Obesity Management in Women

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1 Defining Obesity Obesity Management in Women Alka M. Kanaya, M.D. Assistant Professor of Medicine October 19, 2007 An increase in fat accumulation, to the extent that health may be adversely affected BMI (kg/m 2 ) 1995: BMI <18.5 Underweight Healthy Weight Overweight 30 Obese WHO, 1995 Intl Obesity Task Force, 1997 Worldwide Obesity Adult Obesity: to Race/Ethnicity Total White Female Male Black Female Male Mexican American Female Male Target Nature, Percent NHANES, CDC 1

2 % Sex differences in Weight Obese Overweight Why? 1. Food away from home. 2. Energy-dense foods. 3. Misconceptions regarding low fat foods. 4. Portion distortion 0 Women Men Women Men Women Men Flegal, 2006 White Black Mexican-American Communities Worksites Health Care Schools and Child Care Home Demographic Factors Psychosocial Factors Gene- Environment Interactions Other Food & Beverage Intake Energy Intake Social Norms and Values Sectors of Influence Behavioral Settings Individual Factors Physical Activity Energy Expenditure Government Public Health Health Care Agriculture Education Media Land Use and Transportation Communities Foundations Industry Food Beverage Retail Leisure and Recreation Entertainment Obesity as social contagion Social network analysis 32 year f/u Framingham cohort 12,000 adults weight +/-/maint. Influenced by friends & family, extended to 3 degrees of separation, independent of physical environment Concluded that each individual influences the social norm for her/his circle Thinness as well as obesity contagious Energy Balance Christakis, NEJM,

3 Roadmap 1. Epidemiology 2. Contributors to the epidemic 3. Diets 4. Physical Activity 5. Medications 6. Bariatric Surgery Case 1 A 53 year old woman with HTN and knee pain comes in for follow-up. Weight: 175 lbs Height: 5 3 BMI: 31 kg/m 2 She is interested in weight loss and asks what type of diet you would recommend for her? Which diet is most effective for weight loss? a) The Ornish diet b) The Atkins diet c) The Weight Watcher s diet d) The Zone diet e) They are equally effective f) They all don t work DIET Typical American Comparison of the Diets Food Pyramid & W. Watchers Calorie rest. % CARBS % PROT % FAT NO 50% 20% 30% YES/NO 55-60% 10-15% <30% Zone YES 40% 30% 30% South Beach NO Ind 10-15% M 40-50% M 15-20% M 30-35% Atkins NO Ind <10% M 5-15% Ind 40% M 35% Ind 50% M 45% Ornish NO 70-75% 15-20% <10% 3

4 A head-to-head trial Dansinger, JAMA, 2005 Dansinger, 2005 Weight loss during the BBC trial Truby, BMJ,

5 The Bottom Line 1. The type of diet you choose does not really matter if you stick to it. 2. When energy out exceeds energy in, weight loss is the result. 3. The ideal macronutrient composition of healthy weight loss is still unknown. 4. We don t know the long-term safety of the low carb diets. 5. Moderate-fat diets promote sustainable weight loss and a favorable lipid profile. 6. Strict low-fat diets have been shown to be good for the heart. What works Successful weight losers: both substantial changes in eating and exercise. 50% of participants lost weight on their own without any type of formal program or help. The majority of those who have lost weight and kept it off were successful with a diet: 55% carbohydrate, 20% protein and 25% fat High-protein, low-carbohydrate diets are hard to maintain for life. National Weight Control Registry data Diet Tips Are you ready to lose weight? Set realistic expectations. Choose a diet that is easy to follow and compatible with your lifestyle and health issues. Control your portion size. Fresh fruit and vegetables and whole grains are very important (5 a day goal). Maintaining the weight you lose is key Women with 30 Adverse Events, 25 % Fitness or Fatness? 5.6 Major Adverse Events All Adverse Events Not Obese Obese Not Obese Obese FIT NOT FIT

6 Exercise on Weight Loss Improves short term weight loss when combined with dietary change Best predictor of long-term weight loss Mostly short trials (<6 mo.) No hard endpoints Duration & Intensity on Weight Loss Trial of sedentary & overweight women Vigorous Intensity High Duration Moderate Intensity High Duration 201 Women Moderate Intensity Moderate Duration Intensity: % of age-predicted max HR and perceived exertion Vigorous Intensity Moderate Duration Duration: High: min/d; min/wk Mod: min/d; min/wk Jakicic, Jama,

7 Study Conclusions Moderate to high dose of exercise resulted in a 8-10% body weight reduction after 1 year intervention No greater weight loss with vigorous vs. moderate intensity exercise. But a higher duration of exercise was associated with greater weight loss. Heart Disease prevention Guidelines CDC, ACSM, Surgeon General & AHA: 30 minutes or more of moderate intensity PA (such as brisk walking) on most (preferably all) days of the week = (150 minutes/week) Weight loss Guidelines IOM: to control body weight 60 minutes/day on most days of the week. 12-month RCT: 150 min/wk of moderate intensity exercise to begin, and then progress to 60 minutes/day Case 2 A 43 year old woman with obesity has tried several different diets. She asks you about using a weight loss drug in combination with a healthy diet/exercise. She has no other chronic medical conditions. BMI: 34 kg/m 2 BP: 124/72 mmhg 7

8 Which weight loss medication do you recommend? Obesity Drugs a checkered past a) Phentermine b) Sibutramine c) Orlistat d) Rimonabant e) Any of the above f) None of the above Drug Thyroid hormone Dinitrophenol Amphetamine Fenfluramine Phenylpropanolamine Ephedra Complication Tachycardia, HTN, arrhythmias Dermatitis, hepatitis, visual dysfunction, death Addiction, HTN, MI, death Pulmonary HTN, valvular heart disease Hemorrhagic stroke, death HTN, tachycardia, stroke, seizures, death Approved medications Phentermine (1959) Suppresses appetite & enhances energy expenditure Cardiovascular side effects Sibutramine (1997) Suppresses appetite & enhances energy expenditure Blood pressure side effects Orlistat (1999/OTC 2006) Fat absorption inhibitor Diarrhea side effects Phentermine: Drug Efficacy mean weight loss of 3.6 ( ) vs. Po at 36 weeks Sibutramine: mean weight loss of 4.5 kg ( ) vs. Po at 1 year Orlistat: mean weight loss of 2.9 kg ( ) vs. Po at 1 year 8

9 Drug + lifestyle change Weight (kg) Rimonabant Waist (cm) Weight Loss (kg) Sibutramine alone LS mod. alone Sibutramine + brief Sibutramine + LS Triglycerides HDL Wadden, NEJM, 2005 Principles of Drug Therapy NIH: BMI 30 or 27 kg/m 2 with comorbidity Motivated to begin structured exercise and low calorie diet Begin medications at completion of one month successful diet and exercise Continue medications only if additional weight loss achieved in first month with meds Future Drug Targets Food Intake-central Monoamines (NA, 5-HT, DA) Peptides (NPY, AGRP, POMC, CART, CRH, insulin) Thermogenesis Thyroid hormones Β3-adrenergic agonists UCPs Leptin Vagus Obesity Food Intake-peripheral GI peptides (CCK) Pancreatic peptides (GLP-1, enterostatin, amylin) Fat Absorption Lipase inhibitors Fatty acid transporters Fat Metabolism DGAT Adipocyte differentiation Bray, Nature,

10 Case 3 56 y.o. woman with long-standing obesity, type 2 diabetes, HTN, dyslipidemia, and arthritis has a friend who lost 80 lbs after gastric bypass surgery. She wants to discuss the pros/cons of surgery with you. BMI: 36 kg/m 2 Is she a suitable candidate for bariatric surgery? a) Yes b) No c) Possibly Bariatric Surgery Restrictive Horizontal Gastroplasties Vertical Banded Gastroplasty Silastic Ring Vertical Gastroplasty Adjustable Gastric Banding Malabsorptive Jejunoileal Bypass Biliopancreatic Diversion Duodenal Switch Long Limb Gastric Bypass Restrictive with Malabsorptive Component Roux-en-Y Gastric Bypass VBG Bariatric Surgery Adjustable Gastric Banding Roux-en-Y GB 10

11 Obesity Surgery Works Efficacy: loss of 50% of excess body weight and improvement in many comorbidities Bariatric Surgery: 15 Year Outcomes Sjostrom, 2007 % Resolution Comorbidity Review of 136 studies with 22,092 patients Diabetes Hyperlipidemia HTN Sleep apnea Band VBG GBP D Switch Buchwald, Jama, 2004 SOS Prospective Double Cohort Study Bariatric Surgery Safety HR: 0.76 ( ) p=0.04 Sjostrom, 2007 Mortality: 0% - 1% Morbidity: 30-50% (leaks, diarrhea, emesis, ulcers, gallstones, re-operation) Approved by most payers; cost effective Lifelong medical surveillance needed! 11

12 Whom to Refer Clinically severe obesity BMI 40 or BMI 35 with comorbidities When less invasive methods have failed, high risk of obesity-related morbidity Realistic expectations of the procedure Ability/desire to follow surgically-imposed dietary changes Good social support No active substance abuse or unstable psych. Adherence to medical recommendations NHLBI, 1998; AMA primer, 2003 UCSF Bariatric Surgery Program Long waiting list Patients must lose 10% of their body weight before surgery Must undergo multidisciplinary evaluation Gastroenterology Cardiology Psychiatry Imaging and lab tests required Weight Loss Recommendations Set a realistic weight loss goal 5-7% has the most effect on health Control portion size Choose the diet that is most compatible with your lifestyle Physical activity: To lose weight, 60 minutes/day, most days of the week Focus on fitness at any weight. 12

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