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Gotham Light 3 Steps to Successful Obesity Management Learning objectives • Review recent findings about the biologic regulation of eating and weight control • Discuss the clinical recommendations and benefits of sustained weight loss in overweight and obese patients • Apply principles of motivational interviewing and shared decision-making to improve the clinical management of obesity and promote behavioral changes • Understand current guidelines for managing obesity, including the role of pharmacological therapy as an adjunct to lifestyle changes in reducing weight gain and promoting weight loss • Review reimbursement options for intensive behavioral therapy (IBT) in obesity management Disclosures • Brought to you as a medical education collaboration between the Louisiana Academy of Family Physicians and the Endocrine Society. • Developed by Knighten Health. Supported by an unrestricted educational grant from Novo Nordisk Inc. • James Campbell, MD: No relevant financial relationships with any commercial interests Challenge #1: Scope of the Obesity Epidemic and Limited Provider Resources 1 in 3 American adults are obese The Obesity Belt: Obesity prevalence > 30% 80 million Obese (BMI ≥ 30) Not Obese (BMI < 30) Sources: Behavioral Risk Factor Surveillance System, Source: Prevalence of Self-Reported Obesity Among 2012, CDC; U.S. Census Bureau, 2012 QuickFacts U.S. Adults: “The Obesity Belt” BRFSS, 2013 16,526 obese adults for every Endocrinologist 409 obese adults for every HCP Based on Endocrine Clinical Workforce: Supply and Demand Projections, Endocrine Society, April 2013. Challenge #2: Health Care Providers Rarely Treat Weight First Idiopathic intracranial hypertension Stroke Pulmonary disease Abnormal function Obstructive sleep apnea Cataracts Hypoventilation syndrome Coronary heart disease Nonalcoholic fatty liver disease Steatosis Diabetes Steatohepatitis Dyslipidemia Cirrhosis Hypertension Gall bladder disease Severe pancreatitis Gynecologic abnormalities Abnormal menses Cancer Infertility Breast, uterus, cervix, colon, esophagus, Polycystic ovarian syndrome pancreas, kidney, prostate Osteoarthritis Phlebitis Venous stasis Skin Gout Challenge #3: Resources needed for obesity management Weight First Initiative Addresses the 3 Challenges 1. Enlist primary care practitioners to fight the obesity epidemic through medical management 2. Use motivational interviewing techniques and multiple therapeutic options to treat weight first 3. Support primary care practitioners with practical information and resources for treating obesity 3 components of the pilot: • Faculty and Primary Care leaders workshop obesity management WA curriculum. Primary Care participants MT ME receive CE credits. ND 1 OR MN ID INTERPROFESSIONAL WI NY SD MI TRAINING & WORKSHOP WY WED, MARCH 30, 9AM-3:30PM CA IA PA NE WESTIN, BOSTON WATERFRONT HOTEL OH NV UT IN IL WV CO VA KS MO KY NC TN OK AZ Region V NM AR SC pilot region GA MS AL 2 3 TX LA FL • Primary Care leaders give • www.treatweightfirst.com presentations at state and regional • Enduring materials on association meetings program microsite • CME credit for attendees • CME credit available The case for putting weight first How much body weight does a patient with obesity need to lose to lower his or her risk of health problems and death? A. 10% B. 25% C. 3% D. 8% Obesity is a complex and multifactorial disease1-6 Gut microbiota Fat cells Genetics/ Expenditure Intake epigenetics Energy balance Medications Environment 1. Woods SC et al. Int J Obes Relat Metab Disord. 2002;26(suppl 4):S8-S10. 2. Ludwig DS. JAMA. 2014;311:2167-2168. 3. Speliotes EK et al. Nat Genet. 210;42:937-948. 4. Garvey WT et al. Endocr Pract. 2014;20:977-989. 5. Bray GA, Ryan DH. Ann NY Acad Sci. 2014;1311:1-13. 6. The Obesity Society Infographic Task Force, November 2015. http://www.obesity.org/obesity/resources/facts-about-obesity/infographics. Accessed December 10, 2015. Obesity is “getting worse in this country,” rapidly BMI <18.5 18.5-24.9 25.0-29.9 30.0-34.9 35.0-39.9 >40 underweight normal overweight obesity I obesity II obesity III U.S. adult population 31% 34% 20.6% 8.1% 6.4% 35.1% obese 69% overweight and obese More than two-thirds of U.S. adults Ogden CL, Carroll MD, Flegal KM. JAMA. 2014 Jul;312(2);189-90. Overweight and Obesity Increase Risk of Disease BMI <18.5 18.5-24.9 25.0-29.9 30.0-34.9 35.0-39.9 >40 underweight normal overweight obesity I obesity II obesity III Waist Circumference: Men > 40 in, Women > 35 in Disease risk relative to normal weight and waist circumference High Very High Extremely High Ogden CL, Carroll MD, Flegal KM. JAMA. 2014 Jul;312(2);189-90. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity Obes Res. 1998;6(suppl 2). As little as 3% - 5% weight loss reduces the risk of disease BMI <18.5 18.5-24.9 25.0-29.9 30.0-34.9 35.0-39.9 >40 underweight normal overweight obesity I obesity II obesity III Waist Circumference: Men > 40 in, Women > 35 in Disease risk relative to normal weight and waist circumference High Very High Extremely High Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity Obes Res. 1998;6(suppl 2). Why is losing weight and keeping it off so difficult? Obesity as an endocrine-related disease Under normal conditions, food intake and energy expenditure are balanced by a homeostatic American Medical Association (AMA) system that maintains stability recognizes obesity as a disease: of body fat content over time. • It is a multi-metabolic and hormonal disease state • It has characteristic signs and symptoms Obesity results through a perturbation in CNS regulation • Increase in fat mass associated with obesity is of energy homeostasis. directly related to comorbidities such as type 2 diabetes mellitus, cardiovascular disease, and some types of cancer • Disease results through a perturbation in the central nervous system (CNS) regulation of energy homeostasis Morton GJ, Meek TH, Schwartz MW. Nat Rev Neurosci. 2014 Jun;15(6):367-78. Multiple hormonal signals influence hypothalamic neurons and appetite1-3 Stomach Ghrelin Increases appetite Suppresses appetite Appetite Fat cells Gut Leptin GLP-1, CCK, PYY Pancreas Insulin, Amylin 1. Woods SC et al. Int J Obes Relat Metab Disord. 2002;26(suppl 4):S8-S10. 2. Suzuki K et al. Exp Diabetes Res. 2012;2012:824305. 3. Valassi E et al. Nutr Metab Cardiovasc. 2008;18:158-168. Physiology of reduced obese state Metabolic and hormonal changes drive weight regain The metabolic handicap: reduction in energy expenditure disproportionate to weight reduction. Mr. Smith Mr. Jones 220 pounds 200 pounds needs 2200 kcal/day needs 2000 kcal/day Loses weight to 200 pounds Needs 1830 kcal/day ↑ hunger, ↓satiety ≠ Smith Jones Long-term persistence of hormonal adaptations to weight loss Changes in Weight from Baseline to Week 62 11 lb GAIN 30 lb LOSS 10 week weight-loss program Sumithran P et al. N Engl J Med. 2011;365:1597-1604. 14% weight loss produced changes in 8 hormones that encourage weight regain Mean fasting and postprandial levels of some peripheral signals at baseline and 62 weeks 10-week, lifestyle-based weight loss intervention in healthy overweight and 14% weight loss 14% weight loss obese adults (n=34) led to reduced: increased: • sustained elevations in appetite • Leptin – 65% • Ghrelin stimulating hormone(s) and • Peptide YY • Pancreatic polypeptide • decreases in appetite suppressing • Cholecystokinin • Gastric inhibitory polypeptide hormones • Insulin Net result of these hormonal changes • Amylin is WEIGHT GAIN! Measures of appetite Sumithran P et al. N Engl J Med. 2011;365:1597-1604. What are the risks of overweight? How much weight loss is needed for health benefit? Obesity and comorbidities Idiopathic intracranial hypertension Stroke Pulmonary disease Abnormal function Obstructive sleep apnea Cataracts Hypoventilation syndrome Coronary heart disease Nonalcoholic fatty liver disease Steatosis Diabetes Steatohepatitis Dyslipidemia Cirrhosis Hypertension Gall bladder disease Severe pancreatitis Gynecologic abnormalities Abnormal menses Cancer Infertility Breast, uterus, cervix, colon, esophagus, Polycystic ovarian syndrome pancreas, kidney, prostate Osteoarthritis Phlebitis Venous stasis Skin Gout Modest weight loss has benefits, with greater weight loss associated with greater benefit Measures of glycemia1 Triglycerides1 -3% HDL cholesterol1 Systolic and diastolic blood pressure Hepatic steatosis measured by MRS2 Measures of feeling and function: -5% Symptoms of urinary stress incontinence3 Measures of sexual function4,5 Quality of life measures(IWQOL)6 NASH Activity Score measured on biopsy7 Apnea-hypopnea index8 -10% Reduction in CV events, mortality, remission of T2DM -15% See speaker notes for references. Why is modest weight loss beneficial? SCAT = Subcutaneous Adipose Tissue 10% weight loss = 30% VAT Loss VAT = Visceral Adipose Tissue Deterioration Lipid profile Improvement Impaired Insulin sensitivity Improved Abdominal obesity, VAT VAT After weight loss, increased waist reduced waist circumference Blood insulin circumference Blood glucose Risk markers for thrombosis Inflammatory markers Endothelial Impaired Improved function Increased risk Lowered risk Adapted from: Després J, et al. BMJ. 2001;322:716-720. Summary (Risks of overweight & obesity, Benefits of weight modest weight loss) • Obesity is associated with an increased risk for coronary heart disease, type 2 diabetes, various types of cancer, gallstones, and disability. • Obesity is associated with
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