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Obesity & Metabolic Syndrome: Fat Brothers in Arms. By: Dr. Samuel N. Grief, MD Assistant Professor and Nutrition Educator University of Illinois at Chicago Dept. of Family Medicine Nov.11, 2003. Goals/Objectives. 1. Review BMI 2. Definitions of obesity/metabolic syndrome
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Obesity & Metabolic Syndrome: Fat Brothers in Arms By: Dr. Samuel N. Grief, MD Assistant Professor and Nutrition Educator University of Illinois at Chicago Dept. of Family Medicine Nov.11, 2003
Goals/Objectives • 1. Review BMI • 2. Definitions of obesity/metabolic syndrome • 3. Billing codes for obesity/metabolic syndrome • 4. Treatment of obesity • 5. Conclusion
Body Mass Index (BMI) • BMI defined as: Weight (kg) Height (m2) • BMI replaces the Metropolitan Life height/weight tables. • BMI correlates significantly with body fat, morbidity and mortality. • May be an overestimate in very muscular individuals.
Definition of Obesity Using Body Mass Index Classification BMI (kg/m2) Underweight < 18.5 Normal Weight 19 - 24.9 Overweight 25 - 29.9 Class I Obesity 30 -34.9 Class II Obesity 35 - 39.9 Class III Obesity 40 NHLBI Clinical Guidelines on the Identification, Evaluation and Treatment of Overweight and Obesity in Adults-the Evidence Report. Obesity Research 1998:(suppl.) 53S.
Increase in the Prevalence of Obesity in Adults (Aged 20-74) Flegal KM et al. Overweight and obesity in the US- Prevalence and Trends. 1960-1994. Int J Obesity 1998;22: 39-47.
Body Fat Distribution • People store body fat in two general ways; either above or below the waist. • In both men and women, excess intra-abdominal adipose tissue correlates strongly with cardiovascular disease, dyslipidemia, hypertension, stroke and type 2 diabetes. • Documenting body fat distribution, in conjunction with BMI, is important to assess risk.
Prevalence of Metabolic Syndrome • 22% of US adults have the metabolic syndrome • 43.5% rate among US adults aged 60-69 • Mexican Americans had the highest prevalence of the metabolic syndrome (31.9%) JAMA, January 16, 2002, Vol.287, No.3, pp. 356-359
Definition of Metabolic Syndrome • At least three of the following five criteria: • 1. Abdominal obesity: waist circumference > 102 cm in men and > 88cm in women; • 2. Hypertriglyceridemia: > or = to 150mg/dl • 3. Low HDL: <40 mg/dl in men, <50 in women • 4. High BP: > or = 130/85 mm Hg • 5. High FBS: > or = 110 mg/dl JAMA, January 16, 2002, Vol.287, No.3, pp. 356-359
Billing for Obesity/Metabolic Syndrome • ICD-9 codes: 278.00, 278.01 and 277.9 • Code whenever possible • Expect reimbursement for obesity more often than not • Metabolic syndrome not as well-known among insurance companies • Conclusion: The more you bill, the more likely we all get paid for our services
Case Presentation • 36 y.o. Hispanic female presents for annual gyne and pap exam. Hx of mild intermittent asthma on albuterol. States she would like to lose weight; has tried Atkins diet which worked initially, but she missed the carbs! • ROS: Regular menses, G2P2, vision normal, does notice occasional green-brown nipple d/c bilaterally for about one year.
Case Presentation • O/E: Height 5’6”, Weight 238.5 lbs • BMI: 42 • Waist circumference 38 inches • BP: 130/88 • Rest of exam normal.
Case Presentation Labs: • Cholesterol 140 • Triglycerides 190 • HDL 27 • LDL 75 • Glucose 115 • TSH 1.13 • Prolactin 12.7 • LFTs, rest of chem panel wnl.
Case Presentation • Diagnoses: • Mild intermittent asthma AND • Morbid obesity • Hypertriglyceridemia • Hyperglycemia • Elevated blood pressure OR Metabolic Syndrome
Case Presentation • Treatment Plan: • Dietary advice (diet diary, nutrition counseling, etc.) • Prescription weight loss medicine • Exercise prescription • Follow-up in one month
Body Fat DistributionWaist Circumference • Measured at the mid-point between the iliac crest and the lower rib. • Correlates strongly with intra-abdominal adipose tissue as assessed by CT and MRI. • Upper body obesity defined as a waist circumference: • > 40 inches for men • > 35 inches for women
Obesity-Related Co-Morbidities • CVD, HTN, type 2 diabetes, dyslipidemia • Ischemic stroke • Respiratory problems • Gallbladder disease • Arthritis (DJD) • Cancer • Sleep apnea • Gynecological irregularities
Health Benefits of Weight Loss • Weight loss of 5% to 10% in obese individuals with type 2 diabetes, HTN or dyslipidemia results in: • Improved glycemic control • Reduced blood pressure • Improved lipid profile • Goldstein DJ. Int J Obesity 1992;15:397-415. Wing RR, et al. Arch Int Med 1987;147:1749-1753
Etiology of Obesity Dietary Intake • Increased caloric intake by 220 calories from1970 to 1990. • Increased portion sizes (“super-size”) • Increased frequency of eating outside the home • Fat-free foods perceived as low calorie or calorie free • Increased fast food consumption Ernst N. Am J Clin Nutr 1997;66(suppl):965S-72S.
Etiology of ObesityPhysical Activity • Increased use of labor saving devices. • Decrease in the energy cost of everyday activities.
Etiology of Obesity Labor Saving Devices • Tele-commuting Personal computers • Cellular phones Internet / E-mail • Food deliveries E-Commerce • Escalators/elevators Pay per view movies • Computer games Moving sidewalks • Drive-in windows Garage door openers • Intercoms Remote controls
Treatment of Obesity • Behavioral • Pharmacological • Surgical • Self help programs and books
Treatment of ObesityPharmacological Therapy • Pharmacological interventions to facilitate weight loss and behavior change include: • Enhancing satiety • Decreasing fat absorption • Increasing energy expenditure • Decrease appetite
Orlistat (Xenical): Mechanism of Action • Activity occurs in the stomach and small intestine. • Inhibits gastric and pancreatic lipases. • 30% of ingested fat is unabsorbed and excreted. • Minimal systemic absorption. • Low-fat diet ( 30%) required to minimize side effects.
Orlistat (Xenical)Summary of Research Findings Sjostrom L et al. Lancet 1998;352:167-172.
Orlistat (Xenical)Summary of Reported Adverse Events Adverse Events Overall Incidence(% of Patients) Oily spotting 26.6 Flatus with discharge 23.9 Fecal urgency 22.1 Oily stool 20.0 Oily evacuation 11.9 Increased defecation 10.8 Fecal incontinence 7.7
Orlistat (Xenical)Prescribing Information • 120 mg TID with meals containing fat. • Patients should be on a nutritionally balanced, low-fat diet (< 30%) to minimize side effects. • Prescribe multivitamin to be taken at least two hours before or after the medication. • Orlistat is contraindicated for pregnant or lactating women, and those with chronic malabsorption syndromes or cholestasis.
Sibutramine (Meridia) Mechanism of Action • Serotonin and norepinephrine re-uptake inhibitor SNRI). • Animal research data shows drug reduces body weight by: • Decreasing food intake in rats • Stimulates thermogenesis in rats
Sibutramine (Meridia)Summary of Reported Adverse Event Percent (%) of Patients Adverse Event Placebo (n = 884) Sibutramine (n=2068) Dry mouth 4 17 Anorexia 4 13 Constipation 6 12 Insmnia 5 11 Appetite increase 3 9 Dizziness 4 7 Nausea 3 6 Package insert data, Sibutramine, 1998.
Sibutramine (Meridia) Prescribing Information • For patients with BMI > 30 or > 27 in the presence of risk factors. • 5 to 15 mg per day. • Not for patients on SSRIs (e.g. Paxil, Zoloft, Prozac) • Not for patients with poorly controlled hypertension, history of coronary artery disease, CHF, arrhythmia or stroke. • Regular BP and heart rate monitoring required.
Surgical Treatment of Obesity • Patient selection criteria • BMI > 40 or > 35 for those with weight related co-morbidities. • History of failed conservative weight loss approaches. • No substance abuse and/or psychiatric disorders. • Surgical options • Vertical banded gastroplasty (VBG) • Gastric bypass (GBP) • Outcomes • Weight loss is 25% to 35% of initial weight. • Weight loss is generally well maintained. • Significant improvement in co-morbidities.
Weight Change New Criteria for Success • According to the Institute of Medicine’s report, Weighing the Options: • Successful long-term weight control by our definition means losing at least 5% of body weight and keeping it below our definition of significant weight loss for at least one year. • Weight loss of only 5% to 10% of body weight may improve many of the problems associated with overweight, such as high blood pressure and diabetes. Thomas P (ed). Weighing the Options. Washington, DC: IOM, National Academy Press,1995
Reasons for Abandoning Ideal Weight with Significantly Overweight People • Most cannot achieve ideal weight, even with most aggressive approaches. • Most cannot maintain losses >15% of initial body weight without surgery. • Losses of 5% to 10% of body weight are associated with significant health improvements.
Helping Patients Accepts More Modest Weight Loss • Be clear about what treatment can and cannot do. • Discuss biological limits. • Focus on non-weight outcomes. • Be empathetic about dissatisfaction with weight and shape.
THANK YOU! • Have a good night!