An Overview of for Healthcare Practitioners

June 17, 2019

Preventive Medicine Task Force American Medical Women’s Association Empowering Women & Improving Health Care Since 1915

www.amwa-doc.org Preventive Medicine Task Force Representatives

• Connie Newman MD FACP FAMWA, Diplomate American Board of Obesity Medicine, and American Boards of Internal Medicine, Endocrinology & Metabolism, Adjunct Professor of Medicine, NYU School of Medicine, New York, NY • Amanda Velazquez MD, Diplomate of American Board of Obesity Medicine, Internal Medicine Certified, Southern California Kaiser Permanente, West Los Angeles, CA • Farzanna Haffizulla MD FACP FAMWA, Assistant Dean for Community and Global Health, Assistant Professor, Department of Medical Education, Nova Southeastern University, Dr. Kiran C. Patel College of Allopathic Medicine (NSU MD), Fort Lauderdale, FL • Carlos Pulido MD,. Pre-Med Program Director. American Heritage School • Victoria Silverman, MD/MPH Candidate Class of 2019, University of Miami Miller School of Medicine, Miami FL • Tracey Cook, MD Candidate Class of 2018, Florida State College of Medicine, Tallahassee Florida • Akhila Gummi DO, Family Practice Resident; College Medical Center, Long Beach, CA • Asal Hejazi, Pre-Medicine University of California, Los Angeles, CA • Dela Surti, MPH, Communicable Disease Reporting and Surveillance System (CDRSS) Coordinator at NJ Department of Health, Washington D.C.

Preventive Medicine Task Force American Medical Women’s Association Faculty

Connie Newman MD FACP FAMWA Amanda Velazquez MD Farzanna Haffizulla MD FACP Diplomate American Board of Diplomate American Board of FAMWA Obesity Medicine and American Obesity Medicine and Assistant Dean for Community and Boards of Internal Medicine, American Board of Internal Global Health Endocrinology and Metabolism, Medicine, Southern Assistant Professor, Department of Adjunct Professor of Medicine California Kaiser Permanente Medical Education Div. Endocrinology & Metabolism West Los Angeles, CA Nova Southeastern University NYU School of Medicine Dr. Kiran C. Patel College of New York, NY Allopathic Medicine (NSU MD) Preventive Medicine [email protected] Task Force Fort Lauderdale, FL American Medical Women’s Association Introduction

• Overweight and obesity affect two- thirds of U.S. adults, and one- third of children, and are associated with many chronic illnesses.

• We now understand that obesity itself is a disease with abnormalities in CNS pathways and peripheral hormones, which make it difficult for people to lose weight and maintain weight loss.

• Weight management requires a comprehensive approach including lifestyle and behavioral modifications, potential pharmacotherapy to control appetite, and in severe cases, bariatric surgery.

• This presentation aims to increase knowledge about obesity as a disease, its complications and pathophysiology, and approaches to treatment.

Preventive Medicine Task Force American Medical Women’s Association Learning Objectives

• Definitions, etiology, prevalence, co-morbidities • Regulation of food intake and energy expenditure • Talking about weight • Assessment and development of a treatment plan • Lifestyle management • Pharmacotherapy • Bariatric surgery • Minimally invasive procedures

Preventive Medicine Task Force American Medical Women’s Association SECTION 1 DEFINITIONS, ETIOLOGY, PREVALENCE, CO-MORBIDITIES Definitions

• Obesity: Body Mass Index (BMI) of 30 or higher.

• Body mass index (BMI) – the weight in kilograms divided by the square of the height in meters (kg/m2) – is a commonly used index to classify overweight and obesity in adults.

• WHO defines overweight as a BMI equal to or more than 25, and obesity as a BMI equal to or more than 30.1

• American Medical Association recognized obesity as a disease in 20132

1. “10 Facts on Obesity.” World Health Organization. 2016. http://www.who.int/features/factfiles/obesity/facts/en/. Accessed April 5 2016. 2. American Medical Association. AMA Resolution No. 420 (A-13). June 19, 2013. www.ama-assn.org/assets/meeting/2013a/a13-addendum-refcomm-d.pdf. Accessed September 27, 2013. Preventive Medicine Task Force American Medical Women’s Association Obesity is Complex

• Obesity is a multifactorial condition

• Recognizing obesity as a complex medical condition can facilitate a honest and respectful open conversation between the provider and patient1

Image: Seger JC, Horn DB, Westman EC, et al. Obesity Algorithm, presented by the American Society of Bariatric Physicians, 2014-2015.

1. Kushner RF. Clinical assessment and management of adult obesity. Circulation 2012;126:2870–2877.

Preventive Medicine Task Force American Medical Women’s Association Prevalence of Obesity and Diagnosed Diabetes in U.S. Adults 1994, 2000, 2015

Obesity (BMI ≥30 kg/m2) 1994 2000 2015

No Data < 14.0% 14.0%–17.9% 18.0%–21.9% 22.0%–25.9% ≥26.0%

Diabetes 1994 2000 2015

No Data <4.5% 4.5%–5.9% 6.0%–7.4% 7.5%–8.9% >9.0%

CDC’s Division of Diabetes Translation. United States Surveillance System available at http://www.cdc.gov/diabetes/data, accessed June 14, 2019 Obesity and Diabetes 2015 age adjusted percentage of U.S. adults

Maps of Trends in Diagnosed Diabetes and obesity April 2017. CDC’s Division of Diabetes Translation. United States. https://www.cdc.gov/diabetes/statistics/slides/maps_diabetesobesity_trends.pdf Prevalence of obesity age 20 yrs and older by sex and age in U.S

Total 39.8%, M 38%, F 41.5% Prevalence of obesity in U.S. adults by sex and race and Hispanic origin

Age adjusted prevalence of obesity, age 20 and over 60 2015-2016 54.8 50.6 50 43.1

40 37.9 38.0 36.9

30

20 14.8 10.1 10

0 NH White NH Black NH Asian Hispanic Men Women Source: Hales CM, et.al. 2017 Medical Complications of Obesity1

Pulmonary disease Idiopathic intracranial hypertension asthma Stroke obstructive sleep apnea Cataracts hypoventilation syndrome Nonalcoholic fatty liver disease Coronary heart disease steatosis Diabetes steatohepatitis Dyslipidemia cirrhosis Hypertension

Gall bladder disease Severe pancreatitis Reproductive abnormalities abnormal menses Cancer infertility breast, uterus, cervix polycystic ovarian syndrome colon, esophagus, pancreas Osteoarthritis kidney, prostate Skin Phlebitis Gout venous stasis 1. “Obesity Complications.” Mayo Clinic. June 2015. http://www.mayoclinic.org/diseases-conditions/obesity/basics/complications/CON- 20014834. Accessed April 2016. Obesity associated with 4-5 fold increased risk of osteoarthritis

• 38% of people with obesity have arthritis and 33% are overweight 1 • 1 extra pound of weight increases force on knee by 4 pounds • Osteoarthritis may make it difficult for exercise/physical activity, and exercise is helpful for weight loss and essential for maintenance of lost weight • Weight loss improves knee and hip pain and mobility 2,3 http://thinkloud65.wordpress.com/2012/05/01/osteoarthrit is-the-wear-and-tear-joint-disease

1 Barbour KE et al MMWR Morbidity Mortality Weekly Report 2017;66: 246-253; 2 Christensen R et al Ann Rheum Dis 2007;66: 433-439; 3Rose SA et al Int J Obes 2013; 37:118-128 Relationship of BMI and risk of DM2

93.2 100 Women 114,281 age 30-55 yrs (Nurses Health Study)1 75 Men 27,983 age 40-75 yrs2 54.0 50 40.3 42.1 27.6

21.3 Adjusted Relative Risk Relative Adjusted

- 25 8.1 15.8 5.0 11.6 2.9 4.3 2.2 6.7

Age 1.0 1.5 4.4 1.0 1.0 0 <22 <23 23– 24– 25– 27– 29– 31– 33– 35+ 23.9 24.9 26.9 28.9 30.9 32.9 34.9

Body Mass Index (kg/m2)

1. Colditz G, et al. Ann Intern Med 1995;122:481; 2 Chan J, et al. Diabetes Care 1994;17:961.

Preventive Medicine Task Force American Medical Women’s Association Relationship of BMI and Mortality Pooled data from 57 prospective studies, 2218 men, 3295 women 1

64 • Relative risk for mortality for ages 35-89 adjusted for age and Male smoking 32

• First 5 years of follow- up excluded

• This data demonstrates that an increase in BMI 16 is associated with higher rates of Female

mortality in both CI) (99% per 1000 Deaths Yearly males and females1 8 15 20 25 30 35 40 45 Body Mass Index 1. Whitlock G et al. Prospective Studies.Collaboration Lancet 2009;373:1083 Relationship of BMI and SBP1

1. Alexandra Dudina et al. European Journal of Cardiovascular Prevention & Rehabilitation 2011;18:731-742

Preventive Medicine Task Force American Medical Women’s Association SECTION 2 PATHOPHYSIOLOGY REGULATION OF FOOD INTAKE AND ENERGY EXPENDITURE Appetite is regulated by peripheral hormones and the brain1 : Weight loss ↑ appetite stimulating hormones (ghrelin) & ↓ appetite suppressing hormones (leptin, PYY, CCK, amylin) & thermogenesis, thus causing weight regain

NPY, AGRP ↑ appetite

POMC and α MSH ↑ satiety & energy expenditure

AGRP: agouti-related peptide; α-MSH: α-melanocyte-stimulating hormone; GHSR: growth hormone secretagogue receptor; INSR: insulin receptor; LepR: leptin receptor; MC4R: melanocortin-4 receptor; NPY: neuropeptide Y; POMC: proopiomelanocortin; PYY: peptide YY; Y1R; neuropeptide Y1 receptor; Y2R: neuropeptide Y2 receptor. 1. Apovian CM Aronne LJ Bessesen D et al. J Clin Endocrinol Metab. 2015;100:342-362. Obesity and Hypothalamic Injury1

Fattening Foods Cause Dropout of POMC Neurons and Glial Ensheathment of Arcuate Neurons

• In rats, a high fat diet rapidly induced neuron injury in the hypothalamus, a brain area critical for energy homeostasis.

• This occurred in a few days, before substantial weight gain.

• Extending these findings is MRI evidence for gliosis in the hypothalamus of humans with obesity.

1. Thaler, J et al J Clin Invest. 2012 Jan 3;122(1):153-62. doi: 10.1172/JCI59660. Epub 2011 The Challenges to Losing Weight

• 50 obese men and women • Men 233 lbs/average; Women 200 lbs/average • Very low-calorie diet o Optifast shakes + 2 cups of low-starch vegetables • Total 500 to 550 calories a day for eight weeks

1. Sumithran P, et al. N Engl J Med. 2011;365:1597-1604. Slide: After Aronne LJ Preventive Medicine Task Force American Medical Women’s Association Body fights against weight loss long after dieting has stopped Mean change in weight from baseline to week 62

34 participants completed the study

ITT = intention to treat

10 wk weight-loss program 30 lb wt loss 1 yr, 11 lb weight regain Patients more hungry &

1. Sumithran P, et al. N Engl J Med. 2011;365:1597-1604. preoccupied with food

Preventive Medicine Task Force American Medical Women’s Association High Rate of Relapse After Weight Loss in People with Obesity has a Physiological Basis

14% weight loss in 34 healthy adults with obesity led to changes in appetite stimulating and appetite suppressing hormones that encouraged weight regain Changes at week 62 compared to baseline Reduced appetite Increased Appetite suppressing Stimulating Hormones hormones Leptin - 36%  at wk 62 Ghrelin Peptide YY Pancreatic polypeptide Cholecystokinin Gastric inhibitory polypeptide Insulin Amylin

1. Sumithran P, et al. N Engl J Med. 2011;365:1597-1604.

Preventive Medicine Task Force American Medical Women’s Association Biological Adaptations to Body Weight

Question: How long do these biological adaptations persist w/ calorie restriction? Answer: Evidence suggests often indefinitely1 • Biological pressure to restore bodyweight to the highest-sustained lifetime level gets stronger as weight loss increases.2

Question: Then is a patient ever truly “recovered” from obesity? Answer: • Few individuals ever fully recover from obesity1,2 • Individuals with obesity who lose weight are in “remission” and biologically very different than their counterparts1,2,3

1. Ochner CN., et al.,Biological mechanisms that promote weight regain following weight loss in obese humans.Physiol Behav 2013; 120: 106– 13; 2. Rosenbaum M, Leibel RL. Adaptive thermogenesis in humans. Int J Obes 2010; 34 (suppl 1): S47–55; 3. Ochner C.N. “Treating obesity seriously: When recommendations for lifestyle change confront biological adaptations.” Lancet. 2015. 3(4): pp232-234. Obesity is a Disease

American Medical Association (AMA) recognized obesity as a disease in 20131

Image: http://www.ama-assn.org/ama Defined as: “A multi-metabolic and hormonal disease state with characteristic signs and symptoms; and increase in fat mass associated with obesity is directly related to comorbidities such as type 2 diabetes mellitus, cardiovascular disease, and cancer.”

1. American Medical Association. AMA Resolution No. 420 (A-13). June 19, 2013. www.ama-assn.org/assets/meeting/2013a/a13-addendum-refcomm-d.pdf. Accessed September 27, 2013.

Preventive Medicine Task Force American Medical Women’s Association Obesity Medicine Certification through ABOM

• The American Board of Obesity Medicine (ABOM) offers a certification exam for physicians annually

• As of 2019, more than 3,000 ABOM diplomates throughout the U.S. and Canada

• Learn more at www.abom.org

Preventive Medicine Task Force American Medical Women’s Association SECTION 3 TALKING ABOUT WEIGHT Assessing Readiness to Change

• Appreciating patient readiness to change, the barriers to change and helping patients to anticipate relapse can improve patient satisfaction and decrease physician frustration during the process.2

• If patient is ready to change, agree with patient on reasonable weight and activity goals and write them down. 3

Source: Adapted from DiClemente and Prochaska, 1998 1

1. Prochaska, J.O., Norcross, J.C., Diclemente, C.C. (1994). Changing for Good. New York: Avon Books. 2. Zimmerman, GL; Olsen, CG; Bosworth, MF. A 'stages of change' approach to helping patients change behavior. Am Fam Physician 2000 Mar 1;61(5):1409–16. 3. Practical Guide to the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults, NHLBI 2000. Guidelines for Obesity Screening

Screening for Obesity in Adults: The US Preventive Services Task Force recommends that clinicians screen all adult patients for obesity and offer intensive counseling and behavioral interventions to promote sustained weight loss for obese adults (Grade B recommendation).1

1. U.S. Preventive Services Task Force. Ann Intern Med. 2012;157:373-378.

Preventive Medicine Task Force American Medical Women’s Association Talk to Your Patients About Weight

• USPSTF screening recommendation is based on 2012 systematic review that showed: Intensive counseling led to an average 6% body weight loss, along with improved comorbidities and CV risk factors1 • Weight-related discussions w/ healthcare providers can affect a patient’s participation in attempting weight loss2 • There is no clearly established method for telling patients that they are overweight or obese3 “Real Life Adventures.” Wise, G., Lance, A., 2013. 1. Final Recommendation Statement: Obesity in Adults: Screening and Management. U.S. Preventive Services Task Force. October 2014. http://www.uspreventiveservicestaskforce.org. Accessed Feb 29 2016. 2. Rose SA. Physician weight loss advice and patient weight loss behavior change: A literature review and meta‐analysis of survey data. International journal of obesity (2005). 2013;37(1):118; 118‐128; 128. 3. Baron RB. Telling patients they are overweight or obese: an insult or an effective intervention? Arch Intern Med. 2011;171:312–322. Avoid Weight Bias

• Ask permission to bring up the topic of obesity • Weight bias, or negative attitudes about one’s weight, often lead the patient to avoid seeking care.1 • Patients with weight bias are predisposed to more weight gain.2 • Healthcare professionals can help overcome this barrier by being aware of one’s own implicit bias of obesity.1 • Use “people-first” language: o Example: addressing the patient as having obesity instead of addressing him or her as obese1 • Preferred terms: weight, then excess weight, unhealthy body weight3 • Disliked terms: excess fat, large size, obesity, heaviness

1Puhl R. International J of obesity 2013; 37 (4): 612; STOP Obesity Alliance. Why Weight? A guide to discussing obesity and health with your patients; 2Sutin AR, Terracciano A. PLoS One. 2013;8(7):e70048; 3Tailor A, Ogden J. Avoiding the term “obesity”: an experimental study of the impact of doctors' language on patients' beliefs. Patient Educ Couns. 2009;76:260–264. Motivational Interviewing (MI)

• MI is a therapeutic approach to help individuals work through ambivalence about behavior1 • Numerous studies have shown MI can help individuals improve diet and physical activity 2,3 • The goal is to help patients think about their reasons for and against changing behavior • It is crucial to use reflective listening skills and positive affirmations

1. Miller WR, Rollnick S. Motivational interviewing: preparing people to change. 2nd ed. New York: Guilford Press; 2002. 2. Ber-Smith SM, Stevens VJ, Brown KM, et al. A brief motivational intervention to improve dietary adherence in adolescents. Health Educ. Res. 1999; 14: 399-410. 3. Resnicow K, Jackson A, Wang T, et al. A motivational interivewing intervention to icnrease fruit and vegetable intake through black churches: results of the eat for life trial. Am J Public Health. 2001;91:1686-93. SECTION 4 ASSESSMENT AND DEVELOPMENT OF A TREATMENT PLAN Assessment of the Patient

• Medical history • Height, weight, BMI • Waist circumference • Assessment of comorbidities • Evaluate causes of obesity Image: https://livehealthyosu.com o Medications, metabolic abnormalities, genetics, stages of life (i.e. post-menopausal), environmental factors, psychological and social factors • Assess diet and physical activity • Determine readiness and motivation to lose weight

1. Final Recommendation Statement: Obesity in Adults: Screening and Management. U.S. Preventive Services Task Force. October 2014. http://www.uspreventiveservicestaskforce.org. Accessed Feb 29 2016. Metabolic Syndrome and Obesity

• Being overweight or obese is a risk factor for metabolic syndrome 1 • Metabolic syndrome increases risk for CVD and Type 2 diabetes

1. Kasper, D. L., Hauser, S. L., Jameson, J. L., Fauci, A. S., Longo, D. L., Loscalzo, J., & Harrison, T. R. (2015). Harrison's principles of internal medicine. New York: McGraw-Hill Education. Laboratory tests1

• Fasting glucose (Insulin resistance and Beta cell failure) • Fasting lipid studies (typically high TG & high to normal LDL- C and low HDL-C)

1. Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. J Am Coll Cardiol. 2014;63(25_PA). Weight Promoting Drugs and Alternative Options to Consider

Category Drug Class Weight Gain Alternatives Psychiatric Antipsychotic Clozapine, risperidone, Ziprasidone, aripiprazole olanzapine,quetiapine, haloperidol, perphenazine Antidepressant/ mood Amytriptyline, doxepin, Bupriopion, nefazodone, stabilizers: tricyclic imipramine, nortiptyline, fluoxetine (short term), antidepressants trimipramine, mirtazapine sertraline (< 1 year) Antidepressant/ mood Fluoxetine ?, sertraline ?, stabilizers: SSRIs paroxetine, fluvoxamine Antidepressant/ mood Phenylzine, stabilizers: MAOis tranylcypromine Manic depressive Lithium illness Neurologic Antiepileptic drugs Carbamazepine, Lamotrigine ?, *, gabapentin, valproate * Insulin, sulfonylureas, *, acarbose*, Diabetes- glucose Endocrine thiazolidenediones, miglitol*, pramlintide*, lowering ? Sitagliptin, metiglinide exenatide*, liraglutide* *Weight reducing

1. Apovian C et al J Clin Endocrinol Metab 2015; 100:342-362. Weight Promoting Drugs and Alternative Options to Consider

Category Drug Class Weight Gain Alternatives Gynecologic Oral Progestational sterods, Barrier methods, Contraceptives Progestins, IUD containing combination oral hormones contraceptive pills Endometriosis Depot leuprolide acetate Surgical methods

Cardiovascular Anti- Alpha blocker?, beta blocker? ACE inhibitors ?, calcium hypertensives channel blockers ?, angiotensin-2 receptor blockers? Infectious Antiretroviral Protease inhibitors ------Disease

General Steroid Corticosteroids, progestational NSAIDs hormones agents Antihistamines, Diphenydramine, ? Doxepin?, Decongestants, steroid anticholinergics cyproheptadine? inhalers

*Weight reducing

1. Apovian C et al J Clin Endocrinol Metab 2015; 100:342-362. Development of a Treatment Plan

• Set realistic weight loss goals • Establish health goals • Review patient’s medication list and change or discontinue any weight-promoting drugs • Intervention strategies o Lifestyle interventions: healthy eating, reducing caloric intake, avoiding meal skipping, monitoring portion sizes, ensuring adequate sleep, managing mental illness/stress and increasing physical activity o Pharmacotherapy to increase satiety and decrease appetite o Consider bariatric surgery when indicated

Preventive Medicine Task Force American Medical Women’s Association Treatment Recommendations

BMI (kg/m2) Treatment Plan ≥ 25 Reduced calorie diet, physical activity, behavioral modification ≥27-30 + co-morbidity Consider adding pharmacotherapy* to decrease food intake ≥ 30 Consider adding pharmacotherapy* to decrease food intake ≥35-40 + co-morbidity Consider bariatric surgery** ≥ 40 Consider bariatric surgery** *5% weight loss is considered clinically important by the FDA; discontinue a weight loss medication if weight loss < 5% at 3 mo.1 **Bariatric surgery options includes: Laparoscopic Adjustable Gastric Banding (LAGB), Vertical Sleeve Gastrectomy (VSG), or Roux-en-Y bypass (RYGB)

1. Apovian CM et al 2015 Pharmacological Management of Obesity: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2015; 100: 342-62 SECTION 5 LIFESTYLE MANAGEMENT Adherence to the Diet and Not The Diet Predicts Success “The best diet is the one you like best”

Diet type Adherence score does not predict weight loss predicts weight loss

1. Dansinger, M. L. et al. JAMA 2005;293:43-53. Diet Recommendations • Low Calorie Diet o 1200-1500 kcal/day for women o 1500-1800 kcal/day for men o Achieves weight loss approximately 1-2 pounds/week o Most marketed diets are low calorie1 • Medically supervised Very Low Calorie Diet (VLCD) 2 o < 800 kcal/day for up to 16 weeks, followed by a refeeding diet o May consist of 4 to 5 high protein shakes daily plus vitamins and minerals o Not successful long-term • Meal replacements may be useful

1. Apovian CM, Aronne L, Powell AG. Clinical Management of Obesity. 2015. Professional Communications Inc. West Islip, NY ; 2.. http://www.premierprotein.com Preventive Medicine Task Force American Medical Women’s Association Effectiveness of Commercial Weight Loss Programs

• Randomized controlled trials of weight loss programs versus control/education & counseling

• Data of 12 months or more o Weight Watchers: > 2.6% weight loss vs control o Jenny Craig: > 4.9% weight loss vs control

• Other programs had only short term data o Nutrisystem (>3.8% weight loss vs control), Health Management Resources, Medifast, Optifast)

1. Gudzune KA, et al. Ann Intern Med 2015; 162:501-512 Images: www.weightwatchers.com ; www.jennycraig.com

Preventive Medicine Task Force American Medical Women’s Association Exercise Recommendations

• Maintain health: • 150 min/week of moderate aerobic exercise OR 75min/week of vigorous aerobic exercise1 • AND resistance exercise on 2 or more days of week1

• Weight loss: 150-250 min/week of moderate aerobic exercise2 • Prevent weight re-gain: 150-250 min/week of moderate aerobic exercise Image Source: http://weheartit.com/entry/group/29050901 • Minimum of 10 min bouts in duration for activity3 Remember to encourage gradual, incremental changes to physical activity

1. US Department of Health and Human Services. Physical Activity Guidelines Advisory Committee report 2008. Washington, DC: US Department of Health and Human Services; 2008 [cited Februrary 12, 2016]. Available from: http://www.health.gov/paguidelines/committeereport.aspx 2. Donnelly JE, et al. ACSM position stand on appropriate interventions strategies for weight loss and prevention of weight regain for adults. Med SCI Sports Exerc. 2009; 42(2):459-71. 3. Kushner, Robert F., and Daniel H. Bessesen. Treatment of the Obese Patient. Totowa, N.J.: Humana Press, 2007. Examples of Exercise1

Moderate Intensity Exercise Vigorous Intensity Exercises • Walking moderate or brisk pace •Jogging or running • Water aerobics •Aerobic dancing – high impact • Swimming •Step aerobics • Yoga •Water jogging • Bicycling 5-9 mph •Most competitive sports • Stationary bicycling - moderate effort • Weight training w/ free weight

1. Ainsworth BE, Haskell WL, Leon AS, et al. Compendium of physical activities: classification of energy costs of human physical activities. Medicine and Science in Sports and Exercise 1993;25(1):71-80. Diet + Exercise = The Most Weight Loss1

24 men with obesity

Non-exercise BCDD group lost significantly less weight than the other groups p < 0.01

BCDD Balanced caloric deficit diet PSMF Protein-sparing modified fast

1. Pavlou KN, et al. Am J Clin Nutr. 1989;49(5 Suppl):1115-1123. Food and Activity Monitoring

Food and activity tracking is one of the best predictors of weight loss success

• Nearly all extended treatment studies promote recording of food intake and weight • There is conflicting data about smart-phones improving self- monitoring and weight control1,2,3 • Per the National Weight Control Registry, patients should weigh Image Source: themselves at least weekly https://livehealthyosu.com/2011/08/25/dairy-plus-or- minus/weight-scale/

1. Wang J, et al. Effect of adherence to self-monitoring of diet nad physical activity on weight loss in a technology-supported behavioral intervention. Patient Prefer Adherence. 2012;6:221-6. 2. Burke LE, et al. The effect of electronic self-monitoring on weight loss and dietary intake: a randomized behavioral weight loss trial. Obesity 2011; 19:338-44. 3. Svetkey, L. P., Batch, B. C., Lin, P.-H., Intille, S. S., Corsino, L., Tyson, C. C., Bosworth, H. B., Grambow, S. C., Voils, C., Loria, C., Gallis, J. A., Schwager, J. and Bennett, G. B. (2015), Cell phone intervention for you (CITY): A randomized, controlled trial of behavioral weight loss intervention for young adults using mobile technology. Obesity, 23: 2133–2141. Behavioral interventions are essential1,2

•Comprehensive and high intensity sessions most effective o 12 to 26 sessions a year o Group or individual sessions •Setting weight loss goals •Improving diet, nutrition •Physical activity sessions •Addressing barriers to change •Self monitoring Image: uncommonchick.com •Strategies for maintaining lifestyle changes

1. Ann Intern Med. 2012;157:373-378. 2. http://www.uspreventiveservicestaskforce.org/uspstf11/obeseadult/obesers.htm

Preventive Medicine Task Force American Medical Women’s Association SECTION 6 PHARMACOTHERAPY Indications and Use of Pharmacotherapy1 Indication • Adjunct to low calorie diet & ↑ physical activity • BMI ≥ 30 kg/m2, or BMI ≥ 27 kg/m2 in the presence of at least one weight related comorbid condition (e.g., HTN, Type 2 DM)

Efficacy Criteria • A weight loss of ≥ 5% of body weight at 3 months is considered effective, and safety and efficacy should be assessed at least every 3 mo. thereafter

www.healthtap.com • If a patient does not respond to one medication, discontinue it and try another

• Medication should be initiated with dose escalation based on efficacy and tolerability to the recommended dose, not exceeding the upper approved dose limits.1 1Apovian C et al J Clin Endocrinol Metab 2015; 100:342-362.

Preventive Medicine Task Force American Medical Women’s Association Medications for Weight Loss

* Contra-indications/ Safety and Drug MOA Wt Loss Precautions tolerability

Pregnancy, nursing, CVD, with MAOIs, Dizziness, dry hyperthyroidism, mouth, difficulty * Norepinephrine- 3.6 kg glaucoma, agitated sleeping, releasing agent states, hx drug , abuse, irritability hypersensitivity Chronic Inhibits GI ; GI side effects, rare Xenical lipases, blocks fat 2.9-3.4% gall bladder disease; liver injury,  cyclo- absorption sporine exposure

Phentermine/ Norepinephrine 6.6%; Glaucoma; Birth defect risk, topiramate releasing agent/ 8–9% at hyperthyroidism; minor elevation in GABA receptor high dose MAOIs; Pregnancy heart rate; modulator; metabolic acidosis; Qsymia appetite, increased prolongs satiety creatinine; glaucoma Notably, Mean placebo-adjusted weight loss demonstrated in clinical studies ; all I year except for phentermine 2-24 weeks **Lomaira, a low-dose version of phentermine hydrochloride, in 8-milligram tablets, approved fall 2016, can be taken 8mg PO TID or tablets are scored to be cut in half for 4mg doses if desired. Only approved for short term use of a couple of week. More info at www.lomaira.com Apovian C et al J Clin Endocrinol Metab 2015; 100:342-362 Medications for Weight Loss cont’d

* Contra-indications/ Safety and Drug MOA Wt Loss Precautions tolerability

Lorcaserin Selective 3.6 % CI pregnancy; Use Possible risk of serotonin 2C with extreme caution valvulopathy in Belviq receptor agonist; with serotonergic or obese patients  satiety antidopaminergic with type 2 drugs diabetes; serotonin syndrome / Opioid receptor 4.8% Seizure disorder; Minor increase in antagonist/ uncontrolled HTN; heart rate and ER Dopamine and chronic opioid use; blood pressure; nor-epinephrine MAOIs; Pregnancy seizure risk; reuptake inhibitor; hepatotoxicity; Contrave  appetite, acts suicidal thoughts on reward & behaviors pathways Liraglutide Glucagon-like 5–6% Patients with a Nausea, 3 mg peptide 1 personal or family hypoglycemia, risk analogue, history of medullary for pancreatitis; decreases thyroid carcinoma or rodent thyroid C Saxenda appetite Multiple Endocrine cell tumors Neoplasia type 2; *Mean placebo-adjusted weight loss demonstrated in clinical studies, allPregnancy 1 year Apovian C et al J Clin Endocrinol Metab 2015; 100:342-362. Long-Term Medications for Weight Loss

Drug Frequency & US FDA Weight loss in Drug route of Mechanism of action approval clinical trials, 1 yr administration Orlistat* 1999 120mg PO with meals GI lipase inhibitor, blocks fat absorption 2.9-3.4% Xenical

Phentermine/ July 2012 3.75 mg/23 mg PO QD Noradrenergic agent/ GABA 6.6%; 8–9% at Topiramate × 14 d; receptor modulation; high dose Then, 7.5/46 mg ×14 d  Satiety Qsymia (Schedule IV)

Lorcaserin June 2012 10 mg PO BID Serotonin 2C receptor (Schedule IV) agonist, stimulates  MSH, 3.6% Belviq   Satiety

Naltrexone/ Sept 2014 Oral BID; 8 mg/90 mg Opioid antagonist/ Bupropion ER Escalate dose from 1 Dopamine and norepinephrine 4.8% Contrave tab Q am to 2 tabs BID reuptake inhibitor , Appetite, over 4 weeks, reward system

Liraglutide Dec 2014¶ Once-daily SC; start 0.6 Glucagon-like peptide 1 3.0 mg mg QD, increase by 0.6 analogue 5-6% Saxenda mg weekly to 3.0 mg QD  Appetite *Orlistat 60mg (alli®) is the only over-the-counter FDA approved weight-loss drug. ¶Liraglutide 0.6-1.8 mg was approved in the United States in 2010, as a treatment for type 2 diabetes. Ref: US Prescribing Information for each medication When choosing a medication, consider concomitant diseases 1 Comorbid Disease Avoid Uncontrolled Hypertension / Phentermine, Cardiovascular Disease phentermine/topiramate; naltrexone/bupropion

Depression on sertraline Lorcaserin (risk of serotonin syndrome) History of seizure Naltrexone/bupropion

History of pancreatitis Liraglutide

History of kidney stones Phentermine/topiramate

1. Apovian C et al J Clin Endocrinol Metab 2015; 100:342-362 Metformin and Weight Loss

• Not approved for weight loss or pre-diabetes. • Commonly used off-label at academic weight management centers for patients with pre- diabetes and overweight or obesity • Diabetes prevention trial: mean weight loss 2.1 kg (4.6lbs)

• Potential mechanisms: increased www.healthybloodsugars.com insulin sensitivity; decreased intestinal glucose absorption; decreased gluconeogenesis1

1. Domecq JP et al J Clin Endocrinol Metab 2015; 100: 363-70; Peirson L CMAJ Open 2014; 2(4): E 306-17; Knowler WC et al N Engl J Med 2002; 346: 393-403; Igel L et al Ann Pharmacother 2016; 18: 16 online

Preventive Medicine Task Force American Medical Women’s Association CONQUER Trial1

Weight loss at 56 weeks with Phentermine/Topiramate ER:

BMI 27-45 and ≥2 obesity-related comorbidities (HTN, DLD, DM2, Pre-DM2, Abdominal Obesity)

Phentermine/Topiramate Phentermine/Topiramate Weight Placebo 7.5 mg/46 mg Daily 15 mg/92 mg Daily P Loss (n = 979) (n = 1,538) (n = 981) ≥5% 62% 70% 21% <.001 ≥10% 37% 48% 7% <.001 Mean 8.1 kg 10.2 kg 1.4 kg <.001 weight loss

• Dose-related AEs: dry mouth, constipation, dysgeusia, paresthesia, insomnia, dizziness, anxiety, irritability, disturbance in attention • Endpoint assessments were not available for 31% of participants

1. Gadde KM et al. Lancet. 2011;377:1341-1352. Liraglutide: Weight Loss Over 2 Years1

Patients: BMI 30-40 , age 18-65 All patients on liraglutide/placebo switched to Primary endpoint: weight change liraglutide 2.4 mg at week 52, and then to 3.0 mg between weeks 70 and 96 1. Astrup A et al. Int J Obes (Lond). 2012;36:843-854. Effects of Discontinuing Pharmacotherapy

BLOOM Study: Body weight increases after lorcaserin is switched to 102 placebo Year 1 Year 2 100

98

96

94

Body Weight (kg) Body Weight 92 Placebo in year 1 and 2 (n = 684) 90 Lorcaserin in year 1, placebo in year 2 (n = 275) Lorcaserin in year 1 and 2 (n = 564) 0 0 8 16 24 32 40 48 56 64 72 80 88 96 104 Study Week

1. Smith SR et al. New Engl J Med 2010; 363: 245-56 Pharmacotherapy: Key points

• Medications used for weight loss are adjunctive to lifestyle changes, and are indicated in people with a BMI ≥ 30 or BMI ≥ 27, with at least one comorbidity.

• A medication is considered effective when a 5% or great reduction in weight is achieved within 3 months.

• Selection of the appropriate medication for a patient involves consideration of the patient’s other diseases so that adverse effects can be avoided.

• Before prescribing, it is important to understand the safety profile of the medication, including contraindications and adverse effects. SECTION 7 BARIATRIC SURGERY Assessing Candidacy for Bariatric Surgery A patient is a good candidate for bariatric surgery if he/she has a: • BMI 40 or greater OR • BMI 35 to 40 and at least one obesity related comorbidity (i.e HTN, T2DM, CAD, etc)1 AND : • Failed to lose and maintain weight loss with non surgical methods • Well informed about the surgical procedure (i.e. benefits and risks) • Ready to commit ~6 months of time to prepare for surgery • Educational group classes, series of blood tests, multiple visits with physicians and often a psychologist • Achieve ~5-10% weight loss of total body weight (to reduce size of liver and complications of surgery) • Not planning to get pregnant for at least the next 1-2 years • Ready to quit smoking (if applies)

1. Apovian CM, Aronne L, Powell AC. Clinical Management of Obesity. 2015, Professional Communications Inc. West Islip, New York Preventive Medicine Task Force American Medical Women’s Association Bariatric Surgery Procedures

• Mixed Surgery • Roux-en-Y gastric bypass (RYGB) also called gastric bypass • Restriction of stomach and bypass of small bowel (shortened much less than BPD) • Vertical Sleeve Gastrectomy (VSG) • Removing approximately 80% of stomach • Restrictive • Adjustable gastric banding (LAGB) • Induce early satiety during meals by decreasing stomach volume • Malabsorbtive • Bilio-pancreative diversion (BPD) with duodenal switch • Divert bile into terminal segment of ileum so it is only mixed in final segment of small bowel  drastically reducing nutrient absorption • Used rarely in U.S. - in patients with very high BMI

1. Nat Rev Endocrinol. 2010 February; 6(2) 102-109. doi: 10.1038/nrendo.2009.268

Preventive Medicine Task Force American Medical Women’s Association Commonly used bariatric surgery procedures

Roux-en-Y Vertical Adjustable Gastric sleeve lap band Bypass gastrectomy Safety of Bariatric Surgery

• Operative mortality (up to 30 days) 0.1-2%, lowest with adjustable gastric band • Higher mortality with visceral obesity, BMI ≥ 50, older age, sleep apnea, diabetes mellitus • Early complications include: venous thromboembolism (1%), respiratory insufficiency (<1%), hemorrhage (1%), peritonitis (1%), wound infection (2%) • Most common long term complication is GI obstruction • Meta-analysis of 64 studies found overall 17% complication rate1

1. Poirier P et al. Circulation 2011; Tice JA et al Am J Med 2008; 121:885-93; Chang SH et al JAMA Surg 2014; 149: 275-87; Apovian C et al. Clinical Management of Obesity, 2015,Professional Communications Inc. West Islip, NY

Preventive Medicine Task Force American Medical Women’s Association Data for Weight Loss Success Swedish Obesity Study1

• Swedish subjects with obesity • N=4047 • Prospective Matched Cohort Study • Follow up > 16 yrs

1. Sjostrom L, et al. N Engl J Med. 2007;357:741-752.

Preventive Medicine Task Force American Medical Women’s Association Type 2 Diabetes Remission in the Swedish Obesity Study*

blood glucose <110 mg/dL and no diabetes medication Control Surgery Group Group N=2037 N=2010 At 2 years 16.4% 72.3% At 15 years 6.5% 30.4% • All types of bariatric surgery were associated with higher remission rates vs. usual care • This includes adjustable/nonadjustable banding, VBG, or gastric bypass1

* Prospective, matched surgical intervention study

1. Sjostrom L, et al. N Engl J Med. 2007;357:741-752. Long term Follow-up Data for Mortality: Swedish Obese Subjects (SOS) Study

1. Sjostrom L N Engl J Med 2007: 357-741-752

Preventive Medicine Task Force American Medical Women’s Association SECTION 8: MINIMALLY INVASIVE PROCEDURES Minimally Invasive Procedures

Vagal Blocking Therapy

Duodenal jejunal bypass Gelesis100 liner Device Polymer Endobarrier® Minimally Invasive Procedures

Intragastric Balloon Aspiration Device Intragastric Balloons 1 Aspiration Device 2,3

• BMI 30-40 kg/m2 • Age ≥ 22 yrs with BMI 35-55, • Placed endoscopically; removed 6 mo. failed non surgical treatment • ReShape™ Integrated Dual Balloon • Removes ~30% of food from stomach System • Aspiration process ~20 min o 14.3 lbs (6.8% TBWL at 6 mos; after meal is consumed, 5 -10 n=187) minutes to complete, 3x/day • ORBERA™ Intragastric Balloon System • At 1 yr, 12.1 % weight loss vs o 11.27% TBWL at 12 months 3.6 % in controls (n=1683)1 • Nutritional monitoring1,2

TBWL= total body weight loss 1. ASGE Bariatric Endoscopy Task Force, et al. Gastrointest Endosc. 2015 Sep;82(3):425-38.e5. www.fda.gov/MedicalDevices *Slide adapted from Dr. Dong Kim, BMC Hospital 2. http://aspirebariatrics.com/about-the-aspireassist/ 3. Sullivan S et al. Aspiration therapy leads to weight loss in obese subjects: a pilot study. Gastroenterology. 2013 Dec Summary and Key points

• Obesity is a disease associated with changes in adipose and GI hormones, and defective signaling in hypothalamic pathways responsible for appetite regulation and energy balance.

• Obesity contributes to type 2 diabetes, hypertension, dyslipidemia, atherosclerotic cardiovascular disease, arthritis, & cancer.

• Effective treatment of obesity reduces HbA1C, type 2 diabetes, BP, TGs, episodes of sleep apnea, etc.

Preventive Medicine Task Force American Medical Women’s Association Key points Cont’d

• First line treatment includes diet,  physical activity, behavioral interventions, and adjusting medications that cause weight gain.

• Medications that control appetite help patients adhere to dietary recommendations and lose weight.

• Benefits & risks of pharmacological & surgical therapies should be carefully considered in each patient.

Preventive Medicine Task Force American Medical Women’s Association Conclusions

• Obesity is a complex disease associated with multiple comorbidities.

• We have the tools and skills to treat obesity.

• It is time for us to begin the conversation about weight and work with our patients to develop a plan that will help them lose it.

Preventive Medicine Task Force American Medical Women’s Association Acknowledgments

American Medical Women’s Association AMWA Preventive Medicine Task Force #AMWAprevention www.amwa-doc.org