What is the most common form of malnutrition in the United States

1. What is the most common form of malnutrition in the United States? Obesity

2. What is the most common cause of increased mortality in obese individuals? Coronary artery disease Secondary to increased cardiac risk factors

3. Obesity Strategies for Assessment and Management Leanne M. Yanni, MD

4. A Definition of Obesity A pathologic state characterized by the accumulation of fat in excess of that necessary for optimal body function. Primary Care Medicine

5. The Four Elements Genetic predisposition ob gene and leptin secretion Access to calories Excessive energy intake Insufficient energy output Lack of exercise Low metabolic rate

6. 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? 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?

7. Medical Factors Hypothyroidism Cushing�s syndrome Polycystic Ovarian Syndrome Insulin resistance, hirsutism, amenorrhea, polycystic ovaries Syndrome X Hypertension, hyperlipidemia, insulin resistance Kleine-Levin Syndrome Periodic hyperphagia and hypersomnia

8. Metabolic Syndrome NCEP Guidelines May 2001 Lipid and nonlipid risk factors of metabolic origin Insulin Resistance Identify the metabolic syndrome To reduce underlying causes obesity/physical activity To treat associated risk factors

9. Diagnosis with 3 or more of risk determinants Abdominal Obesity Triglycerides High-density lipoprotein Blood pressure Fasting glucose Waist circumference Above 150mg/dL Men <40, women <50 Above 130/85 Above 110

10. 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. Walter J. Pories

11. Two Steps for the Primary Care Physician Assessment Management

12. Assessment Eyeball Test Body mass index Waist circumference History Overall risk factors Motivation for change

13. �Eyeball Test�

14. Body Mass Index The new vital sign! Correlated with total body fat content Not accurate in muscular individuals Initial assessment and monitoring BMI weight in lbs/(height in inches)2 x 704 Example 5�6� 248lb female 248lbs / (66inches)2 x 704 = 40

15. BMI Chart

17. Waist Circumference Android obesity or �apple-shaped� Higher risk for morbidity and mortality High Risk Men >102 cm (>40 in) Women > 88 cm (>35 in) Not accurate if BMI > 35

18. History Age of onset of obesity Associated circumstances Highest and lowest adult weight Past dieting attempts Current dietary habits Current exercise habits Stressors

19. Overall Risk Assessment Current disease - Very high risk Cardiovascular disease Type II Diabetes Sleep apnea Comorbidities - Moderate risk GERD, OA, Gallstones Cardiovascular risk factors

20. Motivation for Change Motivation for weight reduction Support system Understanding of the �disease� Time available for intervention Financial considerations

21. Goals of Management Prevent Reduce Maintain

22. Management Options Caloric restriction Very low calorie diet (VLCD) Behavioral modification Exercise Drug therapy Surgery

23. Caloric Restriction: Fundamentals Must decrease total calories for weight loss Total fat <30% of total calories Reduce carbohydrates

24. Caloric Restriction for Weight Maintenance Calories to maintain weight Men: 10-12 calories x weight in pounds Women: 8-10 calories x weight in pounds Example 248 pound sedentary female 248 x 8 = 1984 calories

25. Caloric Restriction: Weight loss Energy deficit 500-1000 kcal per day 1-2 pounds per week Example 1984 calories to maintain weight 1984 - 500 = 1484 1484 calories per day to lose 1 pound per week

26. Caloric Restriction: Goals Initial goal 10% of baseline weight over 6-8 months 248lbs - (248lbs x .10) = 223lbs 248-223 = 25 lbs

27. Caloric Restriction: Adjusted body weight Use if > 120% overweight Men: (actual wt � IBW) x .38 + IBW Women: (actual wt � IBW) x .32 + IBW Example 5�6� 248 pound female Ideal body weight = 137lbs (248 - 137) x .32 + 137 = 176lbs *Ideal body weight obtained from chart

28. Very low calorie diets �Supplemented fasts� Liquid formula diets 420-800cal/day Protein-sparing modified fast BMI >30, >50lbs to lose Multi-disciplinary to maintain loss Nutrition, Behavior, Exercise Medical supervision Contraindicated with disease

29. Behavioral Modification5 Components A systemic method for modifying eating, exercise or other behaviors that may contribute to or maintain obesity. Self-monitoring Observation and recording of target behaviors Purpose: awareness of behaviors and influence Research show improved treatment outcomes Stimulus control Identifying and modifying environmental clues with overeating and inactivity 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. 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.

30. Behavioral Modification 3. Cognitive changes Perceptions of themselves and their weight Change internal dialogue that undermines ability to successfully lose weight Many obese: poor self esteem and distorted body image 4. Stress Management Stress is a predictor of relapse and overeating Tension reduction techniques 5. Social Support Including family in the treatment program, participation in community programs, involvement in outside social activities Tension reduction techniques may include diaphragmatic breathing, progressive muscle relaxation, meditation.Tension reduction techniques may include diaphragmatic breathing, progressive muscle relaxation, meditation.

31. Does Behavioral Modification Work? Mild to moderate obesity (BMI<30) Gradual and moderate weight loss Average 1 pound/wk Able to maintain 2/3 of weight lost Multiple Behavioral Strategies improves outcome Used by many weight loss programs

32. Exercise Strategies Cardiac evaluation if sedentary with risk factors Begin with brisk walking 30-45minutes, 3-5x/wk Reach 60-80% of age-adjusted max HR Formula: 200bpm-age Example 43 year old 248 pound female 200bpm - 43 = 157bpm max HR 157 x .60 = 94bpm 157 x .80 = 126bpm Goal: 94 to 126 beats/min

33. Exercise Effects Can burn 150-225 calories per session Modestly contributes to weight loss Benefits Reduces all-cause mortality Decreases abdominal fat Increases cardiorespiratory fitness Helps prevent weight regain

34. Drug Therapy At least 6 months of lifestyle modification Adjunct if BMI >30 without risk factors Adjunct if BMI <30 and 2 comorbidities

35. Noradrenergic Agents

36. Noradrenergic (amphetamine-like) Hypothalamic central-mediated pathway Side effects Insomnia, nervousness, nausea, diarrhea, constipation Complications Increase BP (precipitate angina), arrhythmias, renal failure, psychotic episodes, death Moderate short-term weight-loss when combined with dietary program

37. Serotonergic Agents

38. Serotonergic Fenfluramine (Pondimin) Dexfenfluramine (Redux) Phentermine (Phen-Fen) + Fenfluramine Off the market Primary Pulmonary HTN Valvular Heart Disease

39. Sibutramine (Meridia) Inhibits reuptake of NE, 5-HT, and Dopamine Does not stimulate serotonin secretion Effects Decrease appetite, increase satiety (anorectic) Increase metabolic rate (thermogenic) Initial 10mg dose 40% lost 5% of weight 20% lost 10% of weight Dose-dependent effect Weight gain with drug discontinuation

40. Sibutramine (Meridia) Side effects Constipation, dry mouth, headache, insomnia May increase blood pressure and pulse Contraindications CAD,CHF, arrhythmias, stroke Severe hepatic impairment (cytochrome p450) Use of other serotonergic medications SSRIs 5-HT agonists: lithium, meperidine, fentanyl, MAOIs, dextromethorphan Ineffective for depression

41. Orlistat(Xenical) Gastrointestinal lipase inhibitor Decrease fat absorption Inhibits pancreatic and gastric lipases Unabsorbed triglycerides, cholesterol excreted in feces Blocks 30% of dietary fat 8.5% weight loss at 1 year (5.4% placebo)

42. Orlistat(Xenical) No systemic effects Steatorrhea, flatus, fecal incontinence, oily spotting Mild reduction in Vitamin D, B-carotene Dose 120mg tid with meals Should take with MVI but not within 2 hours

43. Leptin Exogenous leptin in phase I human trials Subcutaneous or IV May help prevent weight regain Stimulant? Increases body temperature and physical activity in mice

44. Metformin Adult onset diabetes First line for overweight type II diabetic Weight loss rather than weight gain

45. Surgery for Obesity Highly motivated Well informed Accept changes in lifestyle

46. Surgery Failed other methods of treatment Multiple comorbidities BMI > 40 BMI 35-40 with severe life threatening complications

47. Surgery Lose 60-80% of excess weight Maximum loss at 18 months to 2 years Weight regain up to 5th year Up to 20% regain all lost weight 1% mortality with experienced surgeons

48. Vertical Banded Gastroplasty (Gastric Stapling) 30ml pouch Amount of weight loss correlates to size of pouch Larger pouch = less weight loss, fewer side effects 70% maintain >20% weight loss at 5 years Not effective in �carbohydrate cravers�

50. Gastric Bypass Gastric pouch with small bowel limb Longer limb = more weight loss, increased side effects 70% loss at 2 years 58% at 5 years 55% at 10 years Non-responders to gastric stapling Better for �carbohydrate cravers�

53. Take Home Points In addition to the �Eye Test� - use the BMI and waist circumference to assess risk, determine treatment plan, and set goals Use multiple strategies for weight loss A reduction in caloric intake of 500-1000calories per day will lose 1 lb per week Start with moderate physical activity of 30 minutes 3-5 days per week Consider drug treatment for BMI >30 or >27 with 2+ comorbidities

54. References Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: Executive Summary National Heart Blood and Lung Institute http://www.nhlbi.nih.gov/ Electronic Textbook � Obesity Guidelines Can download palm pilot version