5 Things to Know About Managing Obesity in Clinical Practice Taraneh Soleymani, MD, FTOS Assistant Professor Department of Nutrition Sciences University of Alabama at Birmingham soltar@uab.edu Disclosure I have no financial interest or conflict of interest in I have no financial interest or conflict of interest in relation to this program/presentation. 1
Objectives THING 2 Obesity Treatment Modalities THING 4 Physical Activity in Weight Management THING 5 Behavioral Modification in Weight Management Why is it important to do? Correlates with body fat Risk estimate: Increase BMI is associated with adverse health conditions Accurate diagnosis & documentation Treatment selection Based on Body Mass Index (BMI) A weight-stature index, used both as a measure of obesity and malnutrition BMI = weight (kg) / Height2 (m2) BMI= weight (lb.) x 703/ height squared (in2) BMI chart Relationship Between BMI and Percent Body Fat in Men and Women Body Fat (%) 70 Women 60 Men 50 40 30 20 10 0 0 10 20 30 40 50 60 Body Mass Index (kg/m 2 ) Adapted from: Gallagher et al. Am J Clin Nutr. 2000;72:694. 2
2013 AHA/ACC/TOS Guidelines for Obesity Recommendation: Measure height and weight and calculate BMI at annual visits or more frequently Body Mass Index Staging 18.5 24.9 kg/m 2 Normal range 25 29.9 kg/m 2 Overweight 30 34.9 kg/m 2 Obesity Stage I 35 39.9 kg/m 2 Obesity Stage II 40 kg/m 2 Extreme Stage III Does BMI give you the complete picture? BMI does not distinguish between lean and fat mass. It is especially less accurate in: Elderly Athletes Certain ethnic groups Waist Circumference: Indirect measure of central adiposity, correlated with visceral fat Excess abdominal fat is an independent predictor of risk factors and morbidity Measurement is recommended for individuals with BMI 25 34.9 kg/m 2 to provide additional information on risk It is unnecessary to measure waist circumference in patients with BMI 35 kg/m 2 because the waist circumference will likely be elevated and will add no additional risk information. Cut points: Women: >88 cm (>35 in) Men: >102 cm (>40 in) Comparison of Anthropometric and Metabolic Variables and Disease Prevalence in Women With Normal vs High WC Values Within Different BMI Categories Arch Intern Med. 2002;162(18):2074-2079. doi:10.1001/archinte.162.18.2074 3
Measuring Waist Circumference Locate upper hip bone and top of right iliac crest Place measuring tape around abdomen at level e of iliac crest, keeping it parallel to the floor Ensure tape is snug but not compressing the skin http://www.nhlbi.nih.gov/guidelines/obesity/prctgd_c.pdf. Waist Circumference is NOT Belt Size Real waist located here = 44 Belt from college located here = 36 Assessing Obesity: BMI, Waist Circumference, and Disease Risk BMI (kg/m 2 ) Disease Risk Relative to Normal Weight and Waist Circumference Men 40 in Men > 40 in Women 35 in Women > 35 in Underweight <18.5 Normal 18.5-24.9 Overweight 25.0-29.9 Increased Obesity Stage I 30.0-34.9 High Obesity Stage II 35.0-39.9 Very high Extreme obesity 40 Extremely high High Very high Very high Extremely high Disease risk for DM2, HTN and CVD. Adapted from: Clinical Guidelines on the Identification, Evaluation and Treatment of Overweight and Obesity in Adults: the Evidence Report. Obesity research and NIH NHLBI, 6(S2), 1998. 4
Ethnic Specific Values for Waist Circumference Objectives THING 2 Obesity Treatment Modalities THING 4 Physical Activity in Weight Management THING 5 Behavioral Modification in Weight Management Lifestyle Modification Pharmacotherapy Surgery Diet Orlistat Phentermine Physical Activity Phentermine/ Topiramate ER Diethylpropion Behavior Therapy Lorcaserin Liraglutide Buproprion/ Naltraxone ER 5
Current Approach to Obesity Treatment Treatment Options Current Patient Risk LOW HIGH BMI Range 25 26.9 27 29.9 30 34.9 35 39.9 40 Diet, exercise, and behavioral therapy Pharmacotherapy Surgery Potential Treatment Risk LOW HIGH + + + + + With a comorbidity + + + With a comorbidity + Complications-Centric Model for Obesity Treatment Objectives THING 2 Obesity Treatment Modalities THING 4 Physical Activity in Weight Management THING 5 Behavioral Modification in Weight Management 6
Composition Calories Diet Strategies for Weight Mangement Very Low Fat Diet Low Fat Diet Moderate Fat Diet 10 20% Total Calories from Fat Pritikin Ornish Primarily plant based 20 35% Total Calories from Fat Dietary Guidelines for Americans Dash American Heart Association Jenny Craig Weight Watchers Nutrisystem 35 45% Total Calories from Fat Mediterranean Diet High Protein Diet > 25% Total Calories from protein ZONE Low Carbohydrate Diet 10 30 % Total Calories from carbohydrate Atkins Ketogenic Very Low Calorie Diet <800 kcal OPTIFAST HMR How Much Calorie to Prescribe? 1. Calculate daily caloric needs and subtract 500 750 kcal: Basal Metabolic Rate equation Mifflin St Jeor: Men: 10 x Weight (kg) + 6.25 x height (cm) 5 x age (y) + 5 Women: 10 x Weight (kg) + 6.25 x height (cm) 5 x age (y) 161 Daily Multiply Basal Metabolic Rate by Activity Factor: Caloric Sedentary = 12 1.2 (little or no exercise, desk job) Needs Lightly active = 1.375 (light exercise/ sports 1 3 days/week) Moderately active = 1.55 (moderate exercise/ sports 6 7 days/week) Very active = 1.725 (hard exercise every day, or exercising 2 x/day) Extra active = 1.9 (hard exercise 2 or more times per day, or training for marathon, or triathlon, etc.) 2. Obesity Guidelines 2013: Women: 1200 1500 kcal/day Men: 1500 1800 kcal/day Bray, G. & Bouchard, C. Handbook of Obesity, Fourth Edition: Surgical Procedures in the Treatment of Obesity and its Comorbidities 7
START BY recommending a diet that your patient is most likely to adhere to for weight loss Keep in mind: A collaborative effort Consider: Previous success and failures with a diet plan Current life circumstances: opportunities & barriers Co-morbidities Educate the patient: Obesity is a disease Weight management is a journey: Trial & Error Importance of keeping a food journal Ask patient to be transparent about their food choices, hunger and challenges of adhering to the diet plan. A Judgment Free Zone Monitor weight loss progress at every visit. Keep an open mind to the possibility of changing the diet if there is poor response. Always CHECK THE FOOD JOURNAL before determining the need to change the diet plan. Objectives THING 2 Obesity Treatment Modalities THING 4 Physical Activity in Weight Management THING 5 Behavioral Modification in Weight Management 8
Short Term Changes in Body Weight 0-2 -4-6 -8-10 -12 0 Months 6 Months Control Diet Exercise Diet + Exercise Wing et al. 1998 Effect of Exercise on 24-Month Weight Loss Maintenance in Overweight Women Jakicic et al. Arch Intern Med. 2008 Physical Activity & Weight Management Physical Activity to prevent weight gain: 150-250 min/wk. (energy equivalent to 1200-200 kcal/wk.) Physical Activity for weight loss: <150 min/wk.: minimal weight loss >150 min/wk.: modest weight loss 2-3 kg >225-420 min/wk.: weight loss of 5-7.5 kg Physical Activity to prevent weight regain: 200-300 min/wk. More is better ACSM Position Stand. Med Sci Sports Exerc. 2009 Feb;41(2):459 71 9
Objectives THING 2 Obesity Treatment Modalities THING 4 Physical Activity in Weight Management THING 5 Behavioral Modification in Weight Management Low-Carbohydrate vs. Low-Fat Diet 63 Participants with Obesity Low- Carbohydrate 20 g/day carbohydrate Increased over time Low-Fat 1200-1500 kcal 25% fat -7% -3.2% 154 Participants with Obesity Low-Carbohydrat e Behavior modification intensity has a significant impact on total amount of weight loss. 6 months 12 months -4.4% -2.5% Low-Fat 11 % 11 % 12 months 24 months 7% 7% Foster GD N Engl J Med. 2003 What is Behavior Therapy? A set of principles and techniques used to help patients ADOPT new habits. Helps patients REPLACE maladaptive behaviors with new eating and activity habits. Helps patients develop a set of SKILLS to regulate their weight The goal: to improve eating, activity, and thinking habits that contribute to a patient s excess weight. 10
Goal Setting Setting appropriate goals is critical for self regulation and behavior change. People engaged in behavior change efforts often set goals that are not helpful or that sabotage their efforts. What are the characteristics of effective goals? Specific Detailed Measurable Objective Achievable Clear Outcome Realistic Likely to be successful Time frame Proximal Goal Setting Identify the goal Cut back on juice Identify the process by which the goal will be achieved Place the measuring cup on the kitchen counter to remind you to measure your juice every morning Advocate for small rather than large changes Cut back on juice from 16 oz. to 8 oz. per day Thank You 11
Intensive Behavioral Therapy (IBT) for Obesity In Primary Care Setting Coverage: Screening for Obesity, Dietary assessment, and Intensive Behavioral Counseling Frequency: Maximum of 22 IBT Sessions One face to face visit every week for 1 st month One face to face visit every other week for month 2 6 One face to face visit every month for month 7 12, If patient looses at least 3kg (6.6 lbs.) Coding: HCPCS Code G0447 (Face to face behavioral counseling for Obesity, 15 minutes) HCPCS Code G0473 (Group counseling for obesity) ICN 907800 August 2012 Medicare Learning Network Self Monitoring i.e. recording one s Strongly behavior associated with weight loss success. Food record is a critical tool for identify eating pattern that t can be modified to reduce calorie intake. Self Monitoring: Dietary Intake Physical Activity Weight Mood Long term weight management is challenging regardless of the weight loss modality. Patient s desire to limit food and energy intake is counteracted by adaptive biological responses to weight loss: Fall in energy expenditure (metabolism) out of proportion to reduction in body mass. Changes in hormones leading to increase appetite. 12