disclosure - uab · 1 5 things to know about managing obesity in clinical practice taraneh...

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5 Things to Know About Managing Obesity in Clinical Practicey

Taraneh Soleymani, MD, FTOSAssistant Professor

Department of Nutrition SciencesUniversity of Alabama at Birmingham

[email protected]

Disclosure

I have no financial interest or conflict of interest inI have no financial interest or conflict of interest in relation to this program/presentation.

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ObjectivesTHING 1 Staging of Overweight and Obesity

THING 2 Obesity Treatment Modalities

THING 3

THING 4

THING 5

Diet in Weight Management

Physical Activity in Weight Management

Behavioral Modification in Weight Management

Staging of Overweight and Obesity

• Why is it important to do?– Correlates with body fat– Risk estimate: Increase BMI is associated with adverse health

conditions– Accurate diagnosis & documentation

Treatment selection

THING 1

– Treatment selection

• Based on Body Mass Index (BMI)– A weight-stature index, used both as a measure of obesity and

malnutrition– BMI = weight (kg) / Height2 (m2) – BMI= weight (lb.) x 703/ height squared (in2)– BMI chart

Body Fat

40

50

60

70Women

Men

Relationship Between BMI and Percent Body Fat in Men and Women

Adapted from: Gallagher et al. Am J Clin Nutr. 2000;72:694.

Fat (%)

Body Mass Index (kg/m2)

0

10

20

30

0 10 20 30 40 50 60

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Staging of Overweight and Obesity

• 2013 AHA/ACC/TOS Guidelines for Obesity Recommendation:– Measure height and weight and calculate BMI at annual visits or

more frequently

THING 1

Body Mass Index Staging

18.5 – 24.9 kg/m2 Normal range

25 – 29.9 kg/m2 Overweight

30 – 34.9 kg/m2 Obesity Stage I

35 – 39.9 kg/m2 Obesity Stage II

≥ 40 kg/m2 Extreme Stage III

Does BMI give you the complete picture?

• BMI does not distinguish between lean and fat mass.• It is especially less accurate in:

– Elderly– Athletes– Certain ethnic groups

• Waist Circumference:– Indirect measure of central adiposity correlated with visceral fatIndirect measure of central adiposity, correlated with visceral fat– Excess abdominal fat is an independent predictor of risk factors and morbidity

• Measurement is recommended for individuals with BMI 25‐34.9 kg/m2 to provide additional information on risk

• It is unnecessary to measure waist circumference in patients with BMI≥35 kg/m2

because the waist circumference will likely be elevated and will add no additional risk information.

• Cut points:– Women: >88 cm (>35 in)– Men: >102 cm (>40 in)

Comparison of Anthropometric and Metabolic Variables and Disease Prevalence in Women With Normal vs High WC Values Within Different BMI Categories

Arch Intern Med. 2002;162(18):2074-2079. doi:10.1001/archinte.162.18.2074

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Measuring Waist Circumference

• Locate upper hip bone and top of right iliac crest

• Place measuring tape around abdomen at level of iliac crest, abdo e at e e o ac c est,keeping it parallel to the floor

• Ensure tape is snug but not compressing the skin

http://www.nhlbi.nih.gov/guidelines/obesity/prctgd_c.pdf.

Waist Circumference is NOT Belt Size

Real waist located here = 44”

Belt from college located here = 36”

Assessing Obesity: BMI, Waist Circumference, and Disease Risk

BMI (kg/m2)Men 40 in

Women 35 in

Underweight —<18 5

Men > 40 in

Women > 35 in

—

Disease Risk Relative to Normal

Weight and Waist Circumference

g

Normal

Overweight

Obesity Stage I

Obesity Stage II

Extreme obesity

—

—

Increased

High

Very high

Extremely high

<18.5

18.5-24.9

25.0-29.9

30.0-34.9

35.0-39.9

40

—

—

High

Very high

Very high

Extremely high

Disease risk for DM2, HTN and CVD. Adapted from: Clinical Guidelines on the Identification, Evaluation and Treatment of Overweight and Obesity in Adults: the Evidence Report. Obesity research and NIH NHLBI, 6(S2), 1998.

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Ethnic Specific Values for Waist Circumference



THING 3

THING 4

THING 5




Lifestyle Modification

Lifestyle Modification Pharmacotherapy Surgery

PhentermineOrlistatDiet

Physical Activity

Phentermine/Topiramate

ERDiethylpropion

Buproprion/Naltraxone

ER

Behavior Therapy

ER

Lorcaserin

Liraglutide

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Current Approach to Obesity Treatment

Treatment OptionsCurrent Patient Risk LOW → HIGH

BMI Range 25–26.9 27–29.9 30–34.9 35–39.9 ≥40

Diet, exercise, and behavioral therapy

Potential + + + + +behavioral therapy Treatment

RiskLOW

↓HIGH

+ + + + +

PharmacotherapyWith a

comorbidity+ + +

SurgeryWith a

comorbidity+

Complications-Centric Model for Obesity Treatment



THING 3

THING 4

THING 5




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CaloriesComposition

Diet Strategies for Weight Mangement

Very Low Fat Diet Low Fat Diet Moderate Fat Diet

10‐20% Total Calories from Fat

20‐35%Total Calories from Fat

35‐45%Total Calories from Fat

PritikinOrnish

Primarily plant based

Dietary Guidelines for AmericansDash

American Heart AssociationJenny Craig

Mediterranean Diet

Weight WatchersNutrisystem

High Protein Diet

> 25% Total Calories from protein

ZONE

Low Carbohydrate Diet

10‐30 % Total Calories from carbohydrate

AtkinsKetogenic

Very Low Calorie Diet

<800 kcal

OPTIFASTHMR

How Much Calorie to Prescribe?

1. Calculate daily caloric needs and subtract 500‐750 kcal:

Basal Metabolic Rate equation ‐Mifflin‐St Jeor:• Men: 10 x Weight (kg) + 6.25 x height (cm) ‐ 5 x age (y) + 5• Women: 10 x Weight (kg) + 6.25 x height (cm) ‐ 5 x age (y) – 161

Multiply Basal Metabolic Rate by Activity Factor: • Sedentary = 1 2 (little or no exercise desk job)

Daily Caloric Sedentary = 1.2 (little or no exercise, desk job)

• Lightly active = 1.375 (light exercise/ sports 1‐3 days/week) • Moderately active = 1.55 (moderate exercise/ sports 6‐7 days/week)• Very active = 1.725 (hard exercise every day, or exercising 2 x/day)• Extra active = 1.9 (hard exercise 2 or more times per day, or training

for marathon, or triathlon, etc.)

2. Obesity Guidelines 2013:Women: 1200 – 1500 kcal/dayMen: 1500 – 1800 kcal/day

Caloric Needs

Bray, G. & Bouchard, C. Handbook of Obesity, Fourth Edition: Surgical Procedures in the Treatment of Obesity and its Comorbidities

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• START BY recommending a diet that your patient is most likely to adhere to for weight loss

• Keep in mind: A collaborative effort

• Consider:Previous success and failures with a diet plan

THING 3 Diet in Weight Management

– Previous success and failures with a diet plan– Current life circumstances: opportunities & barriers – Co-morbidities

• Educate the patient:– Obesity is a disease– Weight management is a journey: Trial & Error– Importance of keeping a food journal

• Ask patient to be transparent about their food choices, hunger and challenges of adhering to the diet plan.

A Judgment Free Zone

• Monitor weight loss progress at every visit.

THING 3 Diet in Weight Management

• Keep an open mind to the possibility of changing the diet if there is poor response.

• Always CHECK THE FOOD JOURNAL before determining the need to change the diet plan.



THING 3

THING 4

THING 5




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-6

-4

-2

0

Short‐Term Changes in Body Weight

-12

-10

-8

0 Months 6 Months

Control Diet Exercise Diet + Exercise

Wing et al. 1998

Effect of Exercise on 24-Month Weight Loss Maintenance in Overweight Women

Jakicic et al. Arch Intern Med. 2008

Physical Activity & Weight Management

• Physical Activity to prevent weight gain:– 150-250 min/wk. (energy equivalent to 1200-200 kcal/wk.)

• Physical Activity for weight loss:– <150 min/wk.: minimal weight loss/ g– >150 min/wk.: modest weight loss 2-3 kg– >225-420 min/wk.: weight loss of 5-7.5 kg

• Physical Activity to prevent weight regain:– 200-300 min/wk.– More is better

ACSM Position Stand. Med Sci Sports Exerc. 2009 Feb;41(2):459‐71

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THING 3

THING 4

THING 5




154 Participants with Obesity

Low-Carbohydrate vs. Low-Fat Diet

Low-Carbohydrate

20 g/day carbohydrateIncreased over time

Low-Fat1200-1500 kcal

25% fat

%

Low-Carbohydrate Low-Fat

11 %

6 months 12 months

63 Participants with Obesity

Behavior modification intensity has a

significant impact on-7% -3.2%

Foster GD N Engl J Med. 2003

-4.4% -2.5%

11 % 11 %

7% 7%

12 months 24 months

significant impact on total amount of

weight loss.

What is Behavior Therapy? • A set of principles and techniques used to help patients ADOPT new

habits.

• Helps patients REPLACE maladaptive behaviors with new eating and activity habits.

• Helps patients develop a set of SKILLS to regulate their weight

• The goal:– to improve eating, activity, and thinking habits that

contribute to a patient’s excess weight.

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Goal Setting

• Setting appropriate goals is critical for self regulation and behavior change.

• People engaged in behavior change efforts often set goals that are not helpful or that sabotage their efforts.g p g

• What are the characteristics of effective goals? – Specific Detailed– Measurable Objective– Achievable Clear Outcome– Realistic Likely to be successful– Time frame Proximal

Goal Setting

• Identify the goal – Cut back on juice

• Identify the process by which the goal will be achievedPlace the measuring cup on the kitchen counter to remind you– Place the measuring cup on the kitchen counter to remind you to measure your juice every morning

• Advocate for small rather than large changes– Cut back on juice from 16 oz. to 8 oz. per day

Thank You

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Intensive Behavioral Therapy (IBT) for Obesity In Primary Care Setting

• Coverage: Screening for Obesity, Dietary assessment, and Intensive Behavioral Counseling

• Frequency: Maximum of 22 IBT Sessions– One face‐to‐face visit every week for 1st month

– One face‐to‐face visit every other week for month 2‐6

– One face‐to‐face visit every month for month 7 – 12 , If patient looses at least 3kg (6.6 lbs.)

• Coding: – HCPCS Code G0447 (Face‐to‐face behavioral counseling for Obesity, 15

minutes)

– HCPCS Code G0473 (Group counseling for obesity)

ICN 907800 August 2012 – Medicare Learning Network

Self Monitoringi.e. recording one’s

behavior• Strongly associated with weight loss success.

• Food record is a critical tool for identify eating tt th t bpattern that can be

modified to reduce calorie intake.

• Self Monitoring:– Dietary Intake

– Physical Activity

– Weight

– Mood

• Long term weight management is challenging regardless of the weight loss modality.

• Patient’s desire to limit food and energy intake is counteracted by adaptive biological responses to weight loss:

– Fall in energy expenditure (metabolism) out of proportion to reduction in body mass.

– Changes in hormones leading to increase appetite.

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