What is the best diet to lose weight

Transcription

1 Challenging Cases in Obesity Management (What me worry?) Ken Fujioka, M.D. Director of Nutrition and Metabolic Research Center for Weight Management Scripps Clinic Dept. of Endocrine Panama Boca Del Toro 2015 What is the best diet to lose weight 36 year old patient comes in for weight gain and is quite certain it is her thyroid. She wants it checked and an Rx for thyroid hormone so she can lose weight. Normal exam including thyroid BMI is 28 waist is 32 inches She states she is on an Organic Clean diet. And exercises a lot almost every day What is your work up? Laboratory work up of the overweight patient What labs do you order? TSH Fasting Comprehensive Metabolic Panel Fasting blood sugar LFTs (fatty liver disease) Renal function Electrolytes (bulimia) Lipid panel (NMR or fractionated) Hemoglobin A1c Males: total testosterone

2 What other information can you gather to help explain the patients increased weight? Have her load an App to record her diet and exercise (My Fitness Pal, Lose it, etc.) If the patient is not comfortable with her smart phone then use pencil and paper Have her weigh daily while she does this and record in smart phone App or paper Results TSH 2.0 Lipids completely normal CMP completely normal (FBS 90) Food record: reveals an average calorie intake of about calories per day Exercise reveals she does Palates(30 mins) 2 days and yoga (60 mins) 5 days a week and burns about 450 calories a week with exercise She lost 3 pounds over this time (2 weeks) How do you treat What do you tell her regarding her thyroid Its normal and giving thyroid hormone would be wrong and could cause problems She now asks for a weight loss medication, is she appropriate for a weight loss medication according to AACE and ENDO guidelines? No, at her BMI she would need a comorbid problem

3 What diet do you prescribe? According to evidence based guidelines Because you did not give her thyroid hormone or a weight loss drug she states how uncaring and how you don t understand But, she would like your opinion on what diet she should follow to lose weight? Low fat, high carb, and raw food diet Mediterranean diet Low- carbohydrate diet Meal replacement for breakfast then a healthy lunch, another meal replacement after work and a healthy dinner Herbal cleanse diet with a high colonic enemas ACC/AHA/TOS The 2013 American College of Cardiology/American Heart Association/The Obesity Society (ACC/AHA/TOS) Guideline for the Management of Overweight and Obesity in Adults suggests that the best approach to nutritional intervention is to use a strategy to which the patient is most likely to adhere A diet the patient can follow And any of the following 1200 to 1500 kcal/d for women and 1500 to 1800 kcal/d for men Energy deficit of 500 to 750 kcal/d An evidence- based diet that restricts certain food types to create an energy deficit by reduced food intake (eg, diets that restrict high- carbohydrate foods, low- fiber foods, or high- fat foods), they all can work

4 Follow up The patient actually did lose weight when she tracked her diet over the 2 weeks She became aware of inappropriate foods and decreased her calories to a point that she began to lose weight Would you make any recommendations regarding her exercise? I hope so, its not even close helping weight loss Exercise RX If you are going to have her count steps then make your first goal 4-6,000 steps per day and slowly see how close she can get to 10,000 If you have her going to the gym or doing various different types of exercise start by trying to get her to burn 1000 calories a week with exercise with a goal of This may take a while or even a Personal Trainer Yoga burns very few calories, it is s till good to do but not if the goal is weight loss (may prevent injury) She want join a Commercial Program and she wants you to recommend one Which of the following programs have controlled trials to demonstrate consistent weight loss Jenny Craig Weight Watchers Nutri- system Medi- fast Atkins diet Answer: Jenny Craig and Weight Watchers

5 Audience Response System (ARS) Which is the best diet for a patient to follow: 1. low carb diet 2. low fat diet 3. Meal replacement (protein shakes 2 times a day with one regular meal) 4. Organic, raw, clean full moon diet 5. Which ever diet the patient can adhere to that results in a 500 to 750 calorie deficit Case number 2 Roy Roy is one of your favorite patients, easy going, jolly but has a some new findings at his annual physical exam BMI 38 Waist 50 ALT 140, AST 70 Fasting blood sugar 108 Triglycerides 240 with an HDL of 29 Roy: more history He has always struggled with his weight and loves to watch sports but has no time to exercise but a hard working salesman He loves his job and life and has no desire to change anything, he travels for work and has a great expense account so he can eat whatever he wants for free He has tried to diet before but did not last long and tried walking but got plantar fasciitis

6 ARS: How do you bring up the topic of weight loss? 1. Tell him that he is becoming a diabetic and we will have to amputate his feet, put him on renal dialysis, but not to worry as he will go blind and will not see what is going on 2. explain he has fatty liver disease, pre- diabetes, and metabolic syndrome and ignore his weight and start metformin 3. explain he has fatty liver disease, pre- diabetes, and metabolic syndrome and ask him if he would like to have a discussion about his weight and some of the newer options that may increase his options of success Where do you start? Start where the patient has already been with prior weight loss treatments In this case the patient has tried diet and exercise before so don t be afraid to talk about medications and bariatric surgery first But remember to come back to them Let the patient know that there are medications available that have shown improvements in weight as well as the cardio- metabolic factors he has Also let the patient know he is heavy enough and has the risk factors that he is a candidate for bariatric surgery but that you would like to try a medical treatment first and if that fails then yes lets consider bariatric surgery ARS: What is the best diet for Roy? 1. Low carb 2. Low fat 3. Mediterranean 4. let the patient choose 5. Fuji Fast food high colonic enema diet

7 ARS: Best Exercise? Since Roy travels and has a history of plantar fasciitis what exercise would be the best? A. 10,000 steps per day B. Stationary bike C. Resistance training (lifting weights) D. Both stationary bike and resistance training Exercise Settle on lifting weights and warming up with stationary bike (5-10 minutes) Eventually he is willing to do the bike for longer periods because he can do s while on the bike He does this while he travels but does make a fuss about having to carry gym clothes as he only does carry on luggage ARS: What medications do we choose for Roy? 1. Phentermine/topiramate 2. Lorcaserin 3. Bupropion/naltrexone 4. Liraglutide 3.0 mgs

8 Liraglutideand Glucose Levels during Oral Glucose- Tolerance Test and Glycemic Status Pi- Sunye r X, Arstrup A, Fujioka K, e t al. N Engl J Me d ;3 7 3 : REGRESSION TO NORMOGLYCEMIA WEEKS 100 Liraglutide 3.0 mg Placebo Proportion (%) % 36% 50% 36% Liraglu t ide 3.0 mg in creased t h e likelihood of normoglycemia OR = 3.6 [95% CI, 3.0 to 4.4] p< Corresponding to a NNT of ~ Week Full analysis set. Statis tic al an al y si s is logisticregression. CI, co nfi de n ce interval; NNT,number needed totreat; OR, odds ratio. Take home message for choice of weight loss medication for Roy There is no best single weight loss medication and its up to you and the patient Binge: consider Topiramate Cravings: consider Bupropion/naltrexone Satiety: consider Lorcaserin Pre Diabetic: consider Liraglutide

9 Case number 3: Susan 32 year old single mom that works full time and takes care of 2 kids (ages 7 and 9) Life s a struggle from a time management standpoint She gets up early to get the kids off to school, works 8 hours then picks up the kids and does homework and prepares dinner When she puts the kids to bed she struggles with wanting to eat inappropriate foods (the kids cookies or ice cream) She sometimes does not want to get out of bed in the morning and occasionally cries herself to sleep Susan Well dressed friendly female patient BMI 34 other vitals all normal Waist 40 inches Labs normal She has tried a million diets and typically loses pounds but gets stuck and then regains the weight Susan becomes teary eyed when she talks about her weight and tells you that one of her son s school mates called her fat and her son punched the kid and she had to go in an see his teacher about it. Treatment Plan for Susan May have to start with meds before diets and exercise as she has done a lot of weight management before Diet? Exercise? Best medication?

10 1. low carb 2. low fat ARS: Best Diet for Susan 3. meal replacements (two protein shakes and one protein bar) with one regular meal per day 4. Raw, organic, clean diet with juice smoothies 3 times a day 5. work with a Dietitian to make a diet for her ARS: Best exercise for Susan 1. walking 10,000 steps per day 2. weight lifting 3. walking 4,000 steps per day when she is at the soccer field waiting for her kids to finish soccer practice 4. exercising on her lunch break by going for a walk or going to the gym ARS: What medications do we choose for Susan? 1. Phentermine/topiramate 2. Lorcaserin 3. Bupropion/naltrexone 4. Liraglutide 3.0 mgs

11 COR-1: Change in Selected Items from the Control of Eating Questionnaire at Week 56 Placebo (n=511) How hungry have you felt? How full have you felt? Naltrexone 16 mg plus bupropion (n=471) Naltrexone 32 mg plus bupropion (n=471) How difficult has it been to control your eating? How difficult has it been to resist any food cravings? How often have you eaten in response to food cravings How often have you had food cravings for starchy foods? Less Cha ng e f ro m b as elin e ( m m) More P <.05 vs placebo. Greenway FL, et al. Lancet. 2010;;376, ITT weight loss at one year Phentermine/topiramate ER 15 mg/92 mg [38] 9.8% vs 1.2% placebo Lorcaserin 10 mg BID Naltrexone/bupropion 32 mg/360 mg [40 5.8% vs 2.5% placebo 5.4% vs 1.3% placebo Liraglutide 3.0 mg 7.4% vs 3.0% placebo Fujioka K. Current and emerging medications for overweight or obesity in people with comorbidities. Diabetes and Obesity 2015 Audience Response System (ARS) A attractive well dressed 48 y/o female patient comes in with a desire for phentermine or something to lose weight. She has an up coming class reunion to go to and wants to make an impression. She wants something to kick start her metabolism and lose 10 pounds Her BMI is 24 and she is in good health with no co- morbid disease.

12 ARS: Which one of the following is the best treatment option for this patient: 1. do not give her phentermine or any weight loss medication 2. its OK to give her phentermine but for only 12 weeks or short term 3. do not give her phentermine but give her low dose thyroid hormone to kick start her metabolism for only 3 months 4. tell her about a new weight loss drug called placebo and how it melts fat off by stimulating the adrenals as it is clear she had adrenal fatigue Thank you for your attention! Questions? Clinical Approaches to address the Obesity epidemic Ken Fujioka, M.D. Director of Nutrition and Metabolic Research Director of The Center for Weight Management Scripps Clinic The End La Jolla, California

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