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2/10/2014


  1. 2/10/2014 ���������������������� ���������������������� �������������������� �������������������� Theodore Feldman, MD,FACC,FACP Medical Director, Center for Prevention and Wellness, Baptist Health Medical Director, South Miami Heart Center Heartwell LLP Clinical Associate Professor of Medicine FIU Wertheim College of Medicine ����������� �������������������������������������������������������� Baptist Hospital Baptist Children’s Hospital Doctors Hospital Homestead Hospital Baptist Cardiac & Mariners Hospital Vascular Institute West Kendall Baptist Outpatient South Miami Hospital Baptist Hospital Services 2 What problem? �������������������� ������������ ����� Increased caloric intake + refined carb consumption & physical inactivity � explosion in incidence of abdominal obesity & epidemic of insulin � � � resistance. 3 1

  2. 2/10/2014 ����������������������� � Obesity is one of the greatest health threats currently facing the United States � BMI > 30 highly prevalent in U.S. � 36% (>78 million) US adults are obese Definitions of Obesity �������������������������� �������� ������������������!������� 2

  3. 2/10/2014 2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society "��������#������$�%&'(� �)�*� *��!� ��������+��������� 3

  4. 2/10/2014 4

  5. 2/10/2014 American College of Physicians for Medical Management of Obese Patients ,��������������������������- .�����/���������!��������� � /������������������.�����!�������������� ,������0��������������������������� � Dietary therapy � Physical activity � Behavior therapy � "Combined" therapy � Pharmacotherapy � Weight8loss surgery ���������������������������������������� !������������ ��������)����1��� 0����,�����2 � ������������������3������� ��������������������4����� �������������� � 5���������������4�������� 6'��������������� � ���������������%&#&&&� ���������������������� 5

  6. 2/10/2014 Top Weight Loss Apps: New York Daily News and Forbes � Topping both lists – and the recipient of the United States Surgeon General’s Healthy Apps Challenge – is an app called "Lose It." 16 Do they really help you lose weight? � Recent pilot randomized control trial has looked into compliance with smartphone apps for weight loss compared tcompared to website or paper diary8based tools � Results 8 better adherence for smartphone apps compared to other conventional weight8loss tools � Participants using smartphone apps lost a mean weight of 10.2 pounds over the course of the 68month trial 6

  7. 2/10/2014 Components of Successful Web Based Weight Loss Tools � According to a recent study in Telemedicine Journal and e8Health � Must allow for self monitoring � Have social support � Have an integrated counselor feedback and communication tool � Incorporate the use of a structured program � Allow for the tailoring of the program to the individual. 19 Baptist Employee Healthy Heart Study Identify those with Metabolic syndrome (MetS)/Type II DM (T2DM) and � screen them for subclinical CVD Diagnosis of three or more of the following: � � Waist circumference >=40 inches in and male and >= 35 inches in a female, Fasting triglyceride level > 150 mg/dl* � � HDL8C < 40 mg/dl in men or < 50 mg/dl in women* � BP > 130/85 mm Hg* � Fasting blood glucose > 110 mg/dl � *Or currently on medication to treat the abnormal condition � Develop a web based treatment program which is effective at reducing the risks associated with MetS Delivering the treatment to a large, diverse population in a cost effective � manner � ��������)��������� : Web8based “South Beach” intervention vs WebMD will result in a significant difference in BMI and markers of subclinical CVD (Berkeley panel, Imaging studies, CAC) at 1 year F/up. Medications • Short8term obesity management • Sympathomimetics ( ����������� , Diethylpropion, Benzphetamine) • Long8term obesity management • Lipase inhibitors ( �������� ) • Recently approved obesity medications • Serotonin agonists ( 0��������7 • Combination agents ( �����������-���������� ) 7

  8. 2/10/2014 22 Phentermine (Suprenza) Type: sympathomimetic Mechanism of action: stimulates the hypothalamus to suppress appetite Year of approval: 1959 FDA approved indication: short8term (< 12 weeks) adjunct to exercise and caloric restriction for BMI ≥ 30 or ≥ 27 in the presence of other risk factors such as hypertension, diabetes or hyperlipidemia Efficacy: 3.6 kg mean weight loss beyond that achieved by placebo at 2824 weeks (meta8analysis of six placebo8controlled trials; ����������������� ����� ������ 2002;26:262873) Adverse effects: risk of dependence and abuse, hypertension, dry mouth, insomnia, tremor, GI disturbance, primary pulmonary hypertension (rare, associated with combined use of fenfluramine in “fen8phen”), valvular heart disease (rare), psychosis (rare) Contraindications: history of CV disease, MAOIs, hyperthyroidism, glaucoma, history of drug abuse, pregnancy, breastfeeding Orlistat (Xenical, Alli) Type: lipase inhibitor Mechanism of action: inhibits the breakdown of triglycerides into absorbable free fatty acids by lipase enzymes in the stomach and pancreas, resulting in less fat being absorbed Year of approval: 1999 (Xenical – prescription 120 mg TID), 2007 (Alli – OTC 60 mg) FDA approved indication: as an adjunct to a reduced8calorie and low8fat diet for weight loss or to lower the risk of regaining weight after prior weight loss Efficacy: 2.9 kg mean weight loss (Xenical) beyond that achieved by placebo at one year (meta8analysis of 15 trials; ����������� ��� 2005;142:532846) Adverse effects: significant diarrhea, fecal incontinence, oily spotting, flatulence, bloating, dyspepsia (all can be reduced with avoidance of fat8rich foods), reduced absorption of fat8soluble vitamins, serious liver injury (rare) Contraindications: malabsorption, cholestasis, impaired liver function, pancreatic disease, pregnancy (added in 2012) 8

  9. 2/10/2014 Lorcaserin (Belviq) Type: serotonin agonist Mechanism of action: activates 58HT 2C receptors in the hypothalamus, resulting in increased proopiomelanocortin (POMC) production, which promotes satiety Year of approval: 2012 FDA approved indication: treatment of obesity for adults with BMI ≥ 30 or ≥ 27 in the presence of other risk factors such as hypertension, diabetes or hyperlipidemia Efficacy: 3.6 kg mean weight loss beyond that achieved by placebo (5.8 kg vs. 2.2 kg) at one year (Phase 3 RCT; ��!�"���� �� 2010; 363:2458256) Adverse effects: headache, nasopharyngitis Contraindications: pregnancy, MAOIs, SSRIs (caution) Phentermine8topiramate (Qsymia) Year of approval: 2012 FDA approved indication: chronic weight management, as an adjunct to a reduced8calorie diet and exercise, for BMI ≥ 30 or ≥ 27, in the presence of other risk factors such as hypertension, diabetes or hyperlipidemia Efficacy: 10.7 kg mean weight loss beyond that achieved by placebo (12.6 kg vs. 1.9 kg) at one year (Phase 3 RCT; �������� (2012); 20 2, 330–342) Adverse effects: tachycardia, insomnia, paresthesias, dizziness, distorted taste sensation, constipation, dry mouth, anxiety, suicidality (rare), acute angle closure glaucoma (rare), metabolic acidosis (rare), increased serum creatinine (rare) Contraindications: pregnancy, glaucoma, hyperthyroidism, MAOIs, history of suicide attempt 1�����3� !8#�1�����3� "�$� 0���- ����������������������������������� !�������������� ��������9�����$� ������ %&'6:('';'7�<6-=>$� 9

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