1 / 78

3 Steps to Successful Obesity Management

3 Steps to Successful Obesity Management. Learning objectives. Review recent findings about the biologic regulation of eating and weight control Discuss the clinical recommendations and benefits of sustained weight loss in overweight and obese patients

langham
Download Presentation

3 Steps to Successful Obesity Management

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. 3 Steps to Successful Obesity Management

  2. Learning objectives • Review recent findings about the biologic regulation of eating and weight control • Discuss the clinical recommendations and benefits of sustained weight loss in overweight and obese patients • Apply principles of motivational interviewing and shared decision-making to improve the clinical management of obesity and promote behavioral changes • Understand current guidelines for managing obesity, including the role of pharmacological therapy as an adjunct to lifestyle changes in reducing weight gain and promoting weight loss • Review reimbursement options for intensive behavioral therapy (IBT) in obesity management

  3. Disclosures • Brought to you as a medical education collaboration between the Louisiana Academy of Family Physicians and the Endocrine Society. • Developed by Knighten Health. Supported by an unrestricted educational grant from Novo Nordisk Inc. • James Campbell, MD: No relevant financial relationships with any commercial interests

  4. Challenge #1: Scope of the Obesity Epidemic and Limited Provider Resources 1 in 3 American adults are obese The Obesity Belt: Obesity prevalence > 30% 80 million Source: Prevalence of Self-Reported Obesity Among U.S. Adults: “The Obesity Belt” BRFSS, 2013 Sources: Behavioral Risk Factor Surveillance System, 2012, CDC; U.S. Census Bureau, 2012 QuickFacts

  5. 16,526 obese adults for every Endocrinologist Based on Endocrine Clinical Workforce: Supply and Demand Projections, Endocrine Society, April 2013. 409 obese adults for every HCP

  6. Challenge #2: Health Care Providers Rarely Treat Weight First Idiopathic intracranial hypertension Stroke Pulmonary disease Abnormal function Obstructive sleep apnea Hypoventilation syndrome Cataracts Coronary heart disease Diabetes Dyslipidemia Hypertension Nonalcoholic fatty liver disease Steatosis Steatohepatitis Cirrhosis Gall bladder disease Severe pancreatitis Gynecologic abnormalities Abnormal menses Infertility Polycystic ovarian syndrome Cancer Breast, uterus, cervix, colon, esophagus, pancreas, kidney, prostate Osteoarthritis Phlebitis Venous stasis Skin Gout

  7. Challenge #3: Resources needed for obesity management

  8. Weight First Initiative Addresses the 3 Challenges • Enlist primary care practitioners to fight the obesity epidemic through medical management • Use motivational interviewing techniques and multiple therapeutic options to treat weight first • Support primary care practitioners with practical information and resources for treating obesity

  9. MI 3 components of the pilot: WA ID MT ME MN ND • Faculty and Primary Care leaders workshop obesity management curriculum. Primary Care participants receive CE credits. OR WI NY 1 SD WY CA NV PA IA UT NE OH IL INTERPROFESSIONAL TRAINING & WORKSHOP IN CO WV MO VA KS KY WED, MARCH 30, 9AM-3:30PM WESTIN, BOSTON WATERFRONT HOTEL AZ NC NM TN OK TX AR SC GA AL MS LA FL Region V 2 3 pilot region • Primary Care leaders give presentations at state and regional association meetings • CME credit for attendees • www.treatweightfirst.com • Enduring materials on program microsite • CME credit available

  10. The case for putting weight first

  11. How much body weight does a patient with obesity need to lose to lower his or her risk of health problems and death? • 10% • 25% • 3% • 8%

  12. Obesity is a complex and multifactorial disease1-6 1. Woods SC et al. Int J ObesRelatMetabDisord. 2002;26(suppl 4):S8-S10. 2.Ludwig DS. JAMA. 2014;311:2167-2168. 3. Speliotes EK et al. Nat Genet. 210;42:937-948. 4. Garvey WT et al. EndocrPract. 2014;20:977-989. 5. Bray GA, Ryan DH. Ann NY Acad Sci. 2014;1311:1-13. 6. The Obesity Society Infographic Task Force, November 2015. http://www.obesity.org/obesity/resources/facts-about-obesity/infographics. Accessed December 10, 2015. Gut microbiota Fat cells Genetics/epigenetics Expenditure Intake Energy balance Medications Environment

  13. Obesity is “getting worse in this country,” rapidly Ogden CL, Carroll MD, Flegal KM. JAMA. 2014 Jul;312(2);189-90.

  14. Overweight and Obesity Increase Risk of Disease Ogden CL, Carroll MD, Flegal KM. JAMA. 2014 Jul;312(2);189-90. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity Obes Res. 1998;6(suppl 2). Waist Circumference: Men > 40 in, Women > 35 in Disease risk relative to normal weight and waist circumference High Very High Extremely High

  15. As little as 3% - 5% weight loss reduces the risk of disease Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity Obes Res. 1998;6(suppl 2). Waist Circumference: Men > 40 in, Women > 35 in Disease risk relative to normal weight and waist circumference High Very High Extremely High

  16. Why is losing weight and keeping it off so difficult?

  17. Obesity as an endocrine-related disease • Under normal conditions, food intake and energy expenditure are balanced by a homeostatic system that maintains stability of body fat content over time. • Obesity results through a perturbation in CNS regulation of energy homeostasis. Morton GJ, Meek TH, Schwartz MW. Nat Rev Neurosci. 2014 Jun;15(6):367-78. American Medical Association (AMA) recognizes obesity as a disease: • It is a multi-metabolic and hormonal disease state • It has characteristic signs and symptoms • Increase in fat mass associated with obesity is directly related to comorbidities such as type 2 diabetes mellitus, cardiovascular disease, and some types of cancer • Disease results through a perturbation in the central nervous system (CNS) regulation of energy homeostasis

  18. Multiple hormonal signals influence hypothalamic neurons and appetite1-3 1. Woods SC et al. Int J ObesRelatMetabDisord. 2002;26(suppl 4):S8-S10. 2.Suzuki K et al. Exp Diabetes Res. 2012;2012:824305. 3. ValassiE et al. NutrMetabCardiovasc. 2008;18:158-168. StomachGhrelin Increases appetite Suppresses appetite Appetite Fat cellsLeptin GutGLP-1, CCK, PYY PancreasInsulin, Amylin

  19. Physiology of reduced obese state Metabolic and hormonal changes drive weight regain The metabolic handicap: reduction in energy expenditure disproportionate to weight reduction. Mr. Smith 220 pounds needs 2200 kcal/day Mr. Jones 200 pounds needs 2000 kcal/day Loses weight to 200 pounds Needs 1830 kcal/day ↑ hunger, ↓satiety ≠ Smith Jones

  20. Long-term persistence of hormonal adaptations to weight loss Sumithran P et al. N Engl J Med. 2011;365:1597-1604. Changes in Weight from Baseline to Week 62 11 lbGAIN 30 lb LOSS 10 week weight-loss program

  21. 14% weight loss produced changes in 8 hormones that encourage weight regain Sumithran P et al. N Engl J Med. 2011;365:1597-1604. Mean fasting and postprandial levels of some peripheral signals at baseline and 62 weeks • 10-week, lifestyle-based weight loss intervention in healthy overweight and obese adults (n=34) led to • sustained elevations in appetite stimulating hormone(s) and • decreases in appetite suppressing hormones • Netresult of these hormonal changes is WEIGHT GAIN!

  22. What are the risks of overweight? How much weight loss is needed for health benefit?

  23. Obesity and comorbidities Idiopathic intracranial hypertension Stroke Pulmonary disease Abnormal function Obstructive sleep apnea Hypoventilation syndrome Cataracts Coronary heart disease Diabetes Dyslipidemia Hypertension Nonalcoholic fatty liver disease Steatosis Steatohepatitis Cirrhosis Gall bladder disease Severe pancreatitis Gynecologic abnormalities Abnormal menses Infertility Polycystic ovarian syndrome Cancer Breast, uterus, cervix, colon, esophagus, pancreas, kidney, prostate Osteoarthritis Phlebitis Venous stasis Skin Gout

  24. Modest weight loss has benefits, with greater weight loss associated with greater benefit See speaker notes for references.

  25. Why is modest weight loss beneficial? Adapted from: Després J, et al. BMJ. 2001;322:716-720. SCAT = Subcutaneous Adipose Tissue VAT = Visceral Adipose Tissue 10% weight loss = 30% VAT Loss VAT VAT SCAT SCAT Abdominal obesity, increased waist circumference After weight loss, reduced waist circumference Increased risk Lowered risk

  26. Summary (Risks of overweight & obesity, Benefits of weight modest weight loss) • Obesity is associated with an increased risk for coronary heart disease, type 2 diabetes, various types of cancer, gallstones, and disability. • Obesity is associated with an increased risk for death, particularly in adults younger than 65 years. • The risk of disease increases with BMI and waist circumference. • Weight loss as little as 3% - 5% in obese individuals is associated with a lower incidence of health problems and death.

  27. Obesity is a disease, but are we talking about it? Post RE et al. Arch Intern Med. 2011;171(4):316-321 Kraschnewski JL et al. Med Care. 2013;51:186–92. Eaton CB, Am J Prev Med. 2002 Oct;23(3):174-9. Wadden TA et al. JAMA. 2014 Nov 5;312(17):1779-91 USPSTF recommends screening all adults for obesity yet: • A third of patients with a BMI ≥ 30 were never told by their doctors that they have obesity • Rates of physician counseling appear to be decreasing, by as much as 25 percent. Those rates are worse for patients with obesity co-morbidities • Family practitioner–patient conversations about nutrition last an average of 55 seconds • Intensive behavioral counseling can induce clinically meaningful weight loss, but there is little research on primary care practitioners providing such care

  28. How much body weight does a patient with obesity need to lose to lower his or her risk of health problems and death? • 10% • 25% • 3% • 8%

  29. STEP 1: Talk to patients about obesity Motivational interviewing and shared decision-making with patients

  30. What is the first thing you should do when discussing weight with patients? • Recommend a diet. • Ask permission to discuss weight. • Ask about their exercise routines. • Explain a high BMI's health risks.

  31. Meet Rosalia: Working mom with a family history of type 2 diabetes • CC: in for annual visit. • SH: 49-year-old office manager for Blue Cross, recently promoted, divorced, 2 children • Does not smoke or drink • Took paroxetine around time of divorce for depression – continues on it. • Her father has T2DM and is on dialysis; She says “I know this runs in families and I don’t want it to happen to me. • Meds: Has been on paroxetine since her divorce 4 years ago, asymptomatic. Workup • Height: 5’8”; weight: 223 lbs; BMI: 34 kg/m2 (comments: “I need to lose at least 80 pounds”) • BP: 130/80 mm; pulse: 70 bpm, Resp: WNL • Mammogram report: normal • Lab Chem Survey: glucose 107, A1c 5.8%, otherwise normal. Cholesterol 238, HDL 64, TG 124, LDL 149. CBC & UA normal. TSH 3.91. Pap smear normal.

  32. How do you think about your patients’ weight struggles? What you might think: She needs to lose at least 80 pounds. I need to start her on metformin, advise her to lose weight and see her back in a year. She can lose weight by just eating a bit less and exercising a bit more. I will tell her about healthy lifestyle. If she struggles, she just needs more resolve. She doesn’t need medications. She can do this on her own. The reality: She can greatly reduce her risk for diabetes with loss of just 11 - 22 pounds. She can improve risk for diabetes, BP, and lipids with weight loss. This needs to be the first and central approach. Weight loss requires skills training. The more intensive the coaching, the greater the chance of meaningful weight loss. Some of her medications caused her to gain weight. She may need help with medications both to lose weight and to address biologic adaptations to weight loss.

  33. The 5As of Obesity Management Vallis M, et al. Can Fam Physician. 2013;59:27-31;​ Meriwether RA, et al. Am Fam Physician. 2008;77(8):1129-3.

  34. Talk to Rosalia using the 5 As of obesity management Ask:“Let’s talk about your exam. Your mammogram is normal and your exam, and most of your tests are fine. But your blood sugar and A1c are higher than we like to see. This is pre-diabetes. The single best thing you could do for your health would be to make some lifestyle changes that produce some weight loss. Is today a good time to talk about your weight?” Rosalia: “Yes, we can talk about it. I know I need to lose weight – at least 80 pounds. I don’t want to end up like my father.” You: I’m glad to hear you are taking this seriously. We can talk about a goal later, but the good news is that you can improve your diabetes risk with 11-22 pounds loss. Let me ask you a few questions to get started.” What if she says, “No”? Assess: • Comorbidities (sleep apnea symptoms, depression symptoms) • Drivers of weight gain (medications including OTC; sleep deprivation, stress) • Complications and Barriers to weight loss success. • Current lifestyle. • What has worked in the past. • What hasn’t worked in the past.

  35. Motivational interviewing (OARS Strategy)

  36. Talk with Rosalia using OARS motivational interviewing strategy Clinician (you): You mentioned 80 pounds, but losing 11-22 pounds and even as little as 8 pounds can reduce your risk. How do you feel about that statement? Or, “What are some of your thoughts on losing weight?" Health is the right reason to make lifestyle changes. You CAN decrease your diabetes risk. Regaining weight is the result of our bodies’ natural defenses. It’s not your fault. It sounds like you are saying you need some help with maintaining lost weight. What do you think about that? That’s one option we can discuss for our long term strategy. I’m hearing that you’ve struggled with weight and recognize how it is affecting your health and quality of life. Ok. Now, let’s discuss some strategies to develop a long-term plan to help you address your concerns Rosalia: I know I can do it because I have done it before. With Weight Watchers online once. I lost 10 pounds in 3 months. I also did Jenny Craig with even more weight loss. I know I will never be skinny, but I want to be healthy and be around for my kids. Yes, but I can’t keep it off, so I wasn’t successful. Yes. I don’t think I can do it without help. I might need something. What about medication? OK! O A Open-ended Affirmative Reflections Summary R S

  37. Talking to patients about weight: Patient-centered communication Keys to Successful Conversations Preventing Weight Bias. Module 2: Helping Without Harming in Clinical Practice. The Rudd Center for Food Policy and Obesity. Yale University.

  38. Summary Vallis M, et al. Can Fam Physician. 2013;59:27-31;​ Meriwether RA, et al. Am Fam Physician. 2008;77(8):1129-3.​

  39. What is the first thing you should do when discussing weight with patients? • Recommend a diet. • Ask permission to discuss weight. • Ask about their exercise routines. • Explain a high BMI's health risks.

  40. STEP 2: Manage obesity with a toolbox of options Guidelines on Pharmacologic Management of Obesity

  41. When should you consider an obesity medication for patients? • To help a patient better adhere to a healthy-eating plan • To help a patient who has lost weight with healthy eating habits and physical activity keep the lost weight off • To help a patient lose more weight than they might lose on their own • All of these

  42. Weight management intensification options Patients with low risk should have lower intensity, lower risk approaches. Higher risk approaches are justified when patients have more complicated obesity. 1. Jensen et al. Circulation 2014;129(25 Suppl 2):S102-38; 2. Courcoulas et al. JAMA 2013;310:2416-2425; 3. LABS consortium. N Engl J Med 2009;361:445-54. Mean Weight Loss 16% 0% 3% 8% 12% 32% Lifestyle plus Obesity Medications Diet and Lifestyle1 Gastric Bypass or Sleeve2 Gastric Band2 From LABS3: Perioperative DVT, thromboembolism or death 1% for gastric band 5% for bypass

  43. Obesity management: A chronic disease requiring life-long care Considerations for patients at different obesity stages Jensen MD, et al. Obesity. 2014;22(S2):S1-S410 Apovian CM et al. J ClinEndocrinolMetab, February 2015, 100(2):34 • Stage 0 obesity • BMI 25-30 or ≥ 30, but no complications/comorbidities • Lifestyle modification, healthy eating, and physical activity • Self-directed weight loss with reduced calorie meal plan and physical activity • Follow patient for development of obesity associated risks. • Stage 1 obesity • BMI ≥ 27 with co-morbidity • Address drivers of weight gain: transition off drugs for co-morbidities that cause weight gain and eliminate other drivers of weight gain • Intensive comprehensive lifestyle intervention • Consider adding weight loss medications to lifestyle therapy program • Stage 2 obesity • BMI ≥ 40 or ≥ 35 with co-morbidity • Unsuccessful with therapies that are less intensive • Consider bariatric surgery • Discuss bariatric surgery • Refer for bariatric surgery evaluation

  44. Pharmacological Management Of Obesity: An Endocrine Society Clinical Practice GuidelineJanuary 15, 2015 Apovian C, Aronne LJ, et al. J ClinEndocrinolMetab. 2015 2015 Feb;100(2):342-62.

  45. Common Medications for Chronic Diseases Associated with Weight ? represents uncertain/under investigation. Apovian CM, et al. J ClinEndocrinolMetab. 2015;100:342-62

  46. Who Qualifies for Obesity Medications? Apovian CM et al. J ClinEndocrinolMetab, February 2015, 100(2):34 We need obesity medications to: • help patients better adhere to their dietary plan • help more patients achieve meaningful weight loss • produce more weight loss so that health benefits will be greater • help patients sustain lost weight Recommendation: Prescribe as an adjunct to diet, exercise and behavior modification for individuals: • with BMI 30+; or 27+ with comorbidity; • who are unable to lose and successfully maintain weight; and • who meet label indications. Strong recommendation based on High quality evidence

  47. Where obesity treatments work: Gut hormone and neuroendocrine targets Mendieta-Zero´n H, Lo´pez M , Die´guez C. Gen Comp Endocrinol. 2008 Feb 1;155(3):481-95. doi: 10.1016/j.ygcen.2007.11.009. Epub 2007 Nov 21. Appetite Suppressing DrugsHypothalamus FDA approved drugs • Naltrexone/Bupropion • Liraglutide 3 Mg • Phentermine/ Topiramate • Lorcaserin • Orlistat Vagal Blocking Device Vagus nerve LAGB surgery Stomach Lipase Inhibitors (Orlistat) Intestines Gastric Bypass, BPD Gastric Sleeve surgeries Intestines Fat Metabolism Drugs (Beloranib) Adipose Tissue

  48. FDA-approved medications and how they work http://www.accessdata.fda.gov/scripts/cder/drugsatfda/http://www.accessdata.fda.gov/scripts/cder/drugsatfda/

  49. Medications approved for chronic weight management – safety and tolerability All data from product label

  50. Weight loss effects and effects independent of weight loss SNRI, serotonin–norepinephrine reuptake inhibitor; SSRI, selective serotonin reuptake inhibitor; MAOI monoamine reuptake inhibitor; BP blood pressure HR heart rate; http://www.accessdata.fda.gov/scripts/cder/drugsatfda/http://www.accessdata.fda.gov/scripts/cder/drugsatfda/

More Related