Jennifer DeBruler MD Medical Director Advocate Weight Management Board Certified Internal Medicine October 2012 Goals for this presentation Discuss low fat diet Mediterranean diet ID: 669954
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Medical Treatment Options for Obesity
Jennifer DeBruler, M.D.Medical Director Advocate Weight ManagementBoard Certified Internal Medicine
October 2012Slide2
Goals for this presentation…
Discuss low fat diet, Mediterranean diet, Paleo dietDiscuss exercise recommendations for weight loss and mantainenceDiscuss medication options for treatment of obesityProvide an office tool to help patients loss weightSlide3
Dietary Guideline for Americans 2010
US Department of Agriculturewww.dietaryguidelines.govDecrease saturated fatConsume >45% from carbohydrateOnce size fits all approach only fits a minority of the populationJeff S. Volek
, PhD, RDSlide4
Re-Examining the Role of Carbohydrate
The Low Fat EraThe increase in calories during the obesity epidemic was largely due to carbohydrate intake.Jeff S. Volek, PhD, RDSlide5
Saturated Fat & the Diet Heart Hypothesis
We know decreased SFA intake leads to increased carb intake which can lead to metabolic syndrome then diabetes and ultimately heart diseaseIs it true that increased SFA intake causes increased plasma LDL and heart disease?Jeff S. Volek, PhD, RDSlide6
What happens to a carbohydrate?
Eat Carbohydrate, it goes into blood glucose and is broken down to glycogen and oxidizedToo much carbohydrate leads to glycogen and excess carbohydrate fuels lipogenesis (fat synthesis)Slide7
Plasma Saturated Fat
Predicts Heart diseaseBr Med J 1982;285993-6Am J Epidemiolo. 1995;142: 469-76Nut Metab Crdiovasc Dis 2003;13:256-66Am Heart J 2008; 156:965-74Predicts DiabetesAJCN. 2003; 78:91-8
Diabetologia. 2005; 48:1999-2005AJCN. 2007; 86:189-97AJCN. 2010; 92:1214-22Slide8
Dietary Saturated Fat and Heart Disease
3 Recent Meta-AnalysesStudyPooled Cohort StudiesBaseline Cohort (n)Follow-Up (yr)
InterpretationSkeaff & Miller. Dietary fat and coronary heart disease: summary of evidence from prospective cohort and randomized controlled trials Ann Nutr
Metab, 2009. 55(1-3): p. 173-201.28280,000
4-25
No association between SFA intake & CHD events/death
Jakobsen
, et al., Major types of dietary fat and risk of coronary heart
disease: a pooled analysis of 11 cohort studies. Am J
Clin
Nutr
, 2009. 89(5): p. 1425-32.
11
344,696
4-10
Increased
SFA intake not associated w/CHD events
Siri-Tarino
et al., Meta-analysis of prospective cohort studies evaluating the association of saturated fat with cardiovascular disease. Am J
Clin
Nutr
,
2010. 91 (3): p. 535-46.
21
347,747
5-23
No association b/t SFA intake & CVD, CHD or strokeSlide9
If you decrease SF, it matters what you replace it with.
Replacing 5% of SFA with carbohydrates increase coronary events.It increases your relative risk of CADJakobsen et al. AJCN , Feb 2011Slide10
Conclusion
When it comes of SFA, you are not what you eatConsumption of carbohydrate at levels that exceed a persons ability to directly oxidize them contributes to increased circulation SFAInstead of telling everyone to restrict dietary saturated fat a more rational and effective strategy would be to focus on ways to help people find their “right” level of carbohydrateFor people with insulin resistance, a low carb lifestyle can have a profoundly beneficial effect on a metabolic risk factors including SFAJeff S.
Volek, PhD, RDSlide11
Mediterranean Diet
Large quantities of minimally processed, fresh, plant-based foods (fruit, vegetables, whole grains, seeds and nuts)Olive oil is principal source of dietary fatLow consumption of red meat and dairyRed Wine in low to moderate amounts with meals45% CarbohydrateLow glycemic loadMinich DM, et al. Nutr
Rev Vol 66(8): 429-444.Slide12
Mediterranean Diet
Lyon Diet Heart StudyProspective secondary prevention in 605 subjects for 5 yearsSubjects randomized to Mediterranean diet with 40% fat, 45% carbsADA Step 1 Diet with 25% fat, 60% carbs
De Lorgeril M. Circulation. 1999; 99: 779-785.Slide13
Mediterranean Diet
Lyon Diet Heart StudyStudy halted after 27 months due to excess mortality in the AHA Step 1 DietTotal mortality (cardiac + non-cardiac) 72% (p<0.0001)Cardiovascular events (MI, CHF, PE) 47% (p<0.0001)De Lorgeril M. Circulation. 1999; 99: 779-785.Slide14
Mediterranean Diet
Lyon Diet Heart StudyThe Mediterranean diet dramatically reduced heart attack and overall mortality compared to the AHA dietNo change in serum lipids, BP, BMIKey difference: Mediterranean diet modifies inflammationDe
Lorgeril M. Circulation. 1999; 99: 779-785.Slide15
Mediterranean Diet
Lyon Diet Heart StudyMediterranean diet includes nutrients known to decrease inflammatory mediators (crp, IL-6, WBC)Omega 3- EFA, DHA-EPAGamma TocopherolFlavenoids, coumarins
anthyrocyaninMed. Diet excludes nutrients that increase inflammatory mediatorsOmega 6-EFA, linoleate and arachidonateIron
Trans fat: increase CRPAlpha tocopherol: reduces gamma tocopherol (Vit
E)Slide16
Mediterranean Diet
Great for moderately obese, 20-30 pounds overweightNot concerned with rapid weight lossFor patients who want to use diet to prevent or treat co-morbids, e.g. Metabolic syndrome, diabetes, CADSlide17
The Paleo Diet
Typical food in the Western Diet were virtually unknown in ancestral human dietsBreads, cereals, rice, and pastaDairy ProductsAdded SaltRefined vegetable oilRefined sugars, except honeyProcessed MeatsAlcoholCordain et al. Am J Clin
Nutr 2001;71:682-92Slide18
The Paleo Diet
Eat like the cavemen eatFresh VeggiesNuts/SeedsHealthful OilsFresh fruitsFish/seafoodGrass produced meatsSlide19
The Paleo Diet
Typical Hunter-Gatherer DietAnimal food energy 55%Hunted animal 27.5%Fished animal 27.5%No processed meatsNo dairy foodPlant food energy 45%No cereal grainsMinimally processed fresh fruits, veggies, seeds & nutsNo Processed Foods
Cordain et al. Am J Clin Nutr 2001;71:682-92Slide20
The Paleo Diet
Nutrient differences between: wild vs. cultivated plant foodSmallerMore fiberLess sugarSlightly greater mineralsVitamin content similarSlide21
The
Paleo Diet Seems like a lot of cholesterol in this diet?Dietary cholesterol has a minimal influence on serum cholesterol.Lowering dietary cholesterol from 491 mg (paleo) to 300mg (recommended) drops serum cholesterol by 4.5 mg/dlLowering dietary cholesterol from 491 mg (paleo) to 219 mg (food pyramid) drops serum cholesterol by 6 mg/dlCutting dietary cholesterol from 491mg to 219 mg would reduce a high cholesterol 240 to 234 or 2.5%
Schonfeld G et al. J Clin Invest 1982;69:1072-80Slide22
The Paleo Diet
High protein diet is more effective than high carbohydrate diet in causing weight lossAfter 6 mo – high protein/low fat group had lost average of 19.6 lbsAfter 6 mo – high carb/low fat group had lost an average of 11.2 lbsSimilar studies have replicated resultsBaba NH et al. 1999Torbay N et al. 2002Johnston CS et al. 2002Parker B et al., 2002
Weigle DS et al, Am J Clin Nutr 2005Slide23
Exercise Recommendations
General Health BenefitModerate aerobic exercise 150 min/wk (about 30 minutes 5x/wk) + strength trainingPrevention of Weight Gain150-250 minutes per week150-300 minutes per weekPrevention of Weight Regain200-300 minutes per week300-420 minutes per weekDonnelly JE. Med Sci Sports Exerc. 2009
USDHHS. PA Guidelines for Americans. 2008Slide24
Medical Clearance for Physical Activity
ACSM Guidelines for Risk StratificationMen>45, women>55 w/2 or more risk factorsRisk factors include:FHx of MI in 1st degree relative M<55, F<65Smoking in last 6 moHypertensionAbnormal lipidsImpaired Fasting Glucose
BMI ≥ 30Sedentary LifestylePlan to exercise at >60% of max, vigorousConsider Stress testingThompson WR, Ed. ACSM’s Guidelines for Exercise Testing & Prescription, 2010Slide25
Medications for Weight Loss
PhenylethylaminesSympathomimetic effectWorks at the hypothalamus and limbic systemAppetite suppressant effectMeta-analysis of phentermine and diethylproprion3.6 kg additional weight loss at 6 mo for phentermine3 kg additional weight loss at 6 mo for
diethylpropionLi, A. Ann Intern Med. 2005.Slide26
Medication for Weight Loss
PhenylethylaminesShort term adjunct in a regimen of weight reduction involving lifestyle changes in management of adult obesityBMI ≥ 30 or ≥ 27 with comorbid conditionContraindication – advanced arteriosclerosis, CAD, mod/severe HTN, hyperthyroid, glaucoma, agitated states, history of known drug abuse, pregnancySlide27
Medication for Weight Loss
PhenylethylaminesAdverse EffectsCV: palpitations, tachycardia, primary pulm HTNCNS: restlessness, dizziness, insomnia, HAGI: dry mouth, diarrhea, constipationEndocrine: impotence, change in libidoSlide28
Medication for Weight Loss
OrlistatGastric and pancreatic lipase inhibitorInhibits uptake of up to 1/3 ingested fatNeeds to be used in accordance with low-fat, calorie controlled diet.Slide29
Medication for Weight Loss
OrlistatMay be used long-term up 4 yrs for weight loss or for weight loss maintenance in adult obese patientsPediatric indication: 12-16 y/o obese adolescentsShould be accompanied by vitamin supplementationCommon SE: fecal soiling, dyspepsia, flatulence, vitamin malabsorbtion, elevated liver enzymesRare SE: severe liver injuryContraindication: cholestasis, malabsorbtion syndrome, liver diseaseSlide30
Medication for Weight Loss
MetforminBiguanide: reduces hepatic glucose production and improves insulin sensitivityInduces modest weight loss initiallyImproves fertility in PCOS patientLost 8 kg more weight over 24 wks than placeboLee A. Obes Res. 1998Slide31
Medication for Weight loss
GLP-1 AgonistsExenatide, liraglutideEnhances glucose dependent insulin releaseSuppress inappropriate glucagon releaseDelays gastric emptying Reduction in food intake directly acting on hypothalamusSlide32
Medication for Weight Loss
GLP-1 AgonistGreat medication for DM treatment and weight lossWorks synergistically with carbohydrate controlled dietNausea common, usually self-limitedWatch out for pancreatitisSlide33
Medication for Weight Loss
BupropionDopamine and norepinephrine reuptake inhibitorTx major depression, smoking cessation, ADHDDo not use in bulimic patients, may lower seizure thresholdSlide34
Medication for Weight Loss
BupropionWorks centrally as an appetite suppressantOnly anti-depressant with consistent weight loss effectMay blunt weight regain in smoking cessationSlide35
Medication for Weight Loss
Phentermine & topiramate ER (Qsymia)BMI ≥ 30 or ≥ 27 with comorbidSynergistic with PhentermineIncreased satiety through reduced GI motilityIncreased taste aversionReduced calorie intakeSE: increased HR, paresthesias
, metabolic acidosisTBD when releasedSlide36
Medication for Weight Loss
Phentermine & topiramate ER (Qsymia)Caution: women of reproductive age Cleft palate in 1st trimesterWomen must be on OCPAvoid with glaucomaHyperthyroidismMAOI’sStudies show 5-10 kg weight lossSlide37
Medication for Weight Loss
Lorcaserin (Belviq) Activates the seratonin 2C receptorWorks at centrally acting satiety receptorsCaution:Valvular HD, CHF, HTNMen with predisposition to erection more than 4 hrs (sickle cell, MM, Leukemia) or deformed penis3.7% weight loss, 7kg.Slide38
Office ToolSlide39
Thank you