Obesity Treatment

1. Obesity Treatment

2. Factors predispose to obesity Genetic – familial tendency. Sex – women more susceptible . Activity – lack of physical activity. Psychogenic – emotional deprivation, depression . Social class – poorer classes. Alcohol – problem drinking. Smoking – cessation smoking. Prescribed drugs – tricyclic derivatives.

3. Weight Gain: Medications

4. Weight Gain: How Does It Happen? Energy imbalance calories consumed not equal to calories used Over a long period of time Due to a combination of several factors Individual behaviors Social interactions Environmental factors Genetics

5. Weight Gain: Energy In 3500 calories = 1 pound 100 calories extra per day = 36,500 extra per year = 10.4 lbs weight gain Question: How much is 100 calories? Answer: Not very much! 1 glass skim milk, or 1 banana, or 1 slice cheese, or 1 tablespoon butter

6. Evolving Pathology More in and less out = weight gain More out and less in = weight loss Hypothalamus control center for hunger and satiety Endocrine disorder where are the hormones?

7. Leptin Protein hormone secreted by adipocytes Levels correlate with lipid content of cells Leptin acts on the hypothalamus to reduce hunger and to stimulate energy expenditure

8. Ghrelin Hormone secreted in the stomach Acts on the hypothalamus to stimulate appetite Levels peak just before meals and drop afterward

9. Bad News for Dieters Leptin Dieting decreases leptin levels Reducing metabolism, stimulating appetite Ghrelin Levels in dieters are higher after weight loss The body steps up ghrelin production in response to weight loss The higher the weight loss, the higher the ghrelin levels

10. Health Consequences of Obesity Major cause of preventable death Increase in mortality from all causes Increase in risk for these cancers Endometrium Breast Prostate Colon Increase in risk of: Hypertension Dyslipidemia Diabetes type 2 Coronary artery disease Stroke Gallbladder disease Osteoarthritis Sleep apnea & respiratory problems

11. Assessment Assess the patient's readiness and willingness to lose weight: Unfortunately those who are most concerned about their weights are not necessarily those who are at the highest health risk. Those who are unable or unwilling to embark on a weight reduction program, but they are willing to take steps to avoid further weight gain or perhaps to work on other risk factors such as cigarette smoking, and they should be encouraged to do so. For those not ready to act, the issue should be deferred and brought up at the next visit

12. Assessment Assess for other risk factors Existing high risk disease: coronary heart disease; other atherosclerotic diseases; type 2 diabetes; sleep apnea Diseases associated with obesity Gynecological problems; osteoarthritis; gallstones; stress incontinence Cardiovascular risk factors (3 or more = high risk) Cigarette smoking; Hypertension; LDL >130; HDL <35; fasting glucose = 110 to 125; family history of premature CHD; men age > 45; women age > 55 Other risk factors Physical inactivity; elevated serum triglycerides Medications associated with obesity

13. Treatment Approach A multi-faceted approach is best Diet Physical activity Behavior change “A” Recommendation

14. Treatment Approach Initial goal: 10% weight loss Significantly decreases risk factors Rate of weight loss 1 to 2 pounds per week Reduction of caloric intake 500-1000 per day Slow weight loss is more stable Rapid weight loss is almost always followed by weight gain Rapid weight loss increases risk for gallstones & electrolyte abnormalities

15. Treatment Approach Aim for 4 - 6 months of weight loss effort Most people will lose 20 to 25 pounds After 6 months, weight loss is more difficult Ghrelin & Leptin are at work! Changes in resting metabolic rate Energy requirements decrease as weight decreases Diet adherence wavers Set goals for weight maintenance for next 6 months, then reassess.

16. Dietary Therapy Weight reduction with dietary treatment is in order for virtually all patients with a BMI 25-30 who have comorbidities and for all patients over BMI 30. Strategies of dietary therapy include teaching about calorie content of different foods, food composition (fats, carbohydrates, and proteins), reading nutrition labels, types of foods to buy, and how to prepare foods.

17. Low-Calorie Step I Diet 1000 to 1200 kcal/day for women 1200 to 1600 kcal/day for men Adjust for current weight & activity Too hungry? increase kcal by 100 - 200/day Not losing? decrease kcal by 100 - 200/day

18. How Much is 1200 Calories? Could you stick to 1200 per day? 1 Big Mac (580) 1 SMALL Fries (210) 1 SMALL shake (430)

19. Low-Calorie Step I Diet

20. Physical Activity Physical activity should be an integral part of weight loss Physical activity alone is less successful than a combined diet & exercise program Increased activity alone does not decrease weight Sustained activity does prevent weight regain Reduces risk for heart disease & diabetes

21. Physical Activity Start slowly Many obese people live sedentary lives Avoid injury Early changes can be activities of daily living Increase intensity & duration gradually Long-term goal 30 to 45 minutes or more of physical activity 5 or more days per week Burn 1000+ calories per week

22. Recommend Physical Activity What does it take to burn 1000 calories per week? Gardening 5 hours Cycling 22 miles Running 11 miles Walking 12 miles Dancing 3 hours

23. Behavioral Strategies Keep a journal of diet & activity Very powerful intervention! Set specific goals re: behaviors Eating Activity Related behaviors Track improvement Weigh & measure on a regular basis

24. Cognitive Strategies Focus on the goals Plan meals & activity Develop reminder systems Anticipate temptations & plan resistance Reward yourself Limit quantities, but do not deprive yourself Have confidence in your ability to succeed Do positive self-talk

25. Pharmacotherapy for Weight Loss Adjunct to diet & physical activity BMI ≥ 30 Or, BMI ≥ 27 with other risk factors Should not be used for cosmetic weight loss Only for risk reduction Use only when 6-month trial of diet & physical activity fails to achieve weight loss

26. Pharmacotherapy for Weight Loss These drugs are only modestly effective 2 to 10 kilogram loss Most occurs in the first 6 months If patient does not lose 2 kilograms in the first 4 weeks, success is unlikely If the first 6 months is successful, continue medication as long as… It is effective in maintaining weight, and Adverse effects are not serious

27. Pharmacotherapy for Weight Loss

28. Weight Loss Surgery 47,000 in 2001; 98,000 in 2003 Types of Obesity Surgery: 1. Restrictive Surgery - uses bands or staples to create food intake restriction: Vertical Banded Gastroplasty (VBG) - is a “pure” restrictive surgery since it only involves surgically creating a stomach pouch.  VBG uses bands and staples and is the most frequently performed procedure for obesity surgery. Gastric Banding – involves the use of a band to create the stomach pouch.  Laparoscopic Gastric Banding (Lap-Band), approved by the FDA in June 2001, is a less invasive procedure in which smaller incisions are made to apply the band.  The band is inflatable and can be adjusted over time

29. Weight Loss Surgery 2. Combined Restrictive and Malabsorptive Surgery - is a combination of restrictive surgery (stomach pouch) with bypass (malabsorptive surgery), in which the stomach is connected to the jejunum or ileum of the small intestine, bypassing the duodenum. Roux-en-Y Gastric Bypass (RGB) - is the most commonly performed gastric bypass procedure, and the second most frequently performed surgery for obesity after VBG.   RGB involves a stomach pouch for food intake restriction.  A direct connection, which is Y-shaped, is made from the ileum or jejunum to the stomach pouch for malabsorption.  Biliopancreatic Diversion (BPD) -is one of the most complicated obesity surgery, sometimes involving the removal of a portion of the stomach.  The remaining section of the stomach is connected to the ileum. BPD successfully promotes weight loss, but this procedure is typically used for persons with severe obesity who have a BMI of 50 or more

30. Weight Loss Surgery Indications 100 pounds overweight or more Or, BMI > 40 Or, BMI > 35 and 2 significant comorbidities Age 18 to 60 Documented failure at nonsurgical efforts Psychological stability

31. Weight Loss Surgery Roux-en-Y gastric bypass Limits food intake Alters digestion Figure from NIDDK website

32. Weight Loss Surgery Complications of surgery Mortality <1% mortality in healthy young adults BMI < 50 2-4% mortality in patients with disease and BMI > 60 Operative complications < 10% Late complications are uncommon Incisional hernias Gallstones Vitamin B12 & iron deficiency Weight loss failure Neurologic symptoms in unusual cases

33. Weight Loss Surgery Outcomes Durable weight loss One study followed pts for 14 years Average excess weight loss = 61.2% 77% with diabetes no longer require meds From Wald meta-analysis in JAMA 2004)

34. Followup Schedule a return visit in 2 to 4 weeks after starting weight loss plan Monitor treatment effectiveness & side effects Schedule monthly visits for first 3 months If making favorable progress See more frequently if monitoring medical complications or chronic disease Reduce frequency of visits after 6 months

35. Followup Monitor weight, BP, pulse at each visit Monitor waist size intermittently Share progress with patient; praise efforts Share lab results with patient Emphasize findings associated with weight reduction Focus on medical benefits Most weight loss doesn’t reach individual’s ‘ideal’ (cosmetic) goal