Nadia Ahmad, MD, MPH. Founding Director Obesity Medicine Institute, Dubai American Board of Obesity Medicine. February 23, 2016

Transcription

1 Nadia Ahmad, MD, MPH Founding Director Obesity Medicine Institute, Dubai American Board of Obesity Medicine February 23, 2016

2 Physical Inactivity Social Stigma Sleep Problems Bulimia Low Self-esteem Hyperlipidemia Fatty Liver Anxiety Binge Eating Heart disease Cancer GERD Venous stasis Obstructive Sleep apnea Peripheral vascular disease Depression 180 PCOS Diabetes Hypertension Back pain Harmful Diet Infertility Arthritis Poor insight Emotional Eating Stress Polypharmacy Poor social support Low Motivation Bipolar Inadequate Follow up

3 Doctor s Won t Take Fat Patients WASHINGTON Under Obamacare, doctors can now refuse obese patients. And they are doing it! Obstetrics-gynecology practices across the country have set weight limits for new patients. If you re obese you will not be allowed to schedule an appointment. If you try to come to the office, you will be thrown out. Doctors said the main reason was their exam tables or other equipment can t handle people over a certain weight, but at least six said heavy women run a higher risk of complications. People don t realize the risk we re taking by taking care of these patients, the newspaper quoted Dr. Albert Triana of South Miami as saying. There s more risk of something going wrong and more risk of getting sued. Everything is more complicated with an obese patient in GYN surgeries and in pregnancies, he told WWN. Under Obamacare, it is not illegal for doctors to refuse overweight patients, and according to the Michelle Obama Rider to the Affordable Healthcare Bill, doctors MUST refuse to care for obese patients. People need to know that obesity will NOT be tolerated in our society any longer, said First Lady Michelle Obama. Weight cutoffs have already been enacted by doctors in thirty-one states. Many who have long complained about high numbers of lawsuits after difficult births and high rates for medical-malpractice insurance. So for all those that are overweight and obese you re on your own from now on! May 17, 2011, Tapp Vann

4 3 Principles of Obesity Management

5 Principle 1: Obesity has biological underpinnings

6 weight maintenance energy ingested energy expended

7 Physics: First Law of Thermodynamics Energy In Energy Used Net Energy Gain/Loss

8 Water If a 35 year-old 70kg man drinks 5 liters of water in a 24-hour period, what is new his blood volume? Baseline blood volume = 5 L Water In Water out Net Change in Blood Vol.

9 Water If a 35 year-old 70 kg man drinks 5 liters of water in a 24-hour period, what is new his blood volume? Baseline blood volume = 5 L Urinary output = 1 ml /kg/ hr = 1.7 L Insensible losses = 0.8 L Water In Water out Net Change in Blood Vol. 5 L 2.5 L 2.5 L New blood volume: 7.5 L!

10 Water If a 35 year-old 70 kg man drinks 5 liters of water in a 24-hour period, what is new his blood volume? Baseline blood volume = 5 L Urinary output = 1 ml /kg/ hr = 4.2 L Insensible losses = 0.8 L Water In Water out Net Change in Blood Vol. 5 L 5 L 0 L New blood volume: 5 L

11 Water balance is complex and regulated

12 Energy balance is complex and regulated Berthoud et al. Physiology. 2008;

13 Energy balance is complex and regulated NEUROTRANSMITTER SYSTEMS Serotonin Dopamine Catecholamines Endocannabinoids GABA Glutamine NEURAL PATHWAYS Sympathetic System Vagal System Myenteric Plexus HORMONES Leptin / Adiponectin Ghrelin CCK GLP-1 / PYY Oxyntomodulin GIP Berthoud et al. Physiology. 2008;

14 Isn t everything in the body regulated? Body Temperature Heart rate Respiratory rate Blood pressure CSF pressure Urine output Lung volumes Blood volume CSF volume Oxygen saturation Serum ph Cholesterol Bile production Blood glucose Serum sodium Serum calcium Vitamin D RBC mass Bone mass Muscle mass Liver mass Milk production Ovulation Coagulation/clotting Hair growth Skin color Fat mass

15 Physics: First Law of Thermodynamics Energy In Energy Used Net Energy Gain/Loss

16 Physiology: First Law of Obesity Net Energy Gain/Loss Energy In Energy Used

17 The Adipostat John R. Speakman et al. Dis. Model. Mech. 2011;4:

18 Principle 1: Obesity has biological underpinnings

19 Principle 2: Obesity is a heterogeneous condition

20 Courtesy of Lee M. Kaplan, MD, PhD, Harvard Medical School The Obesities: 57 and counting Leptin deficiency LepR deficiency MC4R deficiency amsh deficiency Sim-1 deficiency PC-1 deficiency KSR2 deficiency MRAP2 deficiency SH2B1 deficiency BDNF deficiency trkb deficiency Carpenter syndrome Cohen syndrome Ayazi syndrome MOMO syndrome Rubenstein-Taybi syndrome Fragile X syndrome BFL syndrome Albright osteodystrophy Prader- Willi syndrome Bardet-Biedl syndrome Alström syndrome Hypothalamic Hyperphagic Thermogenesis deficient Circadian-disrupted Stress-induced Viral Central Peripheral Diffuse Neonatal Early childhood Peripubertal Gestational Menopausal Healthy Metabolic Inflammatory Diet-dependent Exercise-sensitive Sleep-sensitive Insulin-induced Steroid-induced Progesterone-induced Psychotropic-induced Antibiotic-induced Endocrine disruptor Phentermine-responsive Lorcaserin-responsive Topiramate-responsive Metformin-responsive Bupropion-responsive GLP-1 responsive Bypass-responsive Bypass-resistant Gastric band-responsive

21 Biological complexity leads to clinical heterogeneity Determinants of heterogeneity

22 Environment and lifestyle: The modifiable factors 1 Medications 2 Diet 3 Activity 4 Sleep 5 Stress 6 Circadian rhythm

23 Common medications alter energy regulation Medications that promote weight gain CNS drugs Endocrine agents Miscellaneous 1. Weight gainpromoting medications Atypical Antipsychotics eg. olanzipine Anti-epileptics eg.valproate Lithium Anti-depressants SSRIs eg. paroxetine Tricyclic agents eg. nortriptyline Others eg. venlafaxine,mirtazapine Glucocorticoids eg. prednisone Hormonal contraceptives eg. medroxyprogesterone Diabetes agents Insulin Sulfonylureas eg. glyburide Thiazolidenediones eg. pioglitazone, Beta blockers eg. metoprolol Antihistamines eg. diphenhydramine Sleep aids eg. zolpidem Leslie, et al. QJM. 2007;100:

24 Specific nutrients alter energy regulation Refined carbohydrates Saturated fats 2. Diet

25 Unhealthy muscle alters energy regulation Muscle Myokines? nerve signals Energy Expenditure Brain Leptin signaling 3. Activity Muscle growth factors insulin sensitivity Improved fat oxidation Appetite changes Calorie expenditure Adipose tissue

26 Inadequate sleep alters energy regulation Fatigue Altered thermoregulation 4. Sleep Sleep Deprivation Leptin Ghrelin Obesity Insulin Cortisol Patel & Hu. Obesity. 16(3): ; Knutson et al. Sleep Med Rev. 11(3):

27 Stress alters energy regulation Stress Increased Cortisol 5. Stress Hyperinsulinemia/ Insulin resistance Leptin Resistance Decreased Metabolic Rate and Increased Food Intake Increased Hedonic Drive and Consumption of Palatable Foods Sinha R, Jastreboff AM. Biol Psychiatry. 2013; 73(9):

28 Circadian rhythm is linked to metabolism 6. Circadian rhythm Froy O, Miskin R. Aging. 2010; 2(1): 7-27.

29 Disrupted circadian rhythm alters energy regulation 6. Circadian rhythm

30 Biological complexity leads to clinical heterogeneity Determinants of heterogeneity

31 Epigenetic and developmental factors Predictors Maternal obesity Maternal nutrition Maternal activity Maternal stress BPA exposure Infant feeding Infant sleep Adverse Outcomes Rapid fetal growth High birthweight Rapid infant gain High infant weight Childhood obesity Adolescent obesity Adult obesity

32 Epigenetic and developmental factors High birthweight LGA, macrosomia Birth Childhood Childhood overweight and obesity Transgenerational spread Menopause Post-partum Pregnancy Menarche Increased visceral adiposity Post-partum weight retention Excess gestational weight gain Increased adipose accumulation

33 What kind of apple are you is the question Hunger cues Age of onset Cravings Satiety cues Taste preferences Comorbidities? Response to macronutrients Fat distribution Stress response Propensity to enjoy activity Sleep patterns Weight gain with meds

34 Principle 2: Obesity is a heterogeneous condition Diet Activity Stress Intrauterine Environment Childhood Modifiable Factors Sleep Circadian Rhythm Medication Developmental Effects Puberty Pregnancy Menopause

35 Principle 3: There is broad variability in treatment response

36 Heterogeneity leads to variation in treatment response N Weight Loss

37 Patients (%) Patients (%) Gain 5-10 Gain 0-5 Gain Courtesy of Lee M. Kaplan, MD, PhD, Harvard Medical Gain 5-10 Gain 0-5 Gain >50 Weight loss varies widely among patients 30 Diet (Low-carbohydrate) 30 Drug (Liraglutide) Device (Duodenal liner) 30 Surgery (Gastric Bypass)

38 Aim High: Target Responders N Weight Loss

39 Trial 3 Trial 2 Trial 1 Trialing Treatments Comorbidity reduction Different Medications N Weight Loss Specific Activities? Specific diets N Stress reduction Sleep strategies Weight Loss N Switching meds Weight Loss

40 We need to break the cycle Interpretation: I failed She s non-compliant Assessment: You need to lose weight Result: Limited, weight loss does not meet expectation Recommendation: Eat less, move more Trial: Patient attempts to eat less, move more

41 Causes of Obesity Food Industry Built Environmen t Depression Eating Disorders Diet Activity Stress Intrauterine Environment Childhood Genes Age Socio-political & Cultural Influences Media Work Schedules Treatable Issues Anxiety Other psychiatric issues Modifiable Factors Sleep Circadian Rhythm Medications Developmental Effects Puberty Pregnancy Menopause Fixed Factors Gender Race Adipose Physiology Opportunity for Clinical Intervention high low

42 Summary: 3 Principles of Obesity Obesity has complex biological underpinnings. In order to address obesity, it is paramount that we better understand its pathophysiologic basis. Obesity is a very heterogeneous condition that calls for a more nuanced assessment of the patient to identify specific subtypes. There is broad variability in treatment response and it is likely that different subtypes of obesity respond best to different treatments. The practitioner should be ready to trial multiple treatments and treatment modalities in each patient.