Managing Obesity as a Disease. Disclosure. Objectives

Transcription

1 Managing Obesity as a Disease Ji Hyun Chun (CJ), PA-C, BC-ADM OptumCare Medical Group: Endocrinology, Irvine, CA President, American Society of Endocrine PAs none Disclosure Objectives Recognize obesity as a chronic disease Describe method of screening, making the diagnosis and evaluating complications Develop an overall approach to care (lifestyle/medical/surgical interventions)

2 Q Obesity is: A. A disease B. A risk factor Which of the following is a universal contraindication for weight loss medications A. Pregnancy B. Glaucoma C. Valvular heart disease D. MEN2 syndrome E. Chronic opioid use Q For patients with obesity with complications, how much weight loss is needed for health benefit? A. 1-3% B. 5-10% C % D % E. > 50% Q

3 Obesity Excess adiposity negatively affecting an individual patient s health BRFSS, 1985 No Data <10% 10% 14% BRFSS, 1986 No Data <10% 10% 14%

4 BRFSS, 1987 No Data <10% 10% 14% BRFSS, 1988 No Data <10% 10% 14% BRFSS, 1989 No Data <10% 10% 14%

5 BRFSS, 1990 No Data <10% 10% 14% BRFSS, 1991 No Data <10% 10% 14% 15% 19% BRFSS, 1992 No Data <10% 10% 14% 15% 19%

6 BRFSS, 1993 No Data <10% 10% 14% 15% 19% BRFSS, 1994 No Data <10% 10% 14% 15% 19% BRFSS, 1995 No Data <10% 10% 14% 15% 19%

7 BRFSS, 1996 No Data <10% 10% 14% 15% 19% BRFSS, 1997 No Data <10% 10% 14% 15% 19% 20% BRFSS, 1998 No Data <10% 10% 14% 15% 19% 20%

8 BRFSS, 1999 No Data <10% 10% 14% 15% 19% 20% BRFSS, 2000 No Data <10% 10% 14% 15% 19% 20% BRFSS, 2001 No Data <10% 10% 14% 15% 19% 20% 24% 25%

9 BRFSS, 2002 No Data <10% 10% 14% 15% 19% 20% 24% 25% BRFSS, 2003 No Data <10% 10% 14% 15% 19% 20% 24% 25% BRFSS, 2004 No Data <10% 10% 14% 15% 19% 20% 24% 25%

10 BRFSS, 2005 No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30% BRFSS, 2006 No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30% BRFSS, 2007 No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30%

11 BRFSS, 2008 No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30% BRFSS, 2009 No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30% BRFSS, 2010 No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30%

12 Prevalence of Self-Reported Obesity Among U.S. Adults by State and Territory, BRFSS, 2011 Prevalence estimates reflect BRFSS methodological changes started in These estimates should not be compared to prevalence estimates before *Sample size <50 or the relative standard error (dividing the standard error by the prevalence) 30%. Prevalence of Self-Reported Obesity Among U.S. Adults by State and Territory, BRFSS, 2012 Prevalence estimates reflect BRFSS methodological changes started in These estimates should not be compared to prevalence estimates before *Sample size <50 or the relative standard error (dividing the standard error by the prevalence) 30%. Prevalence of Self-Reported Obesity Among U.S. Adults by State and Territory, BRFSS, 2013 Prevalence estimates reflect BRFSS methodological changes started in These estimates should not be compared to prevalence estimates before *Sample size <50 or the relative standard error (dividing the standard error by the prevalence) 30%.

13 Prevalence of Self-Reported Obesity Among U.S. Adults by State and Territory, BRFSS, 2014 Prevalence estimates reflect BRFSS methodological changes started in These estimates should not be compared to prevalence estimates before *Sample size <50 or the relative standard error (dividing the standard error by the prevalence) 30%. Prevalence of Self-Reported Obesity Among U.S. Adults by State and Territory, BRFSS, 2015 Prevalence estimates reflect BRFSS methodological changes started in These estimates should not be compared to prevalence estimates before *Sample size <50 or the relative standard error (dividing the standard error by the prevalence) 30%. Prevalence of Self-Reported Obesity Among U.S. Adults by State and Territory, BRFSS, 2016 Prevalence estimates reflect BRFSS methodological changes started in These estimates should not be compared to prevalence estimates before *Sample size <50 or the relative standard error (dividing the standard error by the prevalence) 30%.

14 <15% 34 none 15-19% 16 none 20-25% none 3+ D.C % none 22 + Guam 30-35% none 20 + Puerto Rico > 35% none 5 Global Epidemic / Future Accessed 6/12/2018 Our Real Future Peds Obesity Accessed 6/12/2018

15 Health Burden of Obesity Metabolic (Sick Fat Dz) Metabolic syndrome - Pre/diabetes Dyslipidemia - HTN NAFLD - PCOS Biomechanical (Fat Mass Dz) Obstructive sleep apnea - Osteoarthritis Urinary stress incontinence - GERD Disability/immobility Garvey WT et al Advanced Framework for a new diagnosis of obesity as a chronic disease. AACE Accessed 6/16/2018 Economic Burden of Obesity/Overweight Direct cost: $427.8 B 14.3% of US healthcare spending $111.9 B for DM 2 Indirect cost: $988.8 B = Total: $1.42 T (8.2% of US GDP) WEB.pdf. Accessed 6/18/2018

16 Driving Force? Why so difficult? Metabolic adaptation Apovian CM, et al. J Clin Endocrinol Metab. 2015; 100: Metabolic adaptation Weight set point Weight loss Weight regain Ghrelin (orexic) Leptin, PYY, CCK, Amylin (anorexic) Resting energy expenditure appetite / hunger

17 Gaps in Obesity Care Time constraints (priorities) Patient engagement Difficult, emotional conversations Past failures Misaligned perceptions of success Treatment options and coverage Clinician competence Reimbursement Weight bias Reimbursement Yes, it is reimbursed! Patient with obesity who are competent and alert First 6 months: 14 visits Every week for first month Every other week for months 2-6 If >3 kg loss in first 6 months Monthly for months 7-12 Currently only by PCPs Weight Bias Negative attitudes towards individuals with obesity Verbal/physical, off/online, subtle/overt stigma, rejection, prejudice, discrimination Prevents from seeking professional help hampers nation s efforts combat the epidemic

18 Disease vs Risk Factor What makes it a disease? AMA criteria Characteristic signs/symptoms body fat mass Joint pain Impaired mobility Low self esteem Sleep apnea Impairment of normal function Physical impairments Altered physiologic function (inflammation, IR, dyslipidemia, etc) Altered regulation of satiety Results in harm/morbidity CVD DM 2 Metabolic syndrome Cancer Death Obesity Becoming More Recognized as a Disease a chronic, relapsing, multi-factorial, neurobehavioral disease, wherein an increase in body fat promotes adipose tissue dysfunction and abnormal fat mass physical forces, resulting in adverse metabolic, biomechanical, and psychosocial health consequences obesity is a serious chronic disease with extensive and well-defined pathologies, including illness and death Recognizing obesity as a disease will help change the way the medical community tackles this complex issue that affects approximately one in three Americans 2 Obesity is a chronic disease, prevalent in both developed and developing countries, and affecting children as well as adults 3 Mechanick JI et al. Endocr Pract. 2012;18: AMA position statement. At: Accessed Oct WHO. Obesity and overweight. At: Accessed Oct US Food and Drug Administration. Federal Register. 2000;65(4):

19 Why does it matter? Shifts care to an evidence-based chronic disease model Encourages more resources for research, prevention, and treatment Increases reimbursement for obesity care Improves medical education Has potential to reduce weight stigma Kyle TK. Endocrinol Metab Clin N Am. 2016; 45: Chronic Dz Prevention Model BMI < 25 BMI w/o complication BMI > 25 with complication Garvey T et al. Endocr Pract. 2016;22(Suppl 3) Can We Make a Difference? Pool AC et all. Obes Res Clin Pract. 2014;8(2):e131-e139.

20 How Much is Enough? Proper Goal Setting

21 Economic Impact of 5% wgt loss The U.S. could save $611.7 billion in healthcare costs by 2030 if the BMI of the average adult were reduced just 5%. Robert Wood Johnson Foundation. Best Measure of Obesity? Initial screening Body Mass Index (BMI) Supplemental Waist Circumference (WC) Percent Body Fat (%BF) Staging Edmonton Obesity Staging System AACE Complication-specific Staging BMI Kilograms per meters squared (kg/m 2 )

22 Waist Circumference Unit Men Asian Men Women Asian Women Inches Centimeters Pro Cons Well correlate to Not always metabolic disease reproducible (good supplement to BMI <35) Low cost %Body Fat Pro Specific assessment of body fat Monitor progress in body composition changes Cons Cut-off points not validated to metabolic disease Technique may vary and not reproducible Weight Management Tools Surgery Device Medication Behavioral Modification Physical Activity Nutrition

23 Efficacy and Risk Lower risk Diets VLCD Pharma Lower efficacy Devices Higher efficacy Lap band Sleeve Rouxen-Y bypass BPD-DS Higher risk Jensen MD, J Am Coll Cardiol. 2013;pii;s (13) Pharmacotherapy Indication: BMI >30 or >27 with complication Phentermine (Adipex-P, Suprenza)* Orlistat (Alli/Xenical) Lorcaserin (Belviq) Phentermine/topiramate (Qsymia) Naltrexone SR/ Bupropion SR (Contrave) Liraglutide 3.0mg (Saxenda) *short-term (<12 weeks)

24 Efficacy of Meds Baseline weight ~100 kg, average BMI kg/m 2 Garvey WT et al. Endocr Pract Jul;22 Suppl3:1-203 Efficacy and Adverse Events Khera R et al. JAMA. 2016;315: Edge Smoking cessation, Depression: naltrexone/bupropion Type 2 Diabetes Mellitus: lorcaserin, liraglutide Migraine: phentermine/topiramate Craving: Locaserin, naltrexone/bupropion Binge eating: lisdexamphetamine*, phentermine/topiramate, naltrexone/bupropion *not approved for weight loss Kushner RF et al. Obesity Forum Obesity Consults. Oct 2015;Vol 3:No 1

25 Available at aace.com publications clinical practice guidelines scroll down to Obesity Garvey WT et al. Endocr Pract Jul;22 Suppl 3:1-203 Pharmacotherapy Universal contraindication Pregnancy **Phentermine/topiramate ER has fetal toxicity (oral cleft) Comes with REMS. Check pregnancy test prior to start Rx and monthly thereafter Not working? Discontinuation and/or alternative medication should be thought when >5% weight loss is not achieved after 3months of therapy. How about, once patient has reached the goal. Stop the medication?

26 Weight regain after med d/c - Ryan DH and Urquhart. ClinicianReviews. Dec 2015;Vol 25, No 12:S Belviq [prescribing information]: Eisai Inc;2015 Underutilization? Thomas CE, et al. Obesity. 2016;24: Zhang S, et al. Obes Sci Pract. 2016;2: Iatrogenics and Alternatives Apovian CM, et al. J Clin Endocrinol Metab. 2015; 100:

27 Devices

28 Summary Obesity is a chronic disease with multiple complex factors and has to be managed as such. Weight loss is challenged by metabolic adaptation which often leads to weight regain unless proper weight management is implemented. Lifestyle intervention which includes nutrition, physical activity, and behavioral modification, is the core in weight management. Pharmacotherapy can be used as an adjunct but needs to be maintained for its continued effect. Surgery has the highest efficacy but with higher risks which requires lifelong careful monitoring. Obesity is: A. A disease B. A risk factor Q Which of the following is a universal contraindication for weight loss medications A. Pregnancy B. Glaucoma C. Valvular heart disease D. MEN2 syndrome E. Chronic opioid use Q

29 Q For patients with obesity with complications, how much weight loss is needed for health benefit? A. 1-3% B. 5-10% C % D % E. > 50% Q/A Thank you!