The document discusses obesity, including its definition, prevalence, health risks, and approaches to management. It defines obesity as a BMI of 30 kg/m2 or higher. Treatment involves lifestyle changes like diet and exercise, as well as potential pharmacotherapy or bariatric surgery. Behavioral interventions focus on self-monitoring, stimulus control, and nutrition counseling. Approved prescription medications include orlistat, lorcaserin, and phentermine-topiramate, but all have potential side effects. Bariatric surgery may be considered for those with a BMI over 40 or over 35 with comorbidities.
2. Introduction
prevalence of obesity > 30% in adults
associated with increased risk
cardiovascular disease
type 2 diabetes
cancer (i.e., liver, kidney, breast, endometrial, prostate,
and colon).
Overweight and obesity are chronic diseases with
behavioral origins
3.
4. Definition
Body mass index (BMI)
Overweight = BMI range: 25 - 29 kg/m2,
Obesity = BMI ≥ 30 kg/m2.
Body mass index (BMI)= weight(kg)
height(m2)
5.
6. BMI correlates with the amount of body fat
BMI ≠ directly measure body fat
The National Heart, Lung and Blood Institute (NHLBI)
Waist Circumference
7. The NHLBI defines abdominal obesity as:
Waist circumference
Men > 40 inch (102 cm)
Women > 35 inch (88 cm)
Measure at a level parallel to the floor
midpoint between the top of the iliac crest and the lower margin
of the last palpable rib in the mid axillary line.
12. Behavioral Treatment
The goal is
enable patients to monitoring and modifying their food
intake
increasing their physical activity
recognizing and controlling cues that trigger overeating
Behavioral interventions in conjunction with
dietary or drug therapy are more effective than routine
care alone
13. The United States Preventive Services Task Force(
USPSTF) developed the stepwise framework known as
the 5 A’s
5 A’s
• Ask
• Advise
• Assess
• Assist
• Arrange
14. The 5 A’s for Evaluation and Treatment of Obesity
Assess
• Severity of obesity
BMI
waist circumference
Comorbidities
• Food intake and physical activity
• Medications that affect weight or satiety
• Readiness to change behavior
15.
16. Advise
Diagnosis of overweight, obese, or severe obesity
Caloric deficit needed for weight loss
Various types of diets
Appropriateness, cost, and effectiveness of
meal replacements
dietary supplements
over-the-counter weight aids
medications
surgery
Importance of self-monitoring
17. Agree
patient is not ready
discuss at another visit
patient is motivated and ready to change
develop treatment plan
set weight-loss goal at 10% from baseline
patient can do surgery review options
18. Assist
diet plan, physical activity guide, behaviormodification
guide
Web resources based on patient interest or need
method for self-monitoring (e.g., diary)
Review food and activity diary on follow-up (reassess if
initial goal is not met)
19. Arrange
Follow-up appointments to meet patient
needs
Referral to registered dietitian and/or
behavioral specialist
Referral to surgical program
Maintenance counseling to prevent relapse or
weight regain
*helpful for patients who are ready to change
20. Motivational interviewing
for patients who are ambivalent or hesitant about
making lifestyle changes.
physicians ask questions that lead patients to identify
healthy choices that they want to make
gives them an opportunity for self-examination that
may lead to the realization that they can do more to
improve their health
24. Stimulus Control
help long-term maintenance.
Examples
-eating only at the dining table
-not eating while watching television
-not keeping snack foods at home;
25. Nutrition Counseling
dietary recommendations such as
controlling portion sizes
increasing fruit and vegetable
decreasing saturated fat.
reducedcalorie diet can result in meaningful weight
loss
26. National Heart, Lung and Blood Institute guidelines
suggest reduce caloric intake
Reduce
500 - 1,000
kcal/day
weight loss 1-2 lb
(0.45 to 0.90 kg)
/week.
27. Physical Activity
Physicians should routinely recommend regular
physical activity to all patients, not only to those who
are overweight or obese
The 2008 Physical Activity Guidelines for Americans
recommend
≥ 150 minutes of moderate-intensity aerobic activity per
week or
≥ 75 minutes of vigorous-intensity aerobic activity per
week
Aerobic activity should ≥10 minutes per session and
should be spread throughout the week
28. adults should increase their aerobic physical activity to
300 minutes of moderate-intensity or 150 minutes of
vigorous-intensity aerobic activity per week.
Adults should also engage in muscle-strengthening
activities of moderate to high intensity that involve all
major muscle groups on two or more days per week.
29. Pharmacotherapy Prescription anti-obesity drugs can be useful adjuncts
to diet and exercise
for obese adults who have failed to achieve weight loss
with diet and exercise.
30. Prescription weight-loss drugs are approved for
patients who meet the following criteria:
• BMI of 30 kg/m2 or greater
• BMI of 27 kg/m2 or greater
+ an obesity-related condition
hypertension
type 2 diabetes
dyslipidemia
31.
32. Three prescription medications are currently approved
for longterm management of obesity:
orlistat (Xenical)
lorcaserin (Belviq)
combination phentermine-topiramate extended release
(Qsymia).
36. The effectiveness of orlistat has been demonstrated in several
randomized trials
orlistat plus behavioral interventions lost 8% of baseline weight
compared with 5% in the control group after 12 to 18 months
(Bray GA. Drug therapy of obesity. www.UpToDate.com. Accessed
Jan. 15, 2013.)
orlistat resulted in a weight loss of 6.6 lb (3 kg) more than placebo
(LeBlanc ES, O’Connor E, Whitlock EP,et al. Effectiveness of
primary care-relevant treatments for obesity in adults: A systematic
evidence review for the U.S. Preventive Services Task Force. Ann
Intern Med. 2011;15(7)5:434-447.)
Orlistat also has beneficial effects on blood pressure, insulin
resistance, and lipid levels
(Carter R, Mouralidarane A, Ray S, et al. Recent advancements in
drug treatment of obesity. Clin Med. 2012; 12(5):456-460)
39. The adverse effects of orlistat
diarrhea,
abdominal cramping
fecal incontinence
oily spotting
rare reports of severe liver injury
40. Lorcaserin(belviq)
a selective serotonin(5-hydroxytryptamine, or 5-
HT)subtype 2C receptor agonist
reducing appetite and promoting satiety
The FDA approved lorcaserin in 2012
41.
42. Lorcaserin’s safety and effectiveness were evaluated in
three randomized, placebo-controlled, double-blind
studies that were the basis for FDA approval.
These trials included more than 6,000 patients and
lasted at least one year.
The average weight loss with lorcaserin ranged from 3%
- 3.7% over placebo
47% of participants lost at least 5% of their body weight,
compared with 23% for placebo
•Response to lorcaserin should be assessed at 12
weeks
43. Adverse effect
fewer adverse effects than orlistat
The most common adverse effects with lorcaserin
include headache, dizziness, fatigue, nausea, dry
mouth, and constipation
44. Nonselective serotonergic agonists
increased risk of serotonin-associated cardiac valvular
disease
fenfluramine
dexfenfluramine
Theoretically, lorcaserin should not have the same
cardiac effects .it is a selective agonist of serotonin
receptor 2C. However, there are currently few long-
term safety data
46. Serotonin Mechanisms in Heart Valve Disease
Serotonin up-regulate transforming growth factor
(TGF)-β in mesangial cells via G-protein signal
transduction.
characterized by
hyperplastic valvular
endocardial lesions
47. A, Thickened and retracted aortic
cusp (bold arrow) and deposits of
collagen tissue at base of cusp (thin
arrow) in a rat given serotonin
B, Aortic valve in control rat
C, Shortened, thickened, and
collagen-rich cusp in serotonin-
treated rat with aortic valve
insufficiency
http://circ.ahajournals.org/content/111/12/1517/F4.expansion.html
49. two large randomized, double-blind, placebo-
controlled trials.
(U.S. Food and Drug Administration. FDA approves weight-
management drug Qsymia.
www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/uc
m312468.htm. Accessed Feb. 14, 2013.)
These trials included 3,700 patients treated for up to one
year.
The average weight loss in patients taking phentermine-
topiramate ER ranged
from 6.7% (lowest dose) to 8.9% (recommended dose)
over placebo.
50. 62%of patients taking the lowest dose and 70% taking the
recommended dose lost at least 5% of their body weight,
compared with 20% of patients receiving placeb
slightly more effective than orlistat and lorcaserin.
effect on heart rate limit its use in patients with
cardiovascular disease.
51. adverse effects
The most common adverse effects with phentermine-
topiramate ER include paraesthesia, dizziness,
dysgeusia, insomnia, constipation, and dry mouth
should be discontinued gradually because abrupt
cessation of topiramate has been associated with
seizures in some patients
52. Sympathomimetics
4 sympathomimetic agents are currently approved for
short-term use as weight-loss adjuncts:
phentermine
diethylpropion
benzphetamine
phendimetrazine.
53.
54.
55.
56. causing early satiety
evidence is lacking about the long-term risks and
benefits
These agents are contraindicated in patients with
coronary heart disease, hypertension, hyperthyroidism
57. Bariatric Surgery
considered in adults who have not achieved weight
loss with dietary or other treatments
who have a BMI ≥ 40 kg/m2 or
BMI ≥ 35 kg/m2
+ obesity-related comorbidities
-hypertension
- type 2 diabetes
- obstructive sleep apnea)
58. Bariatric Surgery categorized
Restrictive procedures
limit the size of the stomach.
laparoscopic adjustable gastric banding
vertical sleeve gastrectomy
Malabsorptive procedures
restrict the size of the stomach and involve bypassing
a portion of the small intestine.
Roux-en-Y gastric bypass
59.
60. Sustained changes in diet and exercise habits are
essential following bariatric surgery
National Heart, Lung, and Blood Institute. Classification of overweight and obesity by BMI, waist circumference, and associated disease risks. www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/bmi_dis.htm. Accessed March 1, 2013.