Obesity - American Academy of Family Physicians

Transcription

ACTIVITY DISCLAIMER
The material presented here is being made available by the American
Academy of Family Physicians for educational purposes only. This material
is not intended to represent the only, nor necessarily best, methods or
procedures appropriate for the medical situations discussed. Rather, it is
intended to present an approach, view, statement, or opinion of the faculty,
which may be helpful to others who face similar situations.
Obesity
The AAFP disclaims any and all liability for injury or other damages resulting
to any individual using this material and for all claims that might arise out of
the use of the techniques demonstrated therein by such individuals, whether
these claims shall be asserted by a physician or any other person. Every
effort has been made to ensure the accuracy of the data presented here.
Physicians may care to check specific details such as drug doses and
contraindications, etc., in standard sources prior to clinical application. This
material might contain recommendations/guidelines developed by other
organizations. Please note that although these guidelines might be
included, this does not necessarily imply the endorsement by the AAFP.
Myra Muramoto, MD, MPH
CME041 Tuesday, 3:20-4:20 p.m., Location: 145AB
CME042 Wednesday, 12:30-1:30 p.m., Location: 146AB
This CME session is supported by an educational grant to the AAFP from Eisai Inc.
FACULTY DISCLOSURE
It is the policy of the AAFP that all individuals in a position to control
content disclose any relationships with commercial interests upon
nomination/invitation of participation. Disclosure documents are
reviewed for potential conflict of interest (COI), and if identified,
conflicts are resolved prior to confirmation of participation. Only those
participants who had no conflict of interest or who agreed to an
identified resolution process prior to their participation were involved
in this CME activity.
The following Faculty in a position to control content relevant to this
session has disclosed the following relevant financial relationships:
Myra Muramoto, MD, MPH, Sanofi-Aventis (pharmaceuticals) Stock/Bond Holdings
The content of my material/presentation in this CME activity will not
include discussion of unapproved or investigational uses of products
or devices.
Biography
Professor and Sr. Vice Head of Family and Community Medicine,
University of Arizona College of Medicine; Professor of Public Health,
University of Arizona College of Public Health; Practices at the
Abrams Center Family Medicine Center; founding Director of the Quit
& Win Tobacco Free Living Program; founding co-Director of the
Clinical Weight Loss Program.
Assembly Sessions - Endocrine: Obesity, CME041, CME042
Dr. Muramoto practices with the University of Arizona Health Network
(UAHN), serving an ethnically and racially diverse patient population
with a focus on chronic disease treatment and prevention through
lifestyle change. Dr. Muramoto has been teaching for 26 years. This
is her first year speaking at the Assembly.
Learning Objectives
1. Screen patients using BMI to determine whether they are overweight
or obese
2. Devise collaborative care plans that involve intensive,
multicomponent behavioral interventions, including behavioral
management activities
3. Assess risks and benefits of medications as an adjunct to lifestyle
changes in patients who have not lost at least 1.11 lbs (0.5 kg)/ week
after 3 – 6 months of implementing lifestyle changes alone.
4. Establish a multidisciplinary, patient-centered strategy to manage
bariatric treatment options for obese patients; including patient
education, evaluation, coordination of care and follow-up support.
Presentation Agenda
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Obesity: epidemic of a chronic disease
Obesity treatment = chronic disease management
Screening for obesity/overweight
The 5 A’s of obesity management
Specific behavioral intervention strategies
Risks and benefits of weight loss medications
Additional practice resources
Practice recommendations & questions
1
Obesity Trends* Among U.S. Adults
BRFSS, 1985
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
OBESITY: EPIDEMIC OF
CHRONIC DISEASE
Learning Objective:
Screen patients using BMI to determine whether they are overweight or obese
No Data
<10%
10%–14%
Source: Behavioral Risk Factor Surveillance System, CDC.
BRFSS, 1986
BRFSS, 1987
No Data
<10%
10%–14%
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4”
person)
No Data
<10%
BRFSS, 1988
BRFSS, 1989
No Data
<10%
10%–14%
10%–14%
No Data
<10%
10%–14%
2
BRFSS, 1990
BRFSS, 1991
No Data
<10%
10%–14%
No Data
<10%
BRFSS, 1993
No Data
<10%
10%–14%
15%–19%
No Data
<10%
<10%
10%–14%
15%–19%
15%–19%
BRFSS, 1995
No Data
10%–14%
BRFSS, 1994
15%–19%
BRFSS, 1992
10%–14
No Data
<10%
10%–14%
15%–19%
3
BRFSS, 1996
BRFSS, 1997
No Data
<10%
10%–14
No Data
15%–19%
<10%
<10%
10%–14%
15%–19%
≥20%
No Data
<10%
<10%
10%–14%
15%–19%
≥20%
15%–19%
≥20%
BRFSS, 2001
No Data
10%–14%
BRFSS, 2000
≥20%
BRFSS, 1999
No Data
15%–19%
BRFSS, 1998
10%–14%
No Data
<10%
10%–14%
15%–19%
20%–24%
≥25%
4
BRFSS, 2002
BRFSS, 2003
No Data
<10%
10%–14%
15%–19%
20%–24%
No Data
≥25%
<10%
10%–14%
15%–19%
20%–24%
≥25%
<10%
10%–14%
15%–19%
20%–24%
15%–19%
20%–24%
25%–29%
≥30%
BRFSS, 2007
<10%
10%–14%
BRFSS, 2006
No Data
≥25%
No Data
20%–24%
BRFSS, 2005
<10%
15%–19%
BRFSS, 2004
No Data
10%–14%
25%–29%
≥30%
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
5
BRFSS, 2008
BRFSS, 2009
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
BRFSS, 2010
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
34
Obesity Related Chronic Diseases
Use blank slide for large graphs and graphics. 35
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Diabetes Mellitus Type II Cardiovascular disease
Metabolic Syndrome
Nonalcoholic fatty liver disease
Gallstones
Pancreatitis
Obstructive Sleep Apnea
Pulmonary emboli
Osteoarthritis
Gout
Cancer: breast, colon, uterus……
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Questions/Poll Everywhere
• Should obesity be treated as a chronic disease?
OBESITY: A CHRONIC
RELAPSING CONDITION
Learning Objectives:
Devise collaborative care plans that involve intensive, multicomponent behavioral interventions, including behavioral management activities
Obesity: a Chronic Condition
Obesity is a long‐lasting condition that can be controlled but not cured. It often begins in childhood.
Obesity = chronic disease:
• Duration longer than a year, has exacerbations and remissions
• Associated with functional limitations
• Need for on‐going medical care and patient self‐management
Think: obesity treatment = chronic disease management:
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Better control = longer remissions & fewer, less severe exacerbations
Regular monitoring by patient and clinician
Collaborative care plans
Intensive multicomponent behavioral interventions
Action plan for detection/early intervention of exacerbations
Assist and encourage patient self‐management
Overall Obesity Management Goals
Overall GOALS of obesity management:
• Improve patient health
• Improve quality of life
• Improve body weight/composition (reduce fat mass, preserve lean mass
Reframe Success
SCREENING FOR OBESITY
AND OVERWEIGHT
Learning Objective:
Screen patients using BMI to determine whether they are overweight or obese
7
AAFP Recommendations
Calculate BMI
• Screen all adults for obesity using BMI. – Offer or refer patients with BMI > 30 to intensive multicomponent behavioral interventions.
• Screen children > 6 yrs for obesity
– Offer or refer to comprehensive, intensive behavioral interventions if BMI >85th percentile for age.
BMI Calculator
• Kilograms/Meters Formula: weight (kg) / [height (m)]2 = BMI
• Pounds/Inches Formula: weight (lb) / [height (in)]2 x 703 = BMI
BMI < 35: Measure Waist Circumference
• Top of iliac crest
• Indicates abdominal adiposity
• Predicts risk independent of BMI
HIGH RISK Men: > 102 cm (>40 in.)
Women: >88 cm (>35 in.)
>5x RISK of multiple CVD risk factors
BMI for Age Charts
BMI for Age Calculator
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• Should the physician ask the patient for permission to discuss weight?
5 A’S OF OBESITY MANAGEMENT
Learning Objective:
Devise collaborative care plans that involve intensive, multicomponent behavioral interventions, including behavioral management activities
5 A’s for Evaluation & Management
of Obesity
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Ask
Assess
Advise
Agree
Assist/Arrange
ASK: Permission
• Permission to talk about body weight
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Patient‐centered
Principal of Motivational Interviewing
Facilitates patient‐driven behavior change
Facilitates non‐judgmental conversation about weight
“Are you concerned about your weight and its effect on your health and quality of life?”
“Would it be alright if we discussed your weight?”
Vallis, et al. Can Fam Physician 2013 59:27‐31.
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ASK: Explore Readiness to Change
• Motivational interviewing approach
• Establishes where the patient is with their weight
• Helps physician avoid working harder than the patient on weight
“How ready are you to work on your weight?”
ASSESS: Obesity Severity
BMI Classification of overweight/obesity:
• Overweight = BMI 25 – 29.9
• Class 1 = BMI 30 – 34.9 (obesity)
• Class 2 = BMI 35 – 39.9 (severe obesity)
• Class 3 = BMI > 40 (extreme obesity)
• Super obesity = BMI > 50 Waist Circumference Risk Level:
• HIGH RISK: Men: > 102 cm (>40 in.)
Women: >88 cm (>35 in.)
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9
ASSESS: Complications &
ASSESS: Complications &
Comorbidities, Barriers to Management
• Complete medical history and physical exam
The 4 M’s of Obesity
• Mental: • Mechanical
• Metabolic
• Monetary
– PMhx, PShx, FMhx
– Preventive health
• Weight–focused history
– Previous weight loss treatment
– Nutrition history
– Physical activity
• Diagnostic studies as indicated Sharma AM. Obesity reviews. (2010) 11,808‐809.
Mental Complications &
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Depression Anxiety Other behavioral health issues
Cognitive issues
Sleep issues
Inadequate knowledge
Unrealistic expectations for treatment
Sharma AM. Obesity reviews. (2010) 11,808‐809.
Mechanical Complications &
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Metabolic Complications &
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Nutritional deficiencies
Insulin resistance/metabolic syndrome
Type 2 Diabetes
Dyslipidemia
Hypertension
Steatohepatosis
Gout
Gall bladder disease
Polycystic Ovary Syndrome & Infertility
Medications causing weight gain
Osteoarthritis, other musculoskeletal problems
Chronic pain
Obstructive sleep apnea, Restrictive hypoventilation
Esophageal reflux
Urinary incontinence
Intertrigo
Venous thrombosis
Lymphedema
Monetary Complications &
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Low education and/or income
Unemployment and/or disability
Life/health Insurance Bariatric furniture or aids
Oversized clothing
Diet products
Weight loss treatment programs
Surgery
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Metabolic Syndrome Diagnostic Criteria
Any 3 of these 5 criteria: • Waist Circumference:
• Steroid hormones
• Antidiabetic drugs:
– > 130 mm Hg systol.
– > 85 mm Hg diast.
– or drug tx for HTN
– Some insulins
– Sulfonylureas
– Thiazolidinediones
– esp. atypicals
– Lithium
• Elevated fasting glucose
– > 100 mg/dl
– Or drug Tx for hyperglycemia
• Reduced HDL‐C
– < 40 mg/dl (or drug tx for 
HDL‐C)
• Rapid assessment Questionnaire:
– AAFP’s AIM‐HI Fitness Inventory
• Food/beverage diary
– Food diary – at least 7 days record EVERYTHING
– Measure/weigh portions
– Paper or smart phone
• Purpose:
Assess eating patterns, Identify high impact foods
Assess patient motivation
Patient learns important skill for weight management
ADVISE: Health Risks of Excess Weight
– “Control” vs. “Cure”
– “Healthy Lifestyle” vs. “Dieting”
– “Best Weight” vs. “Ideal Weight”
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Antiretrovirals
• Antidepressants
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Propranolol
Prazocin
Clonidine
Nisoldipine
Tricyclics
MAO inhibitors
Some SSRIs
Some antiserotonin agents
– Highly active protease inhibitors
– diphenhydramine
ASSESS: Nutrition/Food Intake
Emphasize:
• Benefits of modest weight loss (5‐7%)
• Benefits of physical activity
• Need for long‐term management plan
• Reframe thinking: • Antihypertensives
• Antihistamines
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– Valproic acid
– Carbemazepine
– Gabapentin
• Antipsychotics
• Elevated Triglycerides
– > 150 mg/dl
– or drug tx for TGs
• Antiseizure drugs
– Glucocorticoids
– Estrogens, progestins
• Elevated BP
– Men: > 102 cm (40 in) – Women: >88 cm (35 in)
Common Medications that May Promote
Weight Gain
Leslie WS, Hankey CR, Lean MEJ. Q J Med 2007; 100:395–404; Malone M. Ann Pharmacother 2005;39:2046‐55.
ASSESS: Physical Activity
• Rapid assessment questionnaire:
– AAFP’s AIM‐HI Fitness Inventory
• Current level/type of leisure physical activity
• Risks to increasing physical activity? • Enjoyable physical activities
– organized or informal?
– alone or with others?
– Inside or outdoors?
• Opportunities and barriers for being more active?
• Goal: increase caloric expenditure
“Dieting” vs. “Healthy Lifestyle”
• Dieting = the smallest number of calories and the greatest amount of exercise that a patient can tolerate.
• Healthy Lifestyle = the smallest number of calories and greatest amount of exercise that a patient can enjoy.
• “Best Weight” = the weight the patient can attain while still enjoying their life.
Freedhoff, Sharma, 2010. Canadian Obesity Network.Toronto, Canada.
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ADVISE: Diet & Physical Activity
• The “best diet” has fewer calories than current diet, that the patient can enjoy and follow long‐term • To lose weight, MUST change diet
– Quantity and/or quality of calories
• To maintain weight loss – must increase physical activity
– Caloric requirements decrease with weight loss • Diet Types:
– Low fat
– Low carbohydrate
– Very low calorie
Low-Fat Diet
• Fat restricted to 20‐35% of total calories, sometimes less
• Weight loss:
– After 6 months, the same as low‐carbohydrate
• Metabolic Effects:
– May reduce fasting glucose and insulin
– Moderate decreases LDL‐C, HDL‐C
• Risks:
– Hunger control may be more difficult
– Significant increase in carbohydrates without sufficient weight loss could increase glucose, insulin, TGs and reduce HDL‐C
Freedhoff and Sharma, 2010. Canadian Obesity Network. Toronto, Canada.
Low-Carbohydrate Diet
• 50‐ 150 grams of carbohydrate/day (sometimes less)
• Weight loss: – first 6 months, modestly greater weight loss than low‐fat
– After 6 months the same as other calorie restricted diets
• Metabolic effects:
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Reduced fasting glucose, insulin, TGs
Increased HDL‐C
May increase LDL‐C
May reduce BP
• Risks: carbohydrate cravings
Very Low Calorie Diet
• 400‐ 800 calories/day
– Commonly use commercially prepared formulas
– Need physician supervision
• Weight loss: more rapid that low fat or low carb
• Metabolic effects:
– Reduces fasting glucose, insulin, TGs & BP; may decrease LDL‐C
– May increase HDL‐C
• Risks include: – Fatigue, nausea, diarrhea, constipation, hair loss, cold intolerance
– Kidney and gall stones, gout
– Insufficient mineral intake ‐> palpitations, dysrhythmias, muscle cramps
ADVISE: Other Treatment Options
• Lifestyle
– Nutrition
– Exercise
– Behavioral programs
• Lifestyle + Weight loss medications
– Meal replacements + medications
– Very Low Calorie Diets + Supplements + medications
• Weight loss surgery REQUIRES:
– Long‐term lifestyle change for long‐term success
– Life‐long medical follow‐up
Adapted from Obesity Algorithm®, 2013‐2014 American Society of Bariatric Physicians®
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AGREE: Management Plan and
Goals
• Realistic weight‐loss expectations/targets
– Lose 1 to 2 lbs/week
– Goal: 10% of initial body weight over 6 months
– Best weight vs. Ideal weight
• Behavioral changes
– Dietary
– Physical Activity
• Written agreement/goals
ASSIST: Diet Changes
ASSIST/ARRANGE:
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Provide diet plan
Provide physical activity guide/exercise Rx
Use motivational interviewing
Provide intensive behavioral intervention
– Year 1: 12‐26 visits
– Patient education resources
– Behavioral change tools
• AAFP Practice Resource: Americans in Motion – Healthy Interventions
ASSIST: Cut Portion Sizes &
Record Foods
Identify 10 favorite/common foods
Apply CAMES Approach
• Cutting portion size
• Adding healthful foods
• Moving eating time
• Eliminating foods
• Substituting foods
• “Calibrate”: Measure foods
and drink for 2‐3 days
• Food diaries increase weight loss success
– Paper journal – Smart phone apps
– AIM‐HI Food & Activity Journal
• NHLBI website: “Portion Distortion” interactive quiz
Mckight TL. “Obesity Management in Family Practice” 2006 Springer, New York. 13
ASSIST: Physical Activity
• Low impact exercise prescription
– Walking
– Swimming
– Bicycling/ stationary bike
• Initial Goal: 150 minutes/week
• Self‐monitoring tools
– Pedometer
– Smart‐phone apps
– Activity trackers
Warburton DE, Nicol CW, Bredin SS: CMAJ 2006 174:801‐809.
ASSIST: Intensive Behavioral
ASSIST: Physical Activity Rx
Therapy
• AIM‐HI Fitness Prescription – Opportunity
– Goal
– Dose
– Benefits
Physical Activity, Healthy Eating, Emotional Well‐being
• FITT
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• Year 1: 12‐26 sessions
– CMS covers up to 22 session IBT/12 months
• Suggested schedule:
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Weekly x 1 month
Q 2 weeks x 2 ‐ 6 months
Monthly x 7‐12 months Total 20 visits
Frequency (# times/week)
Intensity (level of effort)
Time (minutes/session)
Types of Activity (restrictions/ not‐recommended
ARRANGE: Follow-up, Referrals
• Follow‐up appointments for – Intensive behavioral treatment (12‐26 sessions/year)
– Medication adjustments
– Monitoring for weight regain
RISKS AND BENEFITS OF
WEIGHT LOSS MEDICATIONS
• Arrange referrals as indicated
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Dietitian
Behavioral health provider
Bariatric medicine provider
Bariatric surgery program
Learning Objective:
Assess risks and benefits of medications as an adjunct to lifestyle changes in patients who have not lost at least 1.11 lbs (0.5 kg)/ week after 3 – 6 months of implementing lifestyle changes alone.
14
Pharmacotherapy
• Indications: • Which of these medications is not approved for long‐
term use in obesity treatment?
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a. Phentermine
b. Orlistat
c. Combination topiramate/phentermine extended release
d. Lorcaserin
e. Metformin
– BMI > 30, or BMI > 27 + 1 comorbidity
– Patients who have not lost at least 1.11 lbs (0.5 kg)/ week after 3 – 6 months of implementing lifestyle changes alone
• FDA Approved
– Short‐term use (< 12 weeks)
– Long term use
• Off label medications
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Phentermine, Diethylpropion,
Phendimetrazine, Benzphetamine
• Noradrenergic sympathicomimetics: suppress appetite
• Not approved for long‐term use
• Phentermine efficacy: 6.3 kg total, 3.6 kg more than placebo (over 36 weeks) • Adverse effects:
– Dysrhythmias, HTN, chest pain, insomnia
Orlistat (Xenical)
• Inactivates gastric & pancreatic lipase: Blocks fat absorption
• Weight loss efficacy: – 12 months: lost 2.5 ‐ 3.4 kg more that behavioral intervention alone – 24 months: lost 2.5 – 3.3 kg additional weight – 4 years: lost average of 2.7 kg (~ 2.4% of IBW)
• Improvements in: – Blood pressure – Insulin resistance,
– Lipid levels
• Contraindications:
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Advanced/symptomatic CAD; Uncontrolled HTN
Hyperthyroid
Glaucoma
Concurrent TCA or recent MAOi use
• Adverse effects:
– Diarrhea, abdominal cramping, fecal incontinence, oily spotting, flatus
Yanovski. JAMA. 2014;311(1):74‐86. Phentermine + Topiramate (Qsymia)
• Reduced appetite
• Weight loss efficacy:
– 1 yr: 8.1 – 10.2 kg (7.8% ‐ 9.8% IBW)
– 2 yrs: 9.3 – 10.5% • Improvements in: BP, lipids, HgB A1c, inflammatory biomarkers, waist circumference
• Contraindications: pregnancy, glaucoma, hyperthyroid, recent MAOi use
• Adverse effects: Parathesias, dizziness, dry mouth, constipation, dysgusia, increases HR, insomnia, • Teratogen (topiramate) – FDA required REM strategy
Lorcaserin (Belviq)
• Selective serotonin 5HT2C agonist – promotes satiety
• Weight loss efficacy:
– 1 yr: 3.2 kg (3.2% IBW) more than placebo
– 2 yrs: lost 3.2 kg more than placebo
• Improvement in: – BP, LDL‐C, TGs, HgbA1c
•
Adverse effects:
– Headache, nausea, fatigue, dizziness
– ? Valvulopathy, HTN (post‐approval monitoring)
15
Metformin (off-label)
• Improves insulin sensitivity
• Off label use for weight loss:
– In pre‐diabetes, insulin resistant states, – To reduce weight gain with antipsychotics
• 3 kg more weight loss over placebo in patients taking antipsychotics
• Weight loss effect is small
– limited usefulness as monotherapy
– helpful if other indications for use
Americans in Motion Healthy Interventions
ADDITIONAL PRACTICE
RESOURCES
Learning Objective:
Establish a multidisciplinary, patient‐centered strategy to manage bariatric treatment options for obese patients; including patient education, evaluation, coordination of care and follow‐up support. Canadian Obesity Network
• Fitness Inventory Questionnaire
• Fitness Rx pad
• Food & Activity Journal
• Patient handouts
• Portion Tools
• Children’s books
• DVD
• Spanish materials
CDC Weight Management
Research to Practice Series
National Institute of Diabetes and Digestive
and Kidney Diseases
• Summaries of research evidence
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Portion size
Fruits & vegatables
Sugar sweetened beverages
Low‐energy dense foods
Away from home foods
• Patient handouts
• Patient tools
16
Practice Recommendations
• Measure and record BMI at each visit for all adults and adolescents.
• Implement the 5 A’s of obesity management
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Ask
Assess
Advise
Agree
Assist/Arrange
Contact
Myra Muramoto, MD, MPH
Email: myram@email.arizona.edu
• Provide intensive behavioral therapy of 12‐26 visits over first year
17

Obesity - American Academy of Family Physicians

Transcription

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