Nutrition in Obesityd2j7fjepcxuj0a.cloudfront.net/wp-content/uploads/2013/12/13ACG... · Type 2 DM...

Stephen A. McClave, MD

Nutrition in ObesityNutrition in Obesity

Stephen A. McClave, MDStephen A. McClave, MDLouisville, KentuckyLouisville, Kentucky, y, y

Aspects of Obesity Aspects of Obesity CounterCounter--IntuitiveIntuitive

Hides in plain sight, Hides in plain sight,

not recognizednot recognized

Cli i llCli i ll h th t

Hides in plain sight, Hides in plain sight,

not recognizednot recognized

Cli i llCli i ll h th t

Obe

se P

atie

nts (

%)

0

20

40

60

80

100

Overall * Obesity Obesity

80%80%Missed Missed

DxDx

Clinically Clinically heterogeneousheterogeneous

Not a single disorderNot a single disorder

Many clinical typesMany clinical types

Did not start in the past 30 yearsDid not start in the past 30 years

Clinically Clinically heterogeneousheterogeneous

Not a single disorderNot a single disorder

Many clinical typesMany clinical types

Did not start in the past 30 yearsDid not start in the past 30 years

Obesity management made (%)Obesity management not made (%)

Overall *(n=2,543)

Obesitydiagnosed

(n=505)

Obesitynot diagnosed

(n=2,037)

Not just problem of eating too muchNot just problem of eating too much

Very common, growingVery common, growing

Global health priority, not just USGlobal health priority, not just US

Frustrating, resistant to RxFrustrating, resistant to Rx

Not just problem of eating too muchNot just problem of eating too much

Very common, growingVery common, growing

Global health priority, not just USGlobal health priority, not just US

Frustrating, resistant to RxFrustrating, resistant to Rx Peeters Ann Intern Med 2003;138:24Peeters Ann Intern Med 2003;138:24

ACG Regional Postgraduate Course - Nashville, TN Copyright 2013 American College of Gastroenterology

1


Female

NetherlandsNetherlands USUS FranceFrance JapanJapan

Peeters Ann Intern Med 2003;138:24Peeters Ann Intern Med 2003;138:24

Arg Mex Russ Eng Ger Fin Spa Ital FraArg Mex Russ Eng Ger Fin Spa Ital Fra

Male

BMI BMI 25.225.228.628.6 25.525.523.723.7

Increasing ObesityIncreasing Obesity

19631963

20132013

With obesity:With obesity:↓Life expectancy↓Life expectancy↑Chronic disease↑Chronic disease↑Co↑Co--morbid conditionsmorbid conditions

Peeters Ann Intern Med 2003;138:24Peeters Ann Intern Med 2003;138:24


2


Obesity is an Global Epidemic

BMI as an Estimate of Obesity in Asians?BMI as an Estimate of Obesity in Asians?

(Recommend adding 2 points(Recommend adding 2 pointsto BMI for Asian population)to BMI for Asian population)

Who is at High Risk? Who is at High Risk?

Limits of BMILimits of BMI

Metabolic Syndrome Metabolic Syndrome

Increased diabetes, cardiovascular dz, Increased diabetes, cardiovascular dz, , ,, ,

renal dz, hepatic steatosisrenal dz, hepatic steatosis

All studies use BMI, not waist circum All studies use BMI, not waist circum

Harmful effects may not be present Harmful effects may not be present

especially at lower BMI rangeespecially at lower BMI range

Axelsson J Amer J Clin Nutr 2004;80(5):1222Axelsson J Amer J Clin Nutr 2004;80(5):1222


3


Who is at High Risk? Who is at High Risk?

Limits of BMILimits of BMI

•• Impact of central adiposity Impact of central adiposity 11

ICU Mort 25% 44% with central adiposityICU Mort 25% 44% with central adiposity

1 1 CCM 2010;38:1308 CCM 2010;38:1308 22 Moisey LL (Crit Care 2013;17:R206)Moisey LL (Crit Care 2013;17:R206)

ICU Mort 25%→44% with central adiposityICU Mort 25%→44% with central adiposity

•• Impact of sarcopenic obesity Impact of sarcopenic obesity 22

Trauma study (n=149, 71% sarc, 47% overwght/obese)Trauma study (n=149, 71% sarc, 47% overwght/obese)Mortality (14Mortality (14→→32%), 32%), ↓ICU↓ICU--free days, ventfree days, vent--free days with sarcopenia free days with sarcopenia

ObesityObesity

Historical ViewHistorical ViewHistorical ViewHistorical View

FatFatStoresStores

•• Lifestyle choiceLifestyle choice

•• Character flaw (willpower, psychology)Character flaw (willpower, psychology)

Current PerspectiveCurrent Perspective

Complex physiologyComplex physiologyEpidemic from changes in modernEpidemic from changes in modern environmentenvironment

•• Lifestyle choiceLifestyle choice

•• Character flaw (willpower, psychology)Character flaw (willpower, psychology)

Current PerspectiveCurrent Perspective

Complex physiologyComplex physiologyEpidemic from changes in modernEpidemic from changes in modern environmentenvironment Epidemic from changes in modern Epidemic from changes in modern environmentenvironment

Widely recognized as a disease Widely recognized as a disease Huge burden of associated illnessHuge burden of associated illness Devastating effect on efficacy, quality of lifeDevastating effect on efficacy, quality of life

Epidemic from changes in modern Epidemic from changes in modern environmentenvironment Widely recognized as a disease Widely recognized as a disease Huge burden of associated illnessHuge burden of associated illness Devastating effect on efficacy, quality of lifeDevastating effect on efficacy, quality of life


4


Influence of GeneticsInfluence of Genetics85% of US Population at Risk for Obesity85% of US Population at Risk for Obesity

TimingTiming BeforeBefore 18 Days18 Days 21 Days21 Days

BP, mmHgBP, mmHg 110/70110/70 150/100150/100

Weight (lbs)Weight (lbs) 185185 203203

Li idLi id LipidsLipids

TCholTChol 165165 225225 230230

TrigTrig 6060 220220 263263

Liver enzymesLiver enzymes

ALTALT 2020 290290 528528

ASTAST 2121 130130 187187

Influence of GeneticsInfluence of Genetics15% of US Population may be 15% of US Population may be

Protected from ObesityProtected from Obesity

Don Gorski Don Gorski

Fonde du Lac, WisconsinFonde du Lac, Wisconsin

6 foot 2, 184 pounds, BMI = 23.86 foot 2, 184 pounds, BMI = 23.8


5


Obesity and Gut FloraObesity and Gut Flora

LeanLean

Obesity = ↑ Firmicutes : Bacteroidetes ratioObesity = ↑ Firmicutes : Bacteroidetes ratio

DiBaise (Mayo Clin Proceed 2008;83:460)DiBaise (Mayo Clin Proceed 2008;83:460)

ObeseObese

Obesity and Gut FloraObesity and Gut Flora

1.1. ↑ Energy extraction↑ Energy extraction

↑Firmicutes : Bacteroidetes Ratio↑Firmicutes : Bacteroidetes Ratio

2.2. ↓ Fasting↓ Fasting--induced induced adipocyte factoradipocyte factor

3.3. ↑ Adipose deposition↑ Adipose deposition

4.4. ↑ Gut permeability↑ Gut permeability

55 ↑ LPS inflammation↑ LPS inflammation

(Mayo Clin Proceed 2008;83:460)(Mayo Clin Proceed 2008;83:460)

5.5. ↑ LPS, inflammation ↑ LPS, inflammation

6.6. ↓ Insulin sensitivity↓ Insulin sensitivity


6


Obesity and Gut FloraObesity and Gut FloraFirmicutes : Bacteroidetes (F:B) RatioFirmicutes : Bacteroidetes (F:B) Ratio

Animal ClinicalAnimal Clinical

Obese have Obese have ↑ F:B ratio↑ F:B ratio yes yes (?)yes yes (?)

Weight loss causesWeight loss causes ↓ F:B ratio↓ F:B ratio yesyes yesyes Weight loss causes Weight loss causes ↓ F:B ratio↓ F:B ratio yesyes yesyes

High Fat Western (HFW) diet ↑ F:B ratioHigh Fat Western (HFW) diet ↑ F:B ratio yesyes yesyes

Prebiotic prevents weight gain on HFWPrebiotic prevents weight gain on HFW yesyes yesyes

Probiotic causes weight lossProbiotic causes weight loss yesyes nono

Obese microbiota cause ↑ wght in leanObese microbiota cause ↑ wght in lean yes ???yes ???

DiBaise (Mayo Clin Proceed 2008;83:460)

Complications of ObesityComplications of Obesity

MetabolicMetabolic Diabetes, NAFL, gallstonesDiabetes, NAFL, gallstonesgynecologic abnormalitiesgynecologic abnormalities

GERD d t C b iGERD d t C b i

InflammatoryInflammatory

StructuralStructural

DegenerativeDegenerative 606060GERD, pseudotumor Cerebri,GERD, pseudotumor Cerebri,

sleep apnea, hypertension sleep apnea, hypertension

Arthritis, autoimmuneArthritis, autoimmune

Degenerative joint diseaseDegenerative joint disease

PsychologicalPsychological

NeoplasticNeoplastic606060

Prostate, breast, ovarian, endometrial, Prostate, breast, ovarian, endometrial, cervical, lymphoma, renal cellcervical, lymphoma, renal cell

Depression, anxiety panic attacks,Depression, anxiety panic attacks,eating disorderseating disorders


7


Top Three Diseases Due to Obesity:Top Three Diseases Due to Obesity:

Sleep apnea (95%)Sleep apnea (95%)

Type 2 DM (61%)Type 2 DM (61%)

Gallstones, HTN, Gallstones, HTN,

Asthma (25Asthma (25--30%)30%)

Wolf AM (Obes Res 1998;6:97) Wolf AM (Obes Res 1998;6:97) Suratt PM (NEJM 1999)Suratt PM (NEJM 1999)

Variable BMIVariable BMI--Disease RelationshipsDisease Relationships

GallstonesGallstonesDiabetesDiabetes

Rel

ativ

e R

isk

Rel

ativ

e R

isk Elevated cholesterolElevated cholesterol

HypertensionHypertensionVenous thrombosisVenous thrombosisMortalityMortality

Body Mass IndexBody Mass Index2020 3030 3535 4040 45452525


8


Alterations in Hunger/Satiety SignalsAlterations in Hunger/Satiety Signals

HypothalamusHypothalamus

Gh liGh li L l l ( ) l f PP d li (i )L l l ( ) l f PP d li (i )Ghrelin Ghrelin –– Lower levels (approp), loss of PP decline (inapprop)Lower levels (approp), loss of PP decline (inapprop)

PYYPYY –– Lower levels (inapprop), less PP rise (inapprop)Lower levels (inapprop), less PP rise (inapprop)

Insulin Insulin –– Higher levels (approp), but receptor abnormalitiesHigher levels (approp), but receptor abnormalities

Leptin Leptin –– Higher levels (approp), but receptor abnormalitiesHigher levels (approp), but receptor abnormalities

Adiponectin Adiponectin –– Lower levels (inapprop)Lower levels (inapprop)

Resistin Resistin –– Levels increased (inflammation)Levels increased (inflammation)

Obesogenic EnvironmentObesogenic Environment

Energy Dense FoodsEnergy Dense Foods

Fast FoodFast FoodTrans FatsTrans FatsHigh Fructose Corn SyrupHigh Fructose Corn Syrup

Portion SizesPortion Sizes

Decreased Physical ActivityDecreased Physical Activity


9


Fast Food NationFast Food Nation

Preschoolers in 2009 exposed to 21% more McDonaldPreschoolers in 2009 exposed to 21% more McDonald’’s s ads, 9% more Burger King ads, and 56% more Subway ads, 9% more Burger King ads, and 56% more Subway ads compared to 2007ads compared to 2007

84% parents take kids to fast food at least once per week84% parents take kids to fast food at least once per week

Only 12% meals meet basic nutritional standardsOnly 12% meals meet basic nutritional standards

Ronald McDonald character retiredRonald McDonald character retired

California sues McDonaldCalifornia sues McDonald’’s over Happy meals over Happy meal

Etiology of ObesityEtiology of ObesityIncreased Portion SizesIncreased Portion Sizes

Increased caloric intake by 220 calories from 1970 to 1990 Increased caloric intake by 220 calories from 1970 to 1990

Increased portion sizes (Increased portion sizes (““supersuper--sizesize””))p (p ( pp ))

Increased frequency of eating outside the homeIncreased frequency of eating outside the home

FatFat--free foods perceived as low calorie or calorie freefree foods perceived as low calorie or calorie free

Increased fast food consumptionIncreased fast food consumption

Ernst [ Amer J Clin Nutr 1997;66(suppl):965S ]Ernst [ Amer J Clin Nutr 1997;66(suppl):965S ]


10


Etiology of Obesity Etiology of Obesity Labor Saving DevicesLabor Saving Devices

•• TeleTele--commutingcommuting

•• Internet / EInternet / E--mailmail

•• TeleTele--commutingcommuting

•• Internet / EInternet / E--mailmail

•• Cellular phonesCellular phones

•• EE--CommerceCommerce

•• Cellular phonesCellular phones

•• EE--CommerceCommerce

•• Food deliveriesFood deliveries

•• Computer gamesComputer games

•• Moving sidewalksMoving sidewalks

•• Garage door openersGarage door openers

•• Food deliveriesFood deliveries

•• Computer gamesComputer games

•• Moving sidewalksMoving sidewalks

•• Garage door openersGarage door openers

•• Escalators/elevatorsEscalators/elevators

•• DriveDrive--in windowsin windows

•• IntercomsIntercoms

•• Remote controlsRemote controls

•• Escalators/elevatorsEscalators/elevators

•• DriveDrive--in windowsin windows

•• IntercomsIntercoms

•• Remote controlsRemote controls

Added Factor Impacting Outcome Added Factor Impacting Outcome One HitOne Hit--Two Hit Immunologic ModelTwo Hit Immunologic Model

Fat and JollyFat and JollyInflamed Inflamed

(Low Grade SIRS)(Low Grade SIRS)


11


Relationship Between Relationship Between Adipocytes and Macrophages Adipocytes and Macrophages

Nat Rev Immunol Nat Rev Immunol 2006;2006;6:7726:772

LeptinLeptin

Monocyte :Monocyte :ActivationActivationLeptinLeptin

XX

Obesity Increases LevelsObesity Increases Levels

MacrophageMacrophage

ActivationActivationProliferationProliferationMigrationMigration

↑iNOS↑iNOS↑ROS↑ROS

pp

PhagocytosisPhagocytosis

p38p38ERKERK

MicroMicro--organismorganism

IncreasedIncreased↑ROS↑ROS

TNFTNFILIL--66ILIL--1212

P

P

STAT3STAT3 Oxidative StressOxidative Stress

Clinical Effects:Clinical Effects:Insulin resistenceInsulin resistenceIncreased SIRS Increased SIRS Endothel damageEndothel damage


12


AdiponectinAdiponectin Obesity Decreases LevelsObesity Decreases Levels

TLRTLR 44TLRTLR--44

Insulin sens,Insulin sens,Fat oxidation Fat oxidation

HepatocyteHepatocyteCardiac muscCardiac muscSkeletal muscSkeletal musc

AdipocyteAdipocyte

Fat SynthesisFat Synthesis

Disregulated AdipokinesDisregulated Adipokines


13


Type and Distribution of AdiposeType and Distribution of Adipose

Type of Fat : Type of Fat : ypypLCFA >> MUFA >> PUFALCFA >> MUFA >> PUFA(esterified to triglycerides better)(esterified to triglycerides better)

Worst CaseWorst Case: LCFA in organ: LCFA in organBest CaseBest Case: PUFA as trig in periphery: PUFA as trig in periphery

LipotoxicityLipotoxicityStorage of Fat Exceeds Capacity of the Organ,Storage of Fat Exceeds Capacity of the Organ,

Leading to Cellular and Organ DysfunctionLeading to Cellular and Organ Dysfunction

LiverLiverSkeletal MuscleSkeletal Muscle


14


I liI li

EndEnd--Organ EffectsOrgan EffectsOf LipotoxicityOf Lipotoxicity

Insulin Insulin ResistenceResistence

DiabetesDiabetes

DiabeticDiabeticCardiomyopathyCardiomyopathy

NAFLD/NASHNAFLD/NASH

Do Obese Patients Do Obese Patients Have Plenty of Have Plenty of

Nutritional Nutritional Reserves?Reserves?

Jeevanandam M (JCI 1991;87:262)Jeevanandam M (JCI 1991;87:262)


15


Impact of Obesity Impact of Obesity on Hospitalizationon Hospitalization

•• Interferes with patient careInterferes with patient careCannot turn patients wellCannot turn patients well

Pressure soresPressure soresAtelectasis, pneumoniaAtelectasis, pneumonia

Difficult to ventilateDifficult to ventilate –– Apnea, restrictive lung diseaseApnea, restrictive lung diseaseDifficult to ventilate Difficult to ventilate Apnea, restrictive lung diseaseApnea, restrictive lung diseaseDifficulty with diagnostic testsDifficulty with diagnostic tests

TransportTransportDonDon’’t fit in CT, MRIt fit in CT, MRI

Unable to ambulate Unable to ambulate –– High risk for DVTHigh risk for DVT

•• Hepatobiliary diseaseHepatobiliary diseaseNAFL NASH cirrhosisNAFL NASH cirrhosisNAFL, NASH, cirrhosisNAFL, NASH, cirrhosis

•• Respiratory abnormalitiesRespiratory abnormalitiesCentral sleep apneaCentral sleep apneaObstructive sleep apneaObstructive sleep apneaRestrictive lung diseaseRestrictive lung disease

ObesityObesity--Associated Associated Management IssuesManagement Issues

Positioning and transportPositioning and transport

Technical monitoring problemsTechnical monitoring problems

Vascular, surgical accessVascular, surgical access

Neural blockadeNeural blockade

Tracheal intubationTracheal intubation

Airway maintenanceAirway maintenance

Altered pharmacokineticsAltered pharmacokinetics

Aspiration riskAspiration risk

Impaired ventilationImpaired ventilation

Disordered gas exchangeDisordered gas exchange


16


General Care in the ICUGeneral Care in the ICU More bariatric equipmentMore bariatric equipment

Lift TeamsLift Teams

Work related injuriesWork related injuries

Specialized lifting devicesSpecialized lifting devices

Stay in ICU longerStay in ICU longer

Morbidity and Mortality from ObesityMorbidity and Mortality from Obesity

TraumaTrauma Med ICUMed ICU

•• InfectionInfection Increased Increased Increased (VAP)Increased (VAP)

•• Hosp ICU LOSHosp ICU LOS IncreasedIncreased IncreasedIncreased

(Add 2 A(Add 2 AIIIIpoints)points)

Hosp, ICU LOSHosp, ICU LOS IncreasedIncreased IncreasedIncreased

•• MOFSMOFS Increased (x2)Increased (x2) IncreasedIncreased

•• Durat MVDurat MV IncreasedIncreased IncreasedIncreased

•• MortalityMortality Increased (x7)Increased (x7) DecreasedDecreased

Cave, Hurt, Frazier, McClain, McClave (NCP 2008;23:16Cave, Hurt, Frazier, McClain, McClave (NCP 2008;23:16--34)34)


17


Does Obesity Protect Against Mortality?Does Obesity Protect Against Mortality?

Mortality Mortality BENEFITBENEFIT moremorelikely to be seen:likely to be seen:

BMI=32

BMI=16BMI=27

BMI=41

BMI=22

Sur

viva

l Medical ICUMedical ICUObservational studiesObservational studiesControls low BMI<20Controls low BMI<20

Mortality Mortality RISK RISK more more likely to be seen: likely to be seen:

Time (yr)

Peake SL (Medscape Med 2010) Peake SL (Medscape Med 2010)

Trauma SICUTrauma SICUH1N1H1N1MetaMeta--analysis, PRCTsanalysis, PRCTsControls normal wghtControls normal wght

Relationship of BMI to Morbidity and MortalityRelationship of BMI to Morbidity and Mortality

Mullen Ann Surg 2009;250:166Mullen Ann Surg 2009;250:166––172 172 (*p<0.05 vs OR 1.0)(*p<0.05 vs OR 1.0)


18


Assessment Assessment of Obesityof Obesity

WHO Obesity Classification 2013 Kaafarani M (Surg Clin N Am 2011;91:837)WHO Obesity Classification 2013 Kaafarani M (Surg Clin N Am 2011;91:837)

Assessment of ObesityAssessment of Obesity

•• Body Mass IndexBody Mass Index

Weight (kg)/height (m)Weight (kg)/height (m)22

Weight (lb)/height (in)Weight (lb)/height (in)22 x 703x 703Weight (lb)/height (in)Weight (lb)/height (in)22 x 703x 703

•• Waist Circumference (High risk defining upper body obesity)Waist Circumference (High risk defining upper body obesity)

Men >102 cm (40 in.)Men >102 cm (40 in.)

Women >88 cm (35 in.)Women >88 cm (35 in.)

•• Measured at midMeasured at mid--point between the ileac crest and the lower ribpoint between the ileac crest and the lower ribMeasured at midMeasured at mid point between the ileac crest and the lower rib point between the ileac crest and the lower rib

Correlates to intraCorrelates to intra--abdominal adipose tissue on CT, MRIabdominal adipose tissue on CT, MRI

•• High waist circumference associated with increased risk of:High waist circumference associated with increased risk of:

Type 2 DiabetesType 2 Diabetes DyslipidemiaDyslipidemia

HypertensionHypertension ASCVDASCVD


19


Determine Absolute Risk StatusDetermine Absolute Risk Status

•• Disease conditions Disease conditions

CHD type 2 diabetes sleep apneaCHD type 2 diabetes sleep apnea

Concomitant CVD Risk Factors (Add to BMI, Waist Circ) Concomitant CVD Risk Factors (Add to BMI, Waist Circ)

CHD, type 2 diabetes, sleep apneaCHD, type 2 diabetes, sleep apnea(+ = very high risk)(+ = very high risk)

•• ObesityObesity--associated diseases associated diseases Gyn abnormalities, osteoarthritisGyn abnormalities, osteoarthritis

•• Cardiovascular risk factorsCardiovascular risk factorsS ki HTN hi h LDL l HDL I i d l t lS ki HTN hi h LDL l HDL I i d l t lSmoking, HTN, high LDL, low HDL, Impaired gluc tol, Smoking, HTN, high LDL, low HDL, Impaired gluc tol,

family hx (family hx (>>3 = high risk)3 = high risk)

•• Other risk factors:Other risk factors:

Physical inactivityPhysical inactivity

High serum triglycerides (>200 mg/dL)High serum triglycerides (>200 mg/dL)

Obesity Treatment PyramidObesity Treatment Pyramid

SSurgery

Pharmacotherapy

Lifestyle Modification

Diet Physical Activity


20


Health Benefits of Weight Loss

•• Possible Health Benefits:Possible Health Benefits:

Cardiovascular riskCardiovascular risk Blood pressureBlood pressure

Glucose and insulin levelsGlucose and insulin levels Symptoms of DJDSymptoms of DJD

LDL and triglycerides, HDLLDL and triglycerides, HDL Severity of sleep apneaSeverity of sleep apnea

Improved gynecological conditionsImproved gynecological conditions

•• Weight loss of Weight loss of 55––1010% in obese, type 2 diabetes, HTN, dyslipidemia:% in obese, type 2 diabetes, HTN, dyslipidemia:

Improved glycemic controlImproved glycemic control

Reduced blood pressureReduced blood pressure

Improved lipid profileImproved lipid profile

Goldstein (Int J Obes 1992;16:397) Wing (Arch Int Med 1987;147:1749)Goldstein (Int J Obes 1992;16:397) Wing (Arch Int Med 1987;147:1749)

Intentional Weight Loss and Reduction in MortalityIntentional Weight Loss and Reduction in Mortality

6060

Reduction of Adjusted Mortality Rate (%)Reduction of Adjusted Mortality Rate (%)

6060

5050

4040

3030

2020

11––19 lbs lost19 lbs lost

All All Cardiovasc Cancer Obesity Diabetes Cardiovasc Cancer Obesity Diabetes CausesCauses DiseaseDisease Related RelatedRelated Related

Cancer ConditionsCancer Conditions

Williamson (Amer J Epidemiol 1995;141:1128)Williamson (Amer J Epidemiol 1995;141:1128)

1010

00


21


Psychological and Psychological and Behavioral AssessmentBehavioral Assessment

Treatment for chronic binge eating Treatment for chronic binge eating or emotional eatingor emotional eating

Psychological counseling for Psychological counseling for untreated depression, anxiety, untreated depression, anxiety, substance abuse, or other mental health issuessubstance abuse, or other mental health issues

Neuropsychological or other cognitive testingNeuropsychological or other cognitive testing Current and past eating and exercise behaviorsCurrent and past eating and exercise behaviors Understanding, motivation for medical or surgical weight lossUnderstanding, motivation for medical or surgical weight loss

Expectations for treatment outcomes (weight loss, quality of life,Expectations for treatment outcomes (weight loss, quality of life,different treatment options)different treatment options)

Available social supportAvailable social support Current stressors and coping strategiesCurrent stressors and coping strategies

Guide for Selecting Obesity TreatmentGuide for Selecting Obesity Treatment

25–26.9 27–29.9 30–34.9 35–39.9 ≥40

BMI Category (kg/m2)

Treatment

Diet, Exercise,Behavior Tx

Pharmaco-therapy

+ + + + +

With co-morbidities + + +

The Practical Guide: Obesity in Adults (October 2000, NIH Pub No.00The Practical Guide: Obesity in Adults (October 2000, NIH Pub No.00--4084)4084)

therapy

Surgery

morbidities

With co-morbidities +


22


Key Behaviors of Successful Key Behaviors of Successful LongLong--term Weight Managementterm Weight Management

National Weight Control Registry: 3000 pts, aver loss 70 lbs/6 yrsNational Weight Control Registry: 3000 pts, aver loss 70 lbs/6 yrs

•• SelfSelf--monitoring:monitoring:•• SelfSelf--monitoring:monitoring:SelfSelf--monitoring:monitoring:

Diet: record food intake dailyDiet: record food intake daily

Weight: check body weight Weight: check body weight ≥≥ once per wkonce per wk

•• LowLow--calorie, lowcalorie, low--fat diet:fat diet:

Total energy intake: 1300Total energy intake: 1300––1400 kcal/d 1400 kcal/d

Energy intake from Energy intake from fatfat : : 20%20%––25%25%

SelfSelf--monitoring:monitoring:

Diet: record food intake dailyDiet: record food intake daily

Weight: check body weight Weight: check body weight ≥≥ once per wkonce per wk

•• LowLow--calorie, lowcalorie, low--fat diet:fat diet:

Total energy intake: 1300Total energy intake: 1300––1400 kcal/d 1400 kcal/d

Energy intake from Energy intake from fatfat : : 20%20%––25%25%gygy

•• Eat breakfast dailyEat breakfast daily

•• Physical activity:Physical activity: 25002500––3000 kcal/wk (eg, walk 4 mi/d)3000 kcal/wk (eg, walk 4 mi/d)

gygy

•• Eat breakfast dailyEat breakfast daily

•• Physical activity:Physical activity: 25002500––3000 kcal/wk (eg, walk 4 mi/d)3000 kcal/wk (eg, walk 4 mi/d)

Klem (Amer J Clin Nutr 1997;66:239) McGuire (Int J Obes 1998;22:572)Klem (Amer J Clin Nutr 1997;66:239) McGuire (Int J Obes 1998;22:572)

Create a Negative Energy BalanceCreate a Negative Energy Balance3500 kcal = 1 pound of fat3500 kcal = 1 pound of fatSafe weight loss is 1Safe weight loss is 1--2 pounds/week2 pounds/week500 kcal/day deficit needed to achieve 1 lb wght loss/week500 kcal/day deficit needed to achieve 1 lb wght loss/week

Reduce intake by 300 kcal:Reduce intake by 300 kcal:Reduce intake by 300 kcal:Reduce intake by 300 kcal: Or increase activity by 300 kcal:Or increase activity by 300 kcal:

Eliminating Eliminating 2 oz potato 2 oz potato

chips chips

Running 3 Running 3 miles in 30 min miles in 30 min

Substituting Substituting 2 diet sodas 2 diet sodas for 2 regular for 2 regular

sodassodas

Bicycling 8 Bicycling 8 miles in 30 min miles in 30 min

or oror


23


Energy Energy DensityDensity

•• Gastric distention affectsGastric distention affects

meal sizemeal size

•• Isoenergetic low densityIsoenergetic low density

foods cause more gastricfoods cause more gastric

distentiondistention

1200 Kcal Each1200 Kcal Each

•• Obese subjects may chooseObese subjects may choose

foods of higher densityfoods of higher density

Am J Clin Nutrit 2001;73:999 Am J Clin Nutrit 2001;73:999

Diet Energy Density Influences Diet Energy Density Influences ShortShort--term Body Weightterm Body Weight

3

2g)

Energy DensityHighMedium

6 Pts over 3 cross6 Pts over 3 cross--over 14 day periodsover 14 day periods

0

2

1

dy

Wei

gh

t C

han

ge

(kg Medium

Low

*p=0.038, treatment effect Stubbs (Int J Obes 1996;22:980)

1 142 3 4 5 106 7 8 9 11 12 13

Days

-1

-2

Bo


24


Which Weight Which Weight Loss Diet Loss Diet

is the Best ?is the Best ?

Key: Macronutrient composition doesn’t matter! Use what works!Key: Macronutrient composition doesn’t matter! Use what works!

Comparison of Popular Diets for Weight Comparison of Popular Diets for Weight Loss and Heart Disease Risk ReductionLoss and Heart Disease Risk Reduction

Results at 12 monthsResults at 12 months

• LDL decreased in all groups LDL decreased in all groups •• R ti f LDL/HDL d d 10% i llR ti f LDL/HDL d d 10% i ll

AtkinsAtkins ZoneZone Wt WatchersWt Watchers OrnishOrnish

Hi prot, hi fatHi prot, hi fat ←(same)←(same) Lo cal, balancedLo cal, balanced Lo fat, hi carbLo fat, hi carb

ParticipationParticipation 53%53% 65%65% 65%65% 50%50%

Wt. LossWt. Loss 2.1 kg2.1 kg 3.2 kg3.2 kg 3.0 kg3.0 kg 3.3 kg3.3 kg

•• Ratio of LDL/HDL decreased 10% in all groups Ratio of LDL/HDL decreased 10% in all groups •• CRP decreased 15CRP decreased 15--20% in all groups20% in all groups•• Trig, BP, fasting glucose not significantly alteredTrig, BP, fasting glucose not significantly altered•• Amount of weight loss predicted improvement in Amount of weight loss predicted improvement in

cardiac risk factorscardiac risk factors

Dansinger, etal JAMA 293:1, 2005Dansinger, etal JAMA 293:1, 2005


25


Obesity Management Obesity Management Which Diet is Best?Which Diet is Best?

GD Foster (Ann Internal Med 2010) Sacks ( NEJM 2009; 360:859)GD Foster (Ann Internal Med 2010) Sacks ( NEJM 2009; 360:859)

Is Exercise Is Exercise Important?Important?

Myth: Exercise is not a good weight loss strategyMyth: Exercise is not a good weight loss strategy

Only 5% of population meet exercise requirementsOnly 5% of population meet exercise requirements Only 5% of population meet exercise requirementsOnly 5% of population meet exercise requirements

Easier to create energy deficit by less food intakeEasier to create energy deficit by less food intake

•• Food restriction Food restriction –– Key to weight lossKey to weight loss

•• Physical activity Physical activity –– Key to maintenance of weight lossKey to maintenance of weight loss

Biological, environmental pressures oppose food restrictionBiological, environmental pressures oppose food restriction

(but not physical activity)(but not physical activity)JO Hill (JADA 2005;105:S63)JO Hill (JADA 2005;105:S63)


26


Benefits of Exercise in ObesityBenefits of Exercise in Obesity

•• Decreases loss of fatDecreases loss of fat--free mass free mass associated with wght loss associated with wght loss

•• Improves maintenance of wght lossImproves maintenance of wght loss

•• Decreases loss of fatDecreases loss of fat--free mass free mass associated with wght loss associated with wght loss

•• Improves maintenance of wght lossImproves maintenance of wght lossImproves maintenance of wght lossImproves maintenance of wght loss

•• Improves cardiovascular, metabolic Improves cardiovascular, metabolic health, independent of wght losshealth, independent of wght loss

•• Pedometer to measure stepsPedometer to measure steps

(goal 10,000 steps per day)(goal 10,000 steps per day)

Improves maintenance of wght lossImproves maintenance of wght loss

•• Improves cardiovascular, metabolic Improves cardiovascular, metabolic health, independent of wght losshealth, independent of wght loss

•• Pedometer to measure stepsPedometer to measure steps

(goal 10,000 steps per day)(goal 10,000 steps per day)

DietDiet ExerciseExercise Diet + ExerciseDiet + Exercise

Wght loss (kg)Wght loss (kg) 10.7 10.7 ±± 0.50.5 2.9 2.9 ±± 0.40.4 11.0 11.0 ±± 0.60.6

% Body fat decrease% Body fat decrease 6.0 6.0 ±± 1.01.0 3.5 3.5 ±± 0.50.5 7.3 7.3 ±± 0.80.8

Wght loss at 1 year (kg)Wght loss at 1 year (kg) 6.6 6.6 ±± 0.50.5 6.1 6.1 ±± 2.12.1 8.6 8.6 ±± 0.80.8

Despres (Med Sci Sports 1991)Despres (Med Sci Sports 1991)

35*p<0.05

Exercise Helps Preserve FatExercise Helps Preserve Fat--Free Free Mass, Longterm Weight LossMass, Longterm Weight Loss

10

15

20

25

30

0

5

Diet Only Diet Plus Physical Activity

Ballor (Int J Obes Relat Metab Disord 1994;18:35)Ballor (Int J Obes Relat Metab Disord 1994;18:35)Jakicic (JAMA 2003)Jakicic (JAMA 2003)

Men

Women


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Pharmacologic Pharmacologic TherapyTherapy

FDAFDA--approved for wght lossapproved for wght loss FDAFDA approved for wght lossapproved for wght lossXenical (Orlistat) Xenical (Orlistat) –– Blocks GI lipaseBlocks GI lipasePhentermine Phentermine -- SympathomimeticSympathomimeticBelviq (Lorcaserin) Belviq (Lorcaserin) –– 55--HT Serotonin agonist HT Serotonin agonist Qysmia (Phenteramine + Topiramate) Qysmia (Phenteramine + Topiramate) –– Appetite suppressantAppetite suppressant

FDAFDA--approved for other reasons, with wght loss effectsapproved for other reasons, with wght loss effectsMetforminMetformin DiabetesDiabetesMetformin Metformin -- DiabetesDiabetesWellbutrin Wellbutrin –– AntiAnti--anxiety, smoking cessationanxiety, smoking cessationTopamax (Topiramate) Topamax (Topiramate) -- MigraineMigraine

Emerging agentsEmerging agentsContrave (Buproprion/Naltrexone) Contrave (Buproprion/Naltrexone) –– ↓↓Dop/Norepi, narc antag,Dop/Norepi, narc antag,↑satiety↑satietyLiraglutide, Byetta Liraglutide, Byetta –– GLPGLP--1 agonists (1 agonists (↓appetite, ↓gastric emptying)↓appetite, ↓gastric emptying)

Pharmacologic TherapyPharmacologic Therapy

Withdrawn: Aminorex, Sibutramine, Rimonabant, Withdrawn: Aminorex, Sibutramine, Rimonabant, Fenfluramine/dexfenfluramine, DinitrophenolFenfluramine/dexfenfluramine, Dinitrophenol

Overall impact on obesity managementOverall impact on obesity management Overall impact on obesity managementOverall impact on obesity management

Most associated with mild weight lossMost associated with mild weight loss

Longterm effects at one year modest as single therapyLongterm effects at one year modest as single therapy

Aid to exercise, behavior modificationAid to exercise, behavior modification

Value as side effect when selecting drug for other purposesValue as side effect when selecting drug for other purposes

BY Cheung (Ther Adv Drug Safe 2013;4:171) Davidson (JAMA 1999)


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Endoscopic Approaches Endoscopic Approaches to Weight Lossto Weight Loss

Bridge to Bariatric Surgery ? Bridge to Bariatric Surgery ?

The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again.The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again.

EndoCinchEndoCinch


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Bariatric ProceduresBariatric Proceduresn = 22,094 patients ; 2738 citations 1990n = 22,094 patients ; 2738 citations 1990--20022002

Type of ProcedureType of Procedure Lap BandLap Band VSGVSG GBPGBP

% Performed% Performed 37% 6% 57%37% 6% 57%

Excess Weight lostExcess Weight lost 47%47% 55% 62%55% 62%

Operative mortalityOperative mortality 0.1%0.1% 0.1% 0.1% 0.5%0.5%

Resolution of diabetesResolution of diabetes 47%47% 70%70% 84%84%

Buchwald (JAMA 2004;292:1724) Brethauer (SOARD 2009;4: 469)Buchwald (JAMA 2004;292:1724) Brethauer (SOARD 2009;4: 469)

Bariatric SurgeryBariatric SurgerySweedish Obese Sweedish Obese

Subjects (SOS) TrialSubjects (SOS) Trial

Remission fromDiabetes Mellitus

*

*

*p<0.001p<0.001

Sjostrom (J Int Med 2012) Carlsson (NEJM 2012) Sjostrom (JAMA 2004)Sjostrom (J Int Med 2012) Carlsson (NEJM 2012) Sjostrom (JAMA 2004)


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What Can You Do to Help?What Can You Do to Help?

DonDon’’t skip mealst skip meals

Quick Advice Bullet PointsQuick Advice Bullet Points

Liquid calories countLiquid calories count

Portion controlPortion control

Caloric densityCaloric density

Record log of weight Record log of weight and eatingand eating

Increase activityIncrease activity

ConclusionsConclusions

Expect tremendous impact of Expect tremendous impact of obesityobesity on care and on care and management of patients in and out of the hospitalmanagement of patients in and out of the hospital


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