Section 1 Review

Pulmonary diseasePulmonary diseaseabnormal functionabnormal functionobstructive sleep apneaobstructive sleep apneahypoventilation syndromehypoventilation syndrome

Nonalcoholic fatty liver Nonalcoholic fatty liver diseasediseasesteatosissteatosissteatohepatitissteatohepatitiscirrhosiscirrhosis

Coronary heart diseaseCoronary heart disease

DiabetesDiabetes

DyslipidemiaDyslipidemia

HypertensionHypertension

Gynecologic abnormalitiesGynecologic abnormalitiesabnormal mensesabnormal mensesinfertilityinfertilitypolycystic ovarian syndromepolycystic ovarian syndrome

OsteoarthritisOsteoarthritis

SkinSkin

Gall bladder diseaseGall bladder disease

CancerCancerbreast, uterus, cervixbreast, uterus, cervixcolon, esophagus, pancreascolon, esophagus, pancreaskidney, prostatekidney, prostate

PhlebitisPhlebitisvenous stasisvenous stasis

GoutGout

Medical Complications of Obesity

Idiopathic intracranial Idiopathic intracranial hypertensionhypertension

StrokeStroke

CataractsCataracts

Severe pancreatitisSevere pancreatitis

Complications of Childhood obesity

0

1

2

3

4

5

6

Relationship Between Weight Gain in Adulthood and Risk of Type 2

Diabetes MellitusR

ela

tive

Ris

k

Weight Change (kg)Willett et al. N Engl J Med 1999;341:427.

-10 -5 0 5 10 15 20

MenMen

WomenWomen

Diagnosing the Metabolic SyndromeDiagnosing the Metabolic SyndromeDiagnosis is established when 3 of these risk factors are present.

Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA 2001;285:2486-2497.

Risk Factor Defining LevelAbdominal obesity(Waist circumference)

Men Women

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

TG 150 mg/dL

HDL-C

Men Women

<40 mg/dL<50 mg/dL

Blood pressure 130/85 mm Hg

Fasting glucose 110 mg/dL

0

20

40

60

80

100

Increase in Healthcare Costs Among Obese Compared with Lean (BMI <25 kg/m2) Patients*

Incr

ea

se in

Co

st C

om

par

ed

w

ith L

ean

Su

bje

cts

(%)

BMI 30-34 kg/m2 BMI >35 kg/m2

Quesenberry CP Jr et al. Arch Intern Med. 1998;158:466-472.

*HMO Setting: Northern California Kaiser Permanente.

Healthcare visits

Pharmacy

Laboratory tests

All outpatient services

All inpatient services

Total healthcare

• “Doc, I am fat because

my hormones are out of

whack. I know I don’t

eat too much. Can you

check out what’s wrong

with me and give me a

pill to fix it..”

Hormonal Causes of Obesity

• Cushings Syndrome (glucocorticoid excess)• Most treatments for Diabetes Mellitus type 2• NOT Hypothyroidism• Very few (less than 1%) of patients are obese

due to hormonal problems, but a substantial number are obese in part due to diabetes treatment or treatment with glucocorticoids

Selected Medications That Can Cause Weight Gain

• Psychotropic medications

– Tricyclic antidepressants

– Monoamine oxidase inhibitors

– Specific SSRIs

– Atypical antipsychotics

– Lithium

– Specific anticonvulsants

-adrenergic receptor blockers

SSRI=selective serotonin reuptake inhibitor

Diabetes medications

– Insulin

– Sulfonylureas

– Thiazolidinediones

Highly active antiretroviral therapy

Tamoxifen

Steroid hormones

– Glucocorticoids

– Progestational steroids

• “Yea, I know about

balancing food and

activity, but I don’t don’t

eat that much.”

• “I don’t eat more than

other people”

• “I only eat salads.”

0

500

1000

1500

2000

2500

3000

Discrepancy Between Reported and Actual Energy Intake and ExpenditureK

cal/d

Reported*P<0.05 vs reported.Lichtman et al. N Engl J Med 1992;327:1893.

Energy Intake

Actual Reported Actual

Energy Expenditure

**

**

• “My problem is my

metabolism is slow.

Anything at all that

I eat turns to fat.”

0

1000

2000

3000

Relationship Between Resting Energy Expenditure and Fat-free Mass

REE = Resting energy expenditureFat-Free Mass (kg)

RE

E (

kcal

/24

h)

Owen. Mayo Clin Proc 1988;63:503.

30 90 1000 40 50 60 70 80

Lean females

Obese females

Lean males

Obese males

• “Any time I try to lose weight, my metabolism

slows down so much that I can’t lose weight.”

0

500

1000

1500

2000

2500

3000

3500

Energy Metabolism Before and After Weight LossE

nerg

y E

xpen

ditu

re (

kcal

/d)

Before

*P<0.05 vs before weight lossAmatruda et al. J. Clin Invest 1993;92:1236.

Predicted

Mean BMI Reduced from 31 to 23 kg/mMean BMI Reduced from 31 to 23 kg/m22

After Before PredictedAfter

Resting Energy Expenditure

Total Energy Expenditure

**

****

**

• “So obesity is all

genetic. There’s nothing

I can do.”

0

10

20

30

40

50

Gene-Environment Interaction in the Pathogenesis of Obesity

Bod

y M

ass

Inde

x (k

g/m

2 )

Ravussin E et al. Diabetes Care 1994;17:1067-1074.

Pima Indians

Maycoba, Mexico Arizona

P <0.0001

0

100

200

300

400

500

Effect of Portion Size on Energy Intake

500

Am

ount

Con

sum

ed (

g)

Amount of Macaroni and Cheese Served (g)

Rolls et al. Am J Clin Nutr. 2000 Dec;76(6):1207-13.

625 750 1000

5

15

25

35

45

55

Relationship Between Adiposity and Frequency of Eating in a Restaurant

Per

cent

Bod

y F

at

McCrory et al. Obes Res 1999;7:564.

Log Restaurant Food Consumption per Month

0.8 1.0 1.2 1.3 1.51.41.10.9

Partial r = 0.35; P = 0.005

Prevalence of Obesity by Hours of TV per Day: NHES Youth Aged 12-17 in 1967-70 and NLSY Youth Aged

10-15 in 1990

4-54-53-43-42-32-31-21-20-10-1 >5>5

• “There are too many. We can’t treat

obesity because we would be treating

everyone with everything.”

Expert Panel of NHLBI: Assessing Obesity - BMI, Waist Circumference,

and Disease Risk

*An increased waist circumference can denote increased disease risk even in persons of normal weight.*An increased waist circumference can denote increased disease risk even in persons of normal weight.

BMIBMIMen Men 40 in40 in

Women Women 35 in35 in

UnderweightUnderweight

Normal*Normal*

OverweightOverweight

ObesityObesity

Extreme obesityExtreme obesity

——

——

IncreasedIncreased

HighHighVery highVery high

Extremely highExtremely high

<18.5<18.5

18.5-24.918.5-24.9

25.0-29.925.0-29.9

30.0-34.930.0-34.935.0-39.935.0-39.9

4040

CategoryCategoryMen >40 inMen >40 in

Women >35 in Women >35 in

——

——

HighHigh

Very highVery highVery highVery high

Extremely highExtremely high

Disease Risk Relative to NormalDisease Risk Relative to NormalWeight and Waist CircumferenceWeight and Waist Circumference

Adapted fromAdapted from Clinical guidelines Clinical guidelines. National Heart, Lung, and Blood Institute Web site. Available at:. National Heart, Lung, and Blood Institute Web site. Available at:http://www.nhlbi.nih.gov/nhlbi/cardio/obes/prof/guidelns/ob_gdlns.htm. Accessed July 31, 1998.http://www.nhlbi.nih.gov/nhlbi/cardio/obes/prof/guidelns/ob_gdlns.htm. Accessed July 31, 1998.

Expert Panel of NHLBI: Overall Risk of Obesity

• Evaluate the potential presence of other risk factors.

• Some conditions associated with obesity put patients at high risk for subsequent mortality, and will require aggressive modification.

• Other obesity associated conditions are less lethal, but still require treatment.

• Among the risks to consider are: coronary heart disease, other atherosclerotic diseases, type 2 diabetes mellitus, sleep apnea, gynecological abnormalities, osteoarthritis, gallstones, stress incontinence, hypertension, cigarette smoking, hyperlipidemia, and family history of early coronary disease.

Expert Panel of NHLBI: Therapy Decision

• Therapy is Recommended:– BMI > 30– BMI 25 - 29.9, a dangerous waist

circumference and 2 or more risk factors.

• Individuals at lesser risk should be counseled about useful lifestyle changes

if they are ready for a change.

• “So what can we do?

There are all these diets

and pills on the TV, but

nothing seems to work

very well. Is there

anything that actually

helps.”

NHLBI Expert Panel: Goals of Therapy

• Reduce body weight and maintain a lower body weight for the long term.

• An initial weight loss target of 10% of body weight, lost over six months is recommended and will be medically significant. The rate of weight loss should be 1 -2 pounds each week.

• Evidence indicates that greater rates of weight loss do not achieve better long-term results.

• After the first six months of weight loss therapy, the priority should be weight maintenance through combined changes in diet, physical activity, and behavior.

Obese Patients Have Unrealistic Weight Loss GoalsOutcome Weight (lbs) % Reduction

Initial 218 0

Dream 135 38

Happy 150 31

Acceptable 163 25

Disappointed 180 17

Foster et al. J Consult Clin Psychol 1997;65:79.

NHLBI Expert Panel: Changes in “Lifestyle” or Priorities

Food• “Diets” chosen should be long-term • Reduced 500 to 1000 from baseline in calories • Targeting 30% or less of calories as fat • Individualized.

Activity• Activity is most useful in maintaining weight loss• Goal of 30 minutes of moderate activity every day • Increase everyday activity by taking the stairs, etc.

-12

-10

-8

-6

-4

-2

0

Providing Prepackaged Meals Enhances Weight Loss

Wei

ght C

hang

e (k

g)

Jeffery et al. J Consult Clin Psychol 1993;61:1038.

P=0.0001 treatment vs control.P=0.0002 behavior therapy + self-selected diet vs behavior therapy + food provision.

Months0 6 12 18

MaintenanceWeekly

Treatment

Control

Behavior Therapy + Self-selected Diet

Behavior Therapy + Food Provision

“I don’t think I need to

change what I am eating.

I am going to work out and

lose it that way.”

-7.0 -5.0 -3.0 -1.0 1.0

Physical Activity Alone Results in Minimal Weight Loss

Wing. Med Sci Sports Exerc 1999;31(suppl):S547.

*P<0.05 vs control group

Duration of each study ranged from 4 to 12 months.

Stefanick 1998

Stefanick 1998a

Anderssen 1995

Hammer 1989

Verity 1989

Rönnemaa 1988

Wood 1988

Wood 1983

Weight loss (kg)

Control Group

Exercise Group

**

**

0

20

40

60

80

100

Relationship Between Physical Activity and Maintenance of Weight Loss

Not Maintained

Sub

ject

s E

xerc

isin

g (%

)

P<0.001

Kayman et al. Am J Clin Nutr 1990;52:800.

Weight Loss PatternMaintained

-16-14-12-10

-8-6-4-20

Considerable Physical Activity is Necessary for Weight Loss Maintenance

Jakicic et al. JAMA 1999;282:1554.

Cha

nge

in W

eigh

t (kg

)

Time (months)0 6 12 18

Weekly Biweekly Monthly

Concomitant Behavior Therapy

*P<0.05

<150 min/wk<150 min/wk

>150 min/wk>150 min/wk

>200 min/wk>200 min/wk

-25

-20

-15

-10

-5

0

Effect of Decreasing Sedentary Activities vs Increasing Physical Activities on Body Weight in

Children 6-12 Years Old

0Time (months)

Decreased Sedentary Activity

Cha

nge

in P

erce

nt O

verw

eigh

t

Increased Physical Activity

Epstein et al. Health Psychol 1995;14:109.

4 8 12

• “This is so hard. Is

there any good

news?”

Diabetes Prevention Program (DPP)

• Hypothesis: Can diabetes be delayed or prevented by addressing risk factors: impaired glucose tolerance, overweight and sedentary life - using lifestyle changes or metformin?

• 3234 pts of mean age 51, BMI 34, 68% women, 45% minorities and impaired glucose tolerance were randomized to 3 groups at 27 US centers: – Usual care (control)– Metformin 850 mg BID– Lifestyle intervention –

• Goal of 7% weight loss by Food Pyramid, NCEP 1 diet

• Goal of 150 min/wk moderate activity (brisk walking)

Diabetes Development in Diabetes Prevention Program

“Obesity treatment and behavior

change are too hard. I don’t

have time to do this in my clinic.”

Practical Behavior Change• Physicians make a difference • Repetition and follow-up are most useful• Likely better to do with 2-5 minutes repeatedly than

with an hour at once• Education can be done in pieces• Let them know that you know it’s hard and that the

environment is against them• Encourage patients to find their own goals

(motivational interviewing techniques) but encourage specificity - go beyond “watch what I eat”

Review when, where, and how behaviors Review when, where, and how behaviors will be performedwill be performed

Identify behavior change goalIdentify behavior change goal

Have patient keep record of behavior changeHave patient keep record of behavior change

Review progress at next treatment visitReview progress at next treatment visit

Five Steps to Facilitate Behavior Change

Wadden and Foster. Med Clin North Am 2000;84:441.

11

22

55

33

44

Congratulate patient on successes (do not Congratulate patient on successes (do not criticize shortcomings)criticize shortcomings)

Cardinal Behaviors of Successful Long-term Weight Management

National Weight Control Registry Data

• Self-monitoring:– Diet: record food intake daily, limit certain foods or

food quantity– Weight: check body weight >1 x/wk

• Low-calorie, low-fat diet:– Total energy intake: 1300-1400 kcal/d– Energy intake from fat: 20%-25%

• Eat breakfast daily• Regular physical activity: 2500-3000 kcal/wk

(eg, walk 4 miles/d)Klem et al. Am J Clin Nutr 1997;66:239. McGuire et al.Int J Obes Relat Metab Disord 1998;22:572.

-18-16-14-12-10

-8-6-4-20

Long-term Weight Loss is Improved with Long-term Maintenance TherapyW

eigh

t Los

s (%

)

Perri et al. J Consult Clin Psychol 1988;56:529.

0 1 2 3 4 5 6 7 8 9 10 11 12

Time (mo)

13 14 15 16 17

PP <0.05 <0.05

No maintenance txNo maintenance tx

Maintenance txMaintenance tx

Diet andDiet andbehaviorbehaviormodificationmodificationtherapytherapy

Assessing Weight Loss Readiness

• Motivation:• Stress level:• Psychiatric

issues:

• Time availability:

Patient seeks weight reductionPatient seeks weight reduction

Free of major life crisesFree of major life crises

Free of severe depression, Free of severe depression, substance abuse, bulimia nervosasubstance abuse, bulimia nervosa

Patient can devote 15-30 min/d to Patient can devote 15-30 min/d to weight control for next 26 weeksweight control for next 26 weeks

Patient Ready?Patient Ready?Patient Ready?Patient Ready?

Prevent weight gain Prevent weight gain and explore barriers to and explore barriers to

weight reductionweight reduction

Initiate weight loss Initiate weight loss therapytherapy

YESYES NONO

Prevention

• Breastfeeding when possible

• Plotting BMI at each visit

• Anticipatory guidance: 5-2-1-0– “5 a day” fruits and vegetables– Less than 2 hr/day of screen time– At least 1 hour of moderate activity each day– No sweet drinks