Robert Baron, MD, MS Current Strategies for Treating Obesity CURRENT STRATEGIES FOR Prevalence of Obesity 2011-2012 TREATING OBESITY � Obesity prevalence: � Adults 34.9% Robert B. Baron MD MS � Youth 16.9% Professor of Medicine Associate Dean for GME and CME � No change since 2003-2004 Founding Director, UCSF Weight Management Program Ogden Cl, JAMA 2014 Declaration of full disclosure: No conflict of interest Prevalence of Self-Reported Obesity Among U.S. Adults Obesity Disparities: by State and Territory , BRFSS, 2013 Example: BMI >35 WA MT ME ND � Women, 40-59: 19.1% MN VT OR NH ID MA SD WI NY RI MI � White: 16.9%, Black: 30.4%, Asian 4.6%, WY CT IA PA NJ NE NV Hispanic 25.5% OH IN DE UT IL MD CO WV KS VA DC CA MO KY NC TN OK AZ AR SC NM � Men, 40-59: 12.2% AL GA MS AK TX LA � White: 12.8%, Black: 15.7%, Asian 0, FL Hispanic 8.7% HI PR GUAM Ogden, JAMA 2014 15%–<20% 20%–<25% 25%–<30% 30%–<35% ≥35% 1
Robert Baron, MD, MS Current Strategies for Treating Obesity For a 40 yo woman, with normal CLASSIFICATION OF OVERWEIGHT BP, lipids, and FBS which BMI is AND OBESITY BY BMI associated with the lowest all- cause mortality? BMI (kg/m 2 ) Obesity Class Underweight <18.5 18 A. 72% Normal 18.5 – 24.9 B. 24 Overweight 25.0 – 29.9 C. 28 Obesity I 30.0 – 34.9 D. 34 II 35.0 – 39.9 E. 38 20% Extreme Obesity III >40 6% 1% 1% 8 4 8 4 8 1 2 2 3 3 BMI AND MORTALITY: MORTALITY AND OBESITY Overall Meta-analysis of 97 studies of 2.8M people, Combined NHANES I, II, and III data set 270,000 deaths BMI 25-59 y 60-69 y ≥ 70 y BMI HR <18.5 1.38 2.30 1.69 Below 25 (Normal) 1.0 18.5-<25 1.00 1.00 1.00 25-30 (Overweight) 0.94 25 to <30 0.83 0.95 0.91 Above 30 (Obese) 1.18 30 to <35 1.20 1.13 1.03 *** ≥ 35 1.83 1.63 1.17 30-35 (Grade 1 Obesity) 0.95 Above 35 (Grade 2/3 Obesity) 1.29 Flegal, JAMA, 2005 Flegal, JAMA, 2013 2
Robert Baron, MD, MS Current Strategies for Treating Obesity For a 40 yo woman, with normal BP, lipids, and FBS which BMI is Epidemic of Inactivity 60% US adults don ’ ’ ’ ’ t associated with the lowest all- cause mortality? exercise regularly 1. 18 25% are sedentary 2. 24 3. 28 4. 34 5. 38 FITNESS AND MORTALITY EXERCISE FOR OBESITY Aerobics Center Longitudinal Study Meta-analysis of 43 RCTs: 3476 participants 25,714 men, 44 years old, 14 year observational study • Exercise plus diet vs diet alone CV death (RR) – -1.1 kg normal overweight obese Fit 1.0 1.5 1.6 Not fit 3.1 4.5 5.0 • Increased intensity of exercise – -1.5 kg Total death (RR) normal overweight obese Fit 1.0 1.1 1.1 • Exercise without weight loss Not fit 2.2 2.5 3.1 – Reduced: BP, triglycerides, blood sugar Cochrane Collaboration Wei, JAMA 1999 3
Robert Baron, MD, MS Current Strategies for Treating Obesity COMPARISON OF WEIGHT LOSS DIETS WITH DIFFERENT MACRONUTRIENTS ✜ RCT of 811 patients, 4 diets: fat/protein/carbs 20/15/65; 20/25/55; 40/15/45; 40/25/35 ✜ 6 months: 6kg, 7% weight; at 2 years: completers lost 4kg; 15% lost 10% of weight ✜ Results similar for: ✜ 15% pro v. 25% pro ✜ 20% fat v. 40% fat ✜ 35% carbs v. 65% carbs ✜ Attendance highly correlated with weight loss; satiety, hunger, lipids, insulin all equal Sacks, NEJM, 2009 Very Low Calorie Diets (VLCD) vs Low WEIGHT LOSS DIET BOTTOM LINE Calorie Diets (LCD): Meta-analysis of 6 RCTs • The type of diet does not really • Trials with direct comparisons matter for weight loss. • Short-term: mean 12.7 weeks • Long-term: mean 1.9 years • Sticking to the diet does matter Weight loss (as % of initial weight): • Calories “ “ trump ” “ “ ” macronutrients ” ” short-term long-term LCDs 9.7 5.0 VLCDs 16.1 6.3 (p) (0.001) (0.2) • But, select healthy, nutrient rich foods 4
Robert Baron, MD, MS Current Strategies for Treating Obesity 40 yo woman, BMI 36. Much to your surprise (and satisfaction), she has lost 35 pounds. In order to maintain her new weight, her lifelong daily calorie intake should be: 40% A. 2000 kcals B. 1800 kcals 29% C. 1600 kcals D. 1400 kcals 14% 12% E. 1200 kcals 5% s s s s s a l a l a l a l a l c c c c c k k k k k 0 0 0 0 0 0 0 0 0 0 0 8 6 4 2 2 1 1 1 1 40 yo woman, BMI 36. Much to SUCCESSFUL WEIGHT LOSS MAINTENANCE your surprise, she has lost 35 pounds. In order to maintain her • High levels of physical activity new weight, her lifelong daily • Women 2545 kcal/week, men 3293 kcal per week calorie intake should be: • 1-hour moderate intensity per day • Only 9% report no physical activity • Diet low in calories 1. 2000 kcals 1381 kcal day • 2 1800 kcals 4.87 meals or snacks/day • 3 1600 kcals Fast food 0.74/week • 4. 1400 kcals • Regular self-monitoring of weight 5. 1200 kcals • 44% weigh once per day; 31% once per week 5
Robert Baron, MD, MS Current Strategies for Treating Obesity The Neuroendocrinology of Energy Balance Weight Loss With Weight Loss SIBUTRAMINE AND CARDIOVASCULAR OUTCOMES (SCOUT) Medications ✜ 9804 patients, over 55, with CV disease or diabetes Weight loss (% of initial) in excess of placebo: Phentermine-fenfuramine 11.0% ✜ Sibutramine vs. placebo, 3.4 year f/u Sibutramine 5.0% ✜ Outcomes MI, stroke, cardiac arrest, CV death Phentermine 8.1% ✜ Results Orlistat 3.4% ✜ Weight: -1.7 kg ✜ BP: 1.2 vs 1.4 mm Hg Lorcaserin (2012) 3.0% ✜ Combined outcome: 11.4% vs. 10.0% (HR 1.16, p = 0.02) Phentermine/topiramate (2012) 7.8-9.3% ✜ Nonfatal MI: 4.1% vs. 3.1% (HR 1.28; p = 0.02) Buproprion/naltrexone (2014) 2-4% ✜ Nonfatal Stroke: 2.6% vs 1.9% (HR 1.36; p = 0.03) ✜ Death: No differences Liraglutide (2014) 3.7-4.5% James, NEJM 2010 6
Robert Baron, MD, MS Current Strategies for Treating Obesity Wouldn ’ ’ t It Be Easier Just To Have ’ ’ PRINCIPLES OF DRUG THERAPY Surgery ? • NIH: BMI > 30 kg/m 2 or 27 kg/m 2 with co- morbidity (but in my practice almost never) • Motivated to begin structured exercise and low calorie diet • Begin medications at completion of one month successful diet and exercise • Continue medications only if additional weight loss achieved in first month with meds Types of Surgery INDICATIONS FOR BARIATRIC SURGERY Restrictive • Horizontal Gastroplasties • Vertical Banded Gastroplasty (VGB) • Silastic Ring Vertical Gastroplasty (SRVG) Definition BMI • Adjustable Gastric Banding Normal < 25 • Sleeve Gastrectomy Overweight 25-29.9 Malabsorptive Obese, class 1 30-34.9 • Jejunoileal Bypass (JIB) • Biliopancreatic Diversion (BPD) “ Superobese ” Obese, class 2 35-39.9 • Duodenal Switch with co-morbidity • Long Limb Gastric Bypass Obese, class 3 40+ SURGERY 60+ Restrictive with Malabsorptive Component • Roux-en-Y Gastric Bypass (RYGPB) 7
Robert Baron, MD, MS Current Strategies for Treating Obesity Laparoscopic Adjustable Gastric Banding (LAGB) Sleeve Gastrectomy Lap Band Gastric Bypass Restrictive Only Ideal Candidate – BMI 35-40 kg/m2 – Wants to lose 50-100 pounds Benefits – Fewer early risks than other procedures – One hour procedure – Fully Reversible/Removable – Lowest risk of vitamin deficiencies Considerations/Risks – Excess Weight Loss (EWL) 50% – 10-year removal or reoperation rate is >25% – Slower weight loss (1-2lbs/week) compared to other surgeries – Appetite suppression may be difficult to achieve – Least effective for resolving diabetes Sleeve Gastrectomy (Vertical Gastrectomy) UCSF Sleeve Gastrectomy Indications Restriction and Resection Ideal Candidate � Very high risk of co-morbidities – BMI 35-55 kg/m2 – Wants to lose 80-150 lbs Benefits – Excess Weight Loss 70-90% � BMI >60 – 1-2 hour procedure – Recovery ranges from days to weeks – Patients report early and lasting � Possible non-compliance with meds fullness – Intestines stay intact—No (less risk of micronutrient deficiencies) malabsorption – May cure diabetes Considerations/ Risks – Removal of a portion of the � IBD, IBS, abdominal pain, SBO, stomach is permanent – The remaining pouch may expand adhesions, other GI morbidities over time 8
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