ul><ul><li>Increase BP (precipitate angina), arrhythmias, renal failure, psychotic episodes, death </li></ul></ul><ul><li>Moderate short-term weight-loss when combined with dietary program </li></ul>
    35. 37. Serotonergic Agents
    36. 38. Serotonergic <ul><li>Fenfluramine (Pondimin) </li></ul><ul><li>Dexfenfluramine (Redux) </li></ul><ul><li>Phentermine (Phen-Fen) + Fenfluramine </li></ul><ul><li>Off the market </li></ul><ul><ul><li>Primary Pulmonary HTN </li></ul></ul><ul><ul><li>Valvular Heart Disease </li></ul></ul>
    37. 39. Sibutramine (Meridia) <ul><li>Inhibits reuptake of NE, 5-HT, and Dopamine </li></ul><ul><li>Does not stimulate serotonin secretion </li></ul><ul><li>Effects </li></ul><ul><ul><li>Decrease appetite, increase satiety (anorectic) </li></ul></ul><ul><ul><li>Increase metabolic rate (thermogenic) </li></ul></ul><ul><li>Initial 10mg dose </li></ul><ul><ul><li>40% lost 5% of weight </li></ul></ul><ul><ul><li>20% lost 10% of weight </li></ul></ul><ul><li>Dose-dependent effect </li></ul><ul><li>Weight gain with drug discontinuation </li></ul>
    38. 40. Sibutramine (Meridia) <ul><li>Side effects </li></ul><ul><ul><li>Constipation, dry mouth, headache, insomnia </li></ul></ul><ul><ul><li>May increase blood pressure and pulse </li></ul></ul><ul><li>Contraindications </li></ul><ul><ul><li>CAD,CHF, arrhythmias, stroke </li></ul></ul><ul><ul><li>Severe hepatic impairment (cytochrome p450) </li></ul></ul><ul><ul><li>Use of other serotonergic medications </li></ul></ul><ul><ul><ul><li>SSRIs </li></ul></ul></ul><ul><ul><ul><li>5-HT agonists: lithium, meperidine, fentanyl, MAOIs, dextromethorphan </li></ul></ul></ul><ul><li>Ineffective for depression </li></ul>
    39. 41. Orlistat (Xenical) <ul><li>Gastrointestinal lipase inhibitor </li></ul><ul><ul><li>Decrease fat absorption </li></ul></ul><ul><ul><li>Inhibits pancreatic and gastric lipases </li></ul></ul><ul><ul><li>Unabsorbed triglycerides, cholesterol excreted in feces </li></ul></ul><ul><li>Blocks 30% of dietary fat </li></ul><ul><li>8.5% weight loss at 1 year (5.4% placebo) </li></ul>
    40. 42. Orlistat (Xenical) <ul><li>No systemic effects </li></ul><ul><ul><li>Steatorrhea, flatus, fecal incontinence, oily spotting </li></ul></ul><ul><ul><li>Mild reduction in Vitamin D, B-carotene </li></ul></ul><ul><li>Dose 120mg tid with meals </li></ul><ul><ul><li>Should take with MVI but not within 2 hours </li></ul></ul>
    41. 43. Leptin <ul><li>Exogenous leptin in phase I human trials </li></ul><ul><li>Subcutaneous or IV </li></ul><ul><li>May help prevent weight regain </li></ul><ul><li>Stimulant? </li></ul><ul><ul><li>Increases body temperature and physical activity in mice </li></ul></ul>
    42. 44. Metformin <ul><li>Adult onset diabetes </li></ul><ul><li>First line for overweight type II diabetic </li></ul><ul><li>Weight loss rather than weight gain </li></ul>
    43. 45. Surgery for Obesity <ul><li>Highly motivated </li></ul><ul><li>Well informed </li></ul><ul><li>Accept changes in lifestyle </li></ul>
    44. 46. Surgery <ul><li>Failed other methods of treatment </li></ul><ul><li>Multiple comorbidities </li></ul><ul><li>BMI > 40 </li></ul><ul><li>BMI 35-40 with severe life threatening complications </li></ul>
    45. 47. Surgery <ul><li>Lose 60-80% of excess weight </li></ul><ul><li>Maximum loss at 18 months to 2 years </li></ul><ul><li>Weight regain up to 5th year </li></ul><ul><li>Up to 20% regain all lost weight </li></ul><ul><li>1% mortality with experienced surgeons </li></ul>
    46. 48. Vertical Banded Gastroplasty (Gastric Stapling) <ul><li>30ml pouch </li></ul><ul><li>Amount of weight loss correlates to size of pouch </li></ul><ul><li>Larger pouch = less weight loss, fewer side effects </li></ul><ul><ul><li>70% maintain >20% weight loss at 5 years </li></ul></ul><ul><li>Not effective in “carbohydrate cravers” </li></ul>
    47. 50. Gastric Bypass <ul><li>Gastric pouch with small bowel limb </li></ul><ul><li>Longer limb = more weight loss, increased side effects </li></ul><ul><ul><li>70% loss at 2 years </li></ul></ul><ul><ul><li>58% at 5 years </li></ul></ul><ul><ul><li>55% at 10 years </li></ul></ul><ul><li>Non-responders to gastric stapling </li></ul><ul><li>Better for “carbohydrate cravers” </li></ul>
    48. 53. Take Home Points <ul><li>In addition to the “Eye Test” - use the BMI and waist circumference to assess risk, determine treatment plan, and set goals </li></ul><ul><li>Use multiple strategies for weight loss </li></ul><ul><li>A reduction in caloric intake of 500-1000calories per day will lose 1 lb per week </li></ul><ul><li>Start with moderate physical activity of 30 minutes 3-5 days per week </li></ul><ul><li>Consider drug treatment for BMI >30 or >27 with 2+ comorbidities </li></ul>
    49. 54. References <ul><li>Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: Executive Summary </li></ul><ul><li>National Heart Blood and Lung Institute </li></ul><ul><li>http://www.nhlbi.nih.gov/ </li></ul><ul><li>Electronic Textbook – Obesity Guidelines </li></ul><ul><li>Can download palm pilot version </li></ul>