Overweight and Obesity on the Menu. Marwan Akel, Pharm. D, MPH Clinical Assistant Professor School of Pharmacy Lebanese International University

Transcription

1 Overweight and Obesity on the Menu Marwan Akel, Pharm. D, MPH Clinical Assistant Professor School of Pharmacy Lebanese International University

2 Prevention The most efficient and cost-effective approach Children, adolescents and adults Many people: Already require treatment Have co-morbidities Are at risk of further weight gain

3

4

5 Outline Introduction Principles Management Strategies Follow up

6 Overweight and Obesity Prevalence 2013 Institute for Health Metrics and Evaluation (IHME), 2013

7 Numbers in Lebanon Trends in overweight and obesity in Lebanon: evidence from two national cross-sectional surveys (1997 and 2009) Prevalence of obesity in adults: 17.4% in 1997 vs. 28.2% in 2009 The study findings : Alarming increase in obesity prevalence over the 12- year study period Importance of formulating policies and nutritional strategies to curb the obesity rise Nasreddine L, BMC Public Health Sep 17;12:798

8 Introduction Leading health concern Involving all ages and socioeconomic groups Weight is regulated through energy balance and appetite Associated with several chronic diseases, cancers, mental health and eating disorders

9 Obesity and Cancer The relationship between obesity and breast cancer? The relationship between obesity and endometrial cancer? The relationship between obesity and colorectal cancer? The relationship between obesity and kidney cancer? The relationship between obesity and esophageal cancer? The relationship between obesity and pancreatic cancer? The relationship between obesity and thyroid cancer? The relationship between obesity and gallbladder cancer? National Institute of health/ Cancer Institute

10 Introduction Weight gain is hard to avoid and difficult to reverse Unrealistic expectations Care should be centered on the needs of the patient: Culturally appropriate Non-judgmental Enables patient to participate in decision-making

11 Principles Healthcare professionals should recommend strategies for weight loss and provide continuing support Tailored approach is the most effective Goals should focus on: Behavior change Improved health Weight loss

12 Principles

13 Principles Genes Vs. Environment Genetics load the gun, the environment pulls the trigger Fit Vs. Fat Can you be both? Highly fit men with 2 or 3 risk factors had the same mortality risk as low fit men with no risk factors Barlow et al., Int J Obes Metab Disord, 19(suppl 4):41, 1995 and Wei et al., JAMA, 282: 1547, 1999)

14 Drivers of Weight Gain Biology Inheritability Epigenetic changes Early life experience Environment Food supply Portions Alcohol Urban design Disrupted sleep Individual Lifestyle and habits Psychological factors Mobility Society Economic disadvantage Rural and remote areas Culture

15 Need for a Guideline In 2012, 60% of Australian adults were overweight or obese, 25% of them are obese In 2010, more than 78 million adults in the US were obese Current estimates, 69% of adults are either overweight or obese, 35% of them are obese

16 Guidelines

17 Management Australian Canadian Ask Assess Advise Assist Arrange Ask Assess Advise Agree Assist Arrange

18 Ask Ask for permission to discuss weight Weight is a sensitive issue Patients may be embarrassed Patients fear blame

19

20 Ask Be non-judgmental: Do not blame or provoke guilt Do not make assumptions about lifestyle or motivation Do acknowledge that weight management is difficult Explore readiness for change: Use a collaborative approach If patient is not ready: waist of efforts

21 Ask Use motivational interviewing: Listen to patients Validate their experience Acknowledge that they are in control of the decision Create weight-friendly practice: Armless chairs Scales over 160 kgs Large blood pressure cuffs

22

23 Assess Obesity class Obesity related risks Potential causes of weight gain

24 Assess

25 Assess Considerations in interpreting BMIs in adults: Individuals with same BMI may have different ratios of fat to muscles People with high muscle mass => consider higher BMI threshold Women have more body fat than men at equivalent BMIs People lose lean tissue with age Fat distribution consideration: central

26 Assess BMI > 25 kg/m 2 : diet, exercise and behavioral modification BMI > 27 kg/m 2 + co-morbidities : diet, exercise and behavioral modification + pharmacotherapy BMI > 30 kg/m 2 : diet, exercise and behavioral modification + pharmacotherapy BMI > 35 kg/m 2 + co-morbidities : diet, exercise and behavioral modification + bariatric surgery BMI > 40 kg/m 2 : diet, exercise and behavioral modification + bariatric surgery

27 Assess Waist circumference: Better than BMI in predicting CV risks, DM2 and metabolic syndrome Increased risk of complications: > 80 cm in women > 94 cm in men High risk of complications: > 88 cm in women > 102 cm in men

28 Assess Current health behaviors: Dietary considerations: Healthy food? High energy food and soft drinks? Regular eating pattern? Snacks? Binge eating? Physical activity: Sedentary lifestyle? Attitude towards exercise?

29 Assess Drivers of weight gain Weight history: Age of onset Maximum and minimum weights Use of weight loss medications/surgeries Factors that may contribute to weight gain: Quitting smocking Medications

30 Assess Medication that Cause Weight Gain Use Atypical antipsychotics Schizophrenia, Bipolar disorder Oral contraceptives Contraception Beta Blockers (propranolol) Hypertension, Anxiety Insulin Diabetes Lithium Bipolar disorder Pizotifen Migraine, cluster headache Valproic acid Epilepsy Sulphonylureas DM2 Thiozolidinediones DM2 Tricyclic antidepressants Depression Anabolic steroids Various endocrine disorders

31 Advise Obesity risks Benefits of even modest weight loss Need for long term strategy

32 Advise Reduced cardiovascular risk: Reduced systolic blood pressure with weight loss of at least 2 kgs Improvement of lipid profile with sustained loss Reduced cardiovascular and all cause mortality Prevention and improvement of DM2: Delayed progression Improved blood glucose control

33 Advise Improved conditions: Chronic kidney disease Obstructive sleep apnea GERD Osteoarthritis Improved quality of life: Mobility and physical performance Self esteem Depression

34 Advise Life expectancy: Mean loss of 7 years of life per obese individual Comparable to years lost from smoking

35 Assist Promote and sustain weight loss by: Non-pharmacological Pharmacological Surgical

36 Assist Sleep and time management Dietary interventions Physical activity Behavioral/Psychological aspects Low calorie diets Anti-obesity medications Bariatric surgeries

37 Assist Sleep regulation: Hormonal balance Rest Energy Time management: Physical activity Sleeping time Food preparation

38 Assist Dietary intervention: Decrease caloric intake (by 500 kcal/day) Reduce rather than restrict fats and sugars Look at the energy content Organize eating pattern Adjust portion size Choose a hygienic diet Investigate about alcohol consumption

39 Assist Reduced-calorie diets result in clinically meaningful weight loss regardless of which macronutrient they emphasize Sacks, F. M., Bray, G. A., Carey, V. J., et al.,(2009). NEJM, 360(9),

40 Assist Physical activity: Aim is to decrease sedentary lifestyle rather than burning calories Alone is not recommended for weight loss Promote fitness and general well-being min of moderate intensity or min of vigorous intensity per week Transportation: cycling, skating or walking to work Evidence of a specific duration is unclear: lifelong

41 Assist Behavioral: Goal setting Self-monitoring Adherence Relapse prevention Psychological: Emotional eating Food coping strategies

42 Assist Low calorie diets: 800 kcal Medically supervised Only in patients requiring urgent weight loss Meal replacements Adverse effects: cold intolerance, dry skin, hair loss, headaches, fatigue, and dizziness 8-16 weeks only

43 Assist Drug Dosage MOA Status SE CI Phentermine 37.5 mg/day Pharmacological intervention: Table NE Releasing 1960s CNS, CV, GI, Endocrine Diethylpropion 75 mg/day NE Releasing 1960s CNS, CV, GI, Endocrine Orlistat TID Lipase Inhibitor Lorcaserin 10 mg BID 5HT2c Agonist Phentermine/ Topiramate Naltrexone/ Bupropion 7.5 mg P/ 46 mg T ER daily 32 mg/ 360 mg 2 tabs QID GABA Modulation/ NE Releasing Opioid Ant/ DA reuptake Inhibitor 1999 Fat Soluble Vit, GI 2012 HA, Dry mouth, Constipation 2012 Insomnia, Dry mouth, Constipation 2014 Nausea, HA, Constipation Liraglutide 3 mg Inj GLP1 agonist 2014 Nausea, Vomiting, Pancreatitis CV diseases Seizure CV diseases Seizure Malabsorption Preg/Lactation Preg/Lactation Caut: Antidep, Triptans Preg/Lactation, Hyperthyroidism, glaucoma Seizure, Bulimia, Uncontrolled HTN, Anorexia, Subs Withdrawal Medullary Thyroid CA

44 Assist

45 Assist In patients with uncontrolled HTN or history of heart disease: recommend against using sympathomimetics Assess efficacy of drugs monthly for the first 3 months than at least every 3 months Response is deemed effective if weight loss is > 5% of body weight at 3 months If response is ineffective or there are safety and tolerability issues: consider alternative options

46 Assist Initiate therapy with dose escalation based on efficacy and tolerability Do not exceed the upper approved dose boundaries In Patients with DM2, use anti-diabetic medications that promote weight loss like GLP1 analogs in addition to metformin Effective as adjunctive treatment

47 Assist Bariatric surgeries: Adjustable Gastric Banding Sleeve Gastrectomy Roux-en-Y gastric bypass Biliopancreatic Diversion

48 Assist / Agree Developing an appropriate management plan: Addresses the drivers of obesity Improves in health Is tailored to the individual Considers when and to whom to refer On weight loss expectations: kg per week at first Expect a plateau

49 Assist / Agree On sustainable goals and health outcomes: SMART: S: Specific M: Measurable A: Achievable R: Rewarding T: Timely

50 Arrange Early review of the suitability of the plan Continuing support Education sessions and resources availability Long term management Follow ups

51 Key Principles Obesity is a chronic progressive condition Management is about improving health and well being, and not simply reducing numbers on scale Early intervention is crucial but it is never too late to address the problem Success is different for every individual Best weight may not be ideal weight

52 Successful Strategies Maintain high level of physical activity Follow a reduced calorie diet Have breakfast regularly Maintain a consistent life pattern: eating, sleeping, exercising Avoid emotional eating Monitor weight frequently Catch lapses before they become large-scale gains

53

54 Overweight and Obesity à la Carte Thank You