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New Realities on Obesity & Weight Management
Christine Kessler ANP. CNS, BC-ADM, CDTC, FAANP [email protected]
Disclosures
Novo Nordisk – Consultant, Speaker (obesity)
Astra Zeneca – Consultant on T2DM
Medtronic - Consultant on insulin pumps
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Objectives
At the conclusion of this talk, the attendee
will be able to: 1. List at least 5 major epidemiologic factors
influencing the rise of obesity in this country
2. Describe various interconnections between fat, gut &
brain in relation to appetite, calorie utilization and mood
3. Relate the physiologic impact of various weight loss
intervention & prevention strategies as well as way to
reduce weight regain
One simple suggestion….
Call obesity…..
Fast Facts on Obesity (aka “Adiposity”)
• Obesity is a chronic disease, NOT a character flaw – Thus, chronic treatment is necessary
• The cause of obesity is multifactorial – Yep---it is your hormones! – Treatment should be multifaceted
• Obesity is associated with many co-morbidities and soaring medical costs – Intervention can help reduce these
• Obesity continues to rise in this country – Prevention and intervention is imperative
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More Ponderings on Obesity
• You CAN lose wait (keeping it off is hard but…)
• There is HOPE for your patients--and us
• Consider obesity as the common denominator in the waiting room…..
We know the physiologic cause for weight regain.
Obesity Among U.S. Adults • The prevalence of obesity began its meteoric rise in late 1970s
• Currently, no state has an obesity rate < 20%.
• 19 states have adult obesity rates between 30% and <35%. – 1 in 6 children now with obesity
• Only 5 states and the District of Columbia had a prevalence of obesity between 20% and <25%.
• Arkansas, West Virginia and Mississippi (that order) have highest obesity prevalence of 35% or greater.
• Obesity affects 1 in 6 children
• Greater prevalence in Blacks and Latinos—twice as much in women!!
• For obesity rates per state check out this interactive site: http://stateofobesity.org/rates
http:/www.cdc.gov/obesity/data/prevalence-maps.html (Accessed 2/14/2016)
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The Obesity Epidemic
“If this trend continues, almost every single American will be obese by 2040”
- John Foreyt, Director of Behavioral Medicine at Baylor.
We haven’t gotten the obesity epidemic under control.
WHY?
FOOD INTAKE
ENERGY OUTPUT
The Old Obesity Paradigm
Old SHAME Notion: You simply eat too much and move too little
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Recalling fat facts
Obesity is a Complex Multi-factorial Chronic Disease
Obesogenic environment Psychobiologic input Highly palatable, calorie dense food (fast or processed food) Food marketing Reduced physical activity Endocrine disrupting chemicals (EDC) Weight-inducing drugs Less sleep
Food-induced pleasure Stress Smoking cessation Psychology Societal-cultural impact
The Appetite & Satiety Centers Hypothalamus
Genetics Gut Fat
Stanley S et al. Physiol Rev. 2005;85:1131‒1158. 2. Dietrich MO & Horvath TL. Nat Rev Drug Discov. 2012;11:675‒691.
Genetic Impact on Obesity Risk
• Approx. 50 genetic loci associated with BMI, waist-hip ratio, percentage body fat & morbid obesity.
• But only explains a fraction of the inter-individual variation in BMI (low predictive value!) – Extreme rise in prevalence indicates strong environmental
influences (modify genes?)
• Some genetic alterations impact hunger and satiety (and cravings)
• Physical activity attenuates the BMI-increasing effect of some of the genes.
Frayling TM, Ong K. Piecing together the FTO jigsaw. Genome Biol. 2011. 12(2):104 Day FR, Loos RJ. Developments in obesity genetics in the era of genome-wide association studies. J Nutrigenet Nutrigenomics. 2011. 4(4):222-38.
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Most common “Obesity Genes”
• FTO gene most commonly cited obesity gene (regulates ghrelin, an appetite hormone, impacting eating behavior)
• Variant of melanocortin receptor gene (MC4R )
Frayling TM, Ong K. Piecing together the FTO jigsaw. Genome Biol. 2011. 12(2):104
Biologic Pathways for Appetite Regulation & Weight Control
GLP-1 / PYY/ CCK INSULIN LEPTIN
Suppresses appetite
Stimulates appetite
Courtesy: Scott Urquhart PA-C, DFAAPA
Adapted by C. Kessler
Hypothalamus and Appetite
Hypothalamus –neuropeptides- appetite Impact on hypothalamus by insulin, fat & gut incretins
Orexigenic neuropeptides
AgRP NPY
Insulin [inhibited by leptin and insulin]
Anorexigenic neuropeptides
CART POMC
[stimulated by leptin and
insulin]
Eat more
Reduced metabolism
Eat less
Increase metabolism
Suzuki K et al. Exp Diabetes Res. 2012;2012:824305. Created by c. kessler
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Satiety = reward Food addictions &
Carb craving?
Dopamine receptors (D1)
& opioid receptors
activates reward system
https://commons.wikimedia.org/w/index.php?curid=213970
Binge Eating Disorder (BED)
-Once you start—can’t stop
-37% of those with obesity
-Women and men nearly equal
-Unlike bulemia—no corrective
actions
www.mybingeeatingdisorder.com
•i •1
•
■ •
Sumithran P et al. NEJM 2011; 365(17):1597-1604.
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Dementia
The Problem With Fat
• Hypertrophy (or hyperplasia) of fat cells
• Visceral fat releases adipokines that are: – pro-inflammatory (CRP, IL-1, IL-6, TNFa, etc)
– Pro-thrombotic
– pro-growth (more fat!)
• Results is endothelial dysfunction, chronic inflammation
• Associated with numerous co-morbidities
http://www.jisponline.com/searchresult.asp?search=&author=Sunitha+Jagannathachary&journal=Y&but_searc
h=Search&entries=10&pg=1&s=0 (accessed 2/21/2016
Types of FAT (Adipose Tissue AT)
WAT – white
BAT -brown
SAT –SC
VAT- visceral
MAT - muscle
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Most abundant in babies—loss it as we age
Generates non-shivering heat (via TGs)
Same precursors as skeletal muscle
Can mess up PET scans
Counters pro-obesity white fat?
“Turned” on by lowered ambient temp (<64 degrees F)
Less in Asians?
Possible Rx for obesity?
More points on Brown Fat
Irisin: The “Exercise” Hormone
http://www.nature.com/scitable/blog/student-
voices/the_messenger_goddess_of_exercise; accessed 7/2/2014
Skeletal
muslce White
fat Brown fat
EXERCISE Irisin
Weight loss
Improved glucose tolerance
Increased heat generation
Created by c.kessler
How Does Food Make us Fat? • Genetics (nutrigenetics)
• Change in our food*
– Quality & quantity
• GI responses to various nutrients
– Altered microbiome & incretins*
• Neuropeptides—hunger/satiety/mood*
• Brain responses to nutrients*
* Where we can intervene
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So What Can We Do About Obesity?
What works and what doesn’t?
BTW--The quicker you can loose a pound the better the
compliance
Points about Obesity Management
– PCPs must engage in weight management as a pathway to better health for their patients.
– Screen with BMI at every visit. But BMI is only a screening tool.
– Waist circumference is a risk factor. Use the cut points >35 inches for women & >40 inches for men
– Overweight and obese patients should be screened for CVD risk factors and comorbidities.
Jensen MD, Ryan DH et al. Circulation. 2013. http://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437739.71477.ee.citation
CMS Will Reimburse…
• For patients with obesity (BMI >30) who are competent and alert
• For 14 visits in first 6 months:
– One face-to-face visit every week for the first month
– One face-to-face visit every other week for months 2–6
• If 3 kg loss is achieved in 6 months:
– One face-to-face visit every month for months 7–12
• The challenge:
– Must be in primary care setting
– Must be delivered by PC physician or practitioner
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• Intensive behavioral intervention should be consistent with the 5-A Framework highlighted by the U.S. Preventive Services Task Force (USPSTF) • Assess
• Advise
• Agree
• Assist
• Arrange
CMS would like IBT for obesity to be the
following…
What do you need to know before developing a weight loss plan?
• Degree of interest in weight loss…satisfied with weight?
• How much weight loss is desired? Realistic?
• What are the health goals—abilities?
• Has there been dieting in the past?
• What has worked (or not) in the past?
• What has triggered the initial weight gain?.
• Dietary preferences and cultural influences.
Variety of Obesity Management Guidelines
• 2015 Pharmacological Management of Obesity: An Endocrine Society Clinical Practice Guideline.
• 2014 VA/DoD Clinical Practice Guideline for Screening and Management of Overweight and Obesity
• 2013 AHA/ACC/TOS Guidelines for the Management of Overweight and Obesity in Adults
• 2013 American Society of Bariatric Physicians Obesity Algorithm
• 2013 Institute for Clinical Systems Improvement Health Care Guideline on Prevention and Management of Obesity for Adults
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Reality-based Interventions • Behavioral: Changing the thinking paradigm
– Life coaching
– Psych/addiction counseling
• Food/dietary intervention (decrease calorie)
• Exercise/activity (start small)
• Pharmacologic interventions
– Prescription
– OTC
• Surgical bariatric interventions
Ryan D, Kessler C. Exploring Trends in the Multimodal Management of Overweight/Obesity. Clinician
Reviews (CME). 2014; november supplement
Assessment data?
• Height, weight, BMI
• Waist circumference
• Existing comorbidities
• Blood pressure
• Lipid profile (esp. TGs)
• Glycemic status (HbA1c, FPG)
• How is this patient feeling and functioning?
Waist-to-Height Ratio Plus BMI Identifies Obese at Highest CVD Risk. Medscape. Jun 02, 2014.
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Fast Dietary Tips
• Can lose weight quicker with caloric restriction
• Important to understand why they eat and what they eat before prescribing an intensive dietary regimen
– Stress eaters? Binge eaters? Carb addicts?
• Consider cultural and genetic (taste) influences
• Food diaries are of enormous help
• Most diets work—just need to stick with it
• Use diet apps where applicable
• Cut sweetened beverages first!
Dietary Interventions • Two general diet categories
– Balanced, low-calorie (reduced portion) diets • Jenny Craig, Nutrisystems, meal replacements, Weight Watchers ,etc
– Diets with different macronutrient (fat, carbohydrate, protein) compositions.
• The above diets are useful for short-term wgt-loss; NOT for sustained weight loss
• Dietary counseling with a nutritionist is optimal, but not often available—
• BTW: Low-carb vs Low-fat: – Both lose weight – Low-carb—less hunger and cravings – Low-fat—lose more fat stores
Tobias d. et al. Effect of low-fat diet interventions versus other diet interventions on long-term weight change in adults: a systematic review and meta-analysis. The Lancet Diabetes & Endocrinology, 2015 DOI: 10.1016/S2213-8587(15)00367-8 (accessed 2/12/2016) Foster GD et al., Rosenbaum DL, Brill C, et al. Weight and metabolic outcomes after 2 years on a low-carbohydrate versus low-fat diet: a randomized trial. Ann Intern Med. 2010 Aug 3. 153(3):147-57
A word about Very Low Calorie Diets (VLCD)
– Best used in an established , comprehensive
wgt-loss program
– Intake of 800 kcal/day or less (can lose 3.3-5.5 lb/wk)
• Benefit of less than 800 kcal/day not found
– Associated with profound initial (and short-term) wgt-loss
– Weight regain can occur
– Avoid in pregnancy
Very low calorie diets. Drug Ther Bull. 2012 May. 50(5):54-7
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A good dietary intervention
Kessler’s Tips For Weight Loss • Avoid mindless eating—and don’t skip meals
• Portion control—bring portioned food to table to eat – Portion control plates help: MyPlate, toddler plates
etc
• Fiber, fiber, fiber
• Drink before or after meal…reduce during
• Slooowww it down, approx 24 chews
• Avoid eating out so much
• Eat protein & fat first…delay carbs—eat around the plate (curious incretin effects)
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Weight Loss Exercise Pointers • Best to use the word, “activity” vs “exercise
• Exercise alone usually not enough for weight loss
• Focus on on-going health benefits of exercise (not simply a weight-loss tool)
• Determine pain levels, mobility concerns, and motivation
• Screen patient for CV and respiratory adequacy (adjust intensity)
• Diet-alone weight loss reduces muscle mass –have as much if add exercise by 27%;
Villareal DT, et al. Weight loss, exercise, or both and physical function in obese older adults. N Engl J Med. 2011 Mar 31. 364(13):1218-29
Exercise Pointers
• Again: exercise WITH dietary modification is more effective for weight loss (overall health benefits)
• What to suggest: – Endurance training (adjust intensity as needed)
• Aerobic exercise 3-5 days per week
• Continuous or intermittent aerobic activity for 20-60 minutes (OKAY—5 to 10min bouts throughout the day)
– Resistance training (isometric, weights)
– Flexibility training (stretching, modified yoga)
– Go low and slow and give rewards
– Just move!
http://emedicine.medscape.com/article/324583-overview#a8 (accessed 2/14/2016)
Tracking Exercise (& Diet)
• Many apps for smart phones—selected free apps for one or both: – MyFitnessPal
– 7 Minute Workout
– Calorie Counter PRO MyNetDiary
– Diet Assistance
– Amwell (links to providers)
– Diet Assistance (offers diet suggestions too)
– Fooducate
– Endomondo (exercise tracker—highly rated)
– Jawbone UP
– Instant Heart Rate
– Weight Watchers Mobile
– Fitbit (but you have to by the device)
http://www.healthline.com/health/diet-and-weight-loss/top-iphone-android-apps (accessed 2/13/2016)
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So Exercise (for Irisin) !!! or
Just MOVE
150 minutes a week
Okay, now what? • Move to medications
– if BT fails
– Pt has BMI of 27 with 1 co-morbidity
– Pt has BMI > 30
Ryan D, Kessler C. Exploring Trends in the Multimodal Management of Overweight/Obesity. Clinician
Reviews (CME). 2014; november supplement
How Drugs Help
• Stimulants
• Nutrient blockers
• Satiety (appetite suppressant) agents (the new frontier)
–Peripheral
–Central
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What drugs do we have currently?
• phentermine (Adipex-P, Suprenza)
• orlistat (Xenical)
• lorcaserin (Belviq)
• phentermine-topiramate (Qsymia)
• naltrexone-bupropion (Contrave)
• liraglutide (Saxenda)
• FYI---if drug not showing 4-5% weight loss in 12 to 16 weeks—stop it
Ryan D, Kessler C. Exploring Trends in the Multimodal Management of Overweight/Obesity. Clinician
Reviews (CME). 2014; November supplement
Incretin impact Appetite Regulation & Weight Control
GLP-1 / PYY/ CCK INSULIN LEPTIN
Suppresses appetite
Stimulates appetite
Courtesy: Scott Urquhart PA-C, DFAAP
Adapted by C. Kessler
GLP-1 sensitizers/agonists
Gastric bypass Gastric Sleeve
Satiety = reward Food addictions &
Carb craving?
Dopamine receptors (D1)
& opioid receptors
activates reward system
https://commons.wikimedia.org/w/index.php?curid=213970
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Lorcaserin (Belvic) • Action: exact mechanism unknown, activates 5-HT2C
receptors, promoting satiety (selective serotonin agonist) • Dosing: 10 mg bid • DEA Schedule: IV • Pregnancy: X • Monitoring: sx of depression/suicide, glucose at baseline,
CBC • Side effects: HA, fatigue, Serotonin syndrome or
neuroleptic malignant syndrome; valvular heart disease (possible);, depression, suicidal ideation; hypoglycemia with glucose-lowering medications; priapism
• Contraindications:, CKD 3B, CHF, valvular heart disease, pregnancy, depression, DM, bradycardia
• Ave wt. loss 5%
©2013-2014 American Society of Bariatric Physicians and Epocrates
Additional information is available on resource slides at the end
phentermine-topiramate (Qsymia)
• Action: phentermine – short acting sympathomimetic; topiramate – long acting neurostabilizer
• Dosing: 3.75/23 starting dose, titrate to 7.5mg/46mg, 11.25mg/69mg, top dose 15mg/92mg
• DEA Schedule: IV • Pregnancy: X • Monitoring: depression, CV evaluation at baseline,
hypokalemia • Side effects: paresthesias, insomnia, HA , dry mouth, acute
myopia/glaucoma; cognitive impairment; metabolic acidosis; elevated creatinine; hypoglycemia
• Ave wt. loss ranged from 6.7 - to 8.9 % • REMS program
©2013-2014 American Society of Bariatric Physicians and Epocrates
naltrexone-bupropion (Contrave) • Action: an opioid antagonist, and bupropion,
an antidepressant – might help with cravings • Dosing: 8/90mg, 1 tab po qam titrating to max
of 2 tabs po q am and 1 tab po q pm • Pregnancy: X • Monitoring: BP, HR, depression/suicide • Adv. effects: nausea, headache, insomnia • Contraindications: seizure disorders, eating
disorders, chronic opioid use • Ave wt. loss ranged from 5 -10% • Black Box Warning: Suicidal Thoughts and
Behaviors; and Neuropsychiatric Reactions
Medication Insert and Epocrates
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Liraglutide (Saxenda)
• Class: Obesity • Action: glucagon-like peptide-1 receptor agonist • Dosing: Initiate at 0.6 mg per day SQ for one week. In
weekly intervals, increase the dose until a dose of 3 mg is reached.
• Pregnancy: X • Monitoring: monitor for medullary thyroid carcinoma,
pancreatitis, cholelithiasis or cholecystitis, hypoglycemia (especially if patient on sulfonylurea), HR, renal impairment, and depression or suicidal thoughts.
• Adv. effects: nausea, hypoglycemia, diarrhea, fatigue, dizziness, abdominal pain, and increased lipase.
• Ave wt. loss ranged from 5 -10% • REMS program • Avoid if gastroparesis, thyroid ca risk, pancreatitis, severe IBS
Drug Pointers
• Phentermine 3 months only—but…
• Newer prescription drugs approved for chronic use
• Not recommended in pregnancy
• Consider the contraindications and co-morbidities when deciding on a drug to start with
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Sensory Factors:
•Taste
•Smell
•Texture
•Sight
Effects of: •Variety of foods
•Sensory-specific satiety
•Palatability
•Food components
•Ease of access
Brain Mechanisms: •satiety signals to
produce appetite &
reward value
Satiety/Hunger Signals: •Fat cell hormones (leptin)
•Gut hormones (incretins)
•Gastric distention
Cognitive Factors: •Beliefs about the food
•Advertising and culture
Eating
Other Influencers of Food Intake
Adapted from: Rolls ET. Obes Rev. 2007;8(suppl1):67-72.
Family & Social
Influences
Selected OTC Pharmacologic Aids • Satiety agents
– Hoodia: (No)
– Grapeseed oil (no)
– Raspberry ketones (NO!
– Pine nuts (yes) like GLP-1
– 5-HTP (ok) feel full
– Fennel tea (yes) evening help
– Garcinia cambogia (yes...no...maybe) 60% HCA
Drugs Don’t Work So Now What…?
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Common Bariatric Surgery Procedures
No Incretin
effects
Adjustable Gastric Banding Sleeve Gastrectomy Gastric Bypass
(Roux n Y)
GLP-1 ↑
PYY ↑ Ghrelin ↓
Weight Loss +++ Weight Loss + Weight Loss ++++
A variety of new surgical approaches as well as space occupying devices
Questions?