medical treatment options for obesity jennifer debruler, m.d. medical director advocate weight...
TRANSCRIPT
Medical Treatment Options for Obesity
Jennifer DeBruler, M.D.
Medical Director
Advocate Weight Management
Board Certified Internal Medicine
October 2012
Goals for this presentation…
Discuss low fat diet, Mediterranean diet, Paleo diet
Discuss exercise recommendations for weight loss and mantainence
Discuss medication options for treatment of obesity
Provide an office tool to help patients loss weight
– Dietary Guideline for Americans 2010• US Department of Agriculture• www.dietaryguidelines.gov
– Decrease saturated fat– Consume >45% from carbohydrate
– Once size fits all approach only fits a minority of the population
Jeff S. Volek, PhD, RD
Re-Examining the Role of Carbohydrate
The Low Fat Era
The increase in calories during the obesity epidemic was largely due to carbohydrate intake.
Jeff S. Volek, PhD, RD
Saturated Fat & the Diet Heart Hypothesis
We know decreased SFA intake leads to increased carb intake which can lead to metabolic syndrome then diabetes and ultimately heart disease
Is it true that increased SFA intake causes increased plasma LDL and heart disease?
Jeff S. Volek, PhD, RD
What happens to a carbohydrate?
Eat Carbohydrate, it goes into blood glucose and is broken down to glycogen and oxidized
Too much carbohydrate leads to glycogen and excess carbohydrate fuels lipogenesis (fat synthesis)
Plasma Saturated Fat
Predicts Heart disease– Br Med J 1982;285993-6– Am J Epidemiolo. 1995;142: 469-76– Nut Metab Crdiovasc Dis 2003;13:256-66– Am Heart J 2008; 156:965-74
Predicts Diabetes– AJCN. 2003; 78:91-8– Diabetologia. 2005; 48:1999-2005– AJCN. 2007; 86:189-97– AJCN. 2010; 92:1214-22
Dietary Saturated Fat and Heart Disease3 Recent Meta-Analyses
Study Pooled Cohort Studies
Baseline Cohort (n)
Follow-Up (yr)
Interpretation
Skeaff & Miller. Dietary fat and coronary heart disease: summary of evidence from prospective cohort and randomized controlled trials Ann Nutr Metab, 2009. 55(1-3): p. 173-201.
28 280,000 4-25 No association between SFA intake & CHD events/death
Jakobsen, et al., Major types of dietary fat and risk of coronary heart disease: a pooled analysis of 11 cohort studies. Am J Clin Nutr, 2009. 89(5): p. 1425-32.
11 344,696 4-10 Increased SFA intake not associated w/CHD events
Siri-Tarino et al., Meta-analysis of prospective cohort studies evaluating the association of saturated fat with cardiovascular disease. Am J Clin Nutr, 2010. 91 (3): p. 535-46.
21 347,747 5-23 No association b/t SFA intake & CVD, CHD or stroke
If you decrease SF, it matters what you replace it with.
Replacing 5% of SFA with carbohydrates increase coronary events.
It increases your relative risk of CAD
Jakobsen et al. AJCN , Feb 2011
Conclusion
When it comes of SFA, you are not what you eat Consumption of carbohydrate at levels that exceed a
persons ability to directly oxidize them contributes to increased circulation SFA
Instead of telling everyone to restrict dietary saturated fat a more rational and effective strategy would be to focus on ways to help people find their “right” level of carbohydrate
For people with insulin resistance, a low carb lifestyle can have a profoundly beneficial effect on a metabolic risk factors including SFA
Jeff S. Volek, PhD, RD
Mediterranean Diet
Large quantities of minimally processed, fresh, plant-based foods (fruit, vegetables, whole grains, seeds and nuts)
Olive oil is principal source of dietary fat Low consumption of red meat and dairy Red Wine in low to moderate amounts with
meals 45% Carbohydrate Low glycemic load
Minich DM, et al. Nutr Rev Vol 66(8): 429-444.
Mediterranean DietLyon Diet Heart Study
Prospective secondary prevention in 605 subjects for 5 years
Subjects randomized to – Mediterranean diet with 40% fat, 45% carbs– ADA Step 1 Diet with 25% fat, 60% carbs
– De Lorgeril M. Circulation. 1999; 99: 779-785.
Mediterranean DietLyon Diet Heart Study
Study halted after 27 months due to excess mortality in the AHA Step 1 Diet
– Total mortality (cardiac + non-cardiac) 72% (p<0.0001)
– Cardiovascular events (MI, CHF, PE) 47% (p<0.0001)
– De Lorgeril M. Circulation. 1999; 99: 779-785.
Mediterranean DietLyon Diet Heart Study
The Mediterranean diet dramatically reduced heart attack and overall mortality compared to the AHA diet
No change in serum lipids, BP, BMI
Key difference: Mediterranean diet modifies inflammation
De Lorgeril M. Circulation. 1999; 99: 779-785.
Mediterranean DietLyon Diet Heart Study
Mediterranean diet includes nutrients known to decrease inflammatory mediators (crp, IL-6, WBC)– Omega 3- EFA, DHA-EPA– Gamma Tocopherol– Flavenoids, coumarins anthyrocyanin
Med. Diet excludes nutrients that increase inflammatory mediators– Omega 6-EFA, linoleate and arachidonate– Iron– Trans fat: increase CRP– Alpha tocopherol: reduces gamma tocopherol (Vit E)
Mediterranean Diet
Great for moderately obese, 20-30 pounds overweight
Not concerned with rapid weight loss
For patients who want to use diet to prevent or treat co-morbids, – e.g. Metabolic syndrome, diabetes, CAD
The Paleo Diet
Typical food in the Western Diet were virtually unknown in ancestral human diets– Breads, cereals, rice, and pasta– Dairy Products– Added Salt– Refined vegetable oil– Refined sugars, except honey– Processed Meats– Alcohol
– Cordain et al. Am J Clin Nutr 2001;71:682-92
The Paleo Diet
Eat like the cavemen eat– Fresh Veggies– Nuts/Seeds– Healthful Oils– Fresh fruits– Fish/seafood– Grass produced meats
The Paleo Diet
Typical Hunter-Gatherer Diet– Animal food energy 55%
• Hunted animal 27.5%• Fished animal 27.5%• No processed meats• No dairy food
– Plant food energy 45%• No cereal grains• Minimally processed fresh fruits, veggies, seeds & nuts
– No Processed Foods
– Cordain et al. Am J Clin Nutr 2001;71:682-92
The Paleo Diet
Nutrient differences between: – wild vs. cultivated plant food
• Smaller• More fiber• Less sugar• Slightly greater minerals• Vitamin content similar
The Paleo Diet
Seems like a lot of cholesterol in this diet? Dietary cholesterol has a minimal influence
on serum cholesterol.– Lowering dietary cholesterol from 491 mg (paleo) to
300mg (recommended) drops serum cholesterol by 4.5 mg/dl
– Lowering dietary cholesterol from 491 mg (paleo) to 219 mg (food pyramid) drops serum cholesterol by 6 mg/dl
– Cutting dietary cholesterol from 491mg to 219 mg would reduce a high cholesterol 240 to 234 or 2.5%
– Schonfeld G et al. J Clin Invest 1982;69:1072-80
The Paleo Diet
High protein diet is more effective than high carbohydrate diet in causing weight loss– After 6 mo – high protein/low fat group had lost
average of 19.6 lbs– After 6 mo – high carb/low fat group had lost an
average of 11.2 lbs
Similar studies have replicated results– Baba NH et al. 1999– Torbay N et al. 2002– Johnston CS et al. 2002– Parker B et al., 2002– Weigle DS et al, Am J Clin Nutr 2005
Exercise Recommendations
General Health Benefit– Moderate aerobic exercise 150 min/wk (about 30
minutes 5x/wk) + strength training Prevention of Weight Gain
– 150-250 minutes per week– 150-300 minutes per week
Prevention of Weight Regain– 200-300 minutes per week– 300-420 minutes per week
– Donnelly JE. Med Sci Sports Exerc. 2009– USDHHS. PA Guidelines for Americans. 2008
Medical Clearance for Physical Activity
ACSM Guidelines for Risk Stratification– Men>45, women>55 w/2 or more risk factors– Risk factors include:
• FHx of MI in 1st degree relative M<55, F<65• Smoking in last 6 mo• Hypertension• Abnormal lipids• Impaired Fasting Glucose• BMI ≥ 30• Sedentary Lifestyle
– Plan to exercise at >60% of max, vigorous– Consider Stress testing
– Thompson WR, Ed. ACSM’s Guidelines for Exercise Testing & Prescription, 2010
Medications for Weight Loss
Phenylethylamines Sympathomimetic effect Works at the hypothalamus and limbic system Appetite suppressant effect
Meta-analysis of phentermine and diethylproprion– 3.6 kg additional weight loss at 6 mo for phentermine– 3 kg additional weight loss at 6 mo for diethylpropion
– Li, A. Ann Intern Med. 2005.
Medication for Weight Loss
Phenylethylamines Short term adjunct in a regimen of weight
reduction involving lifestyle changes in management of adult obesity
BMI ≥ 30 or ≥ 27 with comorbid condition Contraindication – advanced arteriosclerosis,
CAD, mod/severe HTN, hyperthyroid, glaucoma, agitated states, history of known drug abuse, pregnancy
Medication for Weight Loss
Phenylethylamines Adverse Effects
– CV: palpitations, tachycardia, primary pulm HTN
– CNS: restlessness, dizziness, insomnia, HA– GI: dry mouth, diarrhea, constipation– Endocrine: impotence, change in libido
Medication for Weight Loss
Orlistat
Gastric and pancreatic lipase inhibitor Inhibits uptake of up to 1/3 ingested fat Needs to be used in accordance with low-fat,
calorie controlled diet.
Medication for Weight Loss
Orlistat May be used long-term up 4 yrs for weight loss or for
weight loss maintenance in adult obese patients Pediatric indication: 12-16 y/o obese adolescents Should be accompanied by vitamin supplementation Common SE: fecal soiling, dyspepsia, flatulence,
vitamin malabsorbtion, elevated liver enzymes Rare SE: severe liver injury Contraindication: cholestasis, malabsorbtion syndrome,
liver disease
Medication for Weight Loss
Metformin Biguanide: reduces hepatic glucose
production and improves insulin sensitivity Induces modest weight loss initially Improves fertility in PCOS patient Lost 8 kg more weight over 24 wks than
placebo Lee A. Obes Res. 1998
Medication for Weight loss
GLP-1 Agonists Exenatide, liraglutide Enhances glucose dependent insulin release Suppress inappropriate glucagon release Delays gastric emptying Reduction in food intake directly acting on
hypothalamus
Medication for Weight Loss
GLP-1 Agonist
Great medication for DM treatment and weight loss
Works synergistically with carbohydrate controlled diet
Nausea common, usually self-limited Watch out for pancreatitis
Medication for Weight Loss
Bupropion Dopamine and norepinephrine reuptake
inhibitor Tx major depression, smoking cessation,
ADHD Do not use in bulimic patients, may lower
seizure threshold
Medication for Weight Loss
Bupropion Works centrally as an appetite suppressant Only anti-depressant with consistent weight
loss effect May blunt weight regain in smoking cessation
Medication for Weight Loss
Phentermine & topiramate ER (Qsymia)– BMI ≥ 30 or ≥ 27 with comorbid– Synergistic with Phentermine
• Increased satiety through reduced GI motility• Increased taste aversion• Reduced calorie intake
– SE: increased HR, paresthesias, metabolic acidosis
– TBD when released
Medication for Weight Loss
Phentermine & topiramate ER (Qsymia)– Caution: women of reproductive age
• Cleft palate in 1st trimester• Women must be on OCP• Avoid with glaucoma• Hyperthyroidism• MAOI’s
Studies show 5-10 kg weight loss
Medication for Weight Loss
Lorcaserin (Belviq) – Activates the seratonin 2C receptor– Works at centrally acting satiety receptors– Caution:
• Valvular HD, CHF, HTN• Men with predisposition to erection more than
4 hrs (sickle cell, MM, Leukemia) or deformed penis
– 3.7% weight loss, 7kg.
Office Tool
Thank you