PEP talk TM Weight Management: Talking to Your Overweight Patients - PDF document

PEP talk TM Weight Management: Talking to Your Overweight Patients About Weight Loss Therapies Best Practices Pearls Evaluate and Measure : PEP talk TM Weight Management: Body Mass Index (BMI) Talking to Your Overweight Patients Waist circumference About Weight Loss Therapies Metabolic risk factors Primary Care Decision-Making for Success Discuss Risk and health benefits of 5%-10% weight loss Counsel Lifestyle or refer to a lifestyle modification Scott Kahan, MD, MPH, FTOS Paul P. Doghramji, MD, FAAFP Director, National Center for Weight and Wellness Family Physician Propose Medication Adjuncts appropriately Clinical Director, Strategies to Overcome and Collegeville Family Practice Prevent (STOP) Obesity Alliance Decide on Best Therapy to achieve weight loss goals Medical Director of Health Services George Washington University Ursinus College Milken Institute of Public Health Evaluate Efficacy : Modify therapy to achieve success Collegeville, PA Washington, DC Abdominal Fat Distribution Increases the Risk of Coronary Heart Disease Sedentary Pressures Body workplaces/schools/ to Be Less The Iowa Women’s Health Study entertainment Weight Physically Activity “unfriendly” Biology community design Active Drive-through conveniences 2.5 Elevators/escalators Remote controls 2.0 Labor-saving devices Relative Risk Television/computer 1.5 E in E out Behavior 1.0 0.5 Pressures Portion Sizes Soft drinks/junk food Variety High Energy density in schools Convenience to Eat 0.0 High glycemic index Added Sugar Great Taste 3 2 1 More Low Cost Easy food access Ads/marketing Body Mass Index Tertile Folsom AR et al. Arch Intern Med . 2000;160:2117-2128. Visceral Adiposity: Relative Health Risks of Obesity The Critical Adipose Depot >5x Relative Risk 2-5x Relative Risk 1-2x Relative Risk Type 2 diabetes All-cause mortality Cancer mortality Dyslipidemia HTN Breast CA Subcutaneous Fat Sleep apnea MI and stroke Prostate and colon CA Non alcoholic fatty liver Gout Asthma Abdominal Muscle Hypoventilation syndrome Gallstones GERD Layer PCOS Impaired fertility Intra-abdominal Fat Endometrial CA Anesthetic risk Osteoarthritis of knees HTN, Hypertension MI, Myocardial Infarction PCOS, Polycystic ovary syndrome CA, Cancer GERD, Gastroesophageal reflux disease 1

PEP talk TM Weight Management: Talking to Your Overweight Patients About Weight Loss Therapies Evaluate and Measure Weight – Meaningful Weight Loss is Goal related Health Risk in Patients 2013 AHA/ACC/TOS Guidelines Improvements in glycemic parameters, -3.0% reduction of risk for developing diabetes Screen all patients with BMI at least annually and more Greater improvements in glycemic parameters; frequently, depending on risk factors -5.0% improvement blood pressure, HDL, and triglycerides Use waist circumference measure as a risk factor -10.0% Greater improvements in above parameters Identify high risk patients who need to lose weight B MI ≥30 kg/m 2 -15.0% Even greater improvements in above parameters BMI ≥25 kg/m 2 with at least one risk factor ↑ waist circumference (≥40 inches in men, ≥35 inches in women) Note: Improvement in urinary stress incontinence observed at 5% weight loss and sleep apnea at 10% weight loss AHA, American Heart Association ACC, American College of Cardiology Jensen MD, et al. 2013 AHA/ACC/TOS Guideline. J Am Coll Cardiol . 2014;63(25 Pt B):2985-3023. TOS, The Obesity Society Jensen MD, et al. 2013 AHA/ACC/TOS Guideline. J Am Coll Cardiol . 2014;63(25 Pt B):2985-3023. Counsel Patients on Evaluate for Weight Lifestyle Modifications Related Complications With or without obesity-related CV factors (NIH, AHA, ACCF, ADA) 2013 AHA/ACC/TOS Guidelines Being overweight Patient success linked to provider suggestions!!! and ACE Guidelines Stroke can lead to high blood pressure Measure obesity-associated Prescribe a diet and related health risks complications To achieve reduced caloric intake Glucose, A1c Blood vessel damage Refer to professional or evidence-based program Blood pressure (arteriosclerosis) Lipids Increase physical activity Heart attack or Biomechanical problems, joint pain heart failure Lifestyle Intervention Program Sleep apnea Kidney failure Depression NIH, National Institute of Health AHA, American Heart Association Cancer history ACCF, The American College of Cardiology Foundation ADA, American Diabetes Association Powell-Wiley TM, et al. Obesity . 2012; 20;849-855. Look AHEAD 1-year Data: Impact of How Much Weight Does the State-of-the-Art Lifestyle Intervention Produce? Weight Loss on Glycemic Measures Mean weight loss (%) from baseline by year 0.0 0 0.0 Change in fasting glucose -0.2 -10 -0.5 Change in HbA 1c (%) Year 0 Year 1 Year 2 Year 3 Year 4 -1.0 0 -0.4 -20 (mmol/L) (mg/dL) -1 0.00 -1.01 -1.5 % Weight change -0.6 -30 -0.63 -2 -0.93 -0.92 -2.0 -3 -0.8 -40 -4 -2.5 -4.66 -1.0 -5 -50 -6 -5.04 -7 -6.35 -8 P<.0001 -9 Weight loss category Weight loss category -8.5 Diabetes support and education ILI, Intenstive lifestyle intervention Data presented as adjusted least square means and 95% CIs. Stable weight defined as ± 2% of baseline weight. P<0.0001 vs. baseline for all weight categories. Look AHEAD Research Group. Arch Intern Med . 2010;170:1566-1575. Wing RR, et al. Diabetes Care . 2011;34:1481-1486. 2

PEP talk TM Weight Management: Talking to Your Overweight Patients About Weight Loss Therapies Look AHEAD 1-year Data: Modest Weight Loss Prescribe a Reduced Calorie Diet (5% – 10%) Improved CVD Markers Reduce calories 500-750 kcal/day HDL Change in blood pressure (mm Hg) Change in triglycerides (mg/dL) Diastolic Women LDL Systolic 0 20 0.2 8 0.2 HDL and LDL (mg/dL) 1200-1500 kcal/day or -2 0 0.0 4 0.1 (mmol/L) -4 -20 -0.2 Change in 800 cal x wt. in lbs (mmol/L) -6 0 0.0 -0.4 -40 -8 Men -0.6 -4 -0.1 -10 -60 -0.8 -8 -0.2 -12 -80 1500-1800 kcal/day or -0.10 -14 -100 -12 1000 cal x wt. in lbs Composition not so important: if evidence-based considering patient’s preferences and health Weight loss category Weight loss category Weight loss category status LDL, P =0.3614 Commercial programs (eg. Jenny Craig, Weight Watchers) can Data presented as adjusted least square means and 95% CIs. Stable weight defined as ± 2% of baseline weight. P<0.0001 vs baseline for all weight categories, unless specified otherwise. produce weight loss Wing RR, et al. Diabetes Care . 2011;34:1481-1486. Diet Composition Comparison: Exercise Recommendations Weight Change From Baseline For General Health Protein Fat Carb 0 Moderate intensity physical activity or equivalent* -0.5 150 minutes/week Weight Loss (Kg) -1 Resistance training -1.5 Moderate or high intensity -2 High 2 or more days a week -2.5 Low -3 Weight Loss and Maintenance -3.5 150 to 250 minutes per week moderate intensity -4 High- low 250 minutes or more per week for maintenance -4.5 High-low: High-low: (P=0.22) (P=0.42) (P=0.94) -5 *Defined as activities that are strenuous enough to burn three to six times as much energy per minute as an individual would burn when sitting quietly, Sacks, Bray et al NEJM 2008. or 3 to 6 MET s (Metabolic equivalents). Vigorous-intensity activities burn more than 6 MET s. Propose and Review Comprehensive Lifestyle Program Patient Treatment Options 6 months or more For patients who struggle, intensification of behavioral 12 months for weight maintenance treatment is appropriate Intensification of “Gold standard” is onsite Medications are appropriate treatment should match group or individual sessions for patients with BMI ≥30 or the severity of with trained interventionist complications! ≥27 with a comorbidity Electronically delivered or Bariatric surgery with telephone-based valuable if BMI ≥40 or ≥35 plus gold-standard not available a comorbidity Jensen MD, et al. 2013 AHA/ACC/TOS Guideline. J Am Coll Cardiol . 2014;63(25 Pt B):2985-3023. 3