Transcript Diet and Exercise Counseling in Primary Care

Addressing Obesity and
Exercise in Primary Care
GSP 4th Year Elective 2010
Definitions of Overweight and
Obesity
BMI = weight in kg/height in meters2
(weight in lb/height in inches2)*703
Overweight- BMI 25-29.9
Obesity- BMI > 30
Extreme obesity- BMI > 40
Waist Circumference
Increases risk when increased with BMI
25-35
– Men >102 cm (40 in)
– Women > 88 cm (35 in)
Prevalence of Overweight and
Obesity
1990
– Overweight- 55.9%
– Obesity- 22.9%
2000
– Overweight-64.5%
– Obesity- 30.5%
Associated Risk Factors
Diabetes
Hypertension
High cholesterol
Asthma
Arthritis
Obstructive sleep apnea
Poor health status
Health Burden
Second leading cause of premature
mortality after smoking
300-400,000 deaths per year
Benefits of weight loss
Little evidence that interventions reduce
morbidity or mortality
Weight loss does improve glucose control,
lipid levels and blood pressure
Goals of weight loss and
management
Prevent further weight gain
Reduce body weight
Maintain lower body weight long-term
Weight loss guidelines
Reasonable goal- 10% decrease in weight
over 6 months
Requires a decrease of 300-500 calories
per day up to BMI of 35
Requires a decrease of 500-1000 calories
per day for BMI > 35
Weight loss will usually plateau after 6
months
Maintenance is difficult
Sedentary Lifestyle
Independent risk factor for cardiovascular
and all cause mortality
Hypertension, insulin resistance, elevated
glucose and dyslipidemia all improve with
exercise
Physical Activity
30 minutes on most days recommended
For most individuals, will not produce
significant weight loss alone
Walking briskly for 30-45 minutes will
consume 100-200 calories
Target heart rate: (220-age)*0.6 to 0.9
USPSTF
Recommends clinicians screen all adult
patients for obesity and offer intensive
counseling and behavioral interventions to
promote weight loss for obese adults
Found insufficient evidence to determine
whether counseling patients to promote
physical activity leads to increased
physical activity in adults
Medications
May consider if diet and exercise not
successful
Should have BMI> 30 or >27 with risk
factors
Consider stopping if < 2 kg weight loss
after 4 weeks
Long-term effectiveness uncertain and
many patients discontinue
Sibutramine
Blocks reuptake of norepinephrine and
serotonin
Side effects include increased blood
pressure, heart rate, headache, insomnia,
dry mouth
Should not be used for patients with
uncontrolled hypertension or significant
cardiovascular disease
Dose- 10-15 mg/day
Effectiveness- average weight loss 5%
Orlistat
Lipase inhibitor
Side effects include loose and more
frequent stools
Dose- 120 mg tid
Effectiveness- average weight loss 5%
Combined therapy no more effective,
weight loss limited to 10%
Weight loss surgery
Very successful in some patients
Gastric bypass used at UVA
Indications- unsuccessful medical weight
loss with BMI > 40 or BMI > 35 with
complications
Five A’s
Ask- BMI as a vital sign
Advise- provide brief feedback
Assess- motivation and stage of change
Assist- help patients who wish to lose
weight develop a plan
Arrange follow-up
Dietary counseling for other
conditions
Elevated cholesterol
Cardiovascular disease
Hypertension
Diabetes
Mediterranean Diet
Only diet shown to decrease cardiovascular
morbidity and mortality
RR 0.3-0.5 vs regular or “heart-healthy diet”
(30% fat, 10% saturated fat, 300 g cholesterol/d)
250-300 g fruit, 125-150 g vegetables, 25-50 g
nuts/day
400-500 g whole grains, legumes, rice/d
+/- fish several times a week
3-4 servings of monounsaturated fat/d
References
CLINICAL GUIDELINES ON THE IDENTIFICATION,
EVALUATION, AND TREATMENT OF OVERWEIGHT
AND OBESITY IN ADULTS
– http://www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns.pdf
US PREVENTIVE SERVICES TASK FORCE
– http://www.ahcpr.gov/clinic/uspstfix.htm
MEDITERRANEAN DIET
– Circulation 1999;99:779