Obesity Management for Adults in Primary Care

1. Obesity Management for Adults in Primary Care Carol Birch, ARNP, MSN, FNP-BC, ABBM Adv. Cert. Swedish Weight Loss Services (SWLS) FHC, Seattle, WA December 3, 2013

2. David K, 50 y.o. Feb 2012 • Do you feel equipped to care for him effectively?

3. Objectives • Case Study Illustration to help the PCP: • Describe current obesity and diabetes epidemic • Illustrate pathophysiology of “sick fat” • Describe relationship of obesity to insulin resistance, metabolic syndrome and cardiovascular disease • Describe current treatment paradigm including diet, exercise, behavior change, medications and surgery

4. Current Screening and Treatment Recommendations • The USPSTF recommends screening all adults for obesity. (June 2012) • Clinicians should offer or refer patients with a body mass index (BMI) of 30 kg/m2 or higher to intensive, multicomponent behavioral interventions. • Grade: B Recommendation. • Included in Affordable Care Act (ACA)

5. CMS - Medicare • As of Nov. 29, 2011 • Screening for Obesity • Nutritional Assessment • Coverage for Intensive Behavioral Counseling and Behavioral Therapy (“5 A’s”) • BMI=> 30 • “Primary Care Practitioner in Primary Care Setting” • http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/ICN907800.pdf

6. Epidemic Obesity Trends

9. 1994 2000 1994 2000 No Data <4.5% 4.5-5.9% 6.0-7.4% 7.5-8.9% >9.0% No Data <14.0% 14.0-17.9% 18.0-21.9% 22.0-25.9% >26.0% Age-Adjusted Prevalence of Obesity and Diagnosed Diabetes Among U.S. Adults Aged 18 Years or older Obesity (BMI ≥30 kg/m2) 2010 Diabetes 2010 CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics

10. Things aren’t getting better… • One in 3 children born in 2000 will develop type 2 DM by 2050! • CDC.gov/chronicdisease/resources • Diabetes Care, Dec. 2012; 35(12), 2515-2520

11. Body Mass Index (BMI) • “Avg”ofHt & Wt; Relative Risk Marker of Comorbidities • Weight in Kg / Height in M² • Not specific for gender, age, activity, or body type • Correlates roughly with % body fat Weight x 704 / Height inches / Height inches = BMI

12. What is David’s BMI Height 5 ‘ 8 “ Weight 392 .6 lbs 392 . 6 x 704 / 68 / 68 = BMI = 59 . 7

13. Definitions

14. 4.0 Mortality Risk 3.0 2.0 25 30 35 40 45 1.0 BMI

15. Other Metrics • Waist/Hip ratio • Measured halfway between lowest rib and iliac crests • No uniform agreement of “abnormal,” but ratio ≥ 1 means abdomen larger than hips = apple shape • % Body Fat • No agreed “normal” or “healthy” • Practical goals: < 30% for Women, < 20 % for Men • Excess weight • Total weight – Ideal Body Weight (at 25 BMI) = Excess Weight • % Weight lost Wt lost divided by initial weight

16. David K’s Metrics • Abd circumference 61 inches • Total Body Fat TBF 44.7 % (173.4 lbs) • Fat Free Mass FFM 55.3% (214.6 lbs) • Excess Weight • 392.6 lbs – Wt @ 25 BMI (164.2) = 228.4 lbs

17. Physiological Effects of Obesity Arthritis HigherTraumaDeath Cancer HTN Gall Bladder Asthma Obesity Health Risks Depression Diabetes RenalDisease Incontinence HighCholesterol HeartDisease Stroke Migraines SleepApnea HeartFailure

18. Pathophysiology of Obesity • Based on Adipose Tissue Structure and Function • Metabolically very active

19. Inflammatory Cytokines • TNF-α • Interleukin-1 • IL-6 • IL-8 • Resistin • Monocyte Chemotactic Protein (MCP) • Adipsin • Plasminogen Activator Inhibitor-1 (PAI-1) • Angiotensinogen Lean Adipose Tissue Obese Adipose Tissue with macrophages

20. Cytokines and Inflammation • Inflammatory Cytokines • TNF-α • Interleukin-1 • IL-6 • IL-8 • Resistin • Monocyte Chemotactic Protein (MCP) • Adipsin • Plasminogen Activator Inhibitor-1 (PAI-1) • Angiotensinogen • “Downstream”Effects • Inflammation • CRP • Thrombosis • Atherosclerosis • Dyslipidemia • Type 2 Diabetes • Hypertension • Metabolic Syndrome • Cardio-Metabolic Dz • Androgen Deficiency Carrutherset al.CardiovascularDiabetology 2008 7:30

21. Metabolic syndrome • AKA Dysmetabolic Syndrome • AKA Syndrome X • AKA “Insulin Resistance” • ICD 9 code 277.7 • “Syndrome” of combination abnormalities: • Increased abdominal girth • Blood pressure • Glucose (IFG) • Lipids • +/- microalbuminuria

22. Metabolic SyndromeNCEP ATP III Criteria  3 of the following • Risk Factor Defining Level • Abdominal Obesity (waist circumference) • Men >40 inches • Women >35 inches • Blood Pressure (or w/ Rx) >130/>85 mm Hg • Triglycerides (or w/ Rx) >150 mg/dL • HDL Cholesterol (or w/ Rx) • Men <40 mg/dL • Women <50 mg/dL • Fasting Glucose (or w/ Rx) >110 (100) mg/dL NCEP ATP III. JAMA. 2001;285:2486–2497.

23. Insulin Resistance is Central to Multiple Pathologic Conditions Obesity Polycystic Ovary Disease Hyper-uricemia Athero-sclerosis Insulin Resistance Decreased Fibrinolytic Activity (Thrombosis) Hypertension Dyslipidemia AcanthosisNigricans Impaired Glucose Tolerance Diabetes 2

24. Metabolic Syndrome and CVD • 1209 Finnish men ages 49-60 • All with metabolic syndrome but NO CVD, Cancer or Diabetes at the time of entry • 11.6 year median follow up • Results • ~3 times rate of death from CVD • ~2 times rate of death all cause mortality • 18% all cause mortality vs8% at 13.7 years Lakka, et al. The Metabolic Syndrome and Total and Cardiovascular Disease Mortality in Middle-aged Men; 2002, Vol 288, No 21

25. Factors Contributing to Cardiometabolic Risk Obesity Metabolic Syndrome Age, Race, Gender, Family History Lipids, BP, Glucose Cardiometabolic Risk Diabetes/CVD Risk Hypertension Smoking, Physical Inactivity Abnormal Lipids Brunzell, et al. JACC 2008; 51:1512-1524

26. Natural History of Type 2 Diabetes Years from Diagnosis -15 -10 -5 0 +5 +10 +15 Diagnosed Diabetes Insulin Resistance and Beta cell dropout begin years before Impaired Glucose Tolerance or other clinical signs. Cardiovascular Complications Impaired Glucose Tolerance Insulin Resistance Ramlo-Halstead, Clinical Diabetes. 2000.

27. VLDL LDL HDL Lipid Abnormalities in Metabolic syndrome/Insulin Resistance Normal Insulin Resistance Trend towards inflammatory pattern Triglycerides Number Number HDL2 apo B apo B Size Size Size Robinson. What is the Role of Advanced Lipoprotein Analysis in Practice?; J Am,Coll,Cardiol.2012;60 (25): 2607-2615

28. Treatment Strategies

29. Behavior and Lifestyle Modification • Goal is to help patient learn behaviors and patterns of thinking that support weight loss and weight maintenance • Varied counseling approaches are useful • Motivational Interviewing • Cognitive Behavioral Therapy • Relational/Interpersonal Therapy • 5 A’s approach currently used by Centers for Medicare and Medicaid Services (CMS)

30. Motivational Interviewing • Purpose is to identify and resolve ambivalence • Identifies different stages of readiness • Precontemplation • Contemplation • Preparation • Action • Maintenance • Goal oriented • Directive towards making changes • Questions and listening • Engage and focus on pros and cons of change • Goals are realistic and important • Motivational Interviewing: Helping People Change, 2013.Miller and Rollnick • Counseling Tips for Nutrition Therapists, Vol 1 and 2, 2006. Molly Kellogg

31. Cognitive Behavioral Therapy • Focuses on developing and maintaining new skills • Goal is to alter ineffective thinking and patterns of behavior • Change the way you think and the way you act • Cognitive reframing • Visualization • Rehearsal • Behavior chaining • Stepwise approach • Create structure • Minimize opportunities for error • Substitute • Relaxation • Desensitization • Cognitive Behavioral Therapy, 2011. Judith Beck • The Cognitive Behavioral Workbook for Weight Management, 2009. Laliberte • Skinny Thinking, 2010. Katleman-Prue

32. Relational/Interpersonal Therapy • Oriented towards emotional well being based on satisfying relationships with others • Emotional health requires authentic connection with others • Consider eating problems as a substitute for relationship • Is food a friend or lover? • What is the appropriate relationship with food? • Key Concepts • Connection • Disconnection • Violation • Authenticity • Relational Images • Basis for assumptions

33. Behavior and Lifestyle Modification – 5 As • “5 Major Steps to Intervention (The 5A’s)” – AHRQ • Agency for Healthcare Research and Quality • 5As approach is one way of organizing the behavioral approach to weight counseling, useful for documenting structured approach • Adopted by Centers for Medicare and Medicaid Services (CMS) as guideline for Medicare documentation • ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/5steps.html • obesitynetwork.ca/5As

34. Five Major Steps to Intervention – The 5 A’s

35. Intensive Behavioral Therapy – 5 A’s • Ask • Ask for permission to discuss weight. • Be non judgmental • Ask about health risk(s) and factors affecting choice of behavior change goals or methods. • Explore readiness for change, begin the conversation. • Assess • Assess stage of obesity • Assess Causes and Complications • Medications, Co-morbid conditions, financial limits • obesitynetwork.ca/5As

36. Intensive Behavioral Therapy – 5 A’s • Advise • Give clear, specific, and personalized behavior change advice, including information about personal health harms and benefits • Explain need for long term strategy • Advise on treatment options • Diet • Exercise • Lifestyle Modification • Medication management • Surgery • obesitynetwork.ca/5As

37. Intensive Behavioral Therapy – 5 A’s • Agree • Collaboratively select appropriate treatment goals and methods based on the beneficiary’s interest in and willingness to change the behavior • Assist • Assist the beneficiary in achieving agreed-upon goals • Schedule follow-up contacts • Assist with referrals • obesitynetwork.ca/5As

38. David K • Ask? Definitely ready to change, “tired of this!” • Assess: Class III Super Obese, Causes? Comorbids, Rx, … • Advise: Diet, exercise, lifestyle modify, how to change behavior • Agree: Collaborative plan / Accountability • Assist: Goals, Educ., Resources, Support, Referral

39. DAVID’s Problem List • DM Type 2 (oral) • HTN • OSA w/ CPAP at 18 cm • Gastritis, GERD • NAFLD • Umbilical hernia • Knee pain • Depression • Low Testosterone / ED (His Endocrin. Wants the LAGB first then Rx) • First degree AVB

40. DAVID’s Medications • Metformin 1000 mg BID and • Glyburide 5 mg BID • Prinizide (Lisinopril / HCTZ) 20/12.5 mg • Wellbutrin 150 SR and Zoloft 50 mg • ASA 81 mg • MVI

41. David’s vitals and weight 2012 • Wt 412 lbs on 1/17/2011, 382 lbs by Aug 2011 • BP 130/78 to 171 / 96 • Pulse 72 bpm • Resp 18 • Glucose 135 – 177 Hgb A1c 7.8% June 2012 • Microalb/creat 34.2 • Creat 0.79 • 2011 ALT 26 …. 2012 ALT now 43 • T.C. 130, Trig 100, HDL 35 • Free Test 4.9, SHBG 55.7, FSH 10.1

42. Sept 2012 MSWL • Regence required 6 months MSWL • 3 mo already completed in 2011 at Sound Health • Wt 354.9 lbs BMI 54 • REE 2733 Cal per day • DIET ?

43. Diet • Cornerstone of Obesity Treatment

44. Classification of Diets • Diets in weight management can be thought of in several ways: • Caloric Composition • Nutritional Composition • “Type,” or Brand

45. Diet – Nutritional CompositionMacronutrients • Low Fat • AHA, Ornish, Pritikin • Low Carb • Atkins • High Fat • Atkins • High Protein Names associated with diets are examples only

46. Diet – Type or Brand • Atkins • Protein Power • ZONE • LEARN (balanced cal. deficit) • ADA (diabetic) • South Beach • Weight Watchers • Jenny Craig • Nutrisystems • Optifast • HCG • Mediterranean • Body for Life • DASH • AHA • Pritikin • Ornish • “Whole Food, Plant Based” • Vegan • Vegetarian • Kosher • Halal

47. Diet – Is there a “Best” diet? • Diet should be individualized • All diets can be described in terms of caloric content and macronutrient content • Many different diets have strong adherents • Most obesity medicine specialists use some version of a reduced carbohydrate, high protein approach • All calories are not created equal

48. A to Z Weight Loss Study: A Randomized Trial • 12 month long, randomized • 311 Overweight and Obese Non Menopausal women • 4 Dietary Treatment arms • Atkins – Low Carb (<10%) • Zone – 40% Carb • LEARN – Traditional (Food Pyramid) 55-60% Carb • Ornish – Very Low Fat (<10%) Gardner, Chris. JAMA. 2007;297(9):969-977.

49. A to Z Weight Loss Study: A Randomized Trial Gardner, Chris. JAMA. 2007;297(9):969-977.

50. A to Z Weight Loss Study: A Randomized Trial • Weight Loss at 12 months • Atkins – Low Carb (<10%) • - 4.7 kg • Zone – 40% Carb • - 1.6 kg • LEARN – Traditional (Food Pyramid) 55-60% Carb • -2.2 kg • Ornish – Very Low Fat (<10%) • -2.6 kg Gardner, Chris. JAMA. 2007;297(9):969-977.