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An Overview of Obesity for Healthcare Practitioners

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An Overview of Obesity for Healthcare Practitioners An Overview of Obesity 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.
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