Disclosure I have no financial interest or conflict of interest in - - PDF document

2/13/2017 1

5 Things to Know About Managing Obesity in Clinical Practice y

Taraneh Soleymani, MD, FTOS Assistant Professor Department of Nutrition Sciences University of Alabama at Birmingham soltar@uab.edu

Disclosure

I have no financial interest or conflict of interest in I have no financial interest or conflict of interest in relation to this program/presentation.

2/13/2017 2

Objectives

THING 1

Staging of Overweight and Obesity

THING 2

Obesity Treatment Modalities

THING 3 THING 4 THING 5

Diet in Weight Management Physical Activity in Weight Management Behavioral Modification in Weight Management

Staging of Overweight and Obesity

• Why is it important to do?

– Correlates with body fat – Risk estimate: Increase BMI is associated with adverse health conditions – Accurate diagnosis & documentation Treatment selection

THING 1

– Treatment selection

• Based on Body Mass Index (BMI)

– A weight-stature index, used both as a measure of obesity and malnutrition – BMI = weight (kg) / Height2 (m2) – BMI= weight (lb.) x 703/ height squared (in2) – BMI chart

Body Fat 40 50 60 70 Women Men

Relationship Between BMI and Percent Body Fat in Men and Women

Adapted from: Gallagher et al. Am J Clin Nutr. 2000;72:694.

Fat (%) Body Mass Index (kg/m2) 10 20 30 10 20 30 40 50 60

2/13/2017 3

Staging of Overweight and Obesity

• 2013 AHA/ACC/TOS Guidelines for Obesity Recommendation:

– Measure height and weight and calculate BMI at annual visits or more frequently

THING 1

Body Mass Index Staging

18.5 – 24.9 kg/m2 Normal range 25 – 29.9 kg/m2 Overweight 30 – 34.9 kg/m2 Obesity Stage I 35 – 39.9 kg/m2 Obesity Stage II ≥ 40 kg/m2 Extreme Stage III

Does BMI give you the complete picture?

• BMI does not distinguish between lean and fat mass.
• It is especially less accurate in:

– Elderly – Athletes – Certain ethnic groups

• Waist Circumference:

– Indirect measure of central adiposity correlated with visceral fat Indirect measure of central adiposity, correlated with visceral fat – Excess abdominal fat is an independent predictor of risk factors and morbidity

• Measurement is recommended for individuals with BMI 25‐34.9 kg/m2 to provide

additional information on risk

• It is unnecessary to measure waist circumference in patients with BMI≥35 kg/m2

because the waist circumference will likely be elevated and will add no additional risk information.

• Cut points:

– Women: >88 cm (>35 in) – Men: >102 cm (>40 in)

Comparison of Anthropometric and Metabolic Variables and Disease Prevalence in Women With Normal vs High WC Values Within Different BMI Categories Arch Intern Med. 2002;162(18):2074-2079. doi:10.1001/archinte.162.18.2074

2/13/2017 4

Measuring Waist Circumference

• Locate upper hip bone and top of

right iliac crest

• Place measuring tape around

abdomen at level of iliac crest, abdo e at e e o ac c est, keeping it parallel to the floor

• Ensure tape is snug but not

compressing the skin

http://www.nhlbi.nih.gov/guidelines/obesity/prctgd_c.pdf.

Waist Circumference is NOT Belt Size

Real waist located here = 44” Belt from college located here = 36”

Assessing Obesity: BMI, Waist Circumference, and Disease Risk

BMI (kg/m2)

Men  40 in Women  35 in Underweight — <18 5 Men > 40 in Women > 35 in —

Disease Risk Relative to Normal Weight and Waist Circumference

g Normal Overweight Obesity Stage I Obesity Stage II Extreme obesity — — Increased High Very high Extremely high <18.5 18.5-24.9 25.0-29.9 30.0-34.9 35.0-39.9 40 — — High Very high Very high Extremely high

Disease risk for DM2, HTN and CVD. Adapted from: Clinical Guidelines on the Identification, Evaluation and Treatment of Overweight and Obesity in Adults: the Evidence Report. Obesity research and NIH NHLBI, 6(S2), 1998.

2/13/2017 5

Ethnic Specific Values for Waist Circumference

Objectives

THING 1

Staging of Overweight and Obesity

THING 2

Obesity Treatment Modalities

THING 3 THING 4 THING 5

Diet in Weight Management Physical Activity in Weight Management Behavioral Modification in Weight Management Lifestyle Modification Lifestyle Modification Pharmacotherapy Surgery

Phentermine Orlistat

Diet Physical Activity

Phentermine/ Topiramate ER Diethylpropion Buproprion/ Naltraxone ER

Behavior Therapy

ER Lorcaserin Liraglutide

2/13/2017 6

Current Approach to Obesity Treatment

Treatment Options Current Patient Risk LOW

→

HIGH BMI Range 25–26.9 27–29.9 30–34.9 35–39.9 ≥40 Diet, exercise, and behavioral therapy Potential + + + + + behavioral therapy Treatment Risk LOW

↓

HIGH + + + + + Pharmacotherapy With a comorbidity + + + Surgery With a comorbidity +

Complications-Centric Model for Obesity Treatment

Objectives

THING 1

Staging of Overweight and Obesity

THING 2

Obesity Treatment Modalities

THING 3 THING 4 THING 5

Diet in Weight Management Physical Activity in Weight Management Behavioral Modification in Weight Management

2/13/2017 7

Calories Composition

Diet Strategies for Weight Mangement

Very Low Fat Diet Low Fat Diet Moderate Fat Diet 10‐20%

Total Calories from Fat

20‐35%

Total Calories from Fat

35‐45%

Total Calories from Fat

Pritikin Ornish Primarily plant based Dietary Guidelines for Americans Dash American Heart Association Jenny Craig Mediterranean Diet Weight Watchers Nutrisystem

High Protein Diet

> 25%

Total Calories from protein

ZONE

Low Carbohydrate Diet

10‐30 %

Total Calories from carbohydrate

Atkins Ketogenic

Very Low Calorie Diet

<800 kcal OPTIFAST HMR

How Much Calorie to Prescribe?

• 1. Calculate daily caloric needs and subtract 500‐750 kcal:

Basal Metabolic Rate equation ‐ Mifflin‐St Jeor:

• Men: 10 x Weight (kg) + 6.25 x height (cm) ‐ 5 x age (y) + 5
• Women: 10 x Weight (kg) + 6.25 x height (cm) ‐ 5 x age (y) – 161

Multiply Basal Metabolic Rate by Activity Factor:

• Sedentary = 1 2

(little or no exercise desk job) Daily Caloric Sedentary = 1.2 (little or no exercise, desk job)

• Lightly active = 1.375

(light exercise/ sports 1‐3 days/week)

• Moderately active = 1.55 (moderate exercise/ sports 6‐7 days/week)
• Very active = 1.725

(hard exercise every day, or exercising 2 x/day)

• Extra active = 1.9

(hard exercise 2 or more times per day, or training for marathon, or triathlon, etc.)

• 2. Obesity Guidelines 2013:

Women: 1200 – 1500 kcal/day Men: 1500 – 1800 kcal/day Caloric Needs

Bray, G. & Bouchard, C. Handbook of Obesity, Fourth Edition: Surgical Procedures in the Treatment of Obesity and its Comorbidities

2/13/2017 8

• START BY recommending a diet that your patient is most likely to

adhere to for weight loss

• Keep in mind: A collaborative effort
• Consider:

Previous success and failures with a diet plan

THING 3

Diet in Weight Management – Previous success and failures with a diet plan – Current life circumstances: opportunities & barriers – Co-morbidities

• Educate the patient:

– Obesity is a disease – Weight management is a journey: Trial & Error – Importance of keeping a food journal

• Ask patient to be transparent about their food choices, hunger

and challenges of adhering to the diet plan. A Judgment Free Zone

• Monitor weight loss progress at every visit.

THING 3

Diet in Weight Management

• Keep an open mind to the possibility of changing the diet if there

is poor response.

• Always CHECK THE FOOD JOURNAL before determining the

need to change the diet plan.

Objectives

THING 1

Staging of Overweight and Obesity

THING 2

Obesity Treatment Modalities

THING 3 THING 4 THING 5

Diet in Weight Management Physical Activity in Weight Management Behavioral Modification in Weight Management

2/13/2017 9

• 6
• 4
• 2

Short‐Term Changes in Body Weight

• 12
• 10
• 8

0 Months 6 Months Control Diet Exercise Diet + Exercise

Wing et al. 1998

Effect of Exercise on 24-Month Weight Loss Maintenance in Overweight Women

Jakicic et al. Arch Intern Med. 2008

Physical Activity & Weight Management

• Physical Activity to prevent weight gain:

– 150-250 min/wk. (energy equivalent to 1200-200 kcal/wk.)

• Physical Activity for weight loss:

– <150 min/wk.: minimal weight loss / g – >150 min/wk.: modest weight loss 2-3 kg – >225-420 min/wk.: weight loss of 5-7.5 kg

• Physical Activity to prevent weight regain:

– 200-300 min/wk. – More is better

ACSM Position Stand. Med Sci Sports Exerc. 2009 Feb;41(2):459‐71

2/13/2017 10

Objectives

THING 1

Staging of Overweight and Obesity

THING 2

Obesity Treatment Modalities

THING 3 THING 4 THING 5

Diet in Weight Management Physical Activity in Weight Management Behavioral Modification in Weight Management 154 Participants with Obesity

Low-Carbohydrate vs. Low-Fat Diet

Low- Carbohydrate

20 g/day carbohydrate Increased over time

Low-Fat

1200-1500 kcal 25% fat

%

Low-Carbohydrat e Low-Fat

11 %

6 months 12 months

63 Participants with Obesity

Behavior modification intensity has a significant impact on

• 7%
• 3.2%

Foster GD N Engl J Med. 2003

• 4.4%
• 2.5%

11 % 11 % 7% 7%

12 months 24 months

significant impact on total amount of weight loss. What is Behavior Therapy?

• A set of principles and techniques used to help patients ADOPT new

habits.

• Helps patients REPLACE maladaptive behaviors with new eating and

activity habits.

• Helps patients develop a set of SKILLS to regulate their weight
• The goal:

– to improve eating, activity, and thinking habits that contribute to a patient’s excess weight.

2/13/2017 11

Goal Setting

• Setting appropriate goals is critical for self regulation and

behavior change.

• People engaged in behavior change efforts often set

goals that are not helpful or that sabotage their efforts. g p g

• What are the characteristics of effective goals?

– Specific Detailed – Measurable Objective – Achievable Clear Outcome – Realistic Likely to be successful – Time frame Proximal

Goal Setting

• Identify the goal

– Cut back on juice

• Identify the process by which the goal will be achieved

Place the measuring cup on the kitchen counter to remind you – Place the measuring cup on the kitchen counter to remind you to measure your juice every morning

• Advocate for small rather than large changes

– Cut back on juice from 16 oz. to 8 oz. per day

Thank You

2/13/2017 12

Intensive Behavioral Therapy (IBT) for Obesity In Primary Care Setting

• Coverage: Screening for Obesity, Dietary assessment, and

Intensive Behavioral Counseling

• Frequency: Maximum of 22 IBT Sessions

– One face‐to‐face visit every week for 1st month – One face‐to‐face visit every other week for month 2‐6 – One face‐to‐face visit every month for month 7 – 12 , If patient looses at least 3kg (6.6 lbs.)

• Coding:

– HCPCS Code G0447 (Face‐to‐face behavioral counseling for Obesity, 15 minutes) – HCPCS Code G0473 (Group counseling for obesity)

ICN 907800 August 2012 – Medicare Learning Network

Self Monitoring

i.e. recording one’s behavior

• Strongly associated

with weight loss success.

• Food record is a critical

tool for identify eating tt th t b pattern that can be modified to reduce calorie intake.

• Self Monitoring:

– Dietary Intake – Physical Activity – Weight – Mood

• Long term weight management is challenging regardless of the weight loss

modality.

• Patient’s desire to limit food and energy intake is counteracted by

adaptive biological responses to weight loss: – Fall in energy expenditure (metabolism) out of proportion to reduction in body mass. – Changes in hormones leading to increase appetite.