Making a Difference in the Obesity Epidemic: the Case for PA Leadership

2/10/2017

Making a Difference in the Obesity Epidemic: The Case for PA Leadership

Karli Burridge, MMS, PA-C

Financial Disclosures

• Health Scripts Ambassador- Orexigen

Learning Objectives

After the completion of this presentation, participants should be able to: – Recognize overweight and obesity as chronic diseases – Describe an approach to screening patients, making a diagnosis, and evaluating potential complications – Summarize an overall approach to care, including the roles of behavioral interventions, pharmacotherapy, and bariatric surgery – Identify specific competencies required to manage obesity and overweight

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Obesity is a Chronic Disease

“Obesity is defined as 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 Medicine Association

© American Academy of PAs. All rights reserved. These materials may not be duplicated without the express written permission of AAPA. Obesity Medical Association. Obesity Algorithm. http://obesitymedicine.org/obesity-algorithm/

“ACQUIRING OBESITY IS NOT A PERSONAL CHOICE, BUT A DISEASE WITH SERIOUS HEALTH CONSEQUENCES.” The Obesity Society

© American Academy of PAs. All rights reserved. These materials may not be duplicated without the express written permission of AAPA. Position Statement: Obesity and Disability. January 2015. http://www.obesity.org/obesity/advocacy/obesity-care/obesity-disability.

Why Should Obesity be Considered a Chronic Disease?

Like Crohn’s disease, diabetes, asthma, chronic obstructive pulmonary disease, arthritis, epilepsy, Parkinson’s disease, multiple sclerosis, and heart disease:

• Obesity impairs normal bodily function • Obesity has characteristic signs and symptoms • Obesity is associated with morbidity and mortality • Obesity is a disease state with multiple pathophysiological aspects • Obesity can be managed but not cured. Management requires a range of interventions.

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Implications of Designating Obesity as a Disease

• 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

Obesity Trends* Among U.S. Adults BRFSS, 1995 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19%

Obesity Trends* Among U.S. Adults BRFSS, 2000 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% ≥20%

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Obesity Trends* Among U.S. Adults BRFSS, 2005 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Obesity Trends* Among U.S. Adults BRFSS, 2010 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Prevalence of Self-Reported Obesity Among U.S. Adults by State and Territory, BRFSS, 2015 ¶ Prevalence estimates reflect BRFSS methodological changes started in 2011. These estimates should not be compared to prevalence estimates before 2011.

*Sample size <50 or the relative standard error (dividing the standard error by the prevalence) ≥ 30%.

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Prevalence of Self-Reported Obesity Among Non-

Hispanic Black Adults, by State and Territory, BRFSS, 2012-2014

© American Academy of PAs. All rights *Samplereserved. These materials size may <50 not be orduplicated the without relative the express writtenstandard permission oferror AAPA. (dividing the standard error by the prevalence) ≥ 30%.

Prevalence of Self-Reported Obesity Among Hispanic

Adults, by State and Territory, BRFSS, 2012-2014

© American Academy of PAs. All rights reserved.*Sample These materials size may <50not be duplicated or the without relative the express written standard permission of AAPA. error (dividing the standard error by the prevalence) ≥ 30%.

Body Mass Index (BMI)

• Weight (kg)/[height (m)]2 • A high BMI can indicate high body fatness. BMI can be used as a screening tool, but BMI alone is not diagnostic of the body fatness or health of an individual. • <18.5 kg/m2: Underweight • 18.5 to 24.9 kg/m2: Normal or healthy weight • 25.0 to 29.9 kg/m2: Overweight • ≥30.0 kg/m2: Obese

There is no BMI category for “morbid obesity,” and this term stigmatizes patients and can be a barrier to discussion.

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Burden of Obesity: Projected Obesity-Related Health Care Costs

The U.S. could save $611.7 billion in health care costs by 2030 if the BMI of the average adult were reduced just 5%.

© American Academy of PAs. All rights reserved. These materials may not be duplicated without the express written permission of AAPA. Robert Wood Johnson Foundation. http://healthyamericans.org/assets/files/TFAH2013FasInFatReportFinal%209.9.pdf

Psychosocial Burden of Obesity

• Stigma/Weight Bias1 – People with obesity face bias at work, school, and when receiving health care – People with obesity earn less and receive fewer promotions than non-overweight counterparts in comparable positions – In a survey of 2,449 women with overweight or obesity, 69% said they had experienced bias from physicians • Depression 1,2 • Anxiety 1,2 • Eating disorders 2 • Poor body image 1,2 • Suicidality 1

© American Academy of PAs. All rights reserved. These materials may not be duplicated without the express written permission of AAPA. 1. Yale Rudd Center. http://www.uconnruddcenter.org/files/Pdfs/Rudd_Policy_Brief_Weight_Bias.pdf. 2. Sarwer DB, et al. Endocrinol Metab ClinN Am . 2016;45: 677–688.

Obesity is a Complex, Multifactorial Disease

Obesogenic environment Hedonic input

Genetics Adipose Tissue Gut hormones Medications

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Genetics and Obesity

Impact of Risk Alleles on Average BMI

3000 27.5

27.0 Average(kg/m BMI

2000 26.5

26.0

25.5 2

1000 ) Number Number of individuals

25.0

0 24.5 ≤3 4 5 6 7 8 9 10 11 12 ≥13 Weighted number of risk alleles

The Discovery of the Epidemic Trends in adult overweight, obesity, and extreme obesity among adults age 20 to 74 years: United States. 1960–1962 through 2009–2010 40 Overweight

20 Percent Obese

Extremely Obese 0

National Health and Nutrition Examination Survey 1988-1994, 1999-2000, 2001-2002, 2003-2004, 2005-2006, 2007-2008, and 2009-2010. © American Academy of PAs. All rights reserved. These materials may not be duplicated without the express written permission of AAPA. www.cdc.gov/nchs/data/hestat/obesity_adult_11_12/obesity_adult_11_12.htm

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Environmental Factors

• Easy availability of cheap, energy-dense, highly palatable food. Lack of availability of affordable, healthy food (food deserts). • Work, play, and transportation environments that promote sedentary behavior and require low levels of activity. Lack of safe places to be physically active. • Epigenetic factors and nutritional programming • Gut microbiota • Stress, sleep deprivation • Medications (eg, insulin, TZDs, sulfonylureas, antipsychotics, antidepressants) • Social contagion • Adenovirus 36 • Many more!

Food Intake is Not Simply a Cognitive Function • Central nervous system – Homeostatic system: hunger and satiety – Reward system: overrides to produce food intake even in absence of hunger – Central regulation of energy expenditure • Peripheral signals – Leptin from fat – GLP-1, GIP, PYY, OXM from small intestine – Pancreatic polypeptide, amylin, insulin from pancreas – Ghrelin from stomach

Weight Loss Disproportionately Affects Appetite

Completers Week 62 Weight -9% 95 Leptin -35% Week 10 Leptin Ghrelin Weight -14% 90 Leptin -65% PYY Subjective CCK appetite 85 Insulin 80 Amylin 0 0 8-10 18 26 36 44 52 62 Week

Mean (±SE) changes in weight from baseline to week 62. The weight loss program was started at week 0 and completed at week 10.

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Physiology of Reduced Obese State: Metabolic Adaptation Drives Weight Regain

The metabolic handicap: reduction in energy expenditure disproportionate to weight reduction

Mr. Smith Mr. Jones 220 pounds 200 pounds needs needs 2200 kcal/day 2000 kcal/day

Loses weight to 200 pounds Needs 1830 kcal/day ≠

Smith Jones

Pulmonary Disease Idiopathic Intracranial • Abnormal function Hypertension • Obstructive sleep apnea • Hypoventilation syndrome Stroke

Nonalcoholic Fatty Cataracts Liver Disease • Steatosis Cardiovascular Disease • Steatohepatitis • Coronary artery disease • Cirrhosis • Atherosclerosis • Hypertension Gall Bladder Disease • Myocardial disease • Heart failure Gynecologic Abnormalities • Atrial fibrillation • Abnormal menses • Infertility Type 2 Diabetes • Polycystic ovary syndrome Pancreatitis Osteoarthritis Certain Cancers Skin Phlebitis Gout • Venous stasis • Venous thromboembolism

Pathogenesis of Obesity: Comorbidities

• Burden of fat mass • Organ infiltration by fat, especially the muscle and liver • Location of fat mass: portal vascular system • Products of adipose tissue (adipokines)

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Products of Adipose Tissue

The link between pathophysiology of obesity and associated comorbid conditions

Inflammation Hypertension  Adiponectin  Arthritis (OA and RA TNFα  Angiotensinogen Dyslipidemia  TNF ß  Insulin  FFA Asthma  IL6 Adipose Sleep apnea  Prostaglandins  EGF Tissue Cancer  PAI-1  Adipsin Thrombosis  Cortisol Stroke  Resistin  Estrogen Type 2 diabetes Heart attack  CRP-1 PVD  Leptin Fatty liver disease Insulin resistance

Benefits of Weight Loss

• Patients do not need to achieve their ideal weight to achieve health benefits • Modest weight loss of 5% to 10% of initial body weight produces health benefits • Even a 5% weight loss has been shown to improve beta-cell function and adipose tissue, liver, and muscle insulin sensitivity

Diabetes Prevention Program: Every Kilogram Lost Reduced Risk of Diabetes

years -

10 100person

5 Diabetes Diabetes Incidence rate per

0 -10 -5 0 +5 Change in weight from baseline (kg)

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Modest Weight Loss Has Benefits, with Greater Weight Loss Associated with Greater Benefit • Measures of glycemia1 -3.0% 1 • Triglycerides and HDL cholesterol • Systolic and diastolic blood pressure 2 -5.0% • Hepatic steatosis measured by MR-spectography • Measures of feeling and function: 5 – Symptoms of urinary stress incontinence -10.0% 6,7 – Measures of sexual function 8 – Quality of life measures (IWQOL) 3 -15.0% • NASH Activity Score measured on biopsy 4 • Apnea-hypopnea index • Reduction in CV events, mortality, remission of T2DM

5. Phelan S, et al. J Urol. 2012;187:939-944. 1. Wing RR, et al. Diabetes Care. 2011;34:1481-1486. 6. Wing R, et al. Diab Care. 2013;36:2937-2944. 2. Lazo M, et al. Diabetes Care. 2010;33:2156–2163. 7. Wing R, et al. J Sex Med. 2010;7:156-165. 3. Promrat© American K, et al.Academy Hepatology. of PAs. All rights reserved. 2010;51:121 These materials–129. may not be duplicated without8. the Crosby, express written Manual permission of for AAPA. the IWQOL-LITE Measure. 4. Foster GD, et al. Arch Intern Med. 2009;169:1619–1626. www.qualityoflifeconsulting.com.

Components of an Effective Obesity Management Program

Medications Or Surgery

Behavioral Therapy

Physical Diet Activity

© American Academy of PAs. All rights reserved. These materials may not be duplicated without the express written permission of AAPA. Alamuddin N, et al. Endocrinol Metab ClinNorth Am. 2016 ; 45:565-580.

Behavioral Skills to Support Dietary Changes and Increased Physical Activity

• Behavioral skills that should be cultivated in people engaged in a weight management program include: – Self monitoring – Stimulus control – Problem solving – Goal setting – Relapse prevention

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Pharmacotherapy

FDA-Approved Pharmacotherapy for the Treatment of Obesity

• Phentermine: Generic and branded generics (Adipex-P®, Lomaira™) • Orlistat (Xenical®/alli®) • Lorcaserin (Belviq® and Belviq®SR) • Phentermine/topiramate ER (Qsymia®) • Bupropion SR/Naltrexone SR (Contrave®) • Liraglutide 3.0mg (Saxenda®)

Pharmacotherapy Criteria

BMI: <18.5 18.5-26.9 ≥ 27.0-29.9 ≥ 30.0 >35 >40

With ≥1 With no comorbidity comorbidities (e.g., HTN, DM, dyslipidemia)

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Estimated Weight Loss with Approved Medications

Phentermine Orlistat Lorcaserin Phentermine/ Naltrexone SR/ Liraglutide 3.0 mg Topiramate ER Bupropion SR

5.1% at 28 wks 3.1% at 1 yr 6.6% at I yr 4.8% at 56 wks 3.6% at I yr 5.4% at 56 wks

15 mg daily 120 mg TID 7.5/46 mg 16/180 mg BID 10 mg BID 3 mg daily injection daily

© American Academy of PAs. All rights reserved. These materials may not be duplicated without the express written permission of AAPA. Saunders KH, et al. Endocrinol Metab Clin North A. 2016;45:521-538.

Bariatric Surgery Criteria

BMI: <18.5 18.5-24.9 25.0-29.9 30.0-34.9 >35 >40

With ≥1 With no obesity- comorbidities associated comorbidities (eg, diabetes, obstructive sleep apnea)

FDA-Approved Devices

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Vagal Blocking Therapy (VBLOC)

• Delivers high-frequency electrical pulses to induce intermittent suppression of neural communication between the brain and stomach • Some components of the system are internal and some are external • FDA-approved for patients with a BMI of 40 to 45 kg/m2 or a BMI of 35 to 39.9 kg/m2 and 1 or more obesity-related comorbidity

© American Academy of PAs. All rights reserved. These materials may not be duplicated without the express written permission of AAPA. US Food and Drug Administration. http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/DeviceApprovalsandClearances/Recently-ApprovedDevices/ucm430696.htm

VBLOC

Intragastric Balloon Systems

• Balloon occupies space in the stomach to help patients lose weight • Intragastric balloon systems are FDA-approved for patients with a BMI of 30 to 40 kg/m2 who have been unable to lose weight through diet and exercise. Patients using a balloon system should be in a clinician-supervised diet and exercise plan. • Temporary system removed after 6 months • Three types are available: a single balloon system, a dual balloon system, and a swallowable balloon system

© American Academy of PAs. All rights reserved. These materials may not be duplicated without the express written permission of AAPA. US Food and Drug Administration. http://www.fda.gov/medicaldevices/productsandmedicalprocedures/deviceapprovalsandclearances/recently-approveddevices/ucm457416.htm

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Single Intragastric Balloon

Most Common Bariatric Surgery Procedures

Roux-en-Y Adjustable Sleeve Gastrectomy Gastric Bypass Gastric Band

Malabsorptive and Restrictive Restrictive Restrictive

Small stomach pouch created Approximately 75% of Inflatable, adjustable (30mL); small intestine the stomach is resected band placed around bypassed upper part of the stomach

196,000 total bariatric procedures performed annually.

Currently Available Treatments: Risks and Efficacy

Lower risk

Diets

VLCD Pharma

Lower efficacy Devices Higher efficacy

Lap band Sleeve Roux-en- Y bypass

BPD-DS

Higher risk

© American Academy of PAs. All rights reserved. These materials may not be duplicated without the express written permission of AAPA. VLCD: very low calorie diet; BPD-DS: Biliopancreatic diversion with duodenal switch

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Obesity: PAs Taking the Lead

Why a National Quality Improvement Initiative on Obesity?

AAPA has a strategic imperative to:  Mobilize PAs to make a collective impact on a national scale  Improve PA quality of care related to major public health issues  Distinguish PAs as leaders in care of specific diseases  Establish the profession (and AAPA) as patient centric and issue oriented

Why Obesity? • ~2/3 of all patients seen by PAs are affected by overweight and obesity • PAs are trained as generalists, present in all specialties, and uniquely positioned to diagnose and treat obesity • No other profession has “stepped up to the plate”

“A Framework for PA Intervention for Overweight and Obesity”

• Obesity should be recast as a chronic disease with a focus on prevention and treatment • PA Algorithm – Screen all patients using BMI (take ethnically adjusted anthropomorphic measures into account) – Evaluate and document obesity-related complications – Formulate a patient-centered approach to treatment that includes primary, secondary, and tertiary interventions

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A Comprehensive Online Obesity Curriculum on Learning Central

Topics will include:

• New Approaches to Adult Obesity and Overweight • Evaluating the Patient who has Overweight or Obesity • Lifestyle Interventions: Counseling and Physical Activity • Nutrition • Pharmacologic Therapy • Bariatric Surgery and Endoscopic Devices • Implementing Practice Changes to Support Effective Obesity Management Lifestyle Interventions

PA Competencies in the Management of Overweight and Obesity

• Understanding the model of obesity as a chronic disease as the foundation of approaches to management • Recognizing the physiologic, genetic, and environmental factors contributing to obesity • Conducting patient screening and workup, including the identification of comorbidities • Initiating productive conversations with patients about their weight • Developing a plan of care • Connecting with community resources • Facilitating patient self-management • Coordinating care among the patient, community resources, and other healthcare professionals • Addressing business needs to to support an obesity practice

Summary

• Obesity is a chronic disease. It is caused by environmental and other factors driving expression of this phenotype on the background of genetic risk. • Body weight and body fat distribution are biologically regulated. When weight loss is attempted, biologic and physiologic responses slow metabolism, increase hunger, decrease satiety, and make individuals more sensitive to rewarding food. • Obesity drives morbidity and mortality by the following mechanisms: lipotoxicity, visceral adiposity, fatty infiltration of organs, and the burden of excess fat mass. • Treatment modalities are becoming more effective and safer • PAs have an opportunity to engage all aspects of the disease from prevention to management of obesity-related complications © American Academy of PAs. All rights reserved. These materials may not be duplicated without the express written permission of AAPA.

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Done With This Session?

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Questions?

For more CME and resources visit www.aapa.org/obesity [email protected]