Screening and Management of Obesity

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1 Screening and Management of Obesity Ray Plodkowski, MD Chief Endocrinology and Metabolism VA Sierra Nevada Health Care System, Reno and Medical Director: University of Nevada School of Medicine Division of Endocrinology, Nutrition, and Metabolism Weight Loss Clinic (775)

2 Body Mass Index (BMI) The clinical standard for weight-for-height estimations Body wt (in kg) / [Ht (in meters)] 2 or Body Wt (in lb) / [Ht (in in] 2 X 703.1

3 WHAT IS YOUR BODY MASS INDEX? Chart from CDC: For Adults, aged 20 years and older

4 BMI Clinical Guidelines* Classification BMI (kg/m 2 ) Underweight < 18.5 Normal Weight Overweight Class I Obesity (Mild) Class II Obesity (Moderate) Class III Obesity (Extreme) 40 *NHLBI /NIDDK, NIH. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. The Evidence Report. NIH Publication No , Sept. 1998

5 Why Body Mass Index (BMI)? Wt (kg)/ht (m 2 ) New definitions for overweight and obesity Related to health risk (morbidity & mortality) Simple, inexpensive, noninvasive Nomograms available

6 Limitations of BMI Does not distinguish between high weights due to large muscle mass or edema Can misclassify muscular persons as being overly fat Does not reveal differences in fat distribution (visceral vs. subcutaneous) Does not differentiate between men and women Is not accurate when height is compromised (kyphosis, scoliosis) Should not be used for children < 2 years of age Clinical judgment needed (frail elderly, etc.)

7 Obesity Trends* Among U.S. Adults BRFSS, 1985 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14%

8 Obesity Trends* Among U.S. Adults BRFSS, 1986 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14%

9 Obesity Trends* Among U.S. Adults BRFSS, 1987 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14%

10 Obesity Trends* Among U.S. Adults BRFSS, 1988 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14%

11 Obesity Trends* Among U.S. Adults BRFSS, 1989 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14%

12 Obesity Trends* Among U.S. Adults BRFSS, 1990 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14%

13 Obesity Trends* Among U.S. Adults BRFSS, 1992 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19%

14 Obesity Trends* Among U.S. Adults BRFSS, 1993 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19%

15 Obesity Trends* Among U.S. Adults BRFSS, 1994 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19%

16 Obesity Trends* Among U.S. Adults BRFSS, 1995 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19%

17 Obesity Trends* Among U.S. Adults BRFSS, 1996 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19%

18 Obesity Trends* Among U.S. Adults BRFSS, 1997 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20%

19 Obesity Trends* Among U.S. Adults BRFSS, 1998 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20%

20 Obesity Trends* Among U.S. Adults BRFSS, 1999 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20%

21 Obesity Trends* Among U.S. Adults BRFSS, 2000 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20%

22 Obesity Trends* Among U.S. Adults BRFSS, 2001 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% 24% 25%

23 Obesity Trends* Among U.S. Adults BRFSS, 2002 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% 24% 25%

24 Obesity Trends* Among U.S. Adults BRFSS, 2003 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% 24% 25%

25 Obesity Trends* Among U.S. Adults BRFSS, 2004 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% 24% 25%

26 Obesity Trends* Among U.S. Adults BRFSS, 2005 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30%

27 Obesity Trends* Among U.S. Adults BRFSS, 2006 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30%

28 Obesity Trends* Among U.S. Adults BRFSS, 2007 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30%

29 Obesity Trends* Among U.S. Adults BRFSS, 2008 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30%

30 Age-adjusted percentage of adults aged 20 years who are obese, 2007 MMWR 58: , 2009

31 Age-adjusted percentage of adults aged 20 years with diagnosed diabetes, 2007 MMWR 58: , 2009

32 Why is the Epidemic Occurring? Energy Balance: Intake vs. Output

33 Prevalence of Overweight and Obesity Among US Adults BMI=kg/m2 % 80 Overweight or obese Overweight Obese (BMI 25.0) (BMI ) (BMI 30.0) Increased 100% in 20 years NHANES II (n=11,207) NHANES III (n=14,468) NHANES (n=3601) US Bureau of the Census estimates using the age groups 20-34, 35-44, 45-54, 55-64, and years Flegal KM et al. JAMA. 2002;288:

34 Environment Abundance of palatable, calorie-dense food Number of calories expended in physical activity is insufficient to offset consumption Mechanization limits physical activity Sedentary daily routines consisting of: sitting at work sitting in traffic sitting in front of a television or a computer monitor for most of their waking hours

35 BAGEL 20 Years Ago Today 140 calories 3-inch diameter How many calories are in this bagel?

36 BAGEL 20 Years Ago Today 140 calories 3-inch diameter 350 calories 6-inch diameter Calorie Difference: 210 calories

37 Maintaining a Healthy Weight is a Balancing Act Calories In = Calories Out How long will you have to rake leaves in order to burn the extra 210 calories?* *Based on 130-pound person

38 Calories In = Calories Out If you rake the leaves for 50 minutes you will burn the extra 210 calories.* *Based on 130-pound person

39 SPAGHETTI AND MEATBALLS 20 Years Ago Today 500 calories 1 cup spaghetti with sauce and 3 small meatballs How many calories do you think are in today's portion of spaghetti and meatballs?

40 SPAGHETTI AND MEATBALLS 20 Years Ago Today 500 calories 1 cup spaghetti with sauce and 3 small meatballs Calorie Difference: 525 calories 1,025 calories 2 cups of pasta with sauce and 3 large meatballs

41 Maintaining a Healthy Weight is a Balancing Act Calories In = Calories Out How long will you have to houseclean in order to burn the extra 525 calories?* *Based on 130-pound person

42 Calories In = Calories Out If you houseclean for 2 hours and 35 minutes, you will burn approximately 525 calories.* *Based on 130-pound person

43 Walking = 5 kcal/minute Intake vs Output 100 kcalories = a mile (walking at 3 MPH) Burger King Whopper = 640 calories(kcal) To walk off a Whopper 640/5 = 128 minutes (6 miles) Subway 6 Turkey Sub (no cheese, no mayo) = 289 kcal To walk off a Turkey Sub 289/5 = 57 minutes (3 miles)

44 Breakfast: Calorie Dense Food Blackberry Green Tea Frappuccino 560 (kcal) 12 Grain Bran Muffin 400 (Kcal) Lunch: Double Quarter-Pounder with Cheese Chocolate Shake 32 fl. oz. Super Size Fries Dinner: 760 (kcal) 1150 (kcal) 610 (kcal) ¼ white meat chicken (breast and thigh) 330 (kcal) Mashed Potatoes (8oz) 210 (kcal) Coca-Cola 140 (kcal) Total: 3600 (kcal)

45 Intake vs Output Extreme High Activity: Mountain Climbing 10.0 kcal/minute To Burn off 3600(kcal) = 6 hours of Mountain climbing

46 Intake vs Output Extreme High Activity: Mountain Climbing 10.0 kcal/minute To Burn off Super-sized meal: 3600(kcal) = 6 hours of mountain climbing (or 36 miles of walking!!)

47 Health Risks of Obesity

48 OBESITY is a Gateway Disease As BMI Increases: LDL increases HDL decreases Blood Pressure Increases Cardiovascular events increase Dysmetabolic Syndrome Type 2 Diabetes Cancers (breast, colon, gallbladder, uterine) NHANES III and Hubert HB et al. Circulation 1983;67:

49 Percent NHANES III Prevalence of Hypertension* According to BMI BMI <25 BMI 25-<27 BMI 27-<30 BMI > Men Women *Defined as mean systolic blood pressure 140 mm Hg, mean diastolic 90 mm Hg, or currently taking antihypertensive medication. Brown C et al. Body Mass Index and the Prevalence of Hypertension and Dyslipidemia. Obes Res. 2000; 8:

50 Incidence/1, Year Incidence of Coronary Heart Disease in Men 600 <50 years 50+ years <25 25-< BMI Levels Adapted from Hubert HB et al. Circulation 1983;67: Metropolitan Relative Weight of 110 is a BMI of approximately 25.

51 Incidence/1, Year Incidence of Coronary Heart Disease in Women 500 <50 years 50+ years <25 25-< BMI Levels Adapted from Hubert HB et al. Circulation 1983;67: Metropolitan Relative Weight of 110 is a BMI of approximately 25.

52 Incidence of New Cases per 1,000 Person-Years Obesity and Diabetes Risk < >40 BMI Levels Knowler WC et al. Am J Epidemiol 1981;113:

53 Cholescystectomy BMI Relationship between BMI and crude percentage of women reporting medical problems, surgical procedures, symptoms, and health care utilization. Brown WJ et al. Int J Obes 1998;22:

54 Hysterectomy BMI Brown WJ et al. Int J Obes 1998;22:

55 Back Pain BMI Brown WJ et al. Int J Obes 1998;22:

56 Constant Tiredness BMI Brown WJ et al. Int J Obes 1998;22:

57 Other Risks Congestive Heart Failure Stroke Osteoarthritis Sleep Apnea Cancer (Colon, Breast, Endometrial, Gallbladder)

58 Primary Care Obesity Evaluation

59 Appropriate Office Environment for Obese Patients Waiting room chairs without arms or a larger bench seat with arms Step stools next to examination tables Large gowns and blood pressure cuffs Scale that can weigh extremely obese patients, located in a private area Appropriate obesity educational materials, handouts, and treatment protocols Empathetic, respectful, and supportive office staff Slide Source: Obesityonline.org

60 Medical History Elicit risk factors and symptoms of the manifestations of obesity: Dysmetabolic syndrome Type 2 diabetes Cardiovascular disease (and angina) Sleep apnea Gallstones Potential Pregnancy

61 Family and Social Histories Identify support networks and cultural factors May influence the patient s ability to participate in a weight management program Other household members with obesity May impact the ability for the patient to modify his or her lifestyle and diet. Dietary changes Easier to implement if the other members of the family also adopt healthier nutrition habits.

62 Assessing Weight Loss Readiness Motivation: Stress level: Psychiatric issues: Time availability: Patient seeks weight reduction Free of major life crises Free of severe depression, substance abuse, bulimia nervosa Patient can devote min/d to weight control for next 26 weeks YES Patient Ready? NO Initiate weight loss therapy Prevent weight gain and explore barriers to weight reduction Slide Source: Obesityonline.org

63 Medical Causes of Obesity Hypothyroidism Cushing's syndrome Depression (Beck s depression inventory) Beck AT. The Beck Depression Inventory. San Antonio, TX: The Psychological Corporation; Beck AT, Steer RA, Garbin MG. Psychometric properties of the Beck Inventory: Twenty-five years of evaluation. Clin Psychol Rev. 1988;8:

64 Psychiatric History Comfort Eating (in response to negative emotions) Boredom Sadness and Depression Anger Anorexia Bulimia Binge eating Addictions: Smoking

65 Selected Medications That Can Cause Weight Gain Diabetes medications Insulin Sulfonylureas Thiazolidinediones Highly active antiretroviral therapy Tamoxifen Steroid hormones Glucocorticoids Progestational steroids

66 Selected Medications That Can Cause Weight Gain Psychotropic medications Tricyclic antidepressants Monoamine oxidase inhibitors Specific SSRIs Atypical antipsychotics Lithium Specific anticonvulsants -adrenergic receptor blockers clozapine (Clozaril) 4.4 kg gain* olanzapine (Zyprexa) 4.2 kg* risperidone (Resperdal) 2.1 kg* Paxil, Prozac *Allison DB et al. Am J Psychiatry 1999 Nov;156(11):

67 Exercise History Exercise habits Physical activity patterns Limitations Preferences

68 Physical Exam and Measurements Blood Pressure Waist circumference (Non-Stretchable Tape) Height (wall-mounted stadiometer) Weight (Balance Beam Scale) Calculate BMI: weight (kg)/height (m 2 ) Body Composition (by bio-impedence) Attention to gallbladder The Usual

69 Laboratory Assessment TSH (optional Free T4) CBC Chem 20 Fasting Lipid Panel Pregnancy test Optional 24hr urine cortisol if Cushing s suspected

70 Obesity Treatment Lifestyle therapy (diet, physical activity, and behavioral therapy) is the cornerstone of obesity treatment

71 NIH Guide to Selecting Obesity Treatment Treatment BMI Category >40 Lifestyle Therapy* With Comorbid. With Comorbid. YES YES YES Pharmaco therapy With Comorbid. YES YES YES Surgery With Comorbid. YES *Lifestyle therapy: diet, physical activity, and behavioral therapy. Consider pharmacotherapy only if a patient has not lost 1 pound per week after 6 months of combined lifestyle therapy.

72 Goals of Weight Management/Treatment Prevent further weight gain (minimum goal). Reduce body weight. Maintain a lower body weight over long term.

73 Target Weight: Realistic Goals Substitute healthier weight for ideal or landmark weight. Accept slow, incremental progress to goal. Short-term goal: 5 to 10 percent loss, 1 to 2 lb per week. Interim goal: Maintenance. Long-term goal: Additional weight loss, if desired, and long-term weight maintenance.

74 Increase Physical Activity Most important in preventing weight regain Health benefits independent of weight loss Start slowly and increase gradually Can be single session or intermittent Start with walking 30 minutes 3 days/week Increase to 45 minutes 5 or more days/week Encourage increased lifestyle activities

75 Behavior Therapy Implementation of strategies, based on learning principles, that provide tools for overcoming barriers to compliance with diet or physical activity changes: Self-monitoring Stress management Stimulus control Problem-solving Contingency management Cognitive restructuring Social support

76 Stress Management Defuse situations that lead to overeating: Coping strategies Meditation Relaxation techniques

77 Stimulus Control Behavior change techniques: Learn to shop for healthy foods. Keep high-calorie foods out of the home. Limit the times and places of eating.

78 Cognitive Restructuring Rational thoughts designed to replace negative thoughts: Instead of... I blew my diet this morning by eating that doughnut. Use... Well, I ate the doughnut, but I can still eat in a healthy manner the rest of the day.

79 Determining Daily Calorie Goals for a Weight Loss Diet

80 Why Is Energy Balance Important? Current practice of weight control utilizes the following premises for healthy adults: Calories in > energy out = weight gain. Calories in = energy out = weight maintenance. Calories in < energy out = weight loss. (3500 kcal deficit is needed for 1 pound weight loss per week)

81 What is REE? Resting energy expenditure (REE)= burn rate The number of calories the body uses each day for maintenance of homeostasis. Can measure directly or use formulas Females: 10 Wt (kg) Ht (cm) - 5 age (y) 161 Males: 10 Wt (kg) Ht (cm) - 5 age (y) +5 *Mifflin-St. Jeor ST et al. Am J Clin Nutr 1990;

82 Case Study Patient: Female Age 50 years Height = 60 Weight= 180 lbs. BMI=35

83 Intake: 3 or 7 Day Food Record shows 2100 kcal/day average intake kcal/d Output: 1. REE : kcal/d 2. Physical Activity Factor (Intentional Physical Activity or exercise/wk) 140 min walking (20 min X 7 days) X 5 kcal/min = 700 kcal/week 700 kcal/7 days= kcal/day average 3. TEE = REE (1400) X 1.3 = Intentional PA (100) = ~1900 kcal/d kcal/d Total +200 kcal/d

84 Recommendation for WEIGHT MAINTENANCE (kcal/d): To maintain current weight this patient must decrease intake by -200 kcal/day from the current intake of 2100 kcal/d yielding a 1900 kcal/day diet. Recommendation for WEIGHT REDUCTION (kcal/d): To lose 1 pound per week, a 500 kcal per day deficit is needed In this patient: (-200 kcal/day deficit to maintain weight) + (-500 kcal/day deficit to lose 1 pound per week) = -700 kcal/day total deficit needed to lose 1 lb/week Decrease 2100 KCAL/D intake by -700 kcal/d. = 1400 kcal/d dietary intake

85 Questions? Division of Endocrinology, Nutrition, and Metabolism Weight Loss Clinic (775)

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