Screening and Management of Obesity

Ray Plodkowski, MD Chief Endocrinology and Metabolism VA Sierra Nevada Health Care System, Reno and Medical Director: University of Nevada School of Medicine Division of Endocrinology, Nutrition, and Metabolism Weight Loss Clinic (775)848-4206

Body Mass Index (BMI) The clinical standard for weight-for-height estimations

Body wt (in kg) / [Ht (in meters)] 2 or Body Wt (in lb) / [Ht (in in] 2 X 703.1

WHAT IS YOUR BODY MASS INDEX?

Chart from CDC: For Adults, aged 20 years and older

BMI Clinical Guidelines

*

Classification Underweight Normal Weight Overweight BMI (kg/m < 18.5

2 19 - 24.9

25 - 29.9

) Class I Obesity (Mild) 30 -34.9

Class II Obesity (Moderate) 35 - 39.9

Class III Obesity (Extreme)



40

_______________________________________

*NHLBI /NIDDK, NIH. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. The Evidence Report. NIH Publication No. 98-4083, Sept. 1998

Why Body Mass Index (BMI)?

Wt (kg)/Ht (m

2

)

• • • •

New definitions for overweight and obesity Related to health risk (morbidity & mortality) Simple, inexpensive, noninvasive Nomograms available

Limitations of BMI

Obesity Trends* Among U.S. Adults BRFSS, 1985

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

Obesity Trends* Among U.S. Adults BRFSS, 1986

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

Obesity Trends* Among U.S. Adults BRFSS, 1987

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

Obesity Trends* Among U.S. Adults BRFSS, 1988

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

Obesity Trends* Among U.S. Adults BRFSS, 1989

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

Obesity Trends* Among U.S. Adults BRFSS, 1990

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

Obesity Trends* Among U.S. Adults BRFSS, 1992

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

Obesity Trends* Among U.S. Adults BRFSS, 1993

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

Obesity Trends* Among U.S. Adults BRFSS, 1994

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

Obesity Trends* Among U.S. Adults BRFSS, 1995

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

Obesity Trends* Among U.S. Adults BRFSS, 1996

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

Obesity Trends* Among U.S. Adults BRFSS, 1997

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%

Obesity Trends* Among U.S. Adults BRFSS, 1998

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%

Obesity Trends* Among U.S. Adults BRFSS, 1999

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%

Obesity Trends* Among U.S. Adults BRFSS, 2000

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%

Obesity Trends* Among U.S. Adults BRFSS, 2001

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

Obesity Trends* Among U.S. Adults BRFSS, 2002 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

Obesity Trends* Among U.S. Adults BRFSS, 2003

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

Obesity Trends* Among U.S. Adults BRFSS, 2004

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

Obesity Trends* Among U.S. Adults BRFSS, 2005

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Obesity Trends* Among U.S. Adults BRFSS, 2006

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Obesity Trends* Among U.S. Adults BRFSS, 2007

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Obesity Trends* Among U.S. Adults BRFSS, 2008

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Age-adjusted percentage of adults aged ≥20 years who are obese, 2007 MMWR 58:1259-1263, 2009

Age-adjusted percentage of adults aged ≥20 years with diagnosed diabetes, 2007 MMWR 58:1259-1263, 2009

Why is the Epidemic Occurring?

• Energy Balance: Intake vs. Output

80 60

%

40 20 Prevalence of Overweight and Obesity Among US Adults

BMI=kg/m2

47 Overweight or obese (BMI  25.0) 32 56 33 23 Overweight (BMI 25.0-29.9) 64 34 Obese (BMI  30.0)

Increased 100% in 20 years

31 15 0 NHANES II 1976-1980 (n=11,207) NHANES III 1988-1994 (n=14,468) NHANES † 1999-2000 (n=3601) US Bureau of the Census estimates using the age groups 20-34, 35-44, 45-54, 55-64, and 65-74 years † Flegal KM et al.

JAMA

. 2002;288:1723-1727.

Environment

• • Abundance of palatable, calorie-dense food Number of calories expended in physical activity is insufficient to offset consumption – Mechanization limits physical activity – Sedentary daily routines consisting of: • • • sitting at work sitting in traffic sitting in front of a television or a computer monitor for most of their waking hours

20 Years Ago

BAGEL

Today 140 calories 3-inch diameter How many calories are in this bagel?

20 Years Ago

BAGEL

Today 140 calories 3-inch diameter 350 calories 6-inch diameter Calorie Difference: 210 calories

Maintaining a Healthy Weight is a Balancing Act Calories In = Calories Out

How long will you have to rake leaves in order to burn the extra 210 calories?*

*Based on 130-pound person

Calories In = Calories Out

If you rake the leaves for

50 minutes

you will burn the extra

210 calories.* *Based on 130-pound person

SPAGHETTI AND MEATBALLS

20 Years Ago Today 500 calories 1 cup spaghetti with sauce and 3 small meatballs How many calories do you think are in today's portion of spaghetti and meatballs?

SPAGHETTI AND MEATBALLS

20 Years Ago Today 500 calories 1 cup spaghetti with sauce and 3 small meatballs 1,025 calories 2 cups of pasta with sauce and 3 large meatballs Calorie Difference: 525 calories

Maintaining a Healthy Weight is a Balancing Act Calories In = Calories Out

How long will you have to houseclean in order to burn the extra 525 calories?*

*Based on 130-pound person

Calories In = Calories Out

If you

houseclean for 2 hours and 35 minutes

, you will burn approximately

525 calories.* *Based on 130-pound person

Intake vs Output

• • Walking = 5 kcal/minute 100 kcalories = a mile (walking at 3 MPH) • Burger King Whopper = 640 calories(kcal)

To walk off a Whopper 640/5 = 128 minutes (6 miles)

• Subway 6” Turkey Sub ( no cheese, no mayo ) = 289 kcal

To walk off a Turkey Sub 289/5 = 57 minutes (3 miles)

Calorie Dense Food

Breakfast: Blackberry Green Tea Frappuccino® 12 Grain Bran Muffin Lunch: Double Quarter-Pounder with Cheese Chocolate Shake 32 fl. oz. Super Size Fries Dinner: ¼ white meat chicken (breast and thigh) Mashed Potatoes (8oz) Coca-Cola

Total:

560 (kcal) 400 (Kcal) 760 (kcal) 1150 (kcal) 610 (kcal) 330 (kcal) 210 (kcal) 140 (kcal)

3600 (kcal)

Intake vs Output

Extreme High Activity: Mountain Climbing 10.0 kcal/minute To Burn off 3600(kcal) = 6 hours of Mountain climbing

Intake vs Output

Extreme High Activity: Mountain Climbing 10.0 kcal/minute To Burn off “Super-sized” meal: 3600(kcal) = 6 hours of mountain climbing (or

36 miles

of walking!!)

Health Risks of Obesity

OBESITY is a Gateway Disease

As BMI Increases: – LDL increases – HDL decreases – Blood Pressure Increases – Cardiovascular events increase – Dysmetabolic Syndrome – Type 2 Diabetes – Cancers (breast, colon, gallbladder, uterine) NHANES III and Hubert HB et al. Circulation 1983;67:968-977.

50 40 30 20 10 0

NHANES III Prevalence of Hypertension* According to BMI

14.9

BMI <25 BMI 25-<27 BMI 27-<30 BMI >30 41.9

32.7

27 27.7

22.1

15.2

37.8

Men Women

*Defined as mean systolic blood pressure  140 mm Hg, mean diastolic  90 mm Hg, or currently taking antihypertensive medication.

Brown C et al. Body Mass Index and the Prevalence of Hypertension and Dyslipidemia. Obes Res. 2000; 8:605 619.

26 -Year Incidence of Coronary Heart Disease in Men <50 years 50+ years 600 500 400 300 200 100 0 177 333 255 366 350 440 <25 25-<30 BMI Levels 30+

Adapted from Hubert HB et al. Metropolitan Relative Weight of 110 is a BMI of approximately 25.

Circulation

1983;67:968-977.

26 -Year Incidence of Coronary Heart Disease in Women <50 years 50+ years 500 400 300 200 100 0 76 223 119 268 179 292 <25 25-<30 BMI Levels 30+

Adapted from Hubert HB et al.

Circulation

1983;67:968-977. Metropolitan Relative Weight of 110 is a BMI of approximately 25.

Obesity and Diabetes Risk

100 80 60 40 20 0 <20 20-25 25-30 30-35 BMI Levels 35-40 >40

Knowler WC et al.

Am J Epidemiol

1981;113:144-156.

Cholescystectomy

20 25 30 35 40 BMI Relationship between BMI and crude percentage of women reporting medical problems, surgical procedures, symptoms, and health care utilization.

Brown WJ et al.

Int J Obes

1998;22:520-528.

Hysterectomy

20 25 BMI 30 35 40

Brown WJ et al.

Int J Obes

1998;22:520-528.

Back Pain

20 25 BMI 30 35 40

Brown WJ et al.

Int J Obes

1998;22:520-528.

Constant Tiredness

20 25 BMI 30

Brown WJ et al.

Int J Obes

1998;22:520-528.

35 40

Other Risks

• • • • •

Congestive Heart Failure Stroke Osteoarthritis Sleep Apnea Cancer (Colon, Breast, Endometrial,

Gallbladder)

Primary Care Obesity Evaluation

• • • • • •

Appropriate Office Environment for Obese Patients

Waiting room chairs without arms or a larger bench seat with arms Step stools next to examination tables Large gowns and blood pressure cuffs Scale that can weigh extremely obese patients, located in a private area Appropriate obesity educational materials, handouts, and treatment protocols Empathetic, respectful, and supportive office staff Slide Source: Obesityonline.org

Medical History

Elicit risk factors and symptoms of the manifestations of obesity: • • • • • • Dysmetabolic syndrome Type 2 diabetes Cardiovascular disease (and angina) Sleep apnea Gallstones Potential Pregnancy

Family and Social Histories

• • • Identify support networks and cultural factors – May influence the patient’s ability to participate in a weight management program Other household members with obesity – May impact the ability for the patient to modify his or her lifestyle and diet. Dietary changes – Easier to implement if the other members of the family also adopt healthier nutrition habits.

Assessing Weight Loss Readiness

• • • Motivation: Stress level: Psychiatric issues: • Time availability:

Patient seeks weight reduction Free of major life crises Free of severe depression, substance abuse, bulimia nervosa Patient can devote 15-30 min/d to weight control for next 26 weeks

YES

Initiate weight loss therapy

NO

Patient Ready?

Prevent weight gain and explore barriers to weight reduction Slide Source: Obesityonline.org

Medical Causes of Obesity

• • • Hypothyroidism Cushing's syndrome Depression ( Beck’s depression inventory) Beck AT.

The Beck Depression Inventory.

San Antonio, TX: The Psychological Corporation; 1987.

Beck AT, Steer RA, Garbin MG. Psychometric properties of the Beck Inventory: Twenty-five years of evaluation.

Clin Psychol Rev.

1988;8:77-100.

Psychiatric History

• • • • • Comfort Eating (in response to negative emotions) • • • Boredom Sadness and Depression Anger Anorexia Bulimia Binge eating Addictions: Smoking

Selected Medications That Can Cause Weight Gain

 Diabetes medications – Insulin – Sulfonylureas – Thiazolidinediones  Highly active antiretroviral therapy  Tamoxifen  Steroid hormones – Glucocorticoids – Progestational steroids

• •

Selected Medications That Can Cause Weight Gain

Psychotropic medications – Tricyclic antidepressants – Monoamine oxidase inhibitors – Specific SSRIs – Atypical antipsychotics – Lithium – Specific anticonvulsants  -adrenergic receptor blockers clozapine (Clozaril) 4.4 kg gain* olanzapine (Zyprexa) 4.2 kg* risperidone (Resperdal) 2.1 kg* Paxil, Prozac *Allison DB et al. Am J Psychiatry 1999 Nov;156(11):1686-96

Exercise History

• • • • Exercise habits Physical activity patterns Limitations Preferences

Physical Exam and Measurements

– Blood Pressure – Waist circumference (Non-Stretchable Tape) – Height (wall-mounted stadiometer) – Weight (Balance Beam Scale) – Calculate BMI: weight (kg)/height (m 2 ) – Body Composition (by bio-impedence) – Attention to gallbladder – “The Usual”

Laboratory Assessment

• • • • • • TSH (optional Free T4) CBC Chem 20 Fasting Lipid Panel Pregnancy test Optional – 24hr urine cortisol if Cushing’s suspected

Obesity Treatment

Lifestyle therapy

(diet, physical activity, and behavioral therapy)

is the cornerstone of obesity treatment

NIH Guide to Selecting

Obesity Treatment

BMI Category Treatment 25-26.9

27-29.9

30-34.9

35-39.9

>40 Lifestyle Therapy* Pharmaco therapy Surgery With Comorbid.

With Comorbid.

With Comorbid.

YES YES YES YES With Comorbid.

YES YES YES * Lifestyle therapy: diet, physical activity, and behavioral therapy.

•Consider pharmacotherapy only if a patient has not lost 1 pound per week after 6 months of combined lifestyle therapy.

Goals of Weight Management/Treatment

•

Prevent further weight gain (minimum goal).

•

Reduce body weight.

•

Maintain a lower body weight over long term.

Target Weight: Realistic Goals

•

Substitute “healthier weight” for ideal or landmark weight.

•

Accept slow, incremental progress to goal.

— Short-term goal: 5 to 10 percent loss, 1 to 2 lb per week.

— Interim goal: Maintenance.

— Long-term goal: Additional weight loss, if desired, and long-term weight maintenance.

Increase Physical Activity

• Most important in preventing weight regain • Health benefits independent of weight loss • Start slowly and increase gradually — — — — Can be single session or intermittent Start with walking 30 minutes 3 days/week Increase to 45 minutes 5 or more days/week Encourage increased “lifestyle” activities

Behavior Therapy

Implementation of strategies, based on learning principles, that provide tools for overcoming barriers to compliance with diet or physical activity changes: • Self-monitoring • Stress management • Stimulus control • Problem-solving • Contingency management • Cognitive restructuring • Social support

Stress Management

Defuse situations that lead to overeating:

•

Coping strategies

•

Meditation

•

Relaxation techniques

Stimulus Control

Behavior change techniques:

•

Learn to shop for healthy foods.

•

Keep high-calorie foods out of the home.

•

Limit the times and places of eating.

Cognitive Restructuring

Rational thoughts designed to replace negative thoughts:

Instead of. . .



“I blew my diet this morning by eating that doughnut.”

Use. . .



“Well, I ate the doughnut, but I can still eat in a healthy manner the rest of the day.”

Determining Daily Calorie Goals for a Weight Loss Diet

Why Is Energy Balance Important?

• Current practice of weight control utilizes the following premises for healthy adults: • • Calories in > energy out = weight gain.

Calories in = energy out = weight maintenance.

• Calories in < energy out = weight loss.

(3500 kcal deficit is needed for 1 pound weight loss per week)

What is REE?

• • • Resting energy expenditure (REE)=“burn rate” The number of calories the body uses each day for maintenance of homeostasis.

Can measure directly or use formulas – Females: 10 Wt (kg) + 6.25 Ht (cm) - 5 age (y) –161 – Males: 10 Wt (kg) +6.25 Ht (cm) - 5 age (y) +5

*Mifflin-St. Jeor ST et al. Am J Clin Nutr 1990;51-241-7

Case Study

• • • • • Patient: Female Age 50 years Height = 60” Weight= 180 lbs. BMI=35

Intake:

3 or 7 Day Food Record shows 2100 kcal/day average intake.

+2100 kcal/d Output:

1.

REE :

- 1400 kcal/d

2.

Physical Activity Factor (Intentional Physical Activity or exercise/wk) 140 min walking (20 min X 7 days) X 5 kcal/min = 700 kcal/week 700 kcal/7 days=

- 100 kcal/day average

3.

TEE = REE (1400) X 1.3 = 1800 + Intentional PA (100) = ~1900 kcal/d.

-1900 kcal/d

__________________________________________________________________________________ Total

+200 kcal/d

Recommendation for WEIGHT MAINTENANCE (kcal/d):

To maintain current weight this patient must decrease intake by -200 kcal/day from the current intake of 2100 kcal/d yielding a 1900 kcal/day diet.

Recommendation for WEIGHT REDUCTION (kcal/d):

To lose 1 pound per week, a 500 kcal per day deficit is needed In this patient: (-200 kcal/day deficit to maintain weight) + (-500 kcal/day deficit to lose 1 pound per week) ___________________________________________ = -700 kcal/day total deficit needed to lose 1 lb/week

Decrease 2100 KCAL/D intake by -700 kcal/d. = 1400 kcal/d dietary intake

Questions?

Division of Endocrinology, Nutrition, and Metabolism Weight Loss Clinic (775)848-4206