Clinical Diagnosis and Effective Management Strategies

What Do We Know About Obesity

• Prevalence continues to rise at alarming rate among adults, children and adolescents. Most common medical problem seen in primary care office.

• Is a major cause of preventable death.

• Causes over 40 medical problems affecting 9 organ systems.

• Morbidity and mortality rise with increasing BMI.

How Are We Doing as a Medical Profession?

Obesity is under-diagnosed and under-treated

• Summary of studies

– We are failing to adequately identify the overweight and mildly obese patient – missed opportunities for early prevention and treatment

– We are doing a better job identifying the moderately and severely obese patient presenting with co-morbid conditions, particularly type 2 diabetes, hypertension and hyperlipidemia

Identification & Counseling

Percent of Patients Receiving PCP Advice by Obesity Classification

Simkin-Silverman LR et al. Prev Med 2005;40:71-82.

Told Overweight: %2 (test for linear trend) – 16.5, p – 0.001

Gave Weight Loss Advise: %2 (test for linear trend) – 5.5, p – 0.019

Screening for Obesity in Adults

The U.S. Preventive Services Task Force (USPSTF) recommends that clinicians screen all

adult patients for obesity and offer intensive counseling and behavioral interventions to

promote sustained weight loss for obese adults.

Grade B Recommendation

Ann Intern Med 2003;139:930-932.

Identification and Treatment of Obesity

• Clinical Inertia

• “Failure of the health care providers to initiate or intensify therapy when indicated”

• Obesity – failure to identify the condition– Lack of education, training, and practice organization

aimed at evaluating & treating obesity as a chronic illness

– Practice barriers

– Attitudes of futility, lack of perceived benefit and unrewarding

Adapted from Phillips et al. Ann Intern Med 2001.

Barriers to Obesity Care

“Counseling is unlikely to be effective without understanding the barriers that patients, providers, and systems face and applying targeted strategies

to overcome those behaviors.”

Stange et al. Am J Prev Med 2002.

The PatientKnowledgeAttitudes

ExpectationsDemandsMotivation

Clinician Deliveryof

Obesity Care

Providing Obesity Care

The PracticeEnvironment

Payment StructureType of Visit

Alternative DemandsAvailability of

Staff

Adapted from Jaen et al. J Fam Prac, 1994.

The ClinicianTime

ReimbursementTrainingInterest

Type of Visit

Developing a Chronic Care Model of Care (A Systems Approach)

• Put Prevention Into Practice– AHRQ – www.ahrq.gov

• Improving Chronic Illness Care– http://improvingchroniccare.org– Chronic care training manual– ICIC Improving your practice manual– Tools

Provision of Obesity Care

• Three factors necessary for physicians to intervene

– Adequate recognition of obesity as a medical problem

– Willingness to provide intervention

– Adequate skills or resources to do so

Kristeller & Hoerr. Prev Med 1997.

www.nhlbi.nih.gov

Obesity Treatment Guidelines

www.naaso.org

Obesity Treatment Recommendations

The Office Visit

1. Measure weight, height, waist circumference and record body mass index (BMI)

2. Categorize obesity classification and risk

3. Take a comprehensive history, physical exam, & lab tests for medical condition

4. Assess need for treatment

5. Broach the subject

6. Assess readiness for treatment

The Practical Guide, 2000.

The Evaluation Process Consists of 6 Action Steps

Body Mass Index Chart

He

igh

t

Weight (lbs)

120 130 140 150 160 170 180 190 200 210 220 230 240 250 260 270 280 290 300

5’0” 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59

5’2” 22 24 26 27 29 31 33 35 37 38 40 42 44 46 48 49 51 53 55

5’4” 21 22 24 26 28 29 31 33 34 36 38 40 41 43 45 46 48 50 52

5’6” 19 21 23 24 26 27 29 31 32 34 36 37 39 40 42 44 45 47 49

5’8” 18 20 21 23 24 26 27 29 30 32 34 35 37 38 40 41 43 44 46

5’10”

17 19 20 22 23 24 26 27 29 30 32 33 35 36 37 39 40 42 43

6’0” 16 18 19 20 22 23 24 26 27 29 30 31 33 34 35 37 38 39 41

6’2” 15 17 18 19 21 22 23 24 26 27 28 30 31 32 33 35 36 37 39

6’4” 15 16 17 18 20 21 22 23 24 26 27 28 29 30 32 33 34 35 37

BMI-Associated Disease Risk

Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults—The Evidence Report. Obes Res 1998;6(suppl 2).

Additional risks: Large waist circumference (men > 40 in; women > 35 in)Poor aerobic fitnessSpecific races and ethnic groups

Classification BMI (kg/m2) Risk

Underweight < 18.5 Increased

Normal 18.5 – 24.9 Normal

Overweight 25.0 – 29.9 Increased

Obese I 30.0 – 34.9 High

II 35.0 – 39.9 Very high

III ≥ 40 Extremely high

Rel

ativ

e R

isk

of C

VD

Mor

talit

y

1

2

3

4

5

6

7

8

Lean Normal Obese

Body Fat Category (% Weight as Fat)

< 16.7% 16.7% – 24.9% 25%

Fatness, Fitness, and Cardiovascular Disease Mortality

Lee et al. Am J Clin Nutr 1999;69:373.

Aerobically fit

Unfit

Action BMI Ranges forAsian Populations are Lower

WHO expert consultation. Lancet 2004;363:157.

High to very high risk

• Cardiovascular– Hypertension– Congestive Heart Failure– Cor Pulmonale– Varicose Veins– Pulmonary Embolism– Coronary Artery Disease

• Neurologic– Stroke– Idiopathic intracranial hypertension– Meralgia paresthetica

• Psychological– Depression– Body image disturbance– Stigmatization

• Respiratory– Dyspnea– Obstructive Sleep Apnea– Hypoventilation Syndrome– Pickwickian Syndrome– Asthma

• Endocrine– Metabolic Syndrome – Type 2 diabetes– Dyslipidemia– Polycystic ovarian syndrome (PCOS)/androgenicity – Amenorrhea/infertility menstrual disorders

Systems Review

Kushner and Roth. Endo Metab Clinics N Am 2003.

• Musculoskeletal– Hyperuricemia and gout– Immobility– Osteoarthritis (knees/hips)– Low back pain– Carpal tunnel syndrome

• Integument– Striae distensae (stretch

marks)– Stasis pigmentation of legs– Cellulitis– Acanthosis nigricans/skin

tags– Intertrigo, carbuncles

• Gastrointestinal– GERD– Non-alcoholic fatty liver disease (NAFLD)– Cholelithiasis– Hernias– Colon cancer

• Genitourinary– Urinary stress incontinence– Obesity-related glomerulopathy– Kidney stones– Hypogonadism (M)– Breast and uterine cancer– Kidney cancer– Pregnancy complications

Systems Review

The Metabolic Syndrome

Risk Factor Defining Level

Abdominal Obesity Men Women

Waist Circumference> 102 cm (> 40 in)> 88 cm (> 35 in)

Triglycerides ≥ 150 mg/dL

HDL Cholesterol Men Women

< 40 mg/dL< 50 mg/dL

Blood Pressure ≥ 130 / ≥ 85 mm Hg

Fasting Glucose ≥ 110 mg/dL

ATP III, Executive Summary, 2001.

Importance of Measuring Waist Circumference: BMI 25 – 29.9

(Overweight)

Janssen et al. Arch Intern Med 2002;162:2074-9. NHANES III.

Men (n = 3081) Women (n = 2606)

Prevalence, % NI WC High WC NI WC High WC

Hypertension 23.0 44.8 12.3 37.5

Type 2 DM 2.7 10.6 1.6 10.0

Hyper-chol 17.2 26.2 19.4 35.2

High LDL-C 19.3 27.2 13.6 26.6

Low HDL-C 35.3 49.0 10.0 15.0

Hyper-TG 21.7 36.3 10.6 21.8

Metabolic Syndrome 11.3 29.0 3.6 16.3

Importance of Measuring Waist Circumference: BMI 18.5 – 24.9

(Healthy)

Janssen et al. Arch Intern Med 2002;162:2074-9. NHANES III.

Men (n = 3081) Women (n = 2606)

Prevalence, % NI WC High WC NI WC High WC

Hypertension 15.6 61.2 11.6 42.9

Type 2 DM 1.9 10.6 1.8 7.5

Hyper-chol 11.9 21.9 11.4 32.1

High LDL-C 14.0 29.3 8.8 23.9

Low HDL-C 21.9 15.0 6.7 13.1

Hyper-TG 9.4 12.4 4.5 20.7

Metabolic Syndrome 5.7 9.7 2.9 12.8

Subcutaneous Fat

Abdominal Muscle Layer

Intra-abdominal Fat

Visceral Adiposity:The Critical Adipose Depot

Classification of Overweight and Obesity by BMI, Waist Circumference and

Associated Disease Risks

Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults—The Evidence Report. Obes Res 1998;6(suppl 2).

Disease Risk Relative to Normal Weight and Waist Circumference

BMI(kg/m2)

Obesity Class

Men (≤102 cm) ≤40 inWomen (≤88 cm) ≤35 in

Men (>102 cm) >40 inWomen (>88 cm) >35 in

Underweight < 18.5 -- --

Normal 18.5 – 24.9 -- --

Overweight 25.0 – 29.9 Increased High

Obesity 30.0 – 34.9 I High Very High

35.0 – 39.9 II Very High Very High

Extreme obesity > 40 III Extremely High Extremely High

Percentage of Men with Metabolic Triad* Classified on

Basis of Waist Girth and TG Level

Lemieux et al. Circ 2000;102:179.

84%

53%

83%

12%10%

0

20

40

60

80

100

TG < 177 TG < 177 TG > 177 TG < 177 TG > 177

% o

f m

en w

ith

met

abo

lic

tria

d

waist < 90 90 < waist < 100 waist > 100

* • Insulin• small, dense LDL• apo B

Metabolic Risk Identified by “Hypertriglyceridemic Waist”

Men MenWomen Women

Insu

lin R

esis

tanc

e (

HO

MA

)

Age 18-34 Age 55-74

waist

waist

waist

waist

TG

TG

TG

TG

Waist = 95 cm M 88 cm F

TG = 128 mg/dl

Kahn and Valdez. AJCN 2003;78:928-34.

Despres J-P et al. BMJ 2001;322:716.

Subcutaneous adipose tissue

Abdominally obese (high waist

measurement)

Reduced obesity (low waist measurement)

High LowRisk of coronary heart disease

Visceral adipose tissue

~ 5 – 10% weight loss~ 30% visceral adipose tissue loss (diet, physical activity, pharmacotherapy)

Deteriorated ImprovedLipid profile

Impaired Improved ↑ ↑ ↑ ↑

Insulin sensitivityInsulinemiaGlycemia

↑ ↓Susceptibility to

thrombosis

↑ ↓Inflammation

markers

Impaired ImprovedEndothelial function

Assessing Drug-Induced Causes for Weight Gain

• Diabetes Treatments− Insulin

− Sulfonylureas

− Thiazolidinediones

• Antihistamines (cyproheptadine)• β- and alpha-1 adrenergic receptor

blockers• Chemotherapy agents

− Tamoxifen

• Psychiatric/Neuro− Anti-psychotics− Antidepressants− Lithium− AEDs

• Steroid Hormones− Corticosteroids− Progestational steroids

• HIV Protease inhibitors

Broaching the Subject: Words to Use

• “Are you concerned about your weight?”

• “What is hard about managing your weight?”

• “How does being overweight affect you?”

• “What can’t you do now that you would like to do if you weighed less?”

• “What kind of help do you need to manage your weight?”

How important is it for you to get your weight under control?

0 1 2 3 4 5 6 7 8 9 10

Notimportant

Very important

How confident are you to that you can get your weight under control?

0 1 2 3 4 5 6 7 8 9 10

Notconfident

Very confident

Obesity Treatment Pyramid

Surgery

Pharmacotherapy

Lifestyle Modification

Diet Physical Activity

BMI 40

35

30

25

A Guide to Selecting Treatment

The Practical Guide. 2000.

BMI Category

Treatment 25 - 26.9 27 – 29.9 30 – 34.9 35 – 39.9 ≥ 40

Diet, physical activity, and behavior

With co-morbidity

+ + + +

PharmacotherapyWith

co-morbidity+ + +

SurgeryWith

co-morbidity+

“There is strong evidence that combined interventions of a low calorie diet, increased physical activity, and behavior therapy provide the most successful therapy for weight loss and weight maintenance.”*

NHLBI Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and

Obesity in Adults (1998)

*Evidence Category A

“Low calorie diets can reduce total body weight by an average of 8% over 3 to 12 months.”*

*Evidence Category A

NHLBI Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and

Obesity in Adults (1998)

U.S. Preventive Services Task Force (USPSTF) Recommendations

Fair to good evidence that high-intensity counseling—about diet, exercise, or both—together with behavioral interventions aimed at skill development, motivation, and support strategies produces modest, sustained weight loss (typically 3 to 5 kg for ≥ 1 year) in adults who are obese.

Ann Intern Med 2003;139:930-932.

• Indicated as an adjunct to diet and physical activity for patients with a BMI ≥ 30 or ≥ 27 who also have concomitant obesity-related risk factors or diseases

• Agents– Phentermine (1973): norepinephrine releasing agent

– Sibutramine (1997): serotonin norepinephrine reuptake inhibitor (SNRI)

– Orlistat (1999): gastrointestinal lipase inhibitor

Pharmacotherapy

Additive Effects of Behavior and Meal Replacement Therapy With

Pharmacotherapy for Obesity

Wadden et al. Arch Intern Med 2001;161:218.

0

5

10

15

20

0 2 4 6 8 10 12Time (months)

Wei

ght

Loss

(%

)

Medication, behavior modification and meal replacements

*

*

Medication and behavior modification

Medication alone

*P < 0.05 vs medication alone

“Evidence Statement: Appropriate weight loss drugs can augment diet, physical activity and behavior therapy in weight loss.”*

*Evidence Category B

NHLBI Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and

Obesity in Adults (1998)

“Evidence Statement: Gastrointestinal surgery can result in substantial weight loss, and therefore is an available weight loss option for well-informed and motivated patients with a BMI ≥ 40 or ≥ 35, who have comorbid conditions and acceptable operative risks.”*

*Evidence Category B

NHLBI Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and

Obesity in Adults (1998)

Update: Bariatric SurgeryCurrently Popular Procedures

LapBandTM

Vertical BandedGastroplasty

Gastric Bypass

Biliopancreatic Diversionwith Duodenal Switch

Restriction Malabsorption

Efficacy Outcomes for Weight Reduction Surgeries

RYGB = roux-en-y gastric bypass; BPD = biliopancreatic diversion

Buchwald et al. JAMA 2004;292:1724.

All Surgeries Mean Change

Absolute wt loss (kg) 39.7 kg

BMI decreased 14.2

Initial wt loss (%) 32.6%

Procedure Initial Wt Loss (%)

Gastroplasty 24.3%

RYGB 34.9%

BPD 39.0%

Efficacy for Improvement in Obesity-Related Conditions

Disease

Diabetes

Hyperlipidemia

Hypertension

Obstructive SleepApnea

Completely Resolved

76.8%

70%

61.7%

85.7%

Resolved orImproved

86%

-----

78.5%

83.6%

Buchwald et al. JAMA 2004;292:1724

Conclusion

• Obesity is currently under-recognized and under-treated. Physicians need to identify and evaluate the overweight and obese patient at an earlier stage of development

• Screening begins by measuring BMI, waist circumference and identifying co-morbidities

• Treatment always includes lifestyle modification. Consideration for pharmacotherapy and surgery is based upon the individual patient