WHAT IS OBESITY MEDICINE?

WHAT IS OBESITY MEDICINE?

CLASS II OBESITY CLASS III OBESITYNORMAL WEIGHT OVERWEIGHT CLASS I OBESITYClassification (kg/m2):

18.5-24.9 25.0-29.9 30.0-34.9 35.0-39.9

HOW DO YOU MEASURE OBESITY?

CHRONIC WEIGHT MANAGEMENT REDUCES

THE COST OF LIVING BY REDUCING: 10, 11, 12 CHRONIC WEIGHT MANAGEMENT ALSO REDUCES

DISEASE RISK 13

MEDICATIONS CO-PAYS

FOOD COSTS ACCIDENT PRONENESS

RISK FOR CANCER & OTHER CHRONIC

DISEASES

HOSPITALIZATIONS

MEDICAL VISITS

TIME OFF WORK AND LOST WAGES

Potential impact of 5% average BMI reduction in the U.S. by 2020:

Million hypertension cases avoided3.5 Million cancer

cases avoided0.3

Million heart disease and stroke cases avoided2.9

Million diabetes cases avoided3.6 Million arthritis

cases avoided1.9

BODY MASS INDEX 1, 2 ,3

WHAT DOES COMPREHENSIVE MEDICAL OBESITY TREATMENT INCLUDE?

Behavior MedicationPhysical ActivityNutrition

OBESITY MEDICINE: THE FIELD OF MEDICINE DEDICATED TO THE COMPREHENSIVE CARE OF PATIENTS WITH OBESITY

References: 1 De Lorenzo A, Soldati L, Sarlo F, Calvani M, Di Lorenzo N, Di Renzo L: New obesity classification criteria as a tool for bariatric surgery indication. World J Gastroenterol 2016 22:681-703; 2 Rahman M, Berenson AB: Accuracy of current body mass index obesity classification for white, black, and Hispanic reproductive-age women. Obstet Gynecol 2010 115:982-988; 3 Misra A, Shrivastava U: Obesity and dyslipidemia in South Asians. Nutrients 2013 5:2708-2733; 4 American Council on Exercise: What are the guidelines for percentage of body fat loss? http://www.acefitness.org/acefit/healthy-living-article/60/112/what-are-the-guidelines-for-percentage-of-body-fat (Accessed August 20, 2016). 2009; 5 Jacobson TA IM, Maki KC, Orringer CE, Bays HE, Jones PH, McKenney JM, Grundy SM, Gill EA, Wild RA, Wilson DP, Brown WV: National Lipid Association recommendations for patient-centered management of dyslipidemia: Part 1 - executive summary. J Clin Lipidol 2014 8:473-488; 6 Bays H: Central obesity as a clinical marker of adiposopathy; increased visceral adiposity as a surrogate marker for global fat dysfunction. Curr Opin Endocrinol Diabetes Obes 2014 21:345-351; 7 Carroll JF, Chiapa AL, Rodriquez M, Phelps DR, Cardarelli KM, Vishwanatha JK, Bae S, Cardarelli R: Visceral fat, waist circumference, and BMI: impact of race/ethnicity. Obesity 2008 16:600-607; 8 Wang Z, Ma J, Si D: Optimal cut-off values and population means of waist circumference in different populations. Nutr Res Rev 2010 23:191-199; 9 Sharma AM, Kushner RF: Int J Obes 2009;33:289-95; 10 Health Management Research Center, University of Michigan, 2001; 11 U.S. Bureau of Labor Statistics, Consumer Expenditures in 2006; 12 Colditz, GA: Economic costs of obesity and inactivity. Med Science Sports Exercise 1999; 13 Levi et al: F as in fat: how obesity threatens America’s future. 2012. 14 Waters H, DeVol R: Weighing down America: The health and economic impact of obesity. Milken Institute 2016.

>40

LOOKING BEYOND BMI:

ACCEPTABLE OBESITYClassification: Classification:ESSENTIAL FAT ATHLETES FITNESS

2-5% 6-13% 14-17% 18-24% >25%

>32%10-13% 14-20% 21-24% 25-31%

PERCENT BODY FAT 4 WAIST CIRCUMFERENCE 5, 6, 7, 8

ABDOMINAL OBESITY

>40inches

>102centimeters

STAGE 0 STAGE 1 STAGE 2 STAGE 3 STAGE 4

The Edmonton Obesity Staging System applies a staging system of the medical, mental, and possible functional limitations a patient with obesity may experience, helping clinicians assess risk for that individual and evaluate how their weight affects their health.

No obesity-related risk factors

Pre-clinical risk factors: borderline HTN or DM, minor aches, or psychopathology

Established obesity-related disease: HTN, DM, PCOS, moderate limitations of ADL

Established organ damage: MI, CHF, DM comp, significant limitations of ADL

Severe disabilities: end stage and limitations (e.g., wheelchair use)

EDMONTON OBESITY STAGING SYSTEM 9

>35inches

>88centimeters

%

Clinical Pearls What Is Obesity Medicine?

1) Obesity medicine is the field of medicine dedicated to the comprehensive care of patients with obesity.

2) Obesity medicine clinicians often use measurements other than BMI to diagnose obesity.

3) The comprehensive clinical approach to obesity treatment involves nutrition, physical activity, behavior, and medication.

4) Even modest (5%) weight loss is clinically meaningful and reduces the cost of living for patients with obesity.

5) In 2014, the direct and indirect costs associated with treating obesity and obesity-related conditions totaled $1.42 trillion.14

6) Comprehensive obesity treatment may include intermediary procedures or surgical intervention.

What Is Obesity Medicine?

Behavior MedicationAssessment and Evaluation

Chronic Disease of

Obesity

Physical ActivityNutrition

About the Obesity Medicine Association

The Obesity Medicine Association (OMA) is the largest organization of clinicians dedicated to preventing, treating, and reversing the disease of obesity. Members of OMA believe treating obesity requires a scientific and individualized approach comprised of nutrition, physical activity, behavior, and medication. When personalized, this comprehensive approach helps patients achieve their weight and health goals. Learn more at www.obesitymedicine.org.

Continue Learning Online

Visit bit.ly/obesity-treatment to watch the Fundamentals of Obesity Treatment Course on demand through the Obesity Medicine Academy. This course, worth 4.5 CME/CE credit hours, provides a high-level overview of the six components of clinical obesity treatment and offers tips for implementing basic evaluation and treatment techniques in practice.

Want more? The Obesity Medicine Academy is the premier online learning platform for evidence-based, peer-reviewed education. The Academy’s library contains more than 200 hours of clinically focused education on the most effective approaches for treating obesity and obesity-related conditions. Continue learning now at www.OMAcademy.org.

Chronic Disease of Obesity

Assessment and Evaluation

Nutrition Physical Activity Behavior Medication

© Obesity Medicine Association. All rights reserved. Materials may not be reproduced, redistributed, or translated without written permission.

About the Obesity Treatment Foundation

The Obesity Treatment Foundation is a 501(c)(3) charitable organization developed to elevate awareness among health care providers that obesity is a chronic disease and to amplify the quality and quantity of clinician-driven, practice-based obesity treatment research. Learn more at www.obesitytreatmentfoundation.org.

101 University Blvd. Ste. 330 | Denver, CO 80206 | p 303.770.2526 | f 303.779.4834 | [email protected]

ELEVATEDBLOOD

PRESSURE

DYSLIPIDEMIA

ELEVATED GLUCOSE

CENTRAL ADIPOSITY

Obesity is a chronic, relapsing, multi-factorial, neurobehavioral disease, wherein an increase in body fat promotes adipose tissue dysfunction and abnormal fat mass physical forces, resulting in adverse metabolic, biomechanical, and psychosocial health consequences.

The Definition of Obesity

Obesity Is a Multi-factorial

Disease

Health Consequences of Obesity

Metabolic Syndrome Is a Complex Condition

Impact of Insulin Resistance1

INSULIN RESISTANCE

Impaired Glycemia

Retinopathy, Nephropathy, Neuropathy

Microvascular DiseaseStroke, Coronary Heart Disease

Macrovascular Disease

Metabolic Syndrome

Type 2 Diabetes

Early Cardiovascular Disease

Dyslipidemia

Obesity Hypertension

DiseaseSystem

Cardiovascular

Endocrine

Pulmonary

Gastrointestinal

Neurologic

Renal

Musculoskeletal

Oncology

Hematology

Integument

Psycho-social

Myocardial Infarction • Stroke •Peripheral Vascular Disease • Hypertension • Congestive Heart Failure and Cor Pulmonale • Hypertension • Thromboembolic Events • Varicose Veins

Type 2 Diabetes • Gout • Polycystic Ovary Syndrome • Infertility

Dyspnea • Obstructive Sleep Apnea • Hypoventilation Syndrome • Pickwickian Syndrome • Asthma

Nonalcoholic Fatty Liver Disease • Cholelithiasis • GERD • Hernias

Intracranial Hypertension • Stroke • Nerve Entrapment

Nephrolithiasis • Glomerulopathy • Renal Cancer

Osteoarthritis (Knees, Hips) • Immobility • Low Back Pain • Myalgia • Impaired Balance • Gait Disturbance

Breast Cancer • Endometrial Cancer • Esophageal Cancer • Colon Cancer • Pancreatic Cancer

Prothrombic State • Multiple Myeloma

Stasis Pigmentation • Venous Stasis Ulcers • Cellulitis • Skin Tags • Intertrigo • Carbuncles

Depression • Low Self-esteem • Hopelessness • Body-image Dissatisfaction • Diminished Sex Drive • Impaired Intimacy and Sexual Relationships

COMMON COMPONENTS OF METABOLIC SYNDROME

All content, unless otherwise noted, is adapted from the Obesity Algorithm®. 1. ACCORD STUDY, ADVANCE STUDY JAMA. 2008;300(17):2051-2053

MEDICAL

NEUROBEHAVIO

RAL

IMM

UN

E

GENETIC / EPIGEN

ETIC

EN

DO

CR

INE

EN

VIRONMENT

How Obesity Relates to Metabolic Syndrome and Insulin Resistance

Metabolic consequences of obesity include the components of metabolic syndrome plus proinflammatory and prothrombic states.

Type 2 diabetes is closely associated with obesity and begins with insulin resistance that starts 10 to 15 years prior to diagnosis.

CHRONIC DISEASE OF OBESITY


BehaviorAssessment and Evaluation

Physical ActivityNutrition Medication

Clinical Pearls Chronic Disease of Obesity

1) The negative health impacts of obesity can be broadly characterized as metabolic, biomechanical, or psychological.

2) Hunger and satiety are regulated extensively by a complex system of hormones released by the gastrointestinal system, adipose tissue, and brain.

3) Obesity is strongly associated with multiple cancers, including esophageal, endometrial, and breast cancer.




The Obesity Medicine Association (OMA) is the largest organization of clinicians dedicated to preventing, treating, and reversing the disease of obesity. Members of OMA believe treating obesity requires a scientific and individualized approach comprised of nutrition, physical activity, behavior, and medication. When personalized, this comprehensive approach helps patients achieve their weight and health goals.

Contact Us

101 University Blvd. Ste. 330 | Denver, CO 80206 p 303.770.2526 | f 303.779.4834 | [email protected] www.obesitymedicine.org








OF OBESITY MANAGEMENT

AVOID DEROGATORY LANGUAGE

INSTEAD OFUSE

Overweight

Unhealthy Weight

Heavy

Eating Habits

Physical Activity

Fat

Obese

Morbidly Obese

Diet

Exercise

5 A’S

y For permission to discuss body weight

y About readiness for change

ASK

y About health benefits of modest weight loss (5-10%)

y About long-term strategy and treatment options

ADVISE

y Identify and address barriers

y Provide resources

y Schedule regular follow-up

ARRANGE/ASSIST

y BMI, waist circumference, obesity stage

y Drivers and complications of excess weight

ASSESS

y On realistic expectations, targets, and behavioral changes

AGREE

PATIENT HISTORY

Weight Gain Medical

Previous Weight Loss Eating Disorders

Nutrition

Family

Social

Physical Activity

Age of onset Highest/lowest weight Rate of weight gain Inciting factors/major

life events

Past/current medical problems

Surgical history Allergies Current medications

What’s been tried What worked What didn’t work Motivators

Prior diagnosis Medical treatment(s)

Eating patterns Triggers Reasons for eating out Household factors

Obesity Metabolic diseases Psychiatric disorders

Readiness Motivators Education Occupation Family/household Sleeping behavior Major life stresses/events Tobacco/alcohol/cannabis

/other drug use

Current level of activity Favorite activities Activities able

to maintain Barriers

1 2

3

45

PERFORM A PHYSICAL EXAMINATION

BLOOD PRESSURE

WAISTCIRCUMFERENCE

NECKCIRCUMFERENCE

1. Vallis M, Piccinini-Vallis H, Sharma AM, Freedhoff Y: Clinical review: Modified 5 As: Minimal intervention for obesity counseling in primary care. Can Fam Physician 2013 59:27-31.

RESPIRATORYRATE

EKG

ALSO EXAMINE:- Resting Metabolic Rate- Body Mass Index- Body Composition

1

ASSESSMENT AND EVALUATIONA COMPONENT OF CLINICAL OBESITY TREATMENT


MedicationBehaviorChronic Disease of

Obesity

Physical ActivityNutrition Medication

Clinical Pearls

1) Obtain the patient’s current weight and a thorough weight history during the initial evaluation.

2) Obesity can be defined by an elevated BMI, body fat percentage, waist circumference, and other metabolic factors. Bioelectric impedance is the most commonly used method of measuring body fat percentage.

3) During the physical examination, acanthosis nigricans is a sign of insulin resistance.

4) Laboratory tests and EKG are an important part of the evaluation to diagnose diseases related to obesity.

5) The initial assessment should determine if the patient has other medical problems related to obesity. These co-morbidities need to be monitored as well.






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DIETARY FACTORS TO CONSIDER

CONSIDER THE PATIENT’S:

COMMON NUTRITIONAL APPROACHES

Low-carbohydrate Diet

Mediterranean Diet

Low-fat Diet

<45% of calories from carbohydrates

Ketogenic (< 50 g carbohydrates)

35-40% fat

Fish, nuts, healthy fats, fruits, vegetables, whole grains, legumes, dairy

<20% fat, 55-65% carbs, ~15% protein

<10% saturated fat

triglycerides, HDL cholesterol

cardiovascular mortality, type 2 diabetes

total cholesterol, LDL cholesterol

Characteristics

Characteristics

Health Benefits

Health Benefits

Health Benefits

Health Benefits

Characteristics

DASH Diet

Dietary approaches to stop hypertension

Not intended for weight loss unless caloric intake is restricted

blood pressure

Health Benefits

Characteristics

Meal Replacements

Pre-packaged foods

Isocaloric energy-restricted meal replacements

Can be used with any dietary approach

Greater weight loss with 2 meal replacements per day compared to less frequent use.1

1. Tsai AG, Wadden TA. Obesity 2006;14(8):1283-1293.

Regardless of macronutrient composition, all diets should include physician education and patient monitoring to maintain safety and achieve the optimal long-term effects.

Personal preferences Ethnic or religious requirements Allergies and food intolerances Comorbidities: Hypertension, type 2 diabetes,

dyslipidemia, gout, recurrent kidney stones, liver or kidney disease

Nutritional needs

There are many different dietary options that work, but the right one to use will depend on the individual patient.

Vegetarian Diet

Exclusion of all or most animal proteins

Protein sources: Low-fat dairy, soy, legumes, whole grains, nuts, seeds

LDL cholesterol, cardiovascular mortality, type 2 diabetes

Characteristics Characteristics

Health Benefits

NUTRITIONA COMPONENT OF CLINICAL OBESITY TREATMENT


Clinical Pearls

1) The diet that works is the one the patient can stick with and incorporate into their lifestyle long-term.

2) Think beyond calories – current evidence suggests that not all calories are created equal.

3) Saturated fats and unsaturated fats provide a source of energy, but like calories, not all fats are created equal.

4) Meal replacement strategies can be very effective for weight loss and weight maintenance.

Nutrition

Nutrition


BehaviorPhysical ActivityAssessment and Evaluation

MedicationChronic Disease of

Obesity



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*Donnelly J. Am College Sports Med. 2009.**U.S. Health and Human Services. 2008.

— Moderate aerobic exercise 150 min/week + strength training at least 2x/week

— 150-250 minutes per week*— 150-300 minutes per week**

— 200-300 minutes per week*— 300-420 minutes per week**

HEALTH BENEFITS:

Cardiovascular functionBlood glucose regulation

DyslipidemiaIndependenceSocialization

Sexual functionHDL cholesterol

IMPROVES Blood pressure

Risk of certain cancersMortality rateMedications

Dementia riskPain

Depression

REDUCES

Non-Exercise Activity Thermogenesis (NEAT)

NOT ALL PHYSICALACTIVITY IS EXERCISE

Common daily activities, such as walking, standing, and climbing stairs, can result in up to 2,000 kcal of energy expenditure per day.

CORECOMPONENTSOF AN EXERCISEPRESCRIPTION

FREQUENCY

INTENSITY

TIME

TYPE

ENJOYMENT

GENERAL HEALTH BENEFIT

PREVENTION OF WEIGHT GAIN

PREVENTION OF WEIGHT REGAIN

HOW MUCH PHYSICAL ACTIVITY IS ENOUGH?

GETTING STARTED

Low or no-impact activities

Balance training

Strength training

START


PHYSICAL ACTIVITYA COMPONENT OF CLINICAL OBESITY TREATMENT


BehaviorChronic Disease of

Obesity

Nutrition Medication

Physical Activity


1) Know the physical activity guidelines and share them with your patients. They can’t hit the mark if they don’t know the goal.

2) Set realistic expectations with your patients about physical activity and weight loss. While weight loss is difficult with physical activity alone, it is necessary for successful weight maintenance.

3) Work with your patients to determine the physical activities that meet their interests, needs, and abilities.

4) Identify appropriate resources to share with your patients, such as those available from the Obesity Action Coalition.

5) Have your patients self-track their progress and review it together at follow-up visits.

Physical ActivityClinical Pearls



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INTERPERSONAL THERAPY

COGNITIVE BEHAVIORAL THERAPY

MOTIVATIONAL INTERVIEWING

CORE SKILLS FOR

MOTIVATIONAL

INTERVIEWING

SPIRIT OF

MOTIVATIONAL

INTERVIEWING

Open questions

AffirmationsReflectionsSummaries

CompassionAcceptancePartnershipEvocation

OBESITY

Self-Monitoring

Social Support

StimulusControl

CognitiveRestructuring

ContingencyManagement

Problem-Solving

Stress Management

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

Resolution of conflicts

Adaptation for change

Focus on only one or two problem areas

Target deficits

STAGES OF CHANGE

Pre-contemplation: No intention to change / unaware of need to change

Action: Build self-awareness; discuss risks and benefits; explore ambivalence

Contemplation: Aware of a need to change / interested in changing within next six months

Action: Resolve ambivalence; explore pros and cons; assess knowledge

Preparation: Open to and willing to change within next 30 days

Action: Resolve ambivalence / get commitment

Action: Initiation of change / committing to goal

Action: Provide tailored self-help materials and encouragement for small changes

Maintenance: Continued change for longer than six months

Action: Continued positive reinforcement and periodic follow-up

1

2

3

4

5

BEHAVIORS OF SUCCESSFUL WEIGHT MAINTAINERS*

78% eat breakfast every day

62% watch less than 10 hours of TV per week

90% exercise, on average, about one hour per day

weigh themselves at least once per week75%

*National Weight Control Registry Data; Wyatt et al. Obes Res 2002 Feb;10(2):78-82; Butryn et al. Obesity 2007 Dec;15(12) 3019-6; Raynor et al. Obesity 2006 Oct;14(10); Phelan et al. Obesity 2006 Apr;14(4):710-6.

BEHAVIORAL THERAPY TECHNIQUES

BEHAVIORA COMPONENT OF CLINICAL OBESITY TREATMENT


Nutrition Physical ActivityAssessment and Evaluation

MedicationChronic Disease of

ObesityBehavior


Clinical Pearls

1) Behaviors are affected by brain neurotransmitters, specifically dopamine and serotonin, and are often beyond an individual’s willpower.

2) Recognizing that positive behavioral change can be achieved and maintained is integral to clinically significant weight management.

3) Motivational interviewing and collaborative goal-setting are effective tools in the primary care setting.

4) Understand your role as a clinician in helping patients with the stages of change, utilizing the 5 A’s of obesity management1, and implementing SMART (specific, measurable, achievable, relevant, time-based) goals.

5) Sleep disorders, disordered/dysfunctional eating, and carbohydrate cravings can influence and be influenced by behaviors.

Behavior

1. Vallis M, Piccinini-Vallis H, Sharma AM, Freedhoff Y: Clinical review: Modified 5 As: Minimal intervention for obesity counseling in primary care. Can Fam Physician 2013 59:27-31.



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Purposes: Mechanisms of Action:Anti-obesity medications alter physiology, not only behaviors.

� Treat the disease of obesity � Facilitate the management

of eating behavior � Slow the progression of weight

gain and regain � Improve the weight, health, and

quality of life of the patient

� Decrease hunger � Decrease appetite � Increase satiety � Decrease cravings

� Block fat absorption � Increase adherence by

mitigating biological or genetic factors

Anti-obesity medications are most effective as part of a comprehensive treatment plan that includes nutrition, physical activity, and behavior modification.

How Anti-obesity Medications Make a Difference

Medication Class Mechanisms of Action for Weight Loss

Sympathomimetic aminesPhentermine*, Phendimetrazine*, Diethylpropion*

Orlistat (Xenical®, alli®)

Lorcaserin (Belviq®)

Phentermine/ Topiramate ER (Qsymia®)

Naltrexone/Bupropion (Contrave®)

Liraglutide (Saxenda®)

Pancreatic lipase inhibitor

Serotonin 5HT2c agonist

Sympathomimetic amine + anti-epileptic

Stimulates POMC; naltrexone blocks beta endorphin-mediated suppression of alpha MSH

GLP-1 agonist

Decreases absorption of fat

Decreases appetite and food intake through release of catecholamines in hypothalamus

Decreases food intake and increases satiety through activation of POMC neurons in hypothalamus

Reduces appetite, decreases food consumption and satiety enhancement through release of catecholamines in the hypothalamus

Exerts effect on appetite regulatory center and the reward system to regulate appetite and reduce cravings

Increases satiety, decreases food intake and appetite via GLP-1 receptors in brain

The Anti-obesity Medications:

Manage Your Patients’ Expectations in Advance

DOCUMENT

PARTICIPATE

CONSULT

� Rationale: Initial drug prescription and prescription changes

� Every Visit: Vital signs, appearance, mood, beneficial and adverse effects

� Utilize the Obesity Medicine Association’s CME to keep up with trends and learn best prescribing practices

� Always review the PI � Be aware of the stoppage rules: 5% weight loss

at 12 weeks of full-dose therapy for phentermine, phendimetrazine, diethylpropion, orlistat, lorcaserin, phentermine/topiramate, and naltrexone/bupropion, and 4% weight loss at 12 weeks of full-dose therapy for liraglutide

Discuss anticipated results prior to treatment and set realistic goals.

� Weight loss is often slower than patients expect

� What a patient calls a plateau is often the expected treatment response

� Maintaining weight loss is difficult without an intervention plan

� Regular or intermittent medications may be necessary for long-term maintenance

� Obesity is a chronic disease requiring lifelong treatment

� Long-term favorable patient health outcomes are the primary goal of therapy

� 5-10% weight loss produces health benefits

Always check with your local and state medical/pharmacy boards before prescribing anti-obesity medications. Local and state laws and regulations may vary.

Good Practices When Prescribing Anti-obesity Medications

*FDA-approved only for short-term usage but frequently prescribed off-label for longer durations.

MEDICATIONA COMPONENT OF CLINICAL OBESITY TREATMENT

BehaviorAssessment and Evaluation

Chronic Disease of

Obesity

Physical ActivityNutrition

Clinical Pearls Medication

1) Medication is an evidenced-based tool to support the physiologic and behavioral changes necessary for sustained weight loss.

2) As with other chronic diseases, medications for the treatment of obesity should be used long-term.

3) Medications used to treat other chronic diseases may cause weight gain. It is important to identify these medications during the initial evaluation and switch the patient to a weight-negative medication if possible.

4) Individualizing treatment to meet the patient’s needs is important and should include a comprehensive treatment plan in addition to anti-obesity medication.

5) Individuals who have undergone bariatric surgery may also benefit from an anti-obesity medication post-surgically to control their disease, particularly if they experience weight regain.

Medication




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WHAT IS OBESITY MEDICINE?

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