Addressing Obesity and Exercise in Primary Care

Addressing Obesity and Exercise in Primary Care GSP 4th Year Elective 2010

Definitions of Overweight and Obesity • BMI = weight in kg/height in meters2 (weight in lb/height in inches2)*703 • Overweight- BMI 25-29.9 • Obesity- BMI > 30 • Extreme obesity- BMI > 40

Waist Circumference • Increases risk when increased with BMI 25-35 • Men >102 cm (40 in) • Women > 88 cm (35 in)

Prevalence of Overweight and Obesity • 1990 • Overweight- 55.9% • Obesity- 22.9% • 2000 • Overweight-64.5% • Obesity- 30.5%

Associated Risk Factors • Diabetes • Hypertension • High cholesterol • Asthma • Arthritis • Obstructive sleep apnea • Poor health status

Health Burden • Second leading cause of premature mortality after smoking • 300-400,000 deaths per year

Benefits of weight loss • Little evidence that interventions reduce morbidity or mortality • Weight loss does improve glucose control, lipid levels and blood pressure

Goals of weight loss and management • Prevent further weight gain • Reduce body weight • Maintain lower body weight long-term

Weight loss guidelines • Reasonable goal- 10% decrease in weight over 6 months • Requires a decrease of 300-500 calories per day up to BMI of 35 • Requires a decrease of 500-1000 calories per day for BMI > 35 • Weight loss will usually plateau after 6 months • Maintenance is difficult

Sedentary Lifestyle • Independent risk factor for cardiovascular and all cause mortality • Hypertension, insulin resistance, elevated glucose and dyslipidemia all improve with exercise

Physical Activity • 30 minutes on most days recommended • For most individuals, will not produce significant weight loss alone • Walking briskly for 30-45 minutes will consume 100-200 calories • Target heart rate: (220-age)*0.6 to 0.9

USPSTF • Recommends clinicians screen all adult patients for obesity and offer intensive counseling and behavioral interventions to promote weight loss for obese adults • Found insufficient evidence to determine whether counseling patients to promote physical activity leads to increased physical activity in adults

Medications • May consider if diet and exercise not successful • Should have BMI> 30 or >27 with risk factors • Consider stopping if < 2 kg weight loss after 4 weeks • Long-term effectiveness uncertain and many patients discontinue

Sibutramine • Blocks reuptake of norepinephrine and serotonin • Side effects include increased blood pressure, heart rate, headache, insomnia, dry mouth • Should not be used for patients with uncontrolled hypertension or significant cardiovascular disease • Dose- 10-15 mg/day • Effectiveness- average weight loss 5%

Orlistat • Lipase inhibitor • Side effects include loose and more frequent stools • Dose- 120 mg tid • Effectiveness- average weight loss 5% • Combined therapy no more effective, weight loss limited to 10%

Weight loss surgery • Very successful in some patients • Gastric bypass used at UVA • Indications- unsuccessful medical weight loss with BMI > 40 or BMI > 35 with complications

Five A’s • Ask- BMI as a vital sign • Advise- provide brief feedback • Assess- motivation and stage of change • Assist- help patients who wish to lose weight develop a plan • Arrange follow-up

Dietary counseling for other conditions • Elevated cholesterol • Cardiovascular disease • Hypertension • Diabetes

Mediterranean Diet • Only diet shown to decrease cardiovascular morbidity and mortality • RR 0.3-0.5 vs regular or “heart-healthy diet” (30% fat, 10% saturated fat, 300 g cholesterol/d) • 250-300 g fruit, 125-150 g vegetables, 25-50 g nuts/day • 400-500 g whole grains, legumes, rice/d • +/- fish several times a week • 3-4 servings of monounsaturated fat/d

References • CLINICAL GUIDELINES ON THE IDENTIFICATION, EVALUATION, AND TREATMENT OF OVERWEIGHT AND OBESITY IN ADULTS • http://www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns.pdf • US PREVENTIVE SERVICES TASK FORCE • http://www.ahcpr.gov/clinic/uspstfix.htm • MEDITERRANEAN DIET • Circulation 1999;99:779

Addressing Obesity and Exercise in Primary Care