Adult Obesity Medicine In A Nutshell - PeaceHealth
AdultObesity Medicinein a NutshellKENNA WOOD, DODiplomate American BoardOf Obesity Medicinekwood3@peacehealth.org
Disclosures I have no financial disclosures
Purpose of this presentation Provide a broad overview of thepractice of obesity medicineDetails on the slides can be usedas a guide
ObjectivesUnderstand why obesity isconsidered a disease withmultiple etiologiesUnderstand how to communicatewith patients about their weightand secondary conditionsUnderstand the fundamentals ofdiscussing physical activity andvarious diet options to treatobesityUnderstand the importance ofsleep in affecting weightUnderstand the medications thataffect weightReview the laws affectingcontrolled medications forbariatric practiceReview sources of additionalcontinuing medical education onobesity medicine
Why is obesity CME needed? There is an epidemic Not currently taught in schools Very few providers know how to treat obesity Prevent obesity in children/future adults
Definitions OverweightBMI 25.0-29.9 Class 1 obesityBMI 30.0-34.9 Class 2 obesityBMI 35.0-39.9 Class 3 obesityBMI 40.0
https://www.cdc.gov/obesity/data/databases.html
https://www.cdc.gov
Weight bias Check your biases at the door No one deserves weight problems Every patient deserves respect
What factors contribute toobesity? Food environment StressMicrobiome Home Society Hormones Genetics Sleep Sedentarylifestyles/sedentary jobsDisability
Foodenvironments
Food environment (or lack of access to healthy foods)
HormonesWait, what?!!!
Sicat, J. Pathophysiology (Part 1) OMA presentation
Genetics
Genetics PraderWilli Leptin deficiency
Genetics MC4R Anddeficiencymany others
Sleep
Evidence Sleep loss is associated with obesity Hasler et al. (2004): prospective, N 500, followed 13 years Lower duration of sleep lead to higher BMI atend of study
Evidence Wisconsin Sleep Study, Taheri et al. Sleep 2004. N 1024. Adults With with 7.7 hrs sleep had the lowest BMIless sleep, lower leptin levels, & higher ghrelin levelsReproduced 2 additional studies (n 12 and n 740)
Stress
IntestinalMicrobiomes:associated withobesity
Sedentary jobs/lives
Disability
“Eat less, move more”is not how it worksIt is not that simple.
How do you get started? Ask permission to discuss weightDiscuss: Diet Exercise Sleep/screen for sleep apnea Review medications Determine if medications that control hungerare appropriate to start Determine if patient is a candidate forbariatric surgery
Definition of success 5-10 % total body weight loss within 6months and maintained for at least 1 year
Diet Start with simple changes: Cut down/eliminate sugar sweetenedbeverages & ALL soda Increase vegetable intake Consider meal replacements as an option Use small plates Food order matters
Diet Food order matters Shukla et al. 2015 N 11 Lower glucose &insulin levels withprotein & veggiebefore simplecarbsShukla et al. 2015
Diet Primary diets used for weight loss Plant based dietLow carbohydrate diets (high protein or highhealthy fat/moderate protein) How many grams of carbs? What about patients with CKD, gout, renal stones, gallstones?Mediterranean diet
Mediterranean diet VS Low FatDiet PREDIMED- Primary Prevention of CVD with a Mediterranean Diet Supplemented with EVOOor nuts Parallel group, multi-center, RCT N 7447 High risk for CVD Energy unrestricted Mediterranean diet supplemented with EVOO Energy unrestricted Mediterranean diet supplemented with nuts Control group: low–fat (high carb) diet Mediterranean diet groups associated with lower risk of major CV events over 5 years thanlow fat diet, relative difference of 30%NEJM 2018 PREDIMED
A to Z Weight Loss Study Comparison of the Atkins, Zone, Ornish, and LearnDiets, 2007, N 311, 1 year trial Weight loss significantly better in Atkins dietcompared to Zone dietNo significant statistical difference between weightloss in Zone, Ornish, and LEARN diets Atkins ( 20g carb x 3mo then 50g carb) Zone (40% carb, 30% prot, 30% fat) LEARN (low fat, high carb, based on national guidelines) Ornish (very high carb, 10% fat)Gardner et al. 2007
Weight loss with a Low-carbohydrate,Mediterranean, or Low Fat Diet 2008,N 322, 2 year trial Low fat, restricted calorie (AHA guidelines) Mediterranean, restricted calorie Low-carb, non-restricted calorie Lowcarbohydrate & Mediterranean diets may beeffective alternatives to low fat diets Mediterranean diet: more favorable effects onglycemic controlLow carb diet: more favorable effects on lipidsShai et al. 2008
Fasting Intermittent fasting Daily fasting Alternate day fasting Eating only within an 8 hour window eachdayWhat can you eat/drink during fasting?Must adjust insulin and oral anti-hyperglycemicmedications for fasting
Exercise General health: 150 minutes per week Do they need clearance first? Start from where they are now Physical therapy Pulmonary rehab Cardiac rehab Armchair exercises Pool exercises
Sleep Insomnia Primary or secondary causes Referral, if appropriateObstructive or central sleep apnea Screen If already diagnosed: Are they using appropriate therapy? Is their equipment working well?
Medications that can causeweight gain: Cardiovascular: some BB (propranolol, atenolol,metoprolol) Diabetes: insulin, sulfonylureas,thiazolidinediones, meglitinides Hormones: glucocorticoids, estrogens,progestins might (injectable &implantable) Anti-seizure: carbamazepine, gabapentin,valproate Anti-depressants: some TCAs(ami/doxe/imipramine) some SSRIs (paroxetine),mirtazapine. Other TCAs, SSRIs & SNRIs mayalso have affects Mood stabilizers: gabapentin, lithium, valproate,vigabatrin, carbamazepine Migraine medications: amitriptyline, gabapentin,paroxetine, valproic acid, someBB Antipsychotics: clozapine, olanzapine, zotepine(substantial), quetiapine,risperidone, lithium Possible but less likely:aripiprazole, haloperidol,lurasidone, ziprasidone Hypnotics: diphenhydramine
Medications that can causeweight loss: Diabetes: metformin, GLP-1agonists, SGLT-2inhibitors, alphaglucosidaseinhibitorsHormones:testosterone might Anti-seizure: upropionMood stabilizers:lamotrigineMigraine: topiramate
Medications that are used forweight loss: MetforminPhentermine, phendimetrazine, ate)Belviq (lorcaserin)Naltrexone/bupropion (Contrave)Saxenda (GLP-1 agonist)Orlistat
Is bariatric surgeryappropriate? NationalInstitutes of Health (NIH) established criteria forbariatric surgery in 1992 and are still the most widelyused: BMI 30 with obesity related comorbidity (gastricband only) BMI 35-39.9 with a high risk comorbidity BMI tes
Is bariatric surgeryappropriate? ASMBSupdated position statement on bariatric surgeryin class 1 obesity- Aug 2018 For patients with BMI 30 to 35 kg/m2 and obesity-related comorbiditieswho do not achieve substantial, durable weight loss and co-morbidityimprovement with reasonable nonsurgical methods, bariatric surgeryshould be offered as an option for suitable individuals. In this population,surgical intervention should be considered after failure of nonsurgicaltreatments. Particularly given the presence of high-quality data inpatients with type 2 diabetes, bariatric and metabolic surgery should bestrongly considered for patients with BMI 30 to 35 kg/m2 and type -candidates
How long do you treatoverweight/obesity?How long would you treat any other chronicdiagnosis once it is finally under control? Forever, if needed since it will be a long-term problem Obesity is a chronic disease
Medications: who is a candidateto treat with medications? Not everyone BMI 27.1-29.9 with acomorbidity BMI 30.0 with/without acomorbidity
Laws for writing controlled weightloss medications More limited prescribing than opioids i.e. more rules Oregon Medical Board, Chapter 847, Division 15GENERAL LICENSING RULES, RELATING TO CONTROLLED SUBSTANCES 847-015-0010 Schedule III or IV Controlled Substances — Bariatrics PracticeStatutory/Other Authority: ORS 677.265Laws are different by state. Know your state’slaws!
Rules posted on OMB website: Must prescribe in accordance with FDA productguidelines in effectMust co-prescribe caloric reduction, behaviormodification, and exercise, provided that all ofthe following conditions are met: Thoroughly review prior treatments (yours andothers) to determine if the following conditionsexist: BMI 30 or BMI 27 & weight threatens health (comorbidity)
Rules posted on OMB website: Licensee obtains thorough history, thoroughphysical exam, rules out contraindications touse of controlled substance. (Get an EKG!)To continue Rx beyond 3 months requiresdocumentation Average 2 lb/mo weight loss during active weightreduction treatmentGoal weight maintenance once maintaining weightonly
Copied from OMB Webpage: Violations of this rule constitute“Unprofessional Conduct as the term isused in ORS 677.188(4)(a), (b), or (c),whether or not actual injury to a patient isestablished.”
Helpful hints to avoid insuranceproblems Don’t link any off-label medications to the diagnosis ofobesity/overweight unless you want to see the Rxdenied by insurance Don’t list “overweight” or “obesity” as the primarydiagnosis Primary code should be an associated and/orsecondary diagnosis (i.e. PCOS, OSA) Medicare does cover obesity as a primary diagnosisbut requires very specific documentation
Obesity CME Obesity Medicine Association (OMA) The Obesity Society (TOS) Harvard Medical School Columbia University The Endocrine Society Local CME programs: Legacy/OHSU
American Board of ObesityMedicine (ABOM) Certification Fellowship pathway Completion of on-site 500 hours of obesity orobesity-related conditions CME pathway Minimum 60 credits CME on topics of obesity (AOAcat 1-A, AMA PRA cat 1) 30 must be earned through attendance atspecific sites; other 30 can be earned inattendance or online CME This pathway may end in the next few years
Adult fellowships Boston University School of Medicine/ Boston Medical Center, Boston,MA Geisinger Medical Center, Danville, PA Harvard Medical School / Massachusetts General Hospital, Boston, MA University of Texas McGovern Medical School, Houston, TX New York-Presbyterian Hospital/Weill Cornell Medical Center, New York,NY Wake Forest Baptist Health, Winston-Salem, NC New York University Langone Medical Center, New York, NY20 new programs to open in 2020
Pediatric Fellowships University of Tennessee Health Science Center, Memphis, TN Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE Nationwide Children’s Hospital, Columbus, OH
Do you have to seek ABOMcertification? No, you can simply assist patients in yourpractice
EDUCATIONAL RESOURCES FORHEALTH CARE PROFESSIONALS Use these resources to furtheryour education – and yourstaff’s and patients’ education –about clinical obesitytreatment.Patient Resources Obesity Action Coalition (OAC) www.obesityaction.orgPhysician and Health Care Professional Resources Obesity Medicine Association (OMA) www.obesitymedicine.org Obesity Algorithm www.obesityalgorithm.org American Board of Obesity Medicine(ABOM) www.abom.org Obesity Treatment Foundation www.obesitytreatmentfoundation.org Academy of Nutrition and Dietetics www.eatright.org American Association of ClinicalEndocrinologists www.aace.org
EDUCATIONAL RESOURCES FORHEALTH CARE PROFESSIONALS American Cancer Society www.cancer.org American College of SportsMedicine www.acsm.org American Diabetes Association www.diabetes.org American Heart Association www.heart.org American Society forMetabolic & Bariatric Surgery www.asmbs.org Canadian Obesity Network www.obesitynetwork.ca Hormone Health Network www.hormone.org Mental Health America www.mentalhealthamerica.org
EDUCATIONAL RESOURCES FORHEALTH CARE PROFESSIONALS National Association of AnorexiaNervosa and Associated Disorders www.anad.org National Cancer Institute www.cancer.gov National Eating Disorders Association www.nationaleatingdisorders.org National Institute of Diabetes andDigestive and Kidney Diseases www.niddk.nih.gov National Heart, Lung, and BloodInstitute www.nhlbi.nih.gov The Endocrine Society www.endocrine.org The Obesity Society www.obesity.org STOP Obesity Alliance www.stopobesityalliance.org World Obesity Federation www.worldobesity.org
References Centers for Disease Control (2015), Obesity trends among USAdults. Retrieved l Estruch, R., Ross, E., & Salas-Salvado, J. (2018). Primaryprevention of cardiovascular disease with a Mediterranean dietsupplemented with extra-virgin olive oil or nuts. New EnglandJournal of Medicine, 378(25), e34(1)-e34(14). Gardner et al. (2007). Comparison of the Atkins, Zone, Ornish,and LEARN Diets. The Journal of the American Medical Association, 279 (9), 969-978.
References Hasler, G. et al. (2004). The association between short sleepduration and obesity in young adults: a 13 year prospective study.Sleep. 27(4), 661-6. Lenard NR (2008). Central and peripheral regulation of foodintake and physical activity: pathways and genes. Obesity, 16(3),Figure 4. Shai et al. (2008). Weight Loss with a low-carbohydrate,Mediterranean, or low-fat diet. New England Journal ofMedicine, 359(3), 229-241.
References Sicat, J. (2017). Pathophysiology (Part 1) Presentation forObesity Medicine Association. Image slide 29. Shukla, A. et al. (2015). Food Order Has a Significant Impact onPostprandial Glucose and Insulin Levels. Diabetes Care, 38, e9899. Taheri, S. et al. (2004). Short sleep duration is associated withreduced leptin, elevated ghrelin, and increased body mass index.PLoS Medicine, 1(3), e62.
American Board of Obesity Medicine (ABOM) Certification. Fellowship pathway Completion of on-site 500 hours of obesity or obesity-related conditions CME pathway Minimum 60 credits CME on topics of obesity (AOA cat 1-A, AMA PRA cat 1) 30 must be earned through attendance at specific
Prevalence of obesity and severe obesity in US children, 1999‐2014. Obesity, 2016 May;24(5):1116-23. Wang et al. What childhood obesity prevention programmes work? A systematic review and meta-analysis. Obes Rev, 2015 Langford et al. Obesity prevention and the Health Promoting Schools framework: essential components and barriers to .
Obesity Medicine Association Education Syllabus Health Professional Students Course Title: Obesity Medicine Health Professional Student Rotation – Study Material Mission: To provide foundational information and training in obesity medicine for health professional students in an online format Purpose: Obesity is the most common disease encountered in medical practice.
Obesity Medicine Association Education Syllabus Medical Residents Course Title: Obesity Medicine Health Professional Student Rotation – Study Material Mission: To provide foundational information and training in obesity medicine for medical residents in an online format Purpose: Obesity is the most common disease encountered in medical practice.
influences of childhood obesity are the same as adult obesity. It would also suggest that work to reduce prevalence of obesity needs to take place across the entire population. Causes and solutions to obesity 4 European Society of Cardiology (2014), Adult obesity predicted in almost all European countries by 2030.
Obesity Obesity is a disease where a person’s weight is in an unhealthy range (BMI of 30.0-39.9). It is a disease that can lead to other health problems. Talk with your healthcare provider to better understand and treat obesity. Severe Obesity Someone who is more than 100 pounds over their
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beneficial effect of weight loss on a myriad of obesity-related co- morbidities. In an effort to translate the emerging science and practice of obesity care for clinicians, the . Practical Manual of Clinical Obesity. has been written as a practical, evidence-based companion guide to the textbook . Clinical Obesity in Adults and Children
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