JHI Partners Forum October 2 2012 Richard R Rubin PhD Professor Medicine and Pediatrics The Johns Hopkins University School of Medicine rrubin4jhmiedu Obesity Pandemic Key Points Prevalence ID: 1045114
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1. The Global Obesity PandemicJHI Partners ForumOctober 2, 2012Richard R. Rubin, PhDProfessor, Medicine and PediatricsThe Johns Hopkins University School of Medicinerrubin4@jhmi.edu
2. Obesity Pandemic Key PointsPrevalenceCausesMedical consequencesFinancial consequences
3. BMI Chart
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5. WHO Fact sheet N°311, September 2006, http://www.who.int/mediacentre/factsheets/fs311/en/index.html
6. Almost 70% of the U.S. population are either overweight or obese6Source: CDC/National Center for Health Statistics, National Health Exam SurveyU.S. adult population overweight or obesePercentage, age 20-74Obesity levels in the U.S. have more than doubled since 1980, and currently ~1/3 of adults are obeseIn contrast, the percentage of overweight adults has changed little over the past 40 yrsJust 33% of adults in the U.S. are of normal/under weight, down from 55% which held steady between 1960 and 1980ObeseOverweight19662006197619861996
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8. Portion Sizes 20 Years Ago to Today
9. Drivers of the Obesity PandemicSwinburn et al. The Lancet 2011;378:804-814.
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11. Obesity Prevalence in U.S Children 2-19 Years 1999-2010
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13. 93.2Relationship Between BMI and Risk of Type 2 DiabetesChan J et al. Diabetes Care 1994;17:961.Colditz G et al. Ann Intern Med 1995;122:481.Age-Adjusted Relative RiskBody Mass index (kg/m2)MenWomen<22<2323-23.924-24.925-26.927-28.929-30.931-32.933-34.935+1.02.91.04.31.05.01.58.12.215.84.427.640.354.06.711.621.342.1
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15. Sample data suggest that obese adults can incur close to twice the annual health care costs of normal weight adults153,950<2530-34**35-39*40+*18%*91%*55%Healthcare costs by BMI*$/capita, 2007 * For the U.S. adult population (ages 20-64) Source: McKinsey analysis; D2Hawkeye database of ~20,000 people with biometric data, National Bureau of Economic Research, 2007 census data for population by ageBMIWeighted average cost of the obese is $5,500Normal weightObese3,950
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19. Medical Management of ObesityKimberly Gudzune, MD, MPHAssistant Professor of MedicineJohns Hopkins Digestive Weight Loss CenterJohns Hopkins International Partners ForumOctober 2, 2012
20. ObjectivesEligibility for obesity treatmentDescription of medical management of obesityReview of new weight loss medications coming on the market
21. Weight is more than about looking good…Heart diseaseDiabetesCancerGall stonesFatty liverLung diseaseInfertilityArthritisIncontinenceDisabilityDecreased quality of life!Increased risk of early death!Shorter life span!
22. WHO IS ELIGIBLE FOR OBESITY TREATMENT?
23. Estimating ObesityMeasuring body fat requires specialized equipmentPatients typically identified in the clinical setting using body mass index (BMI) Weight (kg) Height (m)2NIH and WHO have categorized BMI based on increased risk of cardiovascular (CVD) and other diseases
24. BMI Classification of ObesityNormal weightBMI 18.5-24.9 kg/m25’ 11” man @ 5’ 4” woman @ OverweightBMI 25.0-29.9 kg/m25’ 11” man @ 179 lbs5’ 4” woman @ 146 lbsClass I obesityBMI 30.0-34.9 kg/m25’ 11” man @ 215 lbs5’ 4” woman @ 175 lbsClass II obesityBMI 35.0-39.9 kg/m25’ 11” man @ 5’ 4” woman @ Class III obesityBMI≥40 kg/m25’ 11” man @ 287 lbs5’ 4” woman @ 233 lbs
25. Fat DistributionIncreased visceral fat in the abdomen is linked with greater CVD disease riskAssessed by a proxy measure -- waist circumference>40” in men>35” in womenFrom http://www.nhlbi.nih.gov/guidelines/obesity/e_txtbk/txgd/4142.htm
26. CVD Risk AssessmentWaist CircumferenceNormalHighOverweightIncreasedHigh Class I obesityHighVery High Class II obesityVery HighVery High Class III obesityExtremely HighExtremely High
27. Obesity-related ComorbiditiesHypertensionHeart diseaseDyslipidemiaPre-diabetesDiabetes mellitusGastroesophageal reflux diseaseFatty liverBack painArthritisPolycystic ovarian syndromeInfertilityIncontience
28. WHAT SERVICES ENCOMPASS THE MEDICAL MANAGEMENT OF OBESITY?
29. Integrated Weight Management ModelModified from Kushner & Pendarvis 1999Medical CareBehavioralCareExerciseNutrition
30. Medical CareWeight evaluation and management performed by a physicianPrimary care physicianWeight management specialist Physician counseling can be more effective if the 5A’s or motivational interviewing used
31. Medical CareRole of the physician includes evaluation and management of:Goal setting Secondary causes of obesityCo-morbidities associated with weight gainMedications associated with weight gainCandidacy for use of anti-obesity medications
32. Goal SettingInitial goal for weight loss is to achieve a “healthier weight”5-10% loss of initial body weightAccomplishable for most peopleTypically leads to improvement in blood pressure, blood sugar, and other obesity-related diseasesGoal rate of 1-2 lbs lost per weekAccomplishable for most peopleSafeLess risk of weight regain
33. Secondary Causes of ObesityCommonHypothyroidismPolycystic ovarian syndrome (PCOS)RareCushing syndromeHypothalamic obesity syndromes Melanocortin-4 mutations Leptin deficiency
34. Co-morbid ConditionsCardiovascularHypertensionCoronary heart diseasePulmonaryAsthmaObstructive Sleep ApneaMetabolicDiabetes mellitusDyslipidemiaMetabolic syndromeGoutGastrointestinalGERDGallbladder diseaseFatty liver
35. Co-morbid ConditionsMusculoskeletalOsteoarthritisBack painCancerColorectal cancerProstate cancerEndometrial cancerCervical cancerBreast cancerOvarian cancerPancreatic cancerReproductive/GUPCOSInfertilityIncontinence
36. Medications Associated with Weight GainDiseaseType of MedicationHow they cause weight gainExamplesHigh Blood PressureBeta-blockers1-Reduced resting energy expenditure & thermogenesis-Increased tiredness-Reduced exercise tolerance-Increased insulin resistanceMetoprololAtenololCarvedilolAllergiesAnti-histamines2-Increased appetiteDiphenhydramineAnti-inflammatoryCortico-steroids2-3-Impaired glucose tolerance-Increased truncal fatPrednisoneFrom: 1. Sharma et al 2001 2. Malone 2005 3. Cheskin 1999
37. Medications Associated with Weight GainDiseaseType of MedicationHow they cause weight gainExamplesDiabetes mellitusSulfonylureas-Anabolic effects-Increased appetite-Fluid retentionGlyburideGlipizideGlimepirideDiabetes mellitusThiazolidinediones (TZDs)-Increased adipogenesis-Fluid retention-Increased appetitePioglitazoneRosiglitazoneDiabetes mellitusInsulin-Anabolic effects-Increased appetite-Fluid retentionFrom Mitri & Hamdy 2009
38. Medications Associated with Weight GainDiseaseType of MedicationHow they cause weight gainExamplesDepressionSelective Serotonin Reuptake Inhibitors(SSRIs)-Increased appetite-Increased food cravingsFluoxetineSertralineParoxetineDepressionTricyclic Antidepressants (TCAs)-Increased appetiteAmitriptylineNortriptylineSchizo-phreniaAtypical Antipsychotics-Increased appetite and binge eatingOlanzipineQuetiapineRisperidoneFrom Malone 2005
39. NutritionNutrition evaluation and diet planTrained physicianRegistered dieticianCertified nutrition specialist
40. NutritionAssessment of dietary habitsTailor dietary recommendations to individual patient needsWork with physician to address diet and medication changes as needed given co-morbid condition profileAddress patient nutrition education and skill deficiencies
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42. Copyright restrictions may apply.Dansinger, M. L. et al. JAMA 2005;293:43-53.One-Year Changes in Body Weight By Diet Group and By Adherence Level
43. ExercisePhysical activity evaluation performed by an exercise physiologist or personal trainer
44. ExerciseRole of the exercise physiologist and/or personal trainer includes:Assessment of exercise tolerance, metabolic fitness, and cardiovascular riskCreate an individualized exercise prescription
45. WHAT NEW WEIGHT LOSS MEDICATIONS WILL BE AVAILABLE?
46. Criteria for Medication UseElementCriteriaBody Mass Index≥30 kg/m2 ≥27 kg/m2 + an obesity-related condition High blood pressure High cholesterol Pre-diabetes or diabetesPrior attempt at lifestyle changeUnable to achieve a goal of 1 lb of weight loss per week during a 6 month period of diet and exercise changesAny medication must be combined with diet and exercise changes to be effective
47. Patient CounselingExpected weight loss Potential side effects and risksInteractions with other medicationsMedication selected should be tailored to best suit each individual patient
48. QSYMIACombination of phentermine and topiramateWorks by suppressing the appetitePatients lost between 11-24 lbs at 12 months
49. QSYMIACommon side effects include tingling, dizziness, increased heart rate, and depressed mood.May not be a good choice if you have heart, liver or kidney diseaseCauses birth defects
50. BELVIQNew medication that targets a special Serotonin neurotransmitter receptorWorks by suppressing the appetite Patients lost 10-12 lbs at 12 months
51. BELVIQCommon side effects include headache, dizziness, nausea, drowsinessMay not be a good choice if you have heart, liver, or kidney disease
52. What current medication options do I have?ALLI (orlistat)Works by blocking absorption of fat Common side effects include abdominal cramping, bloating, diarrheaMay not be a good choice if you have gastrointestinal issues or liver diseaseADIPEX (phentermine)Works by suppressing the appetiteCommon side effects include headache, dizziness, nauseaMay not be a good choice if you have heart, liver, or kidney disease
53. Digestive Weight Loss Center2360 W. Joppa Rd, Suite 200Lutherville, MD 21093410-583-LOSEhttp://www.hopkinsmedicine.org/digestive_weight_loss_center/index.html
54. Janelle W. Coughlin, Ph.D.Johns Hopkins School of MedicineDepartment of Psychiatry and Behavioral SciencesJohns Hopkins Medicine International Partners ForumOctober 2, 2012Behavioral Lifestyle Interventions for Obesity: The Foundation for Change
55. ObjectivesTo describe important components of behavioral lifestyle interventions for obesityTo summarize outcomes achieved with behavioral lifestyle interventions for obesityTo highlight recent innovative developments in behavioral lifestyle interventions for obesity
56. SurgeryPharmacotherapyLifestyle ModificationDietPhysical ActivityBMIObesity Treatment Pyramid
57. Dietary Approaches to Lifestyle ModificationCalorie Deficit ~1200-2000 kcal/d Dietary Approaches:Low-fatLow-carbohydrateMediterranean Low-glycemic loadPortion-controlled diets
58. Increasing Physical Activity> 180 m/wk MVPA for weight loss Must also include caloric restrictionAssociated with a number of health improvements, independent of weight lossCritical for long-term weight loss maintenance~ 60 m/d MVPACan be performed in short boutsIncreasing other lifestyle activities is also effective > 2000 steps for weight loss; > 6000 to avoid regain
59. Behavioral StrategiesSelf-monitoringGoal SettingStimulus controlProblem solvingCognitive restructuringRelapse PreventionIncrease self-efficacy and social support Motivational Interviewing
60. Weight Loss MaintenancePatients gain ~ 1/3 of their lost weight in the year following treatment Nearly half of participants return to their original weight within 5 years 1:6 adults accomplish > 1 yr of maintaining > 10% of IBWThere is significant evidence that weight loss maintenance interventions can decrease the chance of weight regain Regular ongoing contact following initial weight loss is perhaps the most successful method of preventing weight regain
61. Study DesignPhase IN=1685Behavioral weight loss interventionWeight loss ≥4 kgYesNoPhase II RandomizationN=1032 Self-directed control groupPersonal ContactInteractive TechnologyNo furthercontactPhase I6 monthsPhase II30 monthsData collection prior to Phase I, at randomization, then every 6 months
62. Change from initial weight -2.9 -3.3 -4.2Svetkey et al., 2008
63. Remote/Telephone-deliveredTechnology-BasedPCP-Enhanced or Promoted
64. DesignControlRemoteIn-Person Randomization= Measured weights and other outcomesBaseline6 Mo12 Mo24 Mo
65. InterventionsRemoteIn-PersonMode of DeliveryTelephone only Group meetingsIndividual meetingsTelephoneCoachHealthwaysHopkinsCoach supportCase managementStudy websiteEducational modules Self-monitoring toolsTailored emailsPhysician RolesSupportiveReview weight progress reports
66. *P <0.001 (vs control)Appel et al, NEJM 2011;365:1959-68
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68. SurgeryPharmacotherapyLifestyle ModificationDietPhysical ActivityBMIDoes lifestyle modification enhance the effects of weight loss medications and surgery?
69. Thank YouWadden et al., (March, 2012). Circulation