Learning Objectives 11/8/2014. Obesity: Strategies to Tackle the Epidemic MA ACP Annual Scientific Meeting 1. Body Mass Index Calculation
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1 Fatima Cody Stanford, MD, MPH Obesity Medicine & Nutrition Massachusetts General Hospital Harvard Medical School Learning Objectives Review the prevalence of obesity in the USA Outline pathogenesis and any new concepts Define roles of nutrition, exercise, medicine, and surgery. Body Mass Index Calculation Metric measurements: Weight (kg) Height (m) 2 English measurements: Weight (lb) X 703 Height (in) MA ACP Annual Scientific Meeting 1
2 How is Obesity defined in Adults? Weight Status Category Body Mass Index (BMI) Underweight < 18.5 Normal Weight Overweight Class I Obesity Class II Obesity Class III Obesity 40 Obesity Prevalence in Adults and Children in the United States Number of individuals with obesity, Females Males Number in Millions Adults aged 20 and over Children and Adolescents 2-19 SOURCE: CDC/NCHS, National Health and Nutrition Examination Survey, MA ACP Annual Scientific Meeting 2
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11 Obesity Rates by Race/ Ethnicity in the US 60.00% 50.00% 50% 40.00% 30.00% 20.00% 39% 34% Non-Hispanic Blacks All Hispanics Non-Hispanic Whites 10.00% 0.00% Percentage of Persons with Obesity Obesity Rates Increase as Income Decreases in Women in the US Ethnic Group Non-Hispanic White Non-Hispanic Black 39% 38% 27% 55% 52% 48% Low Income Middle Income High Income Mexican American 45% 46% 35% 0% 20% 40% 60% % of US Women with Obesity Ogden CL et al. NCHS Data Brief MA ACP Annual Scientific Meeting 11
12 Non-Hispanic Black and Mexican American Men have Higher Obesity Rates at Higher Income Levels Ethnic Group Non-Hispanic White Non-Hispanic Black 30% 35% 32% 29% 36% 45% Low Income Middle Income High Income Mexican American 30% 31% 41% 0% 20% 40% 60% % of US Men with Obesity Ogden CL et al. NCHS Data Brief 2010 Obesity: A Multi-factorial Disorder Genetics Environment Development Behavior Gene-Environment Interaction in Obesity Genes Environment FTO (Fat mass and obesity associated) MC4R variants (Melanocortin 4 Receptor) Diet Physical Activity Sleep Habits Circadian Rhythm Thermoregulation Obesity 2014 MA ACP Annual Scientific Meeting 12
13 Obesity and Genetics Hypotonia Almond Shaped Eyes Hyperphagia Learning Disabilities Hypogonadism Delayed Motor Development Prader-Willi Syndrome Polydactyly/ Syndactyly Anosmia Growth retardation Urogenital abnormalities Dilated Cardiomyopathy Visual difficulties Bardet-Biedl Syndrome Hyperphagia Hypogonadism Hyperinsulinism Advanced bone age Hypothyroidism Leptin Deficiency Regulation of Food Intake Regulation of Food Intake Nature Reviews Genetics 10, (July 2009) 2014 MA ACP Annual Scientific Meeting 13
14 Regulation of Food Intake Substance Production Site Effect (Relevant for Feeding) Ghrelin (grow) Anandamide (endocannabinoide, ananda; bliss, delight + amide ) Insulin (insula; island or islet) Leptin (leptos, thin) CCK (cholecystokinin, move the bile-sac ) PYY (peptide tyrosine tyrosine) Stomach (fundusregion, entero-endocrine cells) Neurons in the hypothalamus Small intestine Pancreas (β-cells in islets of Langerhans) Adipocytes (long term) Stomach (short term) Small intestine Ileum colon Appetite (orexigenic) Appetite (orexigenic) Satiety (anorexigenic) glycogen and lipid storage Satiety (anorexigenic) Early satiety (anorexigenic) release of digestive enzymes from exocrine pancreas, bile from the gallbladder and H+ from parietal cells in stomach Satiety (anorexigenic) Development- Fetal Programming Am J Physiol Regul Integr Comp Physiol September; 299(3): R711 R722. Medical Complications of Obesity 2014 MA ACP Annual Scientific Meeting 14
15 NHLBI Obesity Algorithm Guidelines for Selecting Obesity Treatment Treatment Diet, PA, & Behavioral Therapy With comorbidities BMI Category With comorbidities Pharmacotherapy Weight Loss Surgery With comorbidities With comorbidities Prevention of weight gain with lifestyle therapy is indicated in any patient with a BMI 25 kg/m2, even without comorbidities, while weight loss is not necessarily recommended for those with a BMI of kg/m2 or a high waist circumference, unless they have two or more comorbidities. Consider pharmacotherapy only if a patient has not lost 1 pound per week after 6 months of combined lifestyle therapy. The + represents the use of indicated treatment regardless of comorbidities. Dietary Guidelines for Americans-2010 Reduce Na+ intake to <2,300 mg & further to 1500 mg if >51 YO, AA, have HTN, DM, or CKD Consume < 10% of calories from saturated fatty acids Replace with mono/polyunsaturated fats Consume <300 mg per day of dietary cholesterol Keep trans fatty acid consumption as low as possible Reduce intake of calories from solid fats and added sugars Limit the consumption of foods that contain refined grains Alcohol consumption in moderation (no more than 1 drink for women, 2 drinks per men daily) MA ACP Annual Scientific Meeting 15
16 Goal Organization Moderate Aerobic Maintain health Prevent weight gain For weight loss To prevent weight regain Physical Activity Guidelines US dept of Health and Human Services (2008) American College of Sports Medicine (ACSM) American College of Sports Medicine (ACSM) 150 min/wk min/wk >250 min/wk Vigorous Aerobic OR 75 min/wk Role of resistance exercises in weight loss and prevention of weight regain is controversial. Weight loss from exercise is modest (~ averageof 1-3 lbs of additional weight loss). NA NA Resistance Training AND on 2 or more days NA NA Anti-obesity pharmacotherapy agents Drug class/name Phentermine Topiramate Bupropion Zonisamide Lorcaserin Phentermine/ Topiramate GLP-1 agonists (exenatide, liraglutide) Amylin agonist (pramlinitide) Metformin Naltrexone Bupropion/ Naltrexone Criteria for Weight Loss Surgery Body Mass Index (BMI) 40 OR BMI of serious comorbidity Type 2 Diabetes Mellitus Coronary Artery Disease Obstructive Sleep Apnea Prior Unsuccessful Weight Loss Attempts Acceptable operative risks Ability to participate in treatment and long term follow-up An understanding of the operation and the lifestyle changes needed to sustain long term weight loss 2014 MA ACP Annual Scientific Meeting 16
17 54 year old woman Past medical history: Case #1 Untreated hypertension Migraine headaches GERD Irritable Bowel Syndrome Metabolic syndrome Retained 20 lbs with each of her 2 pregnancies Tried many commercial programs which lead to 20 lbs of unsustainable weight loss with each attempt Most significant weight loss with the use of phen-fen in the 1990's (~50 lbs over 6 months) Interested in weight loss medications + behavioral Tx 54 year old woman BMI: 40 BMI: 30 Behavioral BMI: 31? 52 year old woman Past medical history : Well controlled asthma Case #2 Asymptomatic gallstone (noted on CT imaging) Malignant melanoma in situ (s/p excision) Tobacco abuse (quit in 1997) 30 lb. weight gain Tried many commercial programs which lead to 30 lbs of unsustainable weight loss with each attempt Able to sustain nutrition quality after cessation of commercial weight loss without strict adherence there is weight regain to baseline 2014 MA ACP Annual Scientific Meeting 17
18 52 year old woman BMI: 36 Phentermine BMI: 33 BMI: 30 BMI: 32 Behavioral BMI: 29 Topiramate? Case #3 56 year old man Past medical history: Hypertension Hyperlipidemia NAFLD New diagnoses (at initial WC visit) Type 2 Diabetes Mellitus Obstructive Sleep Apnea Vitamin D deficiency Tried many commercial programs which lead to lbs of unsustainable weight loss with each attempt Interested in weight loss medications 56 year old man BMI: 35 BMI: 33 Phentermine +Topiramate Metformin BMI: 32 BMI: MA ACP Annual Scientific Meeting 18
19 25 year old woman Past medical history: Case #4 Spinal stenosis s/p 6 back surgeries with resulting nerve damage Rhabdomyolysis Factor V Leiden DVT Hypothyroidism Patellofemoral syndrome Chronic Pain Depression She has been in a nursing home facility for the last 8 months for rehabilitation following her last surgery Unable to dance in wheel chair due to damage Poor Quality of Life On Weight Promoting Medication(Gabapentin) Led to 6o lbs of weight gain 25 year old woman BMI: 53 Metformin + Topiramate BMI: year old woman s/p RYGB BMI: 44 54% EBWL BMI: 36 BMI: 33 BMI: 31 Topiramate 2014 MA ACP Annual Scientific Meeting 19
20 Conclusion Obesity is multifactorial disease process Conventional weight loss consisting of diet and exercise should be 1 st line Primary care physicians should consider options such as pharmacotherapy and/or bariatric surgery as an option for appropriate patients Patients should be considered to a tertiary referral if their care becomes challenging in the primary care setting Thank you for your time! Fatima Cody Stanford, MD, MPH Obesity Medicine & Nutrition Massachusetts General Hospital Harvard Medical School fstanford@mgh.harvard.edu 2014 MA ACP Annual Scientific Meeting 20
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