Principles of Weight Management

by R.Daniel Braun,MD Indiana U. School of Medicine

Goals of Obesity Therapy

Old

goal: Reduction to Ideal Weight Most significantly obese individuals can not achieve Ideal weight. Most cannot maintain large weight loss. Frustrating to patients and physicians

Goals of Obesity Therapy

New

Goal: Reduction to a HEALTHIER Body Weight Weight loss of as little as 5-15% of initial weight improves many Obesity-related comorbidities Most patients can achieve and maintain weight losses of 10-15% of initial weight

Long Term Behavioral Rx

Study Perri Maximum Loss 14% @ wk 20 Loss last Treatment visit 13% @ wk 72

Viegener
Wadden

9% @ wk 26
14% @ wk 52

9% @ wk 52
12% @ wk 78

Wing

13% @ wk 26

10% @ wk 52

Long Term Pharmacotherapy

Study Andersen Finer Guy-Grand Weintraub Maximum Loss 15% @ wk 26 12% @ wk 8 11% @ wk 34 16% @ wk 34 Loss last Treatment visit 11% @ wk 52 17% @ wk 34 14% @ wk 52 10% @ wk 52 15% @ wk 54 11% @ wk 156

Challenges in Weight Management

To

facilitate patient and provider acceptance of modest weight loss goals To develop treatment models for long term care To demonstrate the benefits of weight management

Definition of Overweight
Body

Mass Index wt(Kg)/ht(m) 2 or wt(lb)/ht(in) 2 X 70 3 BMI < 27 = Normal weight BMI 27-30 = Overweight BMI 31-39 = Obese BMI >39 = Morbidly Obese

Scope of Problem
300,000

Excess deaths per year due to Obesity 51 % of Population in U.S has BMI>30 58% of Females in U.S. have BMI>30

Phenotype of Obese
1. 2. 3. 4. 5. 6. Family is more likely to be overweight. Poorer fitness than the lean, and lesser tendency to exercise. Age group at onset: infant, teen, or adult Immigrants or those becoming westernized in their own natural surroundings tend to become overweihgt. Many efforts and failures to lose weihgt. Many excuses for not being able to change habits or weight. Overeating (binge eating) typically under stress.

Goals of Treatment
Induce

and maintain weight loss Reduce obesity related co-morbidities Help patients adopt a healthy lifestyle Improve patient satisfaction with outcome.

Benefits of Weight Loss

Decreased

glucose Decreased insulin Decreased triglycerides Decreased LDL Cholesterol Decreased blood pressure Decreased uric acid Increased HDL Cholesterol Improved quality of life

Phases of Treatment
Patient

evaluation Treatment decision and selection Goal setting Induction of weight loss Maintainance of weight loss Long term weight management

Patient Evaluation
Medical

History and physical Ekg, blood chemistry panel, waist and hip cicumferences Behavioral Mood, social support, psychopathology Patient readiness, stress, time availability

Treatment Decision and Selection

BMI Category
<25 25>27 27<30 30<35 35<40 >40

Health Risked based on BMI

Minimal Low Moderate High Very High Extremely High

Presence of a co-morbid condition or other risk factor jumps patient to next level of risk based on BMI.
Shapeup America

Treatment Decision and Selection

Health Risk
Minimal & Low

Treatment Options
Healthful eating &/or moderate deficit diet, Increased physical activity Lifestyle change All of above plus low calorie diet All of above plus pharmacotherapy or very low calorie diet (VLCD) All of above plus surgical intervention

Moderate High & Very High Extremely High

Goal Setting
Dream Weight Happy Weight What you would like to weigh. A weight you would be happy with.

Acceptable Weight Less than above but OK Disappointed Weight Less than current, but more than above.

Goal Setting
60 women mean age 40 years, BMI of 36.3
Current Weight Dream Weight Happy Weight Acceptable Weight Disappointed Weight 99.1 kg 61.4 kg 68 kg 74 kg 82 kg (-38%) (-31%) (-25%) (-17%)

Goal Setting
Weight Goal
Dream Weight

% Achieving
0%

Happy Weight
Acceptable Weight

9%
24%

Disappointed Weight
Less than Disappointed

20%
47%
Foster et.al. J Consult Clin Psychol, 1996

Induction of Weight Loss

Identify

Components of Treatment (Diet, activity, lifestyle modification, Pharmacotherapy, etc. Provide overview of course of initial treatment including duration, schedule of visits, and probable results Identify treatment providers and patients responsibilities for behavior change

Maintainance of Weight Loss

Break

maintainance into semesters and schedule regular visits Identify diet, activity, and life style goals for each visit Increase social support and new activities Provide lapse counselling as needed

Long-Term Weight Control

Establish

weight and health criteria and a schedule for monitoring them Determine when treatment should be reinitiated and approach to be used Alleviate patients shame and guilt concerning weight regain

Predictors of Weight Loss

Body

Weight Resting Metabolic Rate Self Efficacy (Says Yes I can do that) Good Attendance Early Weight Loss

Predictors of Greater Weight Loss

Longer

Treatment Pharmacotherapy Supervised Physical Activity Lifestyle Modification

Characteristic of Weight Loss Maintainers

Exercizes

Regularly Monitors weight Regularly (Daily even) Eats Low fat diet tailored to food preferences Has problem focussed coping skills Monitors fat intake peiodically (Food diary esp when weight starts up) Takes medication on regular basis

Caloric Energy Balance

Body

weight remains same when: Caloric Intake = Caloric Expenditure Intake (we all know about that Expenditure 1.Resting Metabolic Rate=(60-70%) Expenditure 2.Thermic Effect of Food= (5-10%) Expenditure 3.Physical Activity = rest of Expenditure

_iet
Careful

Training in : Selection of lower fat foods Modified food guide pyramid Increase fruits & vegetables Lower fat preparation techniques Estimation of portion size

_iet
Moderate

deficit (- 500 Kcal/day) 1200-1500 for women & 1400-2000 for men Low calorie (- 800-1200 Kcal/ day) Very low calory diet (VLCD) (< 800 Kcal/ day)

Energy Deficit Calculation

Calculate

REE (Resting Energy Expenditure) REE = {9.99 * Wt.(Kg)} + {6.25 * Ht. (Cm.)} {4.92 * Age} =Kcal/day Multiply REE by activity factor (AF) AF = 1.6 for males and 1.5 for females Subtract 500 from Result. This = recommended caloric intake and will result in loss of 1 pound per week.

Exercise
Not

enough by itself Hard to Succeed without it 30 min/day (3-7 days/week)

Behavior Modification
Identify

barriers to changing eating and exercise patterns Once identified, change and modify those barriers Involves identifying reasons for inappropriate eating and exercise and changing them

Pharmacologic Management of Obesity

Goal:

To help obese patients achieve a reduction in food intake and a higher level of energy expenditure, not for 3 months or 3 years, but for a lifetime.

History of Obesity Pharmacotherapy

1930s

Scolex 1950s Amphetamines Sold by MDs 1960s Phenethylamines Amphetamine-like agents (Not addictive) 1970s Drug abuse transformation Controlled Substances act 1980s Market dried up (Stigma) 1990s Introduction of New Agents Break three month barrier

Leptin
Protein

produced by the ob gene Obese humans have higher concentrations than non obese counterparts NEJM 1996;334:292-295 Phase I clinical trials began late 1996

Sibutramine
Developed

as Antidepressant & Obesity Inhibits monoamine reuptake Lacks anticholinergic activity No diabetic problem exacerbation Phase I & II trials Adv. Effects Insomnia,irritability, tachycardia HTN in Afr.-Amer. (3-4Torr in whites & 20Torr in Afr.-Amer.

Orlistat/Hydrolipistatin
Potent

gut irreversible lipase inhibitor Pancreatic lipase divides FFA from glycerol Reduces triglyceride and cholesterol absorption Eliminated in feces Lowers Cholesterol (4-11%) & LDL (5-10%) Not dependant on amt fat or fiber ingested 120 mg TID [ac, during, or pc]

Cholecystokinin-8 Agonists
Sulfated

carboxy-terminal of cholecystokinin CCK-8released in response to food intake Generates satiety signal CCK-8 is a peptide. Cannot be given orally or IV Agonists block endogenous CCK-8 breakdown by tripeptidyl peptidase II (TPPII) Duration of action too short for efficacy; looking for other analogues

Initial Weight Loss Response Predicts Long Term Response

Those

who lose 4# in 1st 4 weeks (78%) Mean weight loss = 22 # 60% lost 10% of initial weight Those who do not lose 4# in 1st 4 weeks Mean weight loss = 6 # Only 10% lost 10% of initial weight

For Those Who Dont Lose Weight

Reassess:

Understanding and compliance with diet. physical activity, and drug regimen Accuracy of weight recordings Possible Fluid retention (salt intake, etc) Changes in medical condition Motivation for change Social and personal stress Is the provider of health care the root of the problem ?

For Those Who Dont Lose Weight and There is no Cause Except Noncompliance with Diet & Exercise
Consider changing medication consider referral to: Dietitian Behavioral counsellor Exercise professional Weight Watchers Reconsider goal: i.e. simple maintainance or a rest from weight loss efforts Discuss surgical options if medically or psychologically indicated

Obesity Surgery
Vertical

Banded Gastroplasty 238 patients averaging 245% of IBW lost to average of 140% of IBW After 6 years averaged 150% of IBW

Am.J Surg 1989;157:150-155