OBESITY. Caroline Steinman DO

Transcription

1 OBESITY Caroline Steinman DO

2 No financial disclosures DISCLOSURES

3 OUTLINE Statistics Medications Diets Exercise

4 OBESITY STATISTICS IN INDIANA 65.9% overweight(12) 29.6% obese(12) 28.1% of adults report 2 servings of fruit a day(12) 23.7% of adults report 3 servings of vegetables a day(12) 43.2% of adults achieve 300 minutes a week of moderate intensity activity of 150 minutes a week of high intensity activity (12) 27.2% of adults report no physical activity in the last month(12)

5 HOW WE COMPARE ( 1 3 )

6 MEDICATIONS Phentermine (Adipex) Phentermine and topiramate extended-release (Qsymia) Lorcaserin (Belviq) Naltrexone and bupropion extended-release (Contrave) Orlistat (Xenica/Alli) Liraglutide (Saxenda/Victoza)

7 WHEN TO START MEDICATIONS Indication: BMI > 30 or >27 with 1 weight related comorbid condition (DM, HTN, HLD) Willing to make lifestyle changes No planned pregnancy, preferably on birth control Willing to have monthly visits

8 WHEN TO STOP MEDICATION Reached weight loss goal No or little weight loss over 12 weeks Gained weight New or recently uncontrolled hypertension Side effects If patient desires will offer switch to another medication

9 PHENTERMINE ( ADIPEX) Reduces appetite by increasing activation of adrenergic and dopaminergic receptors Approved in 1959 by the FDA Most wildly prescribed 25.3 million rx to 6.2 million patient between (3) Usually the cheapest and covered by insurances Only approved for short term use (<12 weeks) (3) effect does wear off over time. BUT no great studies on long term safety, possibility of increased BP as well as MI and CVA. (3) Also risk of primary pulmonary hypertension and valvular heart disease Do not use in people with CAD, CVA, arrhythmias, CHF, HTN, hyperthyroidism, glaucoma, agitated states or h/o drug abuse.

10 PHENTERMINE AND TOPIRAMATE EXTENDED-RELEASE (QSYMIA) Mechanism of action: Appetite suppressant and feeling more satisfied after eating Average weight loss 8.1 kg(1) 62% lost at least 5% of weight(1) 37% lost at least 10% of weight(1) Reduced incidence of DM in trial (2) Can raise HR-unsure of long term CVD risk Close monitoring of resting HR and BP Do Not give to patients with recent or unstable vascular disease

11 LORCASERIN (BELVIQ) Selective serotonin receptor agonist Increases satiety Average loss 3.2 kg more than placebo (3) 47% lost at least 5% of weight (3) 23% lost at least 10% of weight (3) Additional decrease of BP LDL and TG more than placebo (3) Side effect-valvulopathy, depression

12 NALTREXONE AND BUPROPION EXTENDED-RELEASE (CONTRAVE) Down regulates hunger signals, feel full sooner and fewer cravings 4-5 KG weight loss more than placebo(3) 48-66% lost at least 5%(3) 25-42% lost at least 10%(3) Warning of suicide and manic episodes due to bupropion Do not give to people on opioids, with uncontrolled HTN or seizure disorder Other side effects: HTN, hepatitis, angle closure glaucoma

13 ORLISTAT (XENICA, ALLI) GI lipase inhibitor causes excretion of 30% of ingested fat Taking TID during or up to 1 hour after meals Available OTC Average weight loss is 3.4 kg more than placebo (3) Shown improvement in decreasing LDL, fasting glucose and BP after 1 year of treatment(3) Frequently discontinued due to GI side effects when low fat diet not followed.

14 LIRAGLUTIDE (SAXENDA/VICTOZA) glucagon-like peptide-1 analog Slows gastric emptying, decreases gluconeogenesis and increasing insulin production Once daily administration plus diet and exercise mean weight loss was kg over 20 weeks(4) Weight loss was 5.4 kg greater than placebo on 3.0 mg daily(5) 76% of individuals lost more than 5% of body weight with 3mg daily.(4) Side effects: pancreatitis, choledocolithiasis, possible thyroid tumors(seen in ratsunknown in humans) Sustained weight loss over 2 years, decreased prevalence of prediabetes (5)

15 DIET DASH Diet Low Fat Low Carbohydrate Paleo diet Vegetarian/Vegan Thrive Diet Whole 30 Beach body 21 day fix Weight Watchers

16 DASH DIET High in fruits and vegetables Moderate in low fat dairy products Low in animal protein Lower consumption of red and processed meats Original dash diet 27% calories from fat Substantial amounts of plant protein from legumes and nuts Whole grains Dashdietoregon.org

17 DASH DIET Counseling plus DASH diet lost an average of 6.1kg compared with just one educational session lost 1.1 kg in 6 months(9) That study also found that those people with the most weight loss has the largest decrease in dietary energy density (9) Nurse s health study with 24 year follow up showed lower coronary heart disease and stoke risk in middle ages women(10)

18 LOW FAT DIET AHA and most others: Fat <30% of calories 67 g of fat for 2000 calorie diet WHO study group: <15%

19 LOW FAT DIET EVIDENCE Post menopausal woman instructed to eat low fat diet (13% lower fat than in control) did not change CVD events (7) Moderate fat diet (35% of calories) showed more weight loss over 18 mos that low fat (20% of calories) Weight loss of 4.1 kg vs 2.9 kg Moderate fat had less drop out rate(8) Many foods labeled as low fat have added sugar so it does not aid in weight loss

20 LOW CARBOHYDRATE DIET 20-30g carbohydrates per day First 6 months lost more weight that low fat, but tended to regain weight by 1 year (11) Physiologically carbs generate more ATP than protein or fat so higher carbs =more available energy=less weight loss(17) Watch replacing carbs with fats

21 PALEO DIET Eat as the cavemen did because it is more natural and they had less chronic diseases. lean meat, fruits, vegetables and nuts, and excluding nonpaleolithic type foods, such as cereal grains, dairy or legumes

22 PALEO DIET EVIDENCE Tiny short term studies show good and weight loss and improve BP, glucose, and cholesterol.(15, 16) A little bigger study over 10 weeks showed weight loss but worsening cholesterol prolife (18) Not many studies, no good studies. Good to reduced processed foods, but whole grains and legumes are not evil.

23 VEGETARIAN/VEGAN DIETS Vegetarian: nothing that causes an animal to die. Foods that come from animals but do not result in their death are ok (milk, eggs) Vegan: Nothing that comes from an animal: no eggs, milk, honey, gelatin

24 VEGETARIAN/VEGAN DIET EVIDENCE Improved cholesterol and overall health(19) Ornish diet (low fat vegetarian, exercise, and stress management) showed reduction in coronary artery stenosis over 1 year (20) Review of RCT vegans lost most weight (2.5 more kg)then control and lacto-ovo vegetarians lose more weight than control(1.4 kg more) ( 24) Need to actually eat vegetables not just vegetarian processed foods.

25 THRIVE DIET Vegan diet, stress reduction, and exercise Start by adding in fruits, vegetables, legumes Then eliminate caffeine, sugar, processed foods, meat, and grains, and limit starchy vegetables Effective based on low carb vegan diet May be difficult in certain areas to get variety of foods needed to maintain health.

26 PSYCHOLOGICAL STRESS Higher number of stressful events and chronic stresses was associated with higher BMI, excessive alcohol use, and smoking (26) higher glucose and insulin levels (26) May promote irregular eating patterns and more calorie dense food consumption (26) Cortisol release increases gluconeogenesis and chronically high cortisol increases insulin resistance and abdominal adiposity (think cushing syndrome)(26)

27 WHOLE 30 Whole 30: eliminate sugar(even artificial), grains, dairy, alcohol and legumes from diet. No evidence for eliminating dairy-conflicting trials (21, 22) Zero studies on legumes Low carb ok in short term Eliminating sugar is helpful Eliminating artificial sugars probably good May lead to weight gain, HTN, elevated glucose(23) In people who regularly consume artificial sugars their brains respond to sucrose and sucralose the same.(23) may blunt body s response to sugar load(23)

28 BEACH BODY 21 DAY FIX Containers for different types of food-fruits, vegetables, proteins, carbs, healthy fats, seeds and dressings and workout dvds ( recommended 30 mins every day). No real studies done Good concept of portion control (amount of containers you can eat depends on your calorie count-information in a book you have to buy) Exercises are cardio plus weight training which is recommended.

29 WEIGHT WATCHERS About watching calories/points Healthy recipes Exercise encouraged Group support Small studies shows it is effective (25) Avg weight loss 5.3 kg at 26 wks, 7.4 kg at 12 wks (25)

30 EXERCISE 300 minutes of moderate exercise per week or 150 minutes of vigorous exercise per week Small study showing that exercise with diet causes more weight loss than just diet, and that even exercise without weight loss redistributes weight and reduces abdominal adiposity.(6)

31 GENERAL TIPS Increase amounts of less energy dense foods. Do not drink your calories Reduced-calorie diets result in clinically meaningful weight loss regardless of which macronutrients they emphasize.(14) Decrease temptation Small changes Patient suggests change

32 GENERAL TIPS CONT. mind-full eating Tracking meals Tracking exercise More than just the number on the scale Frequent follow-ups Change lifestyle, don t just go on a diet

33 QUESTIONS?

34 REFERENCE 1. Dr Kishore M Gadde et al. Effects of low-dose, controlled-release, phentermine plus topiramate combination on weight and associated comorbidities in overweight and obese adults (CONQUER): a randomised, placebo-controlled, phase 3 trial. The Lancet Volume 377, No. 9774, p , 16 April W Timothy Garvey et al. Two-year sustained weight loss and metabolic benefits with controlled-release phentermine/topiramate in obese and overweight adults (SEQUEL): a randomized, placebo-controlled, phase 3 extension study1,2,3 Am J Clin Nutr February 2012 vol. 95 no Susan Z. Yanovski, MD; Jack A. Yanovski, MD, PhD Long-term Drug Treatment for Obesity A Systematic and Clinical Review JAMA. 2014;311(1): doi: /jama Arne Astrup, MD et al., Effects of liraglutide in treatment of obesity: a randomized double-blind, placebo controlled study. The Lancet Volume 374, No 9701, p , Nov A Astrup et al. Safety, tolerability and sustained weight loss over 2 years with the once-daily human GLP-1 analog, liraglutide International Journal of Obesity (2012) 36, ; doi: /ijo ; published online 16 August Robert Ross et al. Reduction in Obesity and Related Comorbid Conditions after Diet-Induced Weight Loss or Exercise-Induced Weight Loss in Men Annals of Internal Medicine Volume 133 Number 2 18 July 2000

35 REFERENCE CONT. 7. Howard BV, Van Horn L, Hsia J, et al. Low-Fat Dietary Pattern and Risk of Cardiovascular Disease: The Women's Health Initiative Randomized Controlled Dietary Modification Trial. JAMA. 2006;295(6): McManus, K; Antinoro, L; Sacks, F A randomized controlled trial of a moderate-fat, low-energy diet compared with a low fat, low-energy diet for weight loss in overweight adults. International Journal of Obesity & Related Metabolic Disorders. Oct2001, Vol. 25 Issue 10, p p 9. Jenny H Ledikwe et al. Reductions in dietary energy density are associated with weight loss in overweight and obese participants in the PREMIER trial1,2,3,4am J Clin Nutr May 2007 vol. 85 no Fung TT, Chiuve SE, McCullough ML, Rexrode KM, Logroscino G, Hu FB. Adherence to a DASH-Style Diet and Risk of Coronary Heart Disease and Stroke in Women. Arch Intern Med. 2008;168(7): Linda Stern, MD et al. The Effects of Low-Carbohydrate versus Conventional Weight Loss Diets in Severely Obese Adults: One-Year Follow-up of a Randomized Trial; 18 May 2004 Annals of Internal Medicine Volume 140 Number State of Indiana. Nutrition, Physical Activity, and Obesity Profile. September 2012

36 REFERENCE CONT. 12. < Accessed 4/20/ Overweight and Obesity CDC Obesity Prevalence Maps < Accessed 4/20/ Frank M. Sack et al. Comparison of Weight-Loss Diets with Different Compositions of Fat, Protein, and Carbohydrates N Engl J Med 2009; 360: February 26, L A Frassetto et al. Metabolic and physiologic improvements from consuming a paleolithic, hunter-gatherer type diet European Journal of Clinical Nutrition (2009) 63, ; doi: /ejcn Tommy Jönsson et al Beneficial effects of a Paleolithic diet on cardiovascular risk factors in type 2 diabetes: a randomized cross-over pilot study Cardiovascular Diabetology 2009, 8:35 doi: / Eugene J Fine and Richard D Feinman Thermodynamics of weight loss diets Nutrition & Metabolism20041:15 DOI: / Michael Smith et al. Unrestricted Paleolithic Diet is Associated with Unfavorable Changes to Blood Lipids in Healthy Subjects International Journal of Exercise Science 7(2) : , 2014.

37 REFERENCE CONT. 14. Ferdowsian HR1, Barnard ND. Effects of plant-based diets on plasma lipids. Am J Cardiol Oct 1;104(7): D. Ornish MD, et al. Can lifestyle changes reverse coronary heart disease?: The Lifestyle Heart Trial The Lancet Volume 336, Issue 8708, 21 July 1990, Pages Michael Zemel et al. Effects of Calcium and Dairy on Body Composition and Weight Loss in African-American Adults Obesity Research Volume 13, Issue 7, pages , July 2005 Mu chen et al. Effects of dairy intake on body weight and fat: a meta-analysis of randomized controlled trials Am J Clin Nutr October 2012 vol. 96 no Susan E. Swithers Artificial sweeteners produce the counterintuitive effect of inducing metabolic derangements Trends Endocrinol Metab Sep; 24(9): Ru-Yi Huang et al. Vegetarian Diets and Weight Reduction: a Meta-Analysis of Randomized Controlled Trials Journal of General Internal Medicine January 2016, Volume 31, Issue 1, pp Adam Gilden Tsai Systematic Review: An Evaluation of Major Commercial Weight Loss Programs in the United States Ann Intern Med. 2005;142: Rajita Sinha, PhD 1,2,3 and Ania M. Jastreboff, MD, PhD Stress as a common risk factor for obesity and addiction Biol Psychiatry May 1; 73(9):