OBESITY: UPDATES AND MANAGEMENT. David J Howard, MD, PhD UNR Med School 10/6/2018

Transcription

1 OBESITY: UPDATES AND MANAGEMENT David J Howard, MD, PhD UNR Med School 10/6/2018

2 Objectives Understand the trends and approaches to patients with excessive weight Understand importance of Metabolic Adaptation following weight loss Appreciate the surgical and pharmaceutical options which may enhance weight loss

3 Description of the problem NHANES Data from % in Men; 41.1% in Women $ billion (~20% of medical spending) Pretty recent problem

4 Description of the problem

5 Description of the problem

6

7 Diet

8 Diet

9 Diet

10 Exercise

11 Energy Balance

12 Metabolic Flexability

13 Studies for Discussion Fothergill and Hall, 2016 Metabolic Adaptation (MA) Schauer et al, 2014 Bariatric Surgery v. Medical Management Rosenbaum and Leibel, 2016 Breakdown of Metabolic Adaptation

14 Biggest Loser Study 14 (of 16) Participants of Biggest Loser Program Aggressive / Rapid Weight Loss and Exercise Program Body Measurements / Metabolic Assessment at Baseline, 30 Weeks, and 6 Years

15 Metabolic Adaptation Variable Baseline 30 Weeks 6 Years BMI (kg/m 2 ) 49.5 ± ± ± 13.4 RMR meas. (kcal/d) Met. Adapt. (kcal/day) 2,607 ± 649 1,996 ± 358 1,903 ± ± ± ± 207

16 Metabolic Adaptation Suggests that Metabolic Adaptation is Long-Term / Life Long Reintroduction into Previous Environment is Challenging to Weight Maintenance

17 Metabolic Adaptation What can we do about this gap? Exercise! Likely 60 / Day High Intensity Probably Useful Helps with Depression (among other problems)

18

19 Interventions Medical Surgical

20 Medications Orlistat (~$90) Phentermine (~$40) Contrave (~$250) Belviq (~$260) Qsymia (~$240) Saxenda (~$1,385)

21 Types of Surgery Roux-en-y gastric bypass Sleeve gastrectomy Dual Balloon System

22 Types of Surgery

23 Surgery Stampede Trial Surgery Had Better Outcomes Than Medical Therapy Decreased %A1C Decreased BMI Fewer DM2 Meds

24 Surgery

25 Surgery Weight Loss is Profound Compared to Current Medical Management Surgery is not for Everyone and Carries Risks Long-Term, May Share Weakness of Medical Management

26 Take Home Lessons Weight Loss is Possible Maintenance is Challenging Lowered metabolic rate and persistant hunger signals Modest Weight Loss is a Victory And less likely to stimulate strong decrease in metabolic rate Medically Monitored Weight Loss Still Within Reach Requires addressing multiple patient factors Requires consistent exercise Requires persistent follow-up Surgery and Medications Should be Considered in Certain Patients

27 Sleep Stress Exercise Weight Diet Sedentariness Relationships

28 Take Home Lessons Call Us With Questions ( ) Karmella Thomas RDN, LD, CDE Karen Bain, RDN, LD, CDE

29 Questions?

30 References Ravussin E, Ryan D. Energy expenditure and weight control: Is the biggest loser the best loser. Obesity 2016;24(8): Magkos F, et al. Effects of moderate and subsequent progressive weight loss on metabolic functionsand adipose tissue biology in humans with obesity. Cell Metab 2016;23: Rosenbaum M, Leibel RL. Models of energy homeostasis in response to maintainence of body weight. Obesity 2016;24(8): Fothergill E, et al. Persistant metabolic adaptation 6 years after The Biggest Loser competition. Obesity 2016;24(8): Wadden T, et al. Effects of weight cycling on the resting energy expenditure and body composition of obese women. Int J Eating Dis 1996; 19(1):5-12. Muller M. Apative thermogenesis: do we need new thinking? Obesity 2016; 24(8): Schauer P, et al. Bariatric surgery versus intensive medical therapy for diabetes 3 year outcomes. NEJM 2014;370(21):

31 References (cont.) Sacks F, et al. Comparison of weight-loss diets with different compositions of fat, protein, and carbohydrates. JCEM 2009;360(9): Von Hippel P, Nahhas R. Extending the history of child obesity in the United States: the Fels longitudinal study, birth years Obesity 2013;21: Goodpaster B, Sparks L. Metabolic flexibility in health and disease. Cell Metab 2017, May: Loprinzi P, et al. Physical activity and dietary behavior in US adults and their combined influenced on health. Mayo Clin Proc 2014;89(2): Laskowski, E. Walking throughout your day keeps depression (and a host of other health problems) away. Mayo Clin Proc 2016; 91(8):