Practical Approaches to the Treatment of Obesity March 11, 2012 - - PowerPoint PPT Presentation

Practical Approaches to the Treatment of Obesity

March 11, 2012

David C.W. Lau, MD, PhD, FRCPC

• Depts. of Medicine, Biochemistry & Molecular Biology and

Cardiac Sciences Julia McFarlane Diabetes Research Centre University of Calgary 403-220-2261 Email: dcwlau@ucalgary.ca

Disclosures

• Research funding:

Can Inst Health Research, AHFMR, Alberta Cancer Board, CDA, AstraZeneca, BMS, Dainippon, Eli Lilly, Novo Nordisk, Pfizer and sanofi-aventis

• Consultant or advisory board member:

Abbott, Allergan, Amgen, AstraZeneca, Bayer, Boehringer-Ingelheim, GSK, Eli Lilly, Merck, Novartis, Novo Nordisk, Pfizer, Roche, sanofi-aventis

• Speaker bureau:

CDA, HSFC, AstraZeneca, Abbott, Bayer, Boehringer- Ingelheim, Eli Lilly, GSK, Merck, Novo Nordisk, Pfizer sanofi-aventis and Sepracor

Objectives

At the end of the presentation the participant will:

• 1. Understand the rationale for obesity management
• 2. Recognize the health benefits of modest weight loss
• 3. Incorporate health behaviour changes in the

management of obesity and related cardiometabolic risks

• 4. Understand the role of pharmacotherapy and

bariatric surgery

• 5. Overcome common barriers to successful weight

management

Body Weight Classification by Body Mass Index (BMI)

Canadian guidelines for body weight classification in adults. Ottawa: Health Canada; 2003

Classification BMI (kg/m2) Risk of co-morbidities

WC <102/88 >102/88 cm *

Healthy wt 18.5-24.9 Normal Overweight 25.0-29.9 Increased High Obese Class I 30.0-34.9 High Very high Class II 35.0-39.9 Very High Class III  40.0 Extremely High

Weight (kg) Height (m2) BMI =

* WC (waist circumference) cut-offs: >102 cm men and > 88 cm in women

All-cause Mortality and BMI

15 20 25 30 35 40 50 4 8 16 32 64

Annual deaths per 1000 Baseline BMI (kg/m2) Male Female

Prospective Studies Collaboration. Lancet 2009;373:1083-96

& 95% CI (floated so matches PSC rate at ages 35-79)

57 prospective studies N = 894,576

Overweight

Male Female

2 4 6 8 10 12 14 2 4 6 8 10 12 14 15 20 25 30 35 50 15 20 25 30 35 50 Vascular Respiratory Cancer (lung, mouth, pharynx, larynx, oes.) Vascular Resp. Cancer (other specified)

Baseline BMI (kg/m2)

Cancer (lung, mouth, pharynx, larynx, oes.) Cancer (other specified)

Lancet 2009;373:1083-96

Adjusted for age, smoking and study; 1st 5 years of follow-up excluded

Annual deaths per 1000

& 95% CI (floated so matches EU rate at ages 35-79)

Mortality and BMI at Ages 35-79 Years

Medical Complications of Obesity

Pulmonary Disease

• Abnormal function
• Obstructive sleep apnea
• Hypoventilation syndrome

Nonalcoholic Fatty Liver Disease

• Steatosis
• Steatohepatitis
• Cirrhosis

Gall Bladder Disease Gynecologic Abnormalities

• Abnormal menses
• Infertility
• Polycystic ovarian syndrome

Idiopathic Intracranial Hypertension Stroke Cataracts

Coronary Heart Disease Diabetes Hypertension Dyslipidemia

Severe Pancreatitis

Cancer

Breast, uterus, cervix, colon, esophagus, pancreas, kidney, prostate Phlebitis

• Venous stasis

Gout Skin Osteoarthritis

Obesity and Burden of Chronic Diseases

• Overweight and obesity are attributable to

the major comorbidities:

• 80% of Type 2 diabetes
• 32% of hypertension
• 30% of pulmonary embolism
• 27% of endometrial cancer

Paeratakul S, et al. Int J Obesity 2002;26:1205-1261

The natural history of type 2 diabetes has changed because of

• besity

and can now

• ccur 30

years earlier!

Global Prevalence

• f Overweight and

Obesity in 1980 and 2008

Finucane MM, et al. Lancet 2011; 377:557-567

9.1 million people from 199 countries Mean BMI in 2008 Men: 23·8 kg/m² (23·6-24·0) Women: 24·1 kg/m² (23·9-24·4) Average BMI of Canadian adults increased by 2 kg/m² to > 25 kg/m² (1981-2007)!

• We recommend measuring BMI in all adults, and in

children and adolescents (aged 2 years and older) [Grade A, Level 3]

• Ethnic-specific values for overweight and obesity

for people of South Asian or oriental descents:

• 23 kg/m2
• 27 kg/m2

Recommendations on Classification

Lau DCW, et al. Can Med Assoc J 2007;176 (8 suppl):S1-S13

Relationship between Glucose Factor and BMI Among South Asians (SA), Chinese (CH), Aboriginals (AP), and Europeans (EC)

Razak F, et al. Circulation 2007; 115:2111-2118

INTER-HEART: 9 Modifiable RFs and MI

Smoking Diabetes Hypertension Abdominal Obesity Psychosocial index Fruits/Vegetables Exercise (-) Alcohol (-) Apo B / Apo AI

Women Men

Yusuf S, et al. Lancet 2004;364:937-952

INTERHEART N=27,000 52 countries Odds Ratio

Waist Circumference Cut-points

Men WC Women  94 cm (37 in)  80 cm (31.5 in)  90 cm (35 in)  80 cm (31.5 in) Central obesity European, Mid-east

• S. Asians, Chinese

Cut Points Risk Factors

Adapted from Lau DCW, et al. Can Med Assoc J 2007;176 (8 suppl):S1-S13

For East Mediterranean, Middle East (Arab) and sub-Saharan African, use European cut-points For South and Central American and Japanese, use South Asian cut- points

Obesity Treatment Pyramid

Obese Class 3 BMI  40 kg/m2 Obese Class 1 BMI  30 kg/m2

Overweight

BMI  25 kg/m2 Obese Class 2

BMI  35 kg/m2

5 Principles That Every Health Care Provider Should Know

• 1. Obesity is a chronic condition which requires a

long-term and sustainable treatment approach

• 2. Successful obesity management is about

improving health and well-being, and not just weight loss

• 3. Early intervention means addressing root causes

and removing barriers

• 4. Success is different for every individual
• 5. A person’s best weight may never be an ideal

weight

• 1. Obesity is a chronic condition!
• Obesity is a chronic and often progressive

condition, not unlike diabetes or hypertension, and requires long-term management to prevent relapse

• Successful management requires realistic and

sustainable long-term treatment strategies

• Short-term "quick-fix" solutions focusing on

maximizing weight loss are unsustainable and associated with high rates of weight regain

• 2. Successful obesity management is about

improving health and well-being

• Obesity management is about improving

health and well-being, and not simply losing weight and waist

• Even modest body weight loss can lead to

significant improvements in health and well- being in many people

• Weight maintenance and prevention of weight

regain are the long-term goals

What is Successful Weight Management?

Natural Course of Weight Gain

Months Years

Body weight (kg) Starting weight

Weight maintenance phase

Weight maintenance

Weight loss phase

• 3. Early intervention means addressing

root causes and removing barriers

• Successful obesity management requires

identification and addressing of both the “root causes” of weight gain as well as the barriers to weight management

• Emotional triggers and sleep deprivation are

examples of root causes that can also pose significant barriers to weight management

• Other causes of energy surfeit can include
• vereating, reduced physical activity or both

• 4. Success is different for every individual
• Patients vary considerably in their readiness

and capacity for weight management

• Success can be defined as:
• quality of life improvements
• higher self-esteem or energy level
• improved overall health and sense of well-being
• modest (5%) weight loss
• prevention of further weight gain, or maintenance
• f the person’s best weight

• 5. A person’s best weight may never be

an ideal weight

• An “ideal” weight or BMI is not a realistic goal

for most patients with obesity

• Setting unachievable targets simply sets the

patient up for failure

• Set realistic and sustainable short-,

intermediate, and long-term goals based on the “best” weight they can attain while still enjoying life and reaping the benefits of improved health

Conduct clinical and Lab investigations to assess comorbidities BP, HR, fasting glucose & lipid profile Devise goals and lifestyle modification program for weight loss &  risk factor 5-10% of body weight loss or 0.5-1 kg (1-2 lb)/ week over 6 months Satisfactory progress

• r goal achieved

Assess and screen for depression, eating and mood disorders Health team to advise lifestyle modification program Regular monitoring Assist with weight maintenance Reinforce lifestyle modification Treat comorbidities and/or health risks Assess barriers to weight loss and readiness to change behaviours Overweight or Obese Adult Measure BMI Measure WC (if BMI < 35 kg/m2) Lifestyle modification program Nutrition: 500-1000 kcal/day reduction Physical Activity: Medical evaluation before starting activity. Initially 30 min of moderate activity 3-5 times/wk, eventually  60 min on most days. Add endurance exercise training Cognitive-Behaviour therapy Pharmacotherapy BMI  27 + risk factors

• r BMI  30

Adjunct to lifestyle modification Consider if patient has not lost 0.5 kg or 1lb/wk by 6 months after lifestyle changes Wt maintenance & prevent wt regain Nutritional therapy Physical Activity Cognitive-behavior therapy Address other risk factors Periodic monitoring of body weight, BMI and WC every 1-2 years Bariatric surgery BMI  35 + RF or BMI  40 Consider if other weight loss attempts have failed. Requires lifelong medical monitoring No Yes No Lau DCW, et al. CMAJ 2007;176(8):1104-1106

CPG Treatment algorithm for obesity

Benefits of Modest Weight Loss

1 kg of weight loss is associated with:

•  CHD risk by 6% in women and 3% in men 1
• 1 mm Hg  in both systolic and diastolic BP 2
•  TC 1%, LDL-C 0.7%, TG ~2% and  HDL-C 0.2% 1
•  0.2 mmol/L glucose 1
• Similar benefits in overweight people with type 2

diabetes 3

• 1. Anderson JW & Konz EC. Obes Res 2001;9(suppl 4):326S-334S
• 2. Neter JE, et al. Hypertension 2003;42:878-884
• 3. Anderson JW, et al. J Am Coll Nutr 2003;22:331-339

Modest Weight Loss Prevents Diabetes!

Diabetes Prevention Prog Res Group. New Engl J Med 2002;346:393-403

~1.2 kg (5%) wt loss  58% RRR Metformin  31% RRR

DPP-OS: 10-year Incidence of Diabetes

DPP Research Group. Lancet 2009;374:1677-1686

5.6 4.9 5.9% 11 7.8 4.8% 7.8 10.6 5.5%

Diabetes Risk Reduction: 34% with Lifestyle and 18% with metformin Median delay in diabetes: 4 yrs by lifestyle and 2 yrs by metformin

“3,500 kcal/lb Rule” = False Dogma!

• Dynamic physiological adaptation to altered body

weight  resting metabolic rate and energy cost of physical activity

• Energy partitioning between storage and

mobilization of body fat and lean tissue

• Energy/kg change in body fat = 39.5 MJ
• 7.6 MJ/kg for lean mass
• 5 x greater energy deficit is required to lose the same

fat mass as lean tissue

• Message: Easy to gain but difficult to lose weight!

Comparison of Weight-Loss Diets with Different Compositions of Fat, Protein, and Carbohydrates

Original Article

Frank M. Sacks, M.D., George A. Bray, M.D., Vincent J. Carey, Ph.D., Steven R. Smith, M.D., Donna H. Ryan, M.D., Stephen D. Anton, Ph.D., Katherine McManus, M.S., R.D., Catherine M. Champagne, Ph.D., Louise M. Bishop, M.S., R.D., Nancy Laranjo, B.A., Meryl S. Leboff, M.D., Jennifer C. Rood, Ph.D., Lilian de Jonge, Ph.D., Frank L. Greenway, M.D., Catherine M. Loria, Ph.D., Eva Obarzanek, Ph.D., and Donald A. Williamson, Ph.D. N Engl J Med 2009;360(9):859-873

• This randomized trial compared the effect of reduced-calorie diets with various

compositions of fat, protein, and carbohydrates on weight loss over a 2-year period

• Compliance with the diets was not high
• No significant differences in weight loss were observed among the various diets
• Reduced-calorie diets appear to have similar effects on weight loss regardless of

their particular compositions

Calories and NOT macronutrients count with weight loss!

Exercise Recommendations

• All individuals considering a vigorous exercise program are

encouraged to first consult their physician or HCP [Grade C, Level 4]

• We suggest long-term, regular physical activity, which is

associated with maintenance of or a modest reduction in body weight in all overweight people [Grade B, Level 2]

• Physical activity and exercise should be sustainable and

tailored to the individual and the total duration can be increased gradually to maximize the weight loss benefits [Grade A, Level 2]

Lau DCW, et al. Can Med Assoc J 2007;176 (8 suppl):S1-S13

Exercise Recommendations 2

• We suggest physical activity (30 minutes of moderate

intensity, increasing when appropriate, to 60 minutes daily) as part of an overall weight loss program [Grade B, Level 2]

• Endurance exercise training may reduce the risk of

cardiovascular morbidity in healthy people and we suggest its use for adults with a high BMI [Grade B, Level 2]

Lau DCW, et al. Can Med Assoc J 2007;176 (8 suppl):S1-S13

Physical Activity Needed for Weight Maintenance

• 80 min/day of moderate activity 1
• 35 min/day of vigorous activity 1
• 77 min/day of moderate activity 2
• 33 min/day of vigorous activity 2
• 60-90 min/day of moderate activity 3
• 45-60 min/day of higher intensity 3

1 Schoeller et al. AJCN 66:551-556, 1997 2 Weinsier et al. AJCN 75:499-504, 2002 3 Stock conf, Ob Res, 2003

Patient Selection, Benefits and Complications of Bariatric Surgery

Frachetti KL, et al. Curr Opin Endocrinol Diabetes Obes 2009;16:119-124

Obesity Surgery

Obesity, Diabetes Co-Morbidities Operative Risks Benefits:

• Weight loss
• Metabolic improvements
• Mortality benefit

Complications:

• Nutrient deficiency
• Dumping syndrome
• Hypoglycemia

Weight Loss and Diabetes Remission

Total LAGB Gastrop G Bypass BPD/DS % EBWL 55.9 46.2 55.5 59.7 63.6 % “Cure” 78.1 56.7 79.7 80.3 95.1 % < 2 yrs 80.3 55.0 81.4 81.6 94.0 % ≥ 2 yrs 74.6 58.3 77.5 70.9 95.9

Buchwald H, et al. Am J Med 2009;122:248-256

Systematic Analysis of 621 studies, N=135,246 Mean age 40.2 years; BMI 47.9 kg/m2; 80% women

Bariatric Surgery for Diabetes

Advantages

• Effective and sustained

long-term weight loss > 10%

• More patients achieve

glycemic and metabolic goal targets

• Reduction in anti-diabetic

medications

• No hypoglycemia
• May be cost-effective

Disadvantages

• Surgical complications

(short- and long-term)

• Remission not achieved in

all patients who achieved > 10% wt loss

• Long surgical wait list
• Requires long-term follow-

up

• Long-term efficacy and

safety data not available

Lau DCW. Can Diabetes 2010;23:3-13

Sjöström L, et al. New Engl J Med 2004;351:2683-2693

SOS: Bariatric Surgery Produces Sustained Long-term Weight Loss

Control Banding Vertical banded gastroplasty Gastric bypass

627 156 451 34 585 150 438 34 594 154 438 34 587 153 438 34 577 149 429 33 563 156 417 32 642 147 412 32 535 144 401 29 627 156 451 34

0.0 0.5 1.0 2.0 3.0 4.0 6.0 8.0 10.0

Years of Follow-up

5

• 45
• 40
• 5
• 10
• 15
• 20
• 25
• 30
• 35
• No. of Subjects

Weight Change (%)

Control Banding Vertical banded gastroplasty Gastric bypass

Key Messages

• Assess obesity and related health risks by measuring

BMI and waist circumference, BP and appropriate lab tests (FBG, lipid profile)

• Identify triggers for overeating and barriers to health

behaviour changes and weight management

• Decrease caloric intake by 500-600 Cal/day and

combine with 150 minutes of physical activity a week

• A modest 5-10% body weight loss confers health

benefits by reducing diabetes and cardiovascular disease risks

• Focus on weight maintenance and prevention of

weight regain as long-term goals

“Superior Doctors Prevent the Disease. Mediocre Doctors Treat the Disease Before Evident. Inferior Doctors Treat the Full Blown Disease.” Huang Dee, 2600 B.C. In Nai Ching, 1st Chinese Medical Text

Thank you

Questions?