Dr. Paola Mansilla-Letelier, MD

1. OBESITPAOLA MANSILLA LETELIER, MD
ENDOCRINOLOGIST
THYROID AND ENDOCRINE CENTER

2. TEXT
LEARNING OBJECTIVES
▸Apply counseling strategies to promote behavior change in
patients with obesity
▸Learn about new guidelines for management of Obesity
▸Select adequate obesity medications taking into account
patient’s Comorbidities

3. CLINICIAN ROLE IN WEIGHT LOSS

4. OBESITY
DEFINITIONS
▸Obesity: Body Mass Index (BMI) of 30 kg/m2 or higher.
▸Body Mass Index (BMI): A measure of an adult’s weight in
relation to his or her height, calculated by using the adult’s
weight in kilograms divided by the square of his or her height
in meters.

5. OBESITY CLASSIFICATION

6. OBESITY
OBESITY PREVALENCE MAPS
▸Adult obesity prevalence by state and territory using self-reported information from the Behavioral
Risk Factor Surveillance System.
▸Obesity is common, serious, and costly
▸The prevalence of obesity was 39.8% and affected about 93.3 million of US adults in 2015~2016.
▸Obesity-related conditions include heart disease, stroke, type 2 diabetes and certain types of
cancer that are some of the leading causes of preventable, premature death. [Read
guidelinesExternal
]
▸The estimated annual medical cost of obesity in the United States was $147 billion in 2008 US
dollars; the medical cost for people who have obesity was $1,429 higher than those of normal
weight
CDC National Center for Health Statistics (NCHS) data briefCdc-pdf
PDF-603KB

7. TEXT
OBESITY
▸Hispanics (47.0%) and non-Hispanic blacks (46.8%) had the
highest age-adjusted prevalence of obesity, followed by non-
Hispanic whites (37.9%) and non-Hispanic Asians (12.7%).
▸The prevalence of obesity was 35.7% among young adults
aged 20 to 39 years, 42.8% among middle-aged adults aged
40 to 59 years, and 41.0% among older adults aged 60 and
older.

8. Prevalence¶ of Self-Reported Obesity Among U.S. Adults by State
and Territory, BRFSS, 2011
*Sample size <50 or the relative standard error (dividing the standard error by the prevalence) ≥ 30%.
¶ Prevalence estimates reflect BRFSS methodological changes started in 2011. These estimates should
not be
compared to prevalence estimates before 2011.

9. Prevalence¶ of Self-Reported Obesity Among U.S. Adults by
State and Territory, BRFSS, 2012
*Sample size <50 or the relative standard error (dividing the standard error by the prevalence) ≥ 30%.
¶ Prevalence estimates reflect BRFSS methodological changes started in 2011. These estimates should
not be
compared to prevalence estimates before 2011.

10. Prevalence¶ of Self-Reported Obesity Among U.S. Adults by
State and Territory, BRFSS, 2013
*Sample size <50 or the relative standard error (dividing the standard error by the prevalence) ≥ 30%.
¶ Prevalence estimates reflect BRFSS methodological changes started in 2011. These estimates should
not be
compared to prevalence estimates before 2011.

11. Prevalence¶ of Self-Reported Obesity Among U.S. Adults by State
and Territory, BRFSS, 2014
*Sample size <50 or the relative standard error (dividing the standard error by the prevalence) ≥ 30%.
¶ Prevalence estimates reflect BRFSS methodological changes started in 2011. These estimates should
not be
compared to prevalence estimates before 2011.

12. Prevalence¶ of Self-Reported Obesity Among U.S. Adults by
State and Territory, BRFSS, 2015
*Sample size <50 or the relative standard error (dividing the standard error by the prevalence) ≥ 30%.
¶ Prevalence estimates reflect BRFSS methodological changes started in 2011. These estimates should
not be
compared to prevalence estimates before 2011.

13. Prevalence¶ of Self-Reported Obesity Among U.S. Adults
by State and Territory, BRFSS, 2016
*Sample size <50 or the relative standard error (dividing the standard error by the prevalence) ≥ 30%.
¶ Prevalence estimates reflect BRFSS methodological changes started in 2011. These estimates should
not be
compared to prevalence estimates before 2011.

14. Prevalence¶ of Self-Reported Obesity Among U.S. Adults
by State and Territory, BRFSS, 2017
¶ Prevalence estimates reflect BRFSS methodological changes started in 2011. These estimates should not be
compared to prevalence estimates before 2011.
*Sample size <50 or the relative standard error (dividing the standard error by the prevalence) ≥
30%.

15. Prevalence¶ of Self-Reported Obesity Among U.S. Adults
by State and Territory, BRFSS, 2018
¶ Prevalence estimates reflect BRFSS methodological changes started in 2011. These estimates should not be
compared to prevalence estimates before 2011.
*Sample size <50 or the relative standard error (dividing the standard error by the prevalence) ≥
30%.

16. OBESITY
PHYSIOLOGY

17. OBESITY
PHYSIOLOGY

18. OBESITY GENES

19. TEXT

20. OBESITY
BRAIN REGIONS AND FOOD INTAKE
RREGULATION

21. OBESITY

22. OBESITY

23. Signaling in the brain of adolescents in response to glucose or fructose: schematic representation
of changes in the periphery and brain after the ingestion of glucose or fructose.
George A. Bray Diabetes 2016;65:1797-1799
©2016 by American Diabetes Association

24. TEXT

25. OBESITY
MANAGEMEN
T

26. TEXT

27. TEXT

28. NUTRITION

29. “LET FOOD
BE THY
MEDICINE”Hippocrates

31. OBESITY
NUTRITION
▸Reduced-calorie meal plan and macronutrient
composition.Reducing total energy (caloric) intake should be
the main component of any weight-loss intervention.
▸Modifying macronutrient composition may be considered to
optimize adherence, eating patterns, weight loss, metabolic
profiles, risk factor reduction, and/or clinical outcomes

32. OBESITY
INTERMITTENT FASTING AND THEIR
EFFICACY FOR WEIGHT LOSS

33. OBESITY
LOW CARB KETOGENIC DIET

34. PHYSICAL
ACTIVITY

35. OBESITY
PHYSICAL ACTIVITY
▸Aerobic physical activity training should be prescribed to patients with overweight or
obesity as a component of lifestyle intervention; the ultimate goal should be ≥150
min/week of moderate exercise performed during 3 to 5 daily sessions per week
▸Behavioral lifestyle intervention and support should be intensified if patients do not
achieve a 2.5% weight loss in the first month of treatment, as early weight reduction is a
key predictor of long- term weight-loss success
▸Promote fat loss while preserving fat-free mass; the goal should be resistance training 2
to 3 times per week consisting of single-set exercises that use the major muscle groups
▸Behavioral lifestyle intervention should be tailored to a patient’s ethnic, cultural,
socioeconomic, and educational background
▸Reduce sedentary behavior
AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY COMPREHENSIVE CLINICAL PRACTICE GUIDELINES FOR MEDICAL CARE OF PATIENTS
WITH OBESITY W. Timothy Garvey, Jeffrey I. Mechanick, Elise M. Brett, Alan J. Garber, Daniel L. Hurley, Ania M. Jastreboff, Karl Nadolsky, Rachel Pessah-Pollack, Raymond Plodkowski, and Reviewers of the
AACE/ACE Obesity Clinical Practice Guidelines. Endocrine Practice 2016 22:Supplement 3, 1-203

36. OBESITY

37. OBESITY
FUN ACTIVITIES

38. BEHAVIOR
THERAPY

39. OBESITY
BEHAVIOR THERAPY
▸Self-monitoring of weight, food intake, and physical activity
▸Clear and reasonable goal-setting
▸Education pertaining to obesity, nutrition, and physical activity
▸Face-to-face and group meetings
▸Stimulus control
▸Systematic approaches for problem solving
▸Stress reduction

40. TEXT
BEHAVIOR THERAPY
▸Cognitive restructuring: cognitive behavioral therapy],
motivational interviewing

41. BARIATRIC
PROCEDU
RES

42. TEXT
DIFFERENT BARIATRIC PROCEDURES

43. OBESITY
EXPECTED WEIGHT LOSS ASSOCIATED WITH
DIFFERENT BARIATRIC SURGICAL PROCEDURES

44. OBESITY
VITAMIN DEFICIENCIES AFTER
BARIATRIC SURGERY

45. NON-
SURGICAL
PROCEDU

46. GASTRIC BALLOON

47. MEDICAL
THERAPY

48. OBESITY
INDICATIONS FOR THERAPY

49. OBESITY
WEIGHT LOSS THERAPY

50. THERE IS NO
PERFECT DRUG

51. OBESITY
WEIGHT LOSS MEDICATIONS AND
THEIR RESPONSE
Goal : About 4-5 % weight at 12-16 weeks

52. OBESITY
WEIGHT LOSS MEDICATIONS AND
THEIR EFFECTS

53. OBESITY
MEDICATION EFFECTS ON WEIGHT
Apovian CM et al. J clin Endocrinol Metab. 2015; 100:342-362

54. OBESITY
Apovian CM et al. J clin Endocrinol Metab. 2015; 100:342-362

55. OBESITY
NON-APPROVED THERAPIES

56. OBESITY
HCG - 500 KCAL
DIET
▸ HCG is a hormone that is produced
by the human placenta during
pregnancy.
▸ Products that claim to contain HCG
are typically marketed in connection
with a very low calorie diet, usually
one that limits calories to 500 per
day.
▸ “reset your metabolism,”
▸ change “abnormal eating patterns”

57. WEIGHT
LOSS
THERAPY IN
DIABETES

58. OBESITY

59. MANAGEMENT FOLLOW UPS
OBESITY

60. OBESITY
WEIGHT LOSS AND GLYCEMIC
CONTROL

61. OBESITY

62. OBESITY

63. TEXT

64. OBESITY
OBESITY + CARDIOVASCULAR DISEASE
Use agents without cardiovascular signals (increased blood
pressure and pulse):
▸Orlistat
▸ Lorcaserin
• Lower risk of increased blood pressure than
phentermine/topiramate

65. OBESITY
SUMMARY
▸ First guideline that specifically names anti-obesity medications and recommended doses
Patient selection criteria:
▸ BMI >27 kg/m2 with one comorbidity
▸ BMI >30 kg/m2 with no comorbidities
▸ Diet, exercise and behavior modification is the foundation of any weight management plan
▸ Provides a blueprint on medications that cause weight gain and their alternatives
▸ New paradigm: treat weight first, then comorbid condition(s

66. OBESITY
SUMMARY
▸Medications can drive weight gain and they can also help patients lose weight and keep it
off
▸Before prescribing, review current medications and try to d/c those causing gain
▸KNOW drug profiles - prescribe the right medication for the right patient
▸Always encourage patient to follow lifestyle changes
▸Evaluate response at ~ 12 weeks on drug and change or increase if weight loss is < 5%
▸MOTIVATE your patient
▸BE AN EXAMPLE

67. THANKS!!

68. TEXT