Weight Management Clinic Program Orientation

 Amy Rothberg, MD, PhD, Andrew Kraftson, MD, Charles Burant, MD, PhD  Christine Fowler, RD, MS and Gina Neshewat, MPH

This is the UM Weight Management Clinic Schedule of Visits. 2

The visits are more frequent during the first 3 months of the program. Thereafter, the visits to the physician are quarterly (every 12 weeks) and monthly to the dietician.

3

Research Program Component

• There are research programs offered by UM • These programs are separate from the clinical program, but can be helpful to add important information to help you manage your health • Participation is voluntary 4

The Scope of Obesity

Obesity Rates: United States

Where is obesity most common in the US?

Obesity Rates: United States

Obesity is especially common in the South. It has 10 out of the 11 states with the highest obesity rates, including Mississippi along with Alabama and Tennessee, which tied for second place.

Obesity Rates: United States

Michigan is the only state in the top 11 that is not in the South.

The prevalence of overweight and obesity changed little between the early 1960s and 1980. Findings from the 1988-1994 and 1999-2004 National Health and Nutrition Examination Surveys, showed substantial increases in overweight among adults.

The upward trend in weight since 1980 reflects primarily an increase in the percentage of adults 20-74 years of age who are obese. In 2003-2004, 67% of adults in that age group were overweight (includes obese); 34% of adults 20-74 years of age were obese (age-adjusted).

Since 1960-1962, the percentage of adults who were overweight but not obese has remained steady at 32%-34% (age-adjusted).

Criteria for overweight: BMI value of 27.8 or greater for men and 27.3 or greater for women. Criteria for obese is BMI greater than 30.

Energy Homeostasis

Body Weight Increase Energy Intake Ingestion of: Protein Fat Carbohydrate Decrease Energy Expenditure Physical Activity Diet-Induced Thermogenesis Basal Metabolic Rate

Body weight is determined by the balance between the calories we consume and the calories we expend (aka: “burn”).

Primary Metabolic Disturbance

Overnutrition, Type 2 Diabetes and CVD

Intermediate Vascular Disease Risk Factor Insulin Resistance Hypertension Intravascular Pathology Clinical Event Dyslipidemia Over-Nutrition Hyperglycemia Hyperinsulinemia Inflammation Atherosclerosis

• • • • •

Coronary arteries Carotid arteries Cerebral arteries Aorta Peripheral arteries Hypercoagulability

CVD

Impaired Fibrinolysis Endothelial Dysfunction

What are the consequences of too much weight? Overnutrition leads to a number of

Growth in Caloric and CHO Intake

There has been a substantial growth in our intake with greater intake of carbohydrates. Between 1974 and 2000, men have increased their caloric consumption by 7% and women by as much as 22%.

MMWR. 2005;53:80-82.

Growth in Caloric and CHO Intake

Caloric Intake (kcal/day)

Years

Men Women

1971 – 1974 1999 – 2000 Change

2450 2618 (+) 168 1542 1877 (+) 335 There has been a substantial growth in our intake with greater intake of carbohydrates. Between 1974 and 2000, men have increased their caloric consumption by 7% and women by as much as 22%.

MMWR. 2005;53:80-82.

These charts illustrate the parallel trend between growth in Vehicle Miles of Travel and the

Growth in Vehicle Miles Traveled

with behavioral change caused by the built environment are, unfortunately, more extreme; they

Growth in “Overweight”

VMT 20000 18000 16000 14000 12000 10000 8000 1969 1977 1983 1990 1995 2001 Growth Trend for Annual Household Vehicle Miles of Travel (VMT) (50% Overall Growth) BMI >30 kg/m2 70 65 60 55 50 45 40 35 30 1969 1977 1983 1990 1995 2001 Growth Trend for Percentage of Americans “Overweight” (40% Overall Growth)

Source: National Household Travel Survey.

But Other Things Are Changing as Well…

Keith SW, et al.

Int J Obes.

2006;30:1585-1594.

Other factors in our environment have contributed to this rise in overweight/obesity. The light of the 1970s.

But Other Things Are Changing as Well…

Keith SW, et al.

Int J Obes.

2006;30:1585-1594.

In parallel with that climb was the average rise in our home temperature setting (yellow), the

But Other Things Are Changing as Well…

(time at jobs) (green). Keith SW, et al.

Int J Obes.

2006;30:1585-1594.

Short term regulation of feeding

Food intake is a complex process. The amount and type of food ingested is determined by: • • • Genes Environmental setting Experience

Short term regulation of feeding

Short term regulation of feeding is governed by: • • • • Taste perception Meal size, caloric density Environmental setting Signals emanating from GI system and energy stores are received and integrated by diverse neuronal circuits in the hypothalamus and brainstem.

“Caloric density” as a concept

Think of foods in terms of calories per pound 490 Fresh corn 2450 1000 Tortillas Tortilla chips

“Caloric density” as a concept

Think of foods in terms of calories per pound 1000 2450 The volume of food consumed and its energy density affect intake through differential stimulation of gastric and post gastric compartments. The stomach is sensitive to cues related to volume and that manipulation of gastric distension affects food intake. 490

“Caloric density” as a concept

Think of foods in terms of calories per pound 490 1000 2450 The lower in caloric density, the greater the volume and the fewer the number of calories. Fresh corn has far fewer calories than a similar serving size of tortillas (made from corn) and Tostito’s® (a product of corn).

Gut Peptides - Satiety Signals

Our sense of hunger and fullness are determined by complex interactions between a number of peptides (proteins) and hormones (such as leptin, PYY, CCK, ghrelin, and insulin) that relay signals from our gut to our brain . We are studying these signals and processes. Mountjoy, Kyiv 2003

As you may know, our eating patterns are affected by more than the caloric and nutritional value of food. The emotional and pleasurable aspects of feeding affect food intake. It will come as no surprise, then, that the brain (particularly parts of the brain called the hypothalamus and the brainstem) has a central role in coordinating the many nutrient, hormonal, and behavioral signals to regulate food intake, metabolism, and ultimately body weight.

These central circuits and neuro-peptides have a pivotal role in triggering hunger and food search, initiating satiety and generating responses to peripheral adiposity (fat) signals.

There are additional brain/central nervous system regions that participate in regulating appetitive behavior by mediating the motivational, cognitive, and emotional components of food intake. Gaining a better understanding of the brain’s role in weight is one of our goals.

Randomized, Clinical Trials to Prevent Diabetes by Lifestyle Modification The UM Weight Management Clinic program has modeled itself after large epidemiological trials of lifestyle intervention. We have summarized data from some of these studies:

Randomized, Clinical Trials to Prevent Diabetes by Lifestyle Modification

Study*

DaQing Study (1997) Finnish Diabetes Prevention Study (2001) Diabetes Prevention Program (2002)

# Patients

530 522 2161

Baseline BMI (kg/m 2 )

26 31 34

Duration of intervention (years)

6 4 3

Lifestyle goals Weight loss at 1 year (kg) Risk Reduction (95% CI)

Weight loss + maintenance of a health diet + exercise 5% weight loss on low fat, high-fiber diet + 30 min exercise per day 7% weight loss + 150 min exercise per week NR 4 7 42% 58% 58%

Nature Clinical Practice 2008; 4:382-393

*All study populations had impaired glucose tolerance

Randomized, Clinical Trials to Prevent Diabetes by Lifestyle Modification

Study* # Patients Baseline BMI (kg/m 2 ) Duration of intervention (years) Lifestyle goals Weight loss at 1 year (kg) Risk Reduction (95% CI)

These two trials split a large group of individuals at high risk for diabetes into two groups: 1. usual care (1997) 530 26 2. intensive lifestyle intervention = eating a low calorie diet of 1,500 calories per day and exercising 150 minutes per week. 6 Weight loss + maintenance of a health exercise NR 42% Finnish Diabetes Prevention Study (2001) 522 31 4 5% weight loss on low fat, high-fiber diet + 30 min exercise per day 4 58% Diabetes Prevention Program (2002) 2161 34 3 7% weight loss + 150 min exercise per week 7 58%

*All study populations had impaired glucose tolerance

Nature Clinical Practice 2008; 4:382-393

Randomized, Clinical Trials to Prevent Diabetes by Lifestyle Modification

Study* # Patients Baseline BMI (kg/m 2 ) Duration of intervention (years) Lifestyle goals Weight loss at 1 year (kg) Risk Reduction (95% CI)

Those that achieved a 5-7% weight loss from baseline weight reduced their risk of progression to diabetes by 58%. This is better than any study that used medications as the primary treatment. 530 26 6 of a health diet + NR 42% exercise Finnish Diabetes Prevention Study (2001) Diabetes Prevention Program (2002) 522 2161 31 34 4 3 5% weight loss on low fat, high-fiber diet + 30 min exercise per day 7% weight loss + 150 min exercise per week 4 7 58% 58%

*All study populations had impaired glucose tolerance

Nature Clinical Practice 2008; 4:382-393

Randomized, Clinical Trials to Prevent Diabetes by Lifestyle Modification

Study* # Patients Baseline BMI (kg/m 2 ) Duration of intervention (years) Lifestyle goals Weight loss at 1 year (kg) Risk Reduction (95% CI)

Lifestyle change continues to be reasonable, rational and feasible approach to weight management and risk reduction of chronic diseases.

(1997) 530 26 6 Weight loss + maintenance of a health diet + NR 42% exercise Finnish Diabetes Prevention Study (2001) Diabetes Prevention Program (2002) 522 2161 31 34 4 3 5% weight loss on low fat, high-fiber diet + 30 min exercise per day 7% weight loss + 150 min exercise per week 4 7 58% 58%

*All study populations had impaired glucose tolerance

Nature Clinical Practice 2008; 4:382-393

Weight Management Clinic

→Goal: Identify strategies that will result in long-term weight management for obese individuals, using the latest research and clinical strategies. →We are dedicated to educating, motivating, and empowering individuals to make healthy lifestyle choices!

Comprehensive Adult Weight Management Clinic Personalized Weight Management Program • • • • • Multidisciplinary approach to weight loss and weight maintenance Intensive induction phase Advice regarding activity/exercise/conditioning Individual one-on-one sessions Focus on prevention of weight regain – Behavioral – Nutritional – Pharmacological

Stepped Obesity Treatment Regimen

• • • • What happens at the first visit to the physician? Your health and weight history is reviewed.

A physical exam is performed.

Your current medication list is examined.

The research is reviewed and your consent to participate is obtained (if you are interested).

Change medication regimen • Eliminate ‘weight positive’ medications • Substitute weight neutral or weight negative medications

Initiate caloric restriction • Initial very-low-calorie diet (VLCD )(800 cals/day) or low calorie-diet (LCD) (1000-1200 cals/day): • Meal substitution/replacement • Dietary counseling: One-on-one with RD • Initial emphasis on calories and caloric density, not fuel The meal replacement diet will not start until you meet formally with the program’s dietician.

Exercise prescription • Individual preference/Get moving • Bouts of activity v. all at once

Research Component (“phenotyping”)

• • • • • Integral to the understanding of obesity Examination of gene-gene interactions and gene environmental interactions- a systems biology approach Identifying the factors that predict success for weight loss and maintenance of weight loss – key to changing our treatment paradigms Examining potential novel therapeutic targets Participation is

VOLUNTARY

Procedures

Mixed Meal Tolerance Testing : 3 hour dynamic test examining hormone excursions (insulin, glucose, and fat hormones) in response to nutrients.

• Metabolomics is the analysis of metabolites performed to generate a specific fingerprint of a current metabolic state at any given time point. It allows characterization of the dynamic changes of the metabolic pattern of person in response to nutrients. • Genetic Analysis identifying obesity and obesity-related genes

Oral Glucose Tolerance Test: 2 hour test to diagnose diabetes*. Resting and exercise tests to determine your resting metabolic rate and exercise capacity/fit ness Questionnaires regarding overall health and impact of weight on emotional and physical well being *1/3 rd of the participants in the program have undiagnosed Type 2 diabetes mellitus.

DXA -measures body composition including fat free mass, fat mass and bone density

Bod Pod -alternative method to measure fat free mass and fat mass

Resting Energy Expenditure measures the fuel the body burns at rest (the number of calories burned at rest)

V02 max treadmill.

Exercise capacity is highly predictive of disease risk, longevity and may predict the ability to lose weight. Graded exercise test done on a

SenseWear Triaxial Accelerometer

Movement/motion sensor Worn for 7 days at intervals: Baseline (prior to diet) 5% weight loss from baseline 10% weight loss from baseline 15% weight loss from baseline 6 months, 12 months and 24 months

Re-Phenotyping:

You will have the option to repeat the testing after the initial 15% weight loss goal is achieved.

Sweet Taste Study II

• Procedure – Questionnaire – Tasting sugar water at various concentrations – Medical record review and linkage to your research data – Compensation: $16 gift card for each research clinic visit – Location: Clinics at Domino’s Farms • Contact – Keiko Asao, Phone 734-232-8270, E-mail [email protected]

• Please find the information in your package. You can turn in the completed response sheet now or mail it.

Weight Maintenance by Sex 125 129 125 120 Male Female 115 111 105 95 114 110 107 104 100 97 106 105 104 104 106 106 103 103 103 103 103 94 92 90 91 93 93 90 92 92 93 90 85 Baseline Week 2 Week 4 Week 8 Week 12 Week 18 Week 24 Week 28 Week 32 Week 36 Week 40 Week 44 Week 48 Week 52 Week 56 Week 60 Number of Weeks in Program

The University of Michigan’s Management Clinic (WMC) Program: Overview Weight

•

Program Design

Highly structured to make weight loss easier and more successful.

• Shakes and soups replace meals and snacks. • Support provided through individual appointments with physician and dietitians. • Daily physical activity aids in weight loss.

12 weeks…

• •

Very Low Calorie Diet ( VLCD ) Phase

Initial 12 weeks: 800 calories per day Foods Allowed:  HMR 800 Shakes  HMR 70+ Shakes if Lactose Intolerant  HMR Chicken Soup

Meal Replacement Prescription

• Personalized for you • Average prescription: 4 - 5 HMR Shakes + 1 HMR Chicken Soup • Concept: “More is Better” but “Stay in the Box”

• • • •

Why use a Very-Low Calorie Diet (VLCD)?

Short term only: initial 12 weeks Medically supervised, guaranteed weight loss Divorce yourself from unhealthy food habits by making meals “decision free” Learn nutrition information, lifestyle and behavioral skills

Meal Replacements Enhance Initial and Long-term Weight Loss 0 Phase 1* CF Phase 2 MR-1 5 10 MR-2 15 0 2 Time (mo) 4 6 8 10 12 18 24 30 36 45 *1200–1500 kcal/d diet prescription.

CF=conventional foods.

MR-2=replacements for 2 meals, 2 snacks daily.

MR-1=replacements for 1 meal, 1 snack daily.

51 Ditschuneit et al. Am J Clin Nutr 1999;69:198.

Fletchner-Mors et al. Obes Res 2000;8:399 .

Why VLCD with HMR ?

• HMR is a national healthcare company specializing in weight loss and weight management.

• HMR is a leading provider of meal replacement system in clinics and hospitals throughout the country.

Weight Maintenance Phase

• Following 15% weight loss, food is reintroduced.

• An individualized diet plan is designed and implemented.

• Maintenance calorie amount is calculated and personalized.

Can people with diabetes use HMR shakes?

• Yes. HMR is frequently recommended by doctors for their patients with diabetes because of the foods' nutritional formulation and low calories.

• Your medication(s) will be monitored by our physicians, and dosage may change throughout the program.

Can I use HMR shakes if I have food allergies?

• HMR products are generally well tolerated by most people. Some of our products, however, contain common allergens such as dairy, eggs, wheat, soy and peanuts . • Please let us know if you have any allergies prior to beginning the shake regime, or if any GI discomfort occurs.

I’m lactose intolerant. Is there lactose in HMR?

• Most of the HMR Shakes contain lactose. However, people who are lactose-intolerant can use HMR shakes by taking a Lactaid® tablet .

• -or HMR 70 Plus shakes are lactose-free + or

Shake Preparation

Blender Instructions: 1. Pour 6 oz. cold water into a blender. Begin mixing on lowest speed.

2. While blender is on, add 1 packet HMR shake mix and blend for 10 seconds.

3. Add 2 ice cubes, 1 at a time (replace blender cover in between) 4. Continue to blend on low speed for 1 – 1 ½ mins. until ice is crushed & shake is smooth

Meal Replacement Prescription:

• • • • • • Add non-caloric flavorings for variety: Spices or seasonings Extracts Diet soda Sugar free pudding or Jell-O mix Sugar free Crystal light Sugar free coffee syrup

Costs of HMR:

You are responsible for purchasing the product (~$2-3 per shake or ~$12/day.)

Ordering HMR:

• • Some easy ways to find HMR are: Saint Joseph Mercy Health System: Ellen Thompson Women’s Health Center 5320 Elliot Drive, Ypsilanti, MI 48197 Phone: 734-712-5540 Fax: 734-712-2722 HMR program website: http://www.hmrprogram.com/ and follow instructions from “order online” link

• • •

Physical Activity

Daily exercise is tracked Active lifestyle is encouraged Further recommendations will be based on the individual

Questions or concerns?

• • • • Please contact: Christine Fowler, RD: [email protected]

Gina Neshewat, MPH:

[email protected]

Andrew Kraftson, MD: [email protected]

Amy Rothberg, MD, PhD: [email protected]

When sending an email, please “cc” everyone so the whole team is able to assist. Thank you! Need to set up your first nutrition visit or reschedule? Please call: 734-647-5871

Thank you!