Clinical Research on Lifestyle Interventions to Treat Obesity and Asthma in Primary Care Jun Ma, M.D., Ph.D.

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1 Clinical Research on Lifestyle Interventions to Treat Obesity and Asthma in Primary Care Jun Ma, M.D., Ph.D. Associate Investigator Palo Alto Medical Foundation Research Institute Consulting Assistant Professor Stanford Prevention Research Center, Stanford School of Medicine

2 Obesity Trends* Among U.S. Adults BRFSS, 1990, 2000, 2010 (*BMI 30, or about 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30%

3

4 Economic Consequences of Obesity Approx. $150 billion in annual medical costs Reduced worker productivity and increased absenteeism and presenteeism Obesity shortens the average lifespan if childhood obesity continues to increase, it could reduce the average lifespan by 2 to 5 years. The current generation of children may become the first in American history to live shorter lives than their parents.

5 Metabolic Syndrome: Constellation of Obesity-related Cardiometabolic Risk Factors Risk Factor Defining Level Fasting glucose, mg/dl 100 Abdominal obesity, in. Elevated waist circumference* Men >40 Women >35 Triglycerides, mg/dl 150 HDL-C, mg/dl Men <40 Women <50 Blood pressure, mm Hg 130/ 85 *Population and country-specific cutoffs; Drug treatment is an alternate indicator Diagnose by presence of 3 or more risk factors Alberti et al., Circulation 2009;120:1640-5

6 E-LITE Trial

7 E-LITE Design Overview Screening, Eligibility, Baseline Data Collection Randomization n = 241 Usual care n = 81 Coach-led intervention n = 79 Self-directed intervention n = 81 Follow-up Data Collection 3, 6, and 15 months

8 E-LITE Design Overview Screening, Eligibility, Baseline Data Collection Randomization n = 241 Usual care n = 81 Coach-led intervention n = 79 Self-directed intervention n = 81 Follow-up Data Collection 3, 6, and 15 months

9 Baseline Characteristics of Study Participants Characteristic All (n=241) Usual Care (n=81) Self- Directed (n=81) Coach- Led (n=79) P Value Female, % Weight, kg 93.8± ± ± ± BMI, kg/m ± ± ± ± Pre-diabetes, % MetS, % Pre-diabetes & MetS, % Abbreviations: BMI, body mass index; MetS, metabolic syndrome.

10 Change in BMI at 15 Months

11 Change in Body Weight

12 Categorical Weight Loss at 15 Months

13 Changes in Cardiometabolic Risk Factors at 15 months Usual care Self-directed Coach-led Waist SBP DBP FPG TG HDL TG/HDL * * * *p<.05; p<.001 vs. usual care Abbreviations: DBP, diastolic blood pressures FPG, fasting plasma glucose HDL, high-density lipoprotein cholesterol SBP, systolic blood pressure TG, triglycerides Waist, waist circumference

14 Distributions of Percent Weight Loss

15 E-LITE Interventions: Effective, Practical, and Generalizable Nationally recognized Group Lifestyle Balance curriculum (http://www.diabetesprevention.pitt.edu/glbmaterials.aspx) Coach-led intervention: 12 weekly groups Self-directed intervention: 12-session DVD Low cost, wide reach health information technologies Lifestyle coaching via secure within a mature electronic health record (EHR) system Lifestyle goal setting and self-monitoring via the American Heart Association s free, secure Heart360 web portal (www.heart360.org)

16 Obesity and Asthma: Summary of Epidemiologic Evidence Concurrent rise in obesity and asthma prevalence A temporally correct and dose-response relationship between BMI and incident asthma Obesity alters prevalent asthma towards a more difficult-to-control phenotype Obesity blunts response to asthma pharmacotherapy

17 Obesity and Incident Asthma Meta-Analysis of Prospective Studies Beuther & Sutherland, Am J Respir Crit Care Med 2007;175:661-6

18 Sex, Obesity, and Incident Asthma Meta-Analysis of Prospective Studies Beuther & Sutherland, Am J Respir Crit Care Med 2007;175:661-6

19 Treatment Guidelines Asthma diagnosis and management guidelines (2007) For the first time explicitly recognized obesity as a comorbidity of asthma Recommends that clinicians consider advising asthma patients who are overweight or obese that weight loss, in addition to improving overall health, might also improve their asthma control (emphasis added) The recommendation was based on uncontrolled studies and limited controlled trials of surgically- or diet-induced weight loss in obese adults with asthma

20 although all four studies are RCTs [randomized controlled trials] there were serious methodological limitations in the studies (unclear risk of selection bias and high risk of detection bias) and imprecision (small sample size) On account of this low quality of evidence, the benefit of weight loss as an intervention for asthma control remains uncertain

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