Obesity Management Across the Lifespan

1. Obesity Management Across the Lifespan Lara Easterwood RN, NP-C

3. Disclosures None

4. Epidemiology 66% of adults in America have a BMI of 25 or more. 33% of those are classified as obese 20% of those are morbidly obese Women>Men African American and Hispanic women have shown the greatest rise in obesity 1980-15% US population obese 2004-33% US population obese 300 million worldwide have a BMI>30

5. Epidemiology 18-20% of US children are obese or overweight, as defined by BMI over the 95th percentile for age and sex 34-36% are at risk of obesity or overweight, with a BMI between 85th and 95th percentiles Females>Males More prevalent in African-American and Hispanic adolescents Caucasians are more affected during early childhood Obesity has a polygenic genetic determinant (25-35%), though environmental factors play a more important part in its development Familial Tendency If both parents are obese, two-thirds of their children will be obese More prevalent in lower socioeconomic groups, probably owing to a lower-protein, higher-calorie diet in these groups Dangerous neighborhoods Severe obesity is independent of socioeconomic factors

6. What Drives Us To Eat? Homeostatic vs Hedonic System Both are regulated centrally, but are believed to be independent. Poor appetite control is due to either a disturbance in homeostatic pathways or due to inappropriate sensitization of the hedonic system. Hedonic Homeostatic-consists of both long-term signaling from adipose tissue and episodic signaling mostly from the gut. Long Term Signaling Episodic

7. Overweight vs Obesity US Preventative Task Force (USPTF 2003) recommends using the BMI Scale Normal Weight: BMI 18.5-24.9 Overweight: BMI 25-29.9 Obesity: BMI 30 or more Subclasses of obesity Central obesity is a strong indication of underlying disease. Waist Circumference Obesity or overweight in children is defined as body mass index (BMI) for age and sex elevated above the 95th percentile Children with elevated BMI between the 85th and 95th percentiles for age and sex are described as 'at risk' for obesity or overweight

8. Risk Factors for Obesity Energy Intake>Energy Expenditure Sedentary Lifestyle Medications Genetics Endocrine Disorders Low Socioeconomic Status Gender Mental Health Conditions

9. Diet If you take in more than you expend�..you gain. Lack of knowledge Lower socioeconomic status Have you ever tried to eat healthy on a budget?

10. Sedentary Lifestyle Physical activity is the key to energy expenditure! Increasing physical activity creates an energy deficit by increasing total energy expenditure�..basically, you lay around�.you get fat! Eat 2500 calories a day, body only needed 1200 that day to sustain function�.the rest has to go somewhere!

11. Medications Know the side effects of the medications you are prescribing Many medications can cause weight gain Antipsychotics, Antidepressants, Anticonvulsants, Insulin, TZDs, Sulfonylureas, Steroids, Beta-Blockers etc.

12. Genetics My little sister�..enough said? Genetics does not cause obesity. Theory is that obesity is influenced by genetic diversity interacting with environmental changes.

13. Depression Reciprocal Lack of energy Lack of Motivation Feeling of worthlessness

14. Endocrine Disorders  Hypothyroidism T2DM Cushing�s Syndrome Prader-Willi Syndrome Turner�s Syndrome Laurence-Moon Syndrome Growth Hormone Deficiency Klinefelter�s Syndrome Polycystic Ovarian Syndrome

15. Hypothyroidism in Children Consider if there are developmental delays, short stature. Exogenous obesity-associated with a height that is tall for age, and so an inappropriately short obese child should undergo endocrine/genetic evaluation. Clinical Features Short stature Developmental delays Constipation Delayed deep tendon reflexes Poor school performance Initial Work-Up-TSH Replacement Therapy

16. Hypothyroidism in Adults Disorder caused by the inadequate secretion of thyroid hormone. Incidence increases with age. Clinical Features Fatigue, Lethargy, Weakness, Constipation, Weight Gain, Cold Intolerance, Muscle Weakness, Slow Speech, Poor Memory, Dry Skin, Brittle, Coarse hair, Dulled expression, Thick tongue, Delayed relaxation phase of DTRs, Peripheral Neuropathies with parasthesias, Weakness, Stiffness. Initial Work-up-TSH Treatment-replacement therapy

17. Cushing�s Syndrome Excess production of glucocorticoids secondary to exaggerated adrenal cortisol production or chronic glucocorticoid therapy. Cushing�s DISEASE is Cushing�s Syndrome caused by pituitary ACTH excess. Rare cause of childhood obesity Features Central obesity Dorsocervical fat pad (increased adipose tissue over the lower posterior neck; also called a 'buffalo hump') Hypertension Easy bruising Striae Amenorrhea Muscle wasting Weakness Initial Workup-Overnight Dexamethasone suppression test Treatment-Varies with cause

18. Prader-Willi Syndrome Usually a sporadic, rather than a familial, genetic disorder. Suspect in children with a history of hypotonia and poor sucking reflex. Absence of a portion of the paternally derived chromosome 15. Clinical Features Reduced fetal movements in utero Hypotonia in infancy Cryptorchidism in infancy Failure to thrive in infancy followed by subsequent obesity Poor sucking reflex Delayed development Hypogonadism Short stature Behavioral and psychiatric problems: depression, obsessive-compulsive disorder, skin-picking Average age of onset of obesity is 2 years, with a range of 6 months to 6 years Inability to control their intake and avidly seek food Treatment-Good infant nutrition, Growth hormone therapy, Sex hormone therapy, Healthy diet, Mental health therapy.

19. Turner�s Syndrome Pattern of malformation characterized by short stature, ovarian hypofunction, loose nuchal skin, and cubitus valgus. Other manifestions-Renal ectopia (horseshoe kidneys), Aortic stenosis, Coarctation of the Aorta, Widely spaced nipples. Chromosomal defect-usually 45,X Chromosome Treatment geared towards age-related problems, learning disabilities, developmental delays, slow growth, and ammenorhea.

20. Labs Useful in Diagnosing Underlying Disease Lipid Panel Fasting Blood Glucose Level Liver Function Tests Thyroid Function Tests Urine Free Cortisol

21. Treatment  Goal is to promote weight loss via behavioral changes, diet, and exercise. Pharmacological and Surgical options are instituted dependant on case severity. The initial goal of weight loss should be a reduction in weight of 10% of baseline within 6 months of therapy. Use a stepwise approach�.start slow, build yourself up. Weekend warrior is not conducive to weight loss. Lifestyle change emphasis�..this is forever!

22. Diet Dietitian if possible Plan based on individual Population-Based Guidelines Food/Nutrition Lifestyle change vs Diet Avoid Fad Diets Portion control Eating frequency Meal Replacements

23. Exercise Frequency Duration Type Use an Individual Approach Be Realistic

24. Behavioral Management Goal is for patients to overcome those obstacles preventing that particular person from achieving their weight loss goal. To assist the individual in making necessary diet and exercise changes. Assess individuals readiness for change. Group Therapy Individualized Problem-Solving Therapy

25. Medications Phentermine Sibutramine Orlistat Metformin Byetta Phentermine/Topiramate

26. Phentermine Oral Sympathomimetic Amine Increases the release of Norepinephrine and Dopamine from nerve terminals and prevents their reuptake Anoretic Indicated for short term use, 8-12 weeks Tolerance to the anoretic effect develops within a few weeks. Do not increase dose to increase effect.

27. Phentermine Phen-Fen PPH Valvular Heart Disease Is Phentermine safe to use alone?

28. Phentermine Dose 8mg 3xdaily 30 minutes before meals or 1-2 hours after meals 15-37.5mg by mouth daily-usually given 2 hours after breakfast

29. Phentermine Side Effects Dizziness, Euphoria, Headache, Insomnia, Overstimulation, Tremor, Psychosis, Restlessness, Blurred Vision, Ocular Irritation, Hypertension, Palpitations, Sinus Tachycardia, Constipation, Diarrhea, Nausea, Vomiting, Dry Mouth (Increased Dental Caries).

30. Phentermine Contraindications Angina, Arterioschlerosis, Arrythmias, Glaucoma, Hypertension, Hyperthyroidism, Pulmonary Hypertension, Valvular Heart Disease, Psychiatric Issues-agitation, history of drug abuse, during or 14 days following the administration of an MAOI-hypertensive crisis may ensue.

31. Sibutramine Approved for long-term management of Obesity. Neurotransmitter Reuptake Inhibitor (Norepinephrine, Dopamine, and Serotonin). Inhibits the reuptake of Neurotransmitters. Norepinephrine increases metabolic rate Serotonin enhances satiety levels

32. Sibutramine Dose 10mg by mouth once daily Titrate to 15mg once daily after four weeks Can start at 5mg once daily if 10mg is not tolerated Max dose 15mg/day

33. Sibutramine Side Effects Constipation, Insomnia, Headache, Xerostomia, Tachycardia, Hypertension, Anorexia. Monitor blood pressure and pulse

34. Sibutramine Contraindications Caution using this medication with patients who are on antidepressants-Serotonin Syndrome Concurrent MAOI use Do not use in those with a major eating disorder Do not use in conjunction with other centrally acting weight loss drugs

35. Orlistat GI Lipase Inhibitor Inhibits absorption of nutrients in the GI tract. Indicated for weight loss and weigh maintenance in conjunction with a reduced calorie diet. Also used to reduce the risk for weight regain after prior weight loss.

36. Orlistat Recommended dose is 120mg capsule three times a day with each main meal containing fat. Can also be taken up to one hour after the meal. Diet should be nutritionally balanced, reduced-calorie, that contains approximately 30% of calories from fat. Counsel patient to take a multivitamin due to the reduced absorption of some fat-soluble vitamins and beta-carotene when taking Orlistat. Supplement should be taken 2 hours after Orlistat or at bedtime.

37. Orlistat Side Effects Flatulence with discharge-wear light colored clothing. Fecal Urgency Fecal Incontinence Steatorrhea Oily Evacuation Abdominal Pain Nausea/Emesis Headache Joint Pain Rare-angioedema, anaphylaxis, elevation in liver enzymes, decreased prothrombin, increased INR in those on anticoagulants, pancreatitis (no direct causal relationship established-most likely due to obesity itself). Diabetic patients-hypoglycemia and abdominal distention.

38. Orlistat Contraindicated in patients with chronic malabsorption syndrome or cholestasis, and in those with known hypersensitivity to this medication. Do not coadminister Cyclosporin and Orlistat. Give 2 hours apart. Monitor Cyclosporin levels more frequently

39. Phentermine/Topiramate Still awaiting FDA approval 15mg Phentermine combined with 92mg Topiramate Phentermine shown to reduce appetite, improve cognition, memory, and psychomotor function Topiramate shown to improve satiety

40. Surgical Options Laparoscopic Roux-en-Y Gastric Bypass Laparoscopic Adjustable Gastric Band Vertical Banded Gastroplasty Jejunoileal Bypass

41. Morbidity/Mortality Risks of Obesity T2DM Cardiovascular Disease Metabolic Syndrome Hypertension Obstructive Sleep Apnea (OSA) Nonalcoholic Fatty Liver Disease (NAFLD) Osteoarthritis Stroke Breast Cancer Asthma Stillbirth

42. Monitoring Regular Follow-Up Individualized Plan of Care Monitor Side Effects of Medications Weigh and calculate BMI during acute weight loss period and at 6 months and 1 year-adjust plan if individualized program is not working.