obesity management in northern ontario · accessed july 20, 2016; 2. puhl r et al. int j obes...
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OBESITY MANAGEMENT IN NORTHERN ONTARIO
Dr. A. Abu-Bakare
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Conflict of Interest Declaration: Nothing to Disclose
Presenter: Dr. Asiru Abu-Bakare
Title of Presentation: Obesity Management In Northern
Ontario
I have no financial or personal relationship related to this
presentation to disclose
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Look what he’s done to himself, if only he had some self-control, or wasn’t so lazy
“Maybe if she exercised more she wouldn’t look like that.””.
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Putting the Patient First
DO SAY….
DON’T SAY
“Patients struggling with…”
• Weight• Unhealthy weight• Weight problems
“Obese patients”
• Obese• Fat• Extremely obese
~20%of patients who perceive weight stigma from their
health care provider would avoid future
appointments or seek out a new health care
provider
Obesity Action Coalition. http://www.obesityaction.org/wp-content/uploads/People-First.pdf. Accessed July 20, 2016; 2. Puhl R et al. Int J Obes (London). 2013;37:612-619.
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Obesity is recognized as a chronic disease and global health issue
“Obesity is a chronic and often progressive condition not unlike diabetes or hypertension.”1
-Canadian Obesity Network
“Obesity is a chronic disease, prevalent in both developed and developing countries, and affecting children as well as adults.”3
-World Health Organization
“Recognizing obesity as a disease will help change the way the medical community tackles this complex issue that affects approximately one in three Americans.”4
-American Medical Association
1. Canadian Obesity Network. 5As of Obesity Management. Downloaded from www.obesitynetwork.ca on November 17, 2014; 2. Mechanick et al. Endocr Pract 2012;18:642–8; 3. TOS Obesity as a Disease Writing Group. Obesity2008;16:1161–77; 4. AMA position statement. Available at: http://www.ama-assn.org/ . 5. CMA Press Release (October 2015). Available at: https://www.cma.ca/En/Pages/cma-recognizes-obesity-as-a-disease.aspx.
“Obesity is a chronic medical disease requiring enhanced research, treatment and prevention efforts.”5
-Canadian Medical Association
“…obesity is a primary disease, and the full force of our medical knowledge should be brought to bear on the prevention and treatment of obesity as a primary disease entity…”2
-American Association of Clinical Endocrinologists
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ObesityMeetsAMACriteria for a Disease
Impairment of Normal Function
•Physical impairments•Altered physiologic
function (inflammation, insulin resistance, dyslipidemia, etc)
•Altered regulation of satiety in the hypothalamus
Characteristic Signs or Symptoms
•Increased body fat mass
•Joint pain•Impaired mobility•Low self-esteem•Sleep apnea•Altered metabolism
Harm or Morbidity
•Cardiovascular disease•Type 2 diabetes•Metabolic syndrome•Cancer•Death
AMA = AmericanMedical Association.
Mechanick JI, et al. Endocr Pract. 2012;18:642-648.
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Is a Chronic Condition with Serious Implications for Life Expectancy
aBased on a meta-analysis of 57 international prospective studies predominantly based in Europe, the United States, Israel, and Australia, including BMI information for 894,576 adults. BMI = body mass index. 1. Whitlock G, et al. Lancet. 2009;373:1083-1096. 2. Garvey WT, et al. [published online May 24, 2016]. Endocr Pract.
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Assessing Obesity
ALT = alanine aminotransferase; BMI = body mass index; FPG = fasting plasma glucose; NAFLD = non-alcoholic fatty liver disease.Adapted from Jensen MD et al. J Am Coll Cardiol. 2014;63:2985-3023; Lau DCW et al. CMAJ. 2007;176:1103-6; CDA Guidelines. Can J Diabetes. 2013;37(suppl 1):S1-212.
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Edmonton Obesity Staging System
BP = blood pressure; FPG = fasting plasma glucose; HDL-C = high-density lipoprotein cholesterol; MI = myocardial infarction; T2D =
Stage Severity Characteristics
0 No obesity-related risk factors, physical symptoms, psychopathology, or functional
limitations
1 Mild
BP ≥130/85 mmHg or ≥125/75 mmHg with T2D
FPG 5.5 – 6.8 mmol/L
Total cholesterol 5.18 – 6.22 mmol/L; triglycerides 1.69- 2.25 mmol/L; HDL-C <1.55 mmol/L
Shortness of breath during physical activity
2 Moderate
Diagnosed/treated hypertension; untreated BP ≥140/90 mmHg or ≥130/80 with T2D T2D or untreated FPG ≥ 6.9 mmol/L
Diagnosed hypercholesterolemia; untreated total cholesterol ≥6.22 mmol/L,
triglycerides ≥2.26 mmol/L, HDL-C < 1.04 mmol/L
Gout, depression, fatigue, urinary leakage, low back pain, joint stiffness Reported
emotional outlook of “generally sad” or “fair” self-reported health
3 Severe
Chest pain, MI, calf pain during exercise, stroke, shortness of breath when sitting or
sleeping, cardiomegaly
Psychological/psychiatric counseling
Reported emotional outlook of “often depressed” or “poor” self-reported health
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Diagnosis
Anthropometric
component Clinical component Prevention and/or
Treatment
Normal BMI < 25 Primary
Overweight BMI 25-29.9No obesity-related
complications Secondary
Obesity Stage 0 BMI ≥30No obesity-related
complicationsSecondary
Obesity Stage 1 BMI ≥25Presence of one or more mild to
moderate obesity-related
complications
Tertiary
Obesity Stage 2 BMI ≥25
Presence of one or more
severe obesity- related
complications
Tertiary
AACE Obesity Staging
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Energy Homeostasis
Energy intake
Ingestion of:
• Proteins
• Fats
• Carbohydrates
Energy expenditure
• Physical activity
• Diet-induced thermogenesis
• Basal metabolic rate
Body Weight
Increase Decrease
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Multiple hormones play a key role in hunger and satiety
BBB, blood-brain barrier; CCK, cholecystokinin; GLP-1, glucagon-like peptide-1; PYY, peptide YY .Suzuki K et al. Exp Diabetes Res. 2012;2012:824305.
AmylinInsulin PYY
GLP-1CCK
Satiety
Hunger
Pancreas Intestines
Ghrelin
Stomach
BBB
Hypothalamus
LeptinAdiponectin Satiety
BBB
BBB
Hypothalamus
Hypothalamus
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Canadian Guidelines for the clinical management of obesity
While behavioural intervention is the cornerstone of weight loss interventions; pharmacotherapy and bariatric surgery are useful adjuncts for appropriate patients
TreatmentBMI category (kg/m2)
≥25 ≥27 ≥30 ≥35 ≥40
Diet & exercise
modification program*
With
comorbidities
With
comorbidities+ + +
PharmacotherapyWith
comorbidities+ + +
Bariatric surgeryWith
comorbidities+
Lau et al. CMAJ 2007;176(8 suppl):Online-1–117
*Behavioural modification program consists of nutrition, physical activity, and cognitive-behaviour therapy.+ indicates a treatment recommendation for that BMI class. BMI, body mass index.
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Health Loss
Cefalu et al. Diabetes Care. 2015; 38:1567-1582.
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Obesity facts summary
1. Obesity is a chronic disease that is associated with multiple comorbidities
2. Obesity is a complex and multifactorial disease, involving energy imbalances, environmental, genetic and hormonal factors. These factors not only impact the progression of obesity, but also the physiological responses following weight loss.
3. Weight reductions of 5–10% of body weight can be beneficial to patients’ overall health.
4. Pharmacological treatments can provide an additional 5–10% reduction in body weight as an adjunct to diet and exercise for weight management.
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