Prevalence of Obesity 2011-2012 TREATING OBESITY Obesity - - PowerPoint PPT Presentation

Current Strategies for Treating Obesity

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Robert Baron, MD, MS

CURRENT STRATEGIES FOR TREATING OBESITY

Robert B. Baron MD MS Professor of Medicine Associate Dean for GME and CME Founding Director, UCSF Weight Management Program Declaration of full disclosure: No conflict of interest

Prevalence of Obesity 2011-2012

Obesity prevalence: Adults 34.9% Youth 16.9% No change since 2003-2004

Ogden Cl, JAMA 2014 Ogden, JAMA 2014

Obesity Disparities: Example: BMI >35

Women, 40-59: 19.1% White: 16.9%, Black: 30.4%, Asian 4.6%, Hispanic 25.5% Men, 40-59: 12.2% White: 12.8%, Black: 15.7%, Asian 0, Hispanic 8.7%

15%–<20% 20%–<25% 25%–<30% 30%–<35% ≥35%

Prevalence of Self-Reported Obesity Among U.S. Adults by State and Territory, BRFSS, 2013

CA MT ID NV UT AZ NM WY WA OR CO NE ND SD TX OK KS IA MN AR MO LA MI IN KY IL OH TN MS AL WI PA WV SC VA NC GA FL NY VT ME HI AK NH MA RI CT NJ DE MD DC PR GUAM

Current Strategies for Treating Obesity

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Robert Baron, MD, MS

For a 40 yo woman, with normal BP, lipids, and FBS which BMI is associated with the lowest all- cause mortality?

A.

18 B. 24 C. 28 D. 34 E. 38

1 8 2 4 2 8 3 4 3 8

6% 72% 1% 1% 20%

CLASSIFICATION OF OVERWEIGHT AND OBESITY BY BMI

Obesity Class BMI (kg/m2) Underweight <18.5 Normal 18.5 – 24.9 Overweight 25.0 – 29.9 Obesity I 30.0 – 34.9 II 35.0 – 39.9 Extreme Obesity III >40

Flegal, JAMA, 2005

BMI AND MORTALITY: Overall

Combined NHANES I, II, and III data set BMI 25-59 y 60-69 y ≥70 y <18.5 1.38 2.30 1.69 18.5-<25 1.00 1.00 1.00 25 to <30 0.83 0.95 0.91 30 to <35 1.20 1.13 1.03 ≥35 1.83 1.63 1.17

Flegal, JAMA, 2013

MORTALITY AND OBESITY

Meta-analysis of 97 studies of 2.8M people, 270,000 deaths BMI HR

Below 25 (Normal) 1.0 25-30 (Overweight) 0.94 Above 30 (Obese) 1.18 *** 30-35 (Grade 1 Obesity) 0.95 Above 35 (Grade 2/3 Obesity) 1.29

Current Strategies for Treating Obesity

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Robert Baron, MD, MS

For a 40 yo woman, with normal BP, lipids, and FBS which BMI is associated with the lowest all- cause mortality?

• 1. 18
• 2. 24
• 3. 28
• 4. 34
• 5. 38

Epidemic of Inactivity

60% US adults don’ ’ ’ ’t exercise regularly 25% are sedentary

Cochrane Collaboration

EXERCISE FOR OBESITY

Meta-analysis of 43 RCTs: 3476 participants

• Exercise plus diet vs diet alone

– -1.1 kg

• Increased intensity of exercise

– -1.5 kg

• Exercise without weight loss

– Reduced: BP, triglycerides, blood sugar

Wei, JAMA 1999

FITNESS AND MORTALITY Aerobics Center Longitudinal Study

CV death (RR) normal

• verweight obese

Fit 1.0 1.5 1.6 Not fit 3.1 4.5 5.0 Total death (RR) normal overweight obese Fit 1.0 1.1 1.1 Not fit 2.2 2.5 3.1 25,714 men, 44 years old, 14 year observational study

Current Strategies for Treating Obesity

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Robert Baron, MD, MS

Sacks, NEJM, 2009

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

Very Low Calorie Diets (VLCD) vs Low Calorie Diets (LCD): Meta-analysis of 6 RCTs

• Trials with direct comparisons
• Short-term: mean 12.7 weeks
• Long-term: mean 1.9 years

Weight loss (as % of initial weight): short-term long-term LCDs 9.7 5.0 VLCDs 16.1 6.3 (p) (0.001) (0.2)

WEIGHT LOSS DIET BOTTOM LINE

• The type of diet does not really

matter for weight loss.

• Sticking to the diet does matter
• Calories “

“ “ “trump” ” ” ” macronutrients

• But, select healthy, nutrient rich

foods

Current Strategies for Treating Obesity

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Robert Baron, MD, MS

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:

• A. 2000 kcals
• B. 1800 kcals
• C. 1600 kcals
• D. 1400 kcals
• E. 1200 kcals

2 k c a l s 1 8 k c a l s 1 6 k c a l s 1 4 k c a l s 1 2 k c a l s

14% 40% 5% 12% 29%

SUCCESSFUL WEIGHT LOSS MAINTENANCE

• High levels of physical activity
• Women 2545 kcal/week, men 3293 kcal per week
• 1-hour moderate intensity per day
• Only 9% report no physical activity
• Diet low in calories
• 1381 kcal day
• 4.87 meals or snacks/day
• Fast food 0.74/week
• Regular self-monitoring of weight
• 44% weigh once per day; 31% once per week

40 yo woman, BMI 36. Much to your surprise, she has lost 35

• pounds. In order to maintain her

new weight, her lifelong daily calorie intake should be:

• 1. 2000 kcals

2 1800 kcals 3 1600 kcals

• 4. 1400 kcals
• 5. 1200 kcals

Current Strategies for Treating Obesity

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Robert Baron, MD, MS The Neuroendocrinology of Energy Balance

Weight Loss With Weight Loss Medications

Weight loss (% of initial) in excess of placebo: Phentermine-fenfuramine 11.0% Sibutramine 5.0% Phentermine 8.1% Orlistat 3.4% Lorcaserin (2012) 3.0% Phentermine/topiramate (2012) 7.8-9.3% Buproprion/naltrexone (2014) 2-4% Liraglutide (2014) 3.7-4.5%

James, NEJM 2010

SIBUTRAMINE AND CARDIOVASCULAR OUTCOMES (SCOUT)

✜ 9804 patients, over 55, with CV disease or diabetes ✜ Sibutramine vs. placebo, 3.4 year f/u ✜ Outcomes MI, stroke, cardiac arrest, CV death ✜ Results

✜ Weight:

• 1.7 kg

✜ BP: 1.2 vs 1.4 mm Hg ✜ Combined outcome: 11.4% vs. 10.0% (HR 1.16, p = 0.02) ✜ Nonfatal MI: 4.1% vs. 3.1% (HR 1.28; p = 0.02) ✜ Nonfatal Stroke: 2.6% vs 1.9% (HR 1.36; p = 0.03) ✜ Death: No differences

Current Strategies for Treating Obesity

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Robert Baron, MD, MS

PRINCIPLES OF DRUG THERAPY

• NIH: BMI > 30 kg/m2 or 27 kg/m2 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

Wouldn’ ’ ’ ’t It Be Easier Just To Have Surgery ?

Definition BMI Normal < 25 Overweight 25-29.9 Obese, class 1 30-34.9 Obese, class 2 35-39.9 Obese, class 3 40+ “Superobese” 60+

SURGERY with co-morbidity

INDICATIONS FOR BARIATRIC SURGERY

Types of Surgery

Restrictive

• Horizontal Gastroplasties
• Vertical Banded Gastroplasty (VGB)
• Silastic Ring Vertical Gastroplasty (SRVG)
• Adjustable Gastric Banding
• Sleeve Gastrectomy

Malabsorptive

• Jejunoileal Bypass (JIB)
• Biliopancreatic Diversion (BPD)
• Duodenal Switch
• Long Limb Gastric Bypass

Restrictive with Malabsorptive Component

• Roux-en-Y Gastric Bypass (RYGPB)

Current Strategies for Treating Obesity

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Robert Baron, MD, MS

Sleeve Gastrectomy

Lap Band Gastric Bypass

Laparoscopic Adjustable Gastric Banding (LAGB)

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)

Restriction and Resection

Ideal Candidate – BMI 35-55 kg/m2 – Wants to lose 80-150 lbs Benefits – Excess Weight Loss 70-90% – 1-2 hour procedure – Recovery ranges from days to weeks – Patients report early and lasting fullness – Intestines stay intact—No malabsorption – May cure diabetes Considerations/ Risks – Removal of a portion of the stomach is permanent – The remaining pouch may expand

• ver time

UCSF Sleeve Gastrectomy Indications

Very high risk of co-morbidities BMI >60 Possible non-compliance with meds (less risk of micronutrient deficiencies) IBD, IBS, abdominal pain, SBO, adhesions, other GI morbidities

Current Strategies for Treating Obesity

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Robert Baron, MD, MS

Roux en Y Gastric Bypass (RNY or Bypass)

Restrictive and Malabsorptive

Most common procedure performed Ideal Candidate – BMI 35-55 kg/m2 – Wants to lose 100- 150 + lbs – May have severe or prolonged medical conditions Benefits – Excess Weight Loss 70-90% – 2 hour procedure – Recovery of days to weeks – Very effective for diabetes – Approximately 100-200 calories per day lost through malabsorption – Procedure is reversible Considerations/Risks – Greater risk for vitamin deficiencies – Dumping syndrome – Smoking, EtOH, NSAIDS use may lead to ulcers

Years

Bariatric Surgery: Weight Change

Resolution of Comorbidities

10 20 30 40 50 60 70 80 90 100

Diabetes Hyperlipidemia HTN Sleep apnea

Band VBG GBP D Switch

% Resolution Comorbidity

Bariatric Surgery – A Systematic Review and Meta-analysis Buchwald H. et al.

• JAMA. 2004; 292(14):1724-37

LABS Consortium, NEJM, 2009

BARIATRIC SURGERY ADVERSE OUTCOMES

• Ten sites, 4776 patients. 3/4 roux-en-y (87% lap); 1/4 lap band
• 30 Day overall mortality: 0.3%
• lap band

0.0%

• roux-en-y (lap)

0.2%

• roux-en-y (open)

2.1%

• Composite (death, DVT, reintervention, 30 + days in hosp): 4.1%
• lap band

1.0%

• roux-en-y (lap)

4.8%

• roux-en-y (open)

7.8%

Current Strategies for Treating Obesity

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Robert Baron, MD, MS

Mortality After Surgery

Community Medicare Data: 55-64 year old

30 days 90 days 1 Year 2.0% 2.7% 5.2%

Sjostrom, NEJM, 2007

Bariatric Surgery and Mortality

Swedish Obese Subjects Study 4047 subjects, surgery vs. matched control. 10.9 years

Max weight loss % Final weight loss % Control 2 Gastric bypass 32 25 Vertical banded Gastroplasty 25 16 Banding 20 14

Sjostrom, NEJM, 2007

Bariatric Surgery and Mortality

Swedish Obese Subjects Study

Deaths HR Rate MI deaths Cancer deaths Control 129 0.063 25 47 Surgery 101 0.76 0.050 13 29 (p = 0.04)

NNT 77 over 11 years (approx 850 per year)

Diet and Exercise After Surgery

Days 1-14

• Thin fluids only
• No solid food
• 32-60 oz fluids per

day

• 400-600 calories

per day

• 50-70 grams of

protein

• Walk 5-10 minutes

every hour

• Wake and walk

after 8 hours

Days 15-30

• Start thick liquids

and soft foods

• 32-60 oz fluids
• 600 calories per day
• 50-70 grams of

protein

• Minimal carbs and

fats

• Start cardio

exercises and light weight lifting

Day 31 and beyond

• Regular foods as

tolerated

• Meats and other

foods should be tender, cut and chewed well and eaten slowly

• 60+ oz fluids
• 600 calories per day
• 50-70 grams of

protein

• Increase physical

activity

Current Strategies for Treating Obesity

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Robert Baron, MD, MS

Pregnancy and Weight-Loss Surgery

Fertility is enhanced after surgery Delay pregnancy for 12 to 18 months after surgery Use non-oral forms

• f birth control

Avoid oral glucose challenge after gastric bypass

SUMMARY

Environmental and public health changes work. Diets work, but not for long in most people (but

they do for some).

Exercise improves health independent of

weight change and aid in weight maintenance.

Continuation of conditions that promote weight

loss promotes weight maintenance (no matter what the intervention).

SUMMARY

Provision of meals and meal replacement

products promote greater weight loss (but mostly in the short term, except for a few).

Medications can help achieve small

amounts weight loss for as long as agents can be used (but little is known about long term outcomes).

Surgery results in long term weight loss

and reductions of diabetes and mortality (but with complications in some/many and a high number needed to treat).

GOALS OF MANAGEMENT

Be as fit as possible at current weight Prevent further weight gain If successful at 1 and 2, begin weight

loss

Current Strategies for Treating Obesity

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Robert Baron, MD, MS The Magic Formula