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Slide 2 Weighing the Evidence on Obesity Erika Pierce, PA-C, MMS Slide 3 Learning Objectives Upon completion of this activity, participants will be able to: Describe the definition, causes, prevalence and risks associated with obesity; Discuss counseling on lifestyle modification for diet, exercise and behavioral changes as first line approaches; Assess the relative risks and benefits of drug therapy including phentermine, orlistat, phentermine/topiramte and lorcaserin; Analyze clinical trials (Look Ahead and POWER-UP) on multi- component primary care-based interventions; Consider the relative risks and benefits of weight loss surgery for selected patients. Slide 4 Disclosures Speaker Off-label use Slide 5 Where Are We Going? The Map Obesity as a Disease Epidemic Medical Risk Having the Conversation Lifestyle Modifications Medications for Weight Loss Phentermine Orlistat Phentermine/topiramate Lorcaserin Weight Loss Surgery Slide 6 Obesity as a Disease adults in U.S. are obese (78 million) adults in U.S. are overweight Current trends has 45% obese by 2030 Annual estimated cost: $150 billion 40% of this cost borne by Medicare & Medicaid Slide 7 Maine Data Adults report 5% less leisure time activity 2000-2010 2011: K-3 rd grade students: 18.4% obese 17% overweight M > F 2011: High school students: 15.9% overweight 12.9% obese M > F Slide 8 Weight Status According to Body Mass Index, Adults Ages 18 years and Older, by Year, Maine, 2000-2010 YearHealthy WeightOverweightObese nN%LCLUCLnN%LCLUCLnN%LCLUCL 20001,804382,09542.840.245.31,607329,97036.934.539.4911181,31720.318.322.3 2001898362,37240.237.942.5888359,86540.037.742.2467178,46019.818.021.6 2002920370,46140.137.842.4838357,62238.736.541.0499195,03921.119.223.0 2003912384,77240.838.543.1848366,89738.936.641.2464191,19120.318.422.1 20041,281373,24838.036.040.01,293374,98738.236.240.2789233,41423.822.025.6 20051,430381,71739.337.441.31,368365,24537.635.739.5895224,15023.121.524.7 20061,456388,66539.337.441.31,391367,60837.235.339.1917231,60823.421.925.0 20072,335361,22336.034.437.52,482385,29738.436.839.91,670257,67425.724.327.0 20082,333373,58437.335.738.82,396365,69636.535.038.01,711262,92226.224.927.6 20092,629347,79134.933.536.42,924381,12938.336.839.82,120266,30726.825.528.1 20102,623355,60935.634.137.12,902366,91936.735.338.12,212276,98727.726.429.0 Source: Behavioral Risk Factor Surveillance System Healthy weight is a BMI between 18.5 and 25, Overweight is a BMI between 25.1 and 30, Obese is a BMI over 30; based on self-reported height and weight. n = unweighted number of adults (numerator); N = weighted number of adults (weighted numerator) LCL = Lower 95% confidence limit of the weighted percentage; UCL = Upper 95% confidence limit of the weighted percentage. All percentages are weighted to be more representative of the population of Maine and to adjust NA = Not available Slide 9 Maine Data: Healthy Weight YearHealthy Weight nN%LCLUCL 20001,804382,09542.840.245.3 2001898362,37240.237.942.5 2002920370,46140.137.842.4 2003912384,77240.838.543.1 20041,281373,24838.036.040.0 20051,430381,71739.337.441.3 20061,456388,66539.337.441.3 20072,335361,22336.034.437.5 20082,333373,58437.335.738.8 20092,629347,79134.933.536.4 20102,623355,60935.634.137.1 Slide 10 Maine Data: Overweight YearOverweight nN%LCLUCL 20001,607329,97036.934.539.4 2001888359,86540.037.742.2 2002838357,62238.736.541.0 2003848366,89738.936.641.2 20041,293374,98738.236.240.2 20051,368365,24537.635.739.5 20061,391367,60837.235.339.1 20072,482385,29738.436.839.9 20082,396365,69636.535.038.0 20092,924381,12938.336.839.8 20102,902366,91936.735.338.1 Slide 11 Maine Data: Obese YearObese nN%LCLUCL 2000911181,31720.318.322.3 2001467178,46019.818.021.6 2002499195,03921.119.223.0 2003464191,19120.318.422.1 2004789233,41423.822.025.6 2005895224,15023.121.524.7 2006917231,60823.421.925.0 20071,670257,67425.724.327.0 20081,711262,92226.224.927.6 20092,120266,30726.825.528.1 20102,212276,98727.726.429.0 Slide 12 Causes of Obesity We live in a food swamp. Social patterns of physical activity Food consumption portion sizes Added sugars, fats, calorie dense foods escalated Consuming more calories Sedentary lifestyles Slide 13 Screening for Obesity Use BMI Waist circumference > 35 inches for women > 40 inches for men Slide 14 Risk for type 2 diabetes, hypertension, or CVD relative to normal weight and waist circumference BMI (kg/m 2 )Men 102 cm ( 40 in) Women 88 cm ( 35 in) Men > 102 cm (> 40 in) Women > 88 cm (> 35 in) Underweight< 18.5-- Normal*18.5-24.9-- Overweight25.0-29.9IncreasedHigh Class I Obesity30.0-34.9HighVery High Class II Obesity35.0-39.9Very High Class III Obesity 40.0Extremely High * Increased waist circumference can also be a marker for increased risk even in persons of normal weight. Slide 15 Diagnosis of overweight or obese must prompt stratification of cardiovascular risk Slide 16 Trends in Obesity Slide 17 Obesity by State Slide 18 2. Medical Risk Slide 19 Overweight & Obesity Associated with Negative Health Outcomes HTN Diabetes Hyperlipidemic Cardiovascular Diseases Sleep Apnea Cancer Pro thrombotic States Musculoskeletal Disease Slide 20 Obesity raises the risk of several major diseases Slide 21 BMI & Mortality Slide 22 3. Having the Conversation Slide 23 Goals 1. Prevent further weight gain 2. Reduce weight 3. Maintain a lower weight over time Slide 24 First Step Screen every patient BMI Waist circumference Determine patients level of motivation Slide 25 Determine patients level of motivation Stage of ReadinessKey Questions Not Ready Raise Awareness Elicit Change Talk* Advise and Encourage Would you be interested in knowing more about reaching a healthy weight? How can I help? What might need to be different for you to consider a change in the future? Unsure Evaluate Ambivalence Elicit Change Talk* Build Readiness Where does that leave you now? What do you see as your next steps? What are you thinking or feeling at this point? How does being overweight affect you? Ready Strengthen Commitment Elicit Change Talk* Facilitate Action Planning Why is this important to you now? What are your ideas for making this work? What is hard about managing your weight? What might get in the way? How might you work around the barriers? How might you reward yourself along the way? * Elicit Change Talk: Encourage patients to present their own arguments for changing behavior. Slide 26 4. Lifestyle Modification Slide 27 Cornerstone of Management Counseling Lifestyle modification Diet Exercise Behavioral Changes Slide 28 Do they Work? DPP Trial Slide 29 Slide 30 Counseling in Primary Care Works: The POWER-UP Study Slide 31 Diet Focus on total calorie reduction Actual diet type does not matter Read more: p. 13-16 Evidence Document Slide 32 Exercise Important in maintaining lower weight Modestly effective at achieving weight loss General health-promoting effects Slide 33 Rx for a Healthier Weight Slide 34 5. Weight Loss Medications Slide 35 Weight Loss Medications Can result in weight loss Use as adjunct to calorie reduced diet Increase physical activity Selected patients BMI > 30 BMI > 27 with comorbid condition Slide 36 FDA Approved Medications Phentermine Sibutramine (Meridia) Orlistat (Xenical) (Alli) Lorcaserin (Belviq) Phentermine IR/Topiramate ER (Qsymia) Slide 37 CAUTION! Long-term safety No Demonstrated long- term benefits in reducing diabetes, HTN, or cardiovascular risk. ! Slide 38 Prior Medication Troubles Removed from the Market Nearly all previous prescription diet medications were removed from the market because of dangerous side effects after one or more years of routine use: amphetamines (cardiovascular toxicity, addiction fenfluramine (Pondimin: pulmonary hypertension dexfenfluramine (Redux: pulmonary hypertension and cardiac valvulopathy) sibutramine (Meridia: cardiovascular toxicity) Slide 39 Common Weight Loss Drugs DrugEfficacyCommon potential side effects Safety orlistat (Xenical, Alli) Weight loss: 2 kg greater than placebo after 4 years of therapy Clinical outcomes: not documented Flatus, greasy/loose stools or diarrhea, fecal incontinence, and abdominal cramps Worsened by increased dietary fat intake Contraindicated during pregnancy. Malabsorption of fat-soluble vitamins; concurrent use of multivitamin recommended Patients on warfarin may need to decrease their warfarin dose. lorcaserin (Belviq) Weight loss: 3.6 kg greater than placebo after 1 year of therapy Clinical outcomes: not documented Nausea Headache Dizziness Contraindicated during pregnancy. Avoid use with other serotonergic agents (including most antidepressants, and some muscle relaxants). Concern over increased rate of cardiac valve disease and a possible increase in the risk of breast tumors. phentermine IR/ topiramate ER (Qsymia) Weight loss: 7.5-8.8 kg greater than placebo after 2 years of therapy Clinical outcomes: not documented Anticholinergic symptoms (such as dry mouth and constipation) Irritability, anxiety, insomnia, and depression Increased heart rate Contraindicated in hyperthyroidism, glaucoma, patients taking MAO inhibitors, pregnancy. Prescribe with a Risk Management Program for women of childbearing age, including monthly pregnancy test. Adjust dose in renal and hepatic impairment. Abuse potential. Discontinuation requires tapering to avoid seizures. Slide 40 Weight Loss at 1 Year for locaserin and phentermine/topiramate Slide 41 Average Retail Costs for Monthly Supplies of Equivalent Doses of Agents* Slide 42 Looking Ahead 5,145 U.S. Adults Overweight or Obese with Diabetes Stopped early Intensive lifestyle modification aim 3.9% greater weight loss 5.3% greater partial or complete remission of Diabetes Enroll higher risk patients Slide 43 No over-the-counter weight loss supplement is effective for weight loss. ! Some products contain illegal stimulants or prescription medications. Ask patients about their use of these supplements and counsel them about their risks. Slide 44 6. Weight Loss Surgery Slide 45 Useful in Severe Obesity Produces substantial weight loss Reduces cardiovascular events & mortality Can improve or eliminate diabetes BUT potential for post-operative complications Slide 46 Common Weight Loss Surgeries Slide 47 Swedish Obese Subjects (SOS) Over 2,000 obese patients (BMI 34 Men, 38 Women) Over 20 years Slide 48 SOS: Weight Loss after Surgery Slide 49 SOS: Reduction in Mortality and Cardiovascular Events Slide 50 Bariatric Surgery: Patient Selection BMI 40 or BMI 35 with weight-related comorbidity Prior attempts at lifestyle modification were unsuccessful No contraindications such as binge-eating disorder, substance abuse, depression, psychosis, or anxiety disorder Acceptable surgery risk Slide 51 Bariatric Surgery: Risks and Benefits BenefitsUncertaintiesRisks Weight loss: rapid and sustained Reduction in HbA1c: elimination of diabetes in some patients Reduction in incidence of diabetes Improvement in other cardiovascular risk factors; hypertension, lipid profile Improved quality of life Reduction in CV events Reduction in all-cause mortality Long-term clinical outcomes in less obese diabetic patients with BMI < 35 Prevalence of weight regain over time in routine use Post-surgical complications including increased morbidity and mortality in the short term Nutritional and electrolyte deficiencies GI symptoms Slide 52 Tips for Management Calculate BMI for all patients. If BMI 25, discuss the health risks of being overweight or obese. Assess patients readiness to modify lifestyle and define success in terms of realistic goals. Slide 53 Tips for Management There is solid evidence that lifestyle interventions can reduce weight: Food intake is the key to weight loss. Exercise can help with weight management and improves health. Counseling in primary care actually works. Slide 54 Tips for Management Prescription drugs have some efficacy data but safety concerns limit their use. Weight loss surgery is selected patients can lead to long-term weight loss and decreased risk of diabetes and mortality. Slide 55 Questions?