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Section 1 Review

Section 1 Review. Medical Complications of Obesity. Idiopathic intracranial hypertension. Pulmonary disease abnormal function obstructive sleep apnea hypoventilation syndrome. Stroke. Cataracts. Nonalcoholic fatty liver disease steatosis steatohepatitis cirrhosis.

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Section 1 Review

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  1. Section 1 Review

  2. Medical Complications of Obesity Idiopathic intracranial hypertension Pulmonary disease abnormal function obstructive sleep apnea hypoventilation syndrome Stroke Cataracts Nonalcoholic fatty liver disease steatosis steatohepatitis cirrhosis Coronary heart disease Diabetes Dyslipidemia Hypertension Severe pancreatitis Gall bladder disease Cancer breast, uterus, cervix colon, esophagus, pancreas kidney, prostate Gynecologic abnormalities abnormal menses infertility polycystic ovarian syndrome Osteoarthritis Phlebitis venous stasis Skin Gout

  3. Complications of Childhood obesity

  4. -10 -5 0 5 10 15 20 Relationship Between Weight Gain in Adulthood and Risk of Type 2 Diabetes Mellitus Men Women Relative Risk Weight Change (kg) Willett et al. N Engl J Med 1999;341:427.

  5. Diagnosing the Metabolic Syndrome Diagnosis is established when 3 of these risk factors are present. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA 2001;285:2486-2497.

  6. Healthcare visits Pharmacy Laboratory tests All outpatient services All inpatient services Total healthcare Increase in Healthcare Costs Among Obese Compared with Lean (BMI <25 kg/m2) Patients* Increase in Cost Compared with Lean Subjects (%) BMI 30-34 kg/m2 BMI >35 kg/m2 *HMO Setting: Northern California Kaiser Permanente. Quesenberry CP Jr et al. Arch Intern Med. 1998;158:466-472.

  7. “Doc, I am fat because my hormones are out of whack. I know I don’t eat too much. Can you check out what’s wrong with me and give me a pill to fix it..”

  8. Hormonal Causes of Obesity • Cushings Syndrome (glucocorticoid excess) • Most treatments for Diabetes Mellitus type 2 • NOT Hypothyroidism • Very few (less than 1%) of patients are obese due to hormonal problems, but a substantial number are obese in part due to diabetes treatment or treatment with glucocorticoids

  9. Selected Medications That Can Cause Weight Gain • Diabetes medications • Insulin • Sulfonylureas • Thiazolidinediones • Highly active antiretroviral therapy • Tamoxifen • Steroid hormones • Glucocorticoids • Progestational steroids • Psychotropic medications • Tricyclic antidepressants • Monoamine oxidase inhibitors • Specific SSRIs • Atypical antipsychotics • Lithium • Specific anticonvulsants • -adrenergic receptor blockers SSRI=selective serotonin reuptake inhibitor

  10. “Yea, I know about balancing food and activity, but I don’t don’t eat that much.” • “I don’t eat more than other people” • “I only eat salads.”

  11. Discrepancy Between Reported and Actual Energy Intake and Expenditure Energy Expenditure Energy Intake * Kcal/d * Reported Actual Reported Actual *P<0.05 vs reported. Lichtman et al. N Engl J Med 1992;327:1893.

  12. “My problem is my metabolism is slow. Anything at all that I eat turns to fat.”

  13. 0 30 40 50 60 70 80 90 100 Relationship Between Resting Energy Expenditure and Fat-free Mass Lean females Obese females Lean males Obese males REE (kcal/24 h) Fat-Free Mass (kg) REE = Resting energy expenditure Owen. Mayo Clin Proc 1988;63:503.

  14. “Any time I try to lose weight, my metabolism slows down so much that I can’t lose weight.”

  15. Energy Metabolism Before and After Weight Loss Mean BMI Reduced from 31 to 23 kg/m2 Resting Energy Expenditure Total Energy Expenditure * * Energy Expenditure (kcal/d) * * Before After Predicted Before After Predicted *P<0.05 vs before weight loss Amatruda et al. J. Clin Invest 1993;92:1236.

  16. “So obesity is all genetic. There’s nothing I can do.”

  17. Gene-Environment Interaction in the Pathogenesis of Obesity P <0.0001 Pima Indians Body Mass Index (kg/m2) Maycoba, Mexico Arizona Ravussin E et al. Diabetes Care 1994;17:1067-1074.

  18. Effect of Portion Size on Energy Intake Amount Consumed (g) 500 625 750 1000 Amount of Macaroni and Cheese Served (g) Rolls et al. Am J Clin Nutr. 2000 Dec;76(6):1207-13.

  19. 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 Log Restaurant Food Consumption per Month Relationship Between Adiposity and Frequency of Eating in a Restaurant Percent Body Fat Partial r = 0.35; P = 0.005 McCrory et al. Obes Res 1999;7:564.

  20. Prevalence of Obesity by Hours of TV per Day: NHES Youth Aged 12-17 in 1967-70 and NLSY Youth Aged 10-15 in 1990 0-1 1-2 2-3 3-4 4-5 >5

  21. “There are too many. We can’t treat obesity because we would be treating everyone with everything.”

  22. Expert Panel of NHLBI: Assessing Obesity - BMI, Waist Circumference, and Disease Risk Disease Risk Relative to NormalWeight and Waist Circumference Men 40 inWomen 35 in Men >40 in Women >35 in Category BMI Underweight Normal* Overweight Obesity Extreme obesity <18.5 18.5-24.9 25.0-29.9 30.0-34.935.0-39.9 40 — — Increased HighVery high Extremely high — — High Very highVery high Extremely high *An increased waist circumference can denote increased disease risk even in persons of normal weight. Adapted from Clinical guidelines. National Heart, Lung, and Blood Institute Web site. Available at:http://www.nhlbi.nih.gov/nhlbi/cardio/obes/prof/guidelns/ob_gdlns.htm. Accessed July 31, 1998.

  23. Expert Panel of NHLBI: Overall Risk of Obesity • Evaluate the potential presence of other risk factors. • Some conditions associated with obesity put patients at high risk for subsequent mortality, and will require aggressive modification. • Other obesity associated conditions are less lethal, but still require treatment. • Among the risks to consider are: coronary heart disease, other atherosclerotic diseases, type 2 diabetes mellitus, sleep apnea, gynecological abnormalities, osteoarthritis, gallstones, stress incontinence, hypertension, cigarette smoking, hyperlipidemia, and family history of early coronary disease.

  24. Expert Panel of NHLBI: Therapy Decision • Therapy is Recommended: • BMI > 30 • BMI 25 - 29.9, a dangerous waist circumference and 2 or more risk factors. • Individuals at lesser risk should be counseled about useful lifestyle changes if they are ready for a change.

  25. “So what can we do? There are all these diets and pills on the TV, but nothing seems to work very well. Is there anything that actually helps.”

  26. NHLBI Expert Panel: Goals of Therapy • Reduce body weight and maintain a lower body weight for the long term. • An initial weight loss target of 10% of body weight, lost over six months is recommended and will be medically significant. The rate of weight loss should be 1 -2 pounds each week. • Evidence indicates that greater rates of weight loss do not achieve better long-term results. • After the first six months of weight loss therapy, the priority should be weight maintenance through combined changes in diet, physical activity, and behavior.

  27. Obese Patients Have Unrealistic Weight Loss Goals Foster et al. J Consult Clin Psychol 1997;65:79.

  28. NHLBI Expert Panel: Changes in “Lifestyle” or Priorities Food • “Diets” chosen should be long-term • Reduced 500 to 1000 from baseline in calories • Targeting 30% or less of calories as fat • Individualized. Activity • Activity is most useful in maintaining weight loss • Goal of 30 minutes of moderate activity every day • Increase everyday activity by taking the stairs, etc.

  29. Providing Prepackaged Meals Enhances Weight Loss WeeklyTreatment Maintenance Control Behavior Therapy + Self-selected Diet Weight Change (kg) Behavior Therapy + Food Provision 0 6 12 18 Months P=0.0001 treatment vs control. P=0.0002 behavior therapy + self-selected diet vs behavior therapy + food provision. Jeffery et al. J Consult Clin Psychol 1993;61:1038.

  30. “I don’t think I need to change what I am eating. I am going to work out and lose it that way.”

  31. Physical Activity Alone Results in Minimal Weight Loss Stefanick 1998 Stefanick 1998a Anderssen 1995 Hammer 1989 Verity 1989 Rönnemaa 1988 Wood 1988 Wood 1983 Control Group Exercise Group * * * * Weight loss (kg) *P<0.05 vs control group Duration of each study ranged from 4 to 12 months. Wing. Med Sci Sports Exerc 1999;31(suppl):S547.

  32. Relationship Between Physical Activity and Maintenance of Weight Loss P<0.001 Subjects Exercising (%) Not Maintained Maintained Weight Loss Pattern Kayman et al. Am J Clin Nutr 1990;52:800.

  33. Considerable Physical Activity is Necessary for Weight Loss Maintenance Concomitant Behavior Therapy Weekly Biweekly Monthly <150 min/wk >150 min/wk Change in Weight (kg) *P<0.05 >200 min/wk 0 6 12 18 Time (months) Jakicic et al. JAMA 1999;282:1554.

  34. Effect of Decreasing Sedentary Activities vs Increasing Physical Activities on Body Weight in Children 6-12 Years Old Increased Physical Activity Change in Percent Overweight Decreased Sedentary Activity 0 4 8 12 Time (months) Epstein et al. Health Psychol 1995;14:109.

  35. “This is so hard. Is there any good news?”

  36. Diabetes Prevention Program (DPP) • Hypothesis: Can diabetes be delayed or prevented by addressing risk factors: impaired glucose tolerance, overweight and sedentary life - using lifestyle changes or metformin? • 3234 pts of mean age 51, BMI 34, 68% women, 45% minorities and impaired glucose tolerance were randomized to 3 groups at 27 US centers: • Usual care (control) • Metformin 850 mg BID • Lifestyle intervention – • Goal of 7% weight loss by Food Pyramid, NCEP 1 diet • Goal of 150 min/wk moderate activity (brisk walking)

  37. Diabetes Development in Diabetes Prevention Program

  38. “Obesity treatment and behavior change are too hard. I don’t have time to do this in my clinic.”

  39. Practical Behavior Change • Physicians make a difference • Repetition and follow-up are most useful • Likely better to do with 2-5 minutes repeatedly than with an hour at once • Education can be done in pieces • Let them know that you know it’s hard and that the environment is against them • Encourage patients to find their own goals (motivational interviewing techniques) but encourage specificity - go beyond “watch what I eat”

  40. Five Steps to Facilitate Behavior Change 1 Identify behavior change goal Review when, where, and how behaviors will be performed 2 3 Have patient keep record of behavior change 4 Review progress at next treatment visit Congratulate patient on successes (do not criticize shortcomings) 5 Wadden and Foster. Med Clin North Am 2000;84:441.

  41. Cardinal Behaviors of Successful Long-term Weight ManagementNational Weight Control Registry Data • Self-monitoring: • Diet: record food intake daily, limit certain foods or food quantity • Weight: check body weight >1 x/wk • Low-calorie, low-fat diet: • Total energy intake: 1300-1400 kcal/d • Energy intake from fat: 20%-25% • Eat breakfast daily • Regular physical activity: 2500-3000 kcal/wk (eg, walk 4 miles/d) Klem et al. Am J Clin Nutr 1997;66:239. McGuire et al.Int J Obes Relat Metab Disord 1998;22:572.

  42. 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Time (mo) Long-term Weight Loss is Improved with Long-term Maintenance Therapy No maintenance tx Maintenance tx Weight Loss (%) Diet andbehaviormodificationtherapy P <0.05 Perri et al. J Consult Clin Psychol 1988;56:529.

  43. Assessing Weight Loss Readiness Patient seeks weight reduction Free of major life crises Free of severe depression, substance abuse, bulimia nervosa Patient can devote 15-30 min/d to weight control for next 26 weeks • Motivation: • Stress level: • Psychiatric issues: • Time availability: YES NO Patient Ready? Initiate weight loss therapy Prevent weight gain and explore barriers to weight reduction

  44. Prevention • Breastfeeding when possible • Plotting BMI at each visit • Anticipatory guidance: 5-2-1-0 • “5 a day” fruits and vegetables • Less than 2 hr/day of screen time • At least 1 hour of moderate activity each day • No sweet drinks

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