Obesity Treatment

Factors predispose to obesity

Genetic – familial tendency.Sex – women more susceptible .Activity – lack of physical activity.Psychogenic – emotional deprivation,

depression .Social class – poorer classes. Alcohol – problem drinking. Smoking – cessation smoking. Prescribed drugs – tricyclic derivatives.

Weight Gain: Medications

Disease ExamplesDiabetes Insulin, sulfonylureas

Depression Tricyclics

Seizures Valproic acid, Tegretol

Hypertension Clonidine, α-blockers, β-blockers

Hormones Progesterone

Weight Gain: How Does It Happen?

Energy imbalance calories consumed not equal to calories used

Over a long period of timeDue to a combination of several factors

Individual behaviorsSocial interactionsEnvironmental factorsGenetics

Weight Gain: Energy In

3500 calories = 1 pound

100 calories extra per day = 36,500 extra per year = 10.4 lbs weight gain

Question: How much is 100 calories? Answer: Not very much!

1 glass skim milk, or 1 banana, or 1 slice cheese, or 1 tablespoon butter

Evolving Pathology

More in and less out = weight gainMore out and less in = weight lossHypothalamus

control center for hunger and satietyEndocrine disorder

where are the hormones?

Leptin

Protein hormone secreted by adipocytesLevels correlate with lipid content of cellsLeptin acts on the hypothalamus to

reduce hunger and to stimulate energy expenditure

Ghrelin

Hormone secreted in the stomach Acts on the hypothalamus to stimulate appetite Levels peak just before meals and drop

afterward

Bad News for Dieters

Leptin Dieting decreases leptin levels Reducing metabolism, stimulating appetite

Ghrelin Levels in dieters are higher after weight loss The body steps up ghrelin production in

response to weight loss The higher the weight loss, the higher the

ghrelin levels

Health Consequences of Obesity

Major cause of preventable death

Increase in mortality from all causes

Increase in risk for these cancers Endometrium Breast Prostate Colon

Increase in risk of: Hypertension Dyslipidemia Diabetes type 2 Coronary artery disease Stroke Gallbladder disease Osteoarthritis Sleep apnea &

respiratory problems

Assessment

Assess the patient's readiness and willingness to lose weight : Unfortunately those who are most concerned about

their weights are not necessarily those who are at the highest health risk.

Those who are unable or unwilling to embark on a weight reduction program, but they are willing to take steps to avoid further weight gain or perhaps to work on other risk factors such as cigarette smoking, and they should be encouraged to do so.

For those not ready to act, the issue should be deferred and brought up at the next visit

Assessment

Assess for other risk factors Existing high risk disease:

coronary heart disease; other atherosclerotic diseases; type 2 diabetes; sleep apnea

Diseases associated with obesity Gynecological problems; osteoarthritis; gallstones; stress

incontinence Cardiovascular risk factors (3 or more = high risk)

Cigarette smoking; Hypertension; LDL >130; HDL <35; fasting glucose = 110 to 125; family history of premature CHD; men age > 45; women age > 55

Other risk factors Physical inactivity; elevated serum triglycerides

Medications associated with obesity

Treatment Approach

A multi-faceted approach is bestDietPhysical activityBehavior change

“A” Recommendation

Treatment Approach

Initial goal: 10% weight loss Significantly decreases risk factors

Rate of weight loss 1 to 2 pounds per week Reduction of caloric intake 500-1000 per day

Slow weight loss is more stable Rapid weight loss is almost always followed by

weight gain Rapid weight loss increases risk for gallstones &

electrolyte abnormalities

Treatment Approach

Aim for 4 - 6 months of weight loss effort Most people will lose 20 to 25 pounds After 6 months, weight loss is more difficult

Ghrelin & Leptin are at work! Changes in resting metabolic rate Energy requirements decrease as weight

decreases Diet adherence wavers

Set goals for weight maintenance for next 6 months, then reassess.

Dietary Therapy

Weight reduction with dietary treatment is in order for virtually all patients with a BMI 25-30 who have comorbidities and for all patients over BMI 30.

Strategies of dietary therapy include teaching about calorie content of different foods, food composition (fats, carbohydrates, and proteins), reading nutrition labels, types of foods to buy, and how to prepare foods.

Low-Calorie Step I Diet

1000 to 1200 kcal/day for women

1200 to 1600 kcal/day for men

Adjust for current weight & activity Too hungry?

increase kcal by 100 - 200/day

Not losing? decrease kcal by

100 - 200/day

How Much is 1200 Calories?

Could you stick to 1200 per day?

1 Big Mac (580)1 SMALL Fries (210)1 SMALL shake (430)

Low-Calorie Step I Diet

Nutrient Recommended intake

Calories 500 to 1000 kcal/day reduction from usual

Total fat <30% of total calories

Cholesterol <300 mg per day

Protein <15% of total calories

Carbohydrate >55% of total calories

Sodium Chloride

<2.4 g sodium, or <6 g sodium chloride

Calcium 1000 to 1500 mg/day

Fiber 20 to 30 g/day

Physical Activity

Physical activity should be an integral part of weight loss

Physical activity alone is less successful than a combined diet & exercise program Increased activity alone

does not decrease weight Sustained activity does

prevent weight regain Reduces risk for heart disease & diabetes

Physical Activity

Start slowly Many obese people live sedentary lives Avoid injury Early changes can be activities of daily living

Increase intensity & duration gradually Long-term goal

30 to 45 minutes or more of physical activity 5 or more days per week Burn 1000+ calories per week

Recommend Physical Activity

What does it take to burn

1000 calories per week?

Running 11 miles

Walking 12 miles

Dancing 3 hours

Gardening 5 hours

Cycling 22 miles

Behavioral Strategies

Keep a journal of diet & activity Very powerful intervention!

Set specific goals re: behaviors Eating Activity Related behaviors

Track improvement Weigh & measure on a regular basis

Cognitive Strategies

Focus on the goals Plan meals & activity Develop reminder systems Anticipate temptations & plan resistance Reward yourself Limit quantities, but do not deprive yourself Have confidence in your ability to succeed Do positive self-talk

Pharmacotherapy for Weight Loss

Adjunct to diet & physical activityBMI ≥ 30Or, BMI ≥ 27 with other risk factors Should not be used for cosmetic weight

lossOnly for risk reduction

Use only when 6-month trial of diet & physical activity fails to achieve weight loss

Pharmacotherapy for Weight Loss

These drugs are only modestly effective2 to 10 kilogram lossMost occurs in the first 6 months

If patient does not lose 2 kilograms in the first 4 weeks, success is unlikely

If the first 6 months is successful, continue medication as long as… It is effective in maintaining weight, andAdverse effects are not serious

Pharmacotherapy for Weight Loss

Drug Dose Action Adverse Effects

Sibutramine

(Merida)

5/10,/15 mg

10 mg po qd to start. May be increased to 15 mg or decreased to 5 mg

Nor epinephrine, dopamine & serotonin reuptake inhibitor

Increase in heart rate & blood pressure

Orlistat

(Xenical)

120 mg

120 mg po tid before meals

Inhibits pancreatic lipase, decreases fat absorption

Decrease in absorption of fat-soluble vitamins; soft stools and anal leakage

Weight Loss Surgery

47,000 in 2001; 98,000 in 2003 Types of Obesity Surgery: 1. Restrictive Surgery - uses bands or staples to create food

intake restriction: Vertical Banded Gastroplasty (VBG) - is a “pure” restrictive

surgery since it only involves surgically creating a stomach pouch.  VBG uses bands and staples and is the most frequently performed procedure for obesity surgery.

Gastric Banding – involves the use of a band to create the stomach pouch. 

Laparoscopic Gastric Banding (Lap-Band), approved by the FDA in June 2001, is a less invasive procedure in which smaller incisions are made to apply the band.  The band is inflatable and can be adjusted over time

Weight Loss Surgery

2. Combined Restrictive and Malabsorptive Surgery - is a combination of restrictive surgery (stomach pouch) with bypass (malabsorptive surgery), in which the stomach is connected to the jejunum or ileum of the small intestine, bypassing the duodenum. Roux-en-Y Gastric Bypass (RGB) - is the most commonly performed

gastric bypass procedure, and the second most frequently performed surgery for obesity after VBG.   RGB involves a stomach pouch for food intake restriction.  A direct connection, which is Y-shaped, is made from the ileum or jejunum to the stomach pouch for malabsorption. 

Biliopancreatic Diversion (BPD) - is one of the most complicated obesity surgery, sometimes involving the removal of a portion of the stomach.  The remaining section of the stomach is connected to the ileum. BPD successfully promotes weight loss, but this procedure is typically used for persons with severe obesity who have a BMI of 50 or

more

Weight Loss Surgery

Indications100 pounds overweight or moreOr, BMI > 40Or, BMI > 35 and 2 significant comorbiditiesAge 18 to 60Documented failure at nonsurgical effortsPsychological stability

Weight Loss Surgery

Roux-en-Y gastric bypass Limits food intake Alters digestion

Figure from NIDDK website

Weight Loss Surgery

Complications of surgery Mortality

<1% mortality in healthy young adults BMI < 50 2-4% mortality in patients with disease and BMI > 60

Operative complications < 10%

Late complications are uncommon Incisional hernias Gallstones Vitamin B12 & iron deficiency Weight loss failure Neurologic symptoms in unusual cases

Weight Loss Surgery Outcomes

Durable weight loss One study followed pts for 14 years

Average excess weight loss = 61.2%77% with diabetes no longer require

meds From Wald meta-analysis in JAMA 2004)

Followup

Schedule a return visit in 2 to 4 weeks after starting weight loss plan Monitor treatment effectiveness & side effects

Schedule monthly visits for first 3 months If making favorable progress See more frequently if monitoring medical

complications or chronic disease Reduce frequency of visits after 6 months

Followup

Monitor weight, BP, pulse at each visit Monitor waist size intermittently Share progress with patient; praise efforts Share lab results with patient

Emphasize findings associated with weight reduction

Focus on medical benefits Most weight loss doesn’t reach individual’s ‘ideal’

(cosmetic) goal