Addressing Obesity and Addressing Obesity and Exercise in Primary CareExercise in Primary Care

GSP 4GSP 4thth Year Elective 2010 Year Elective 2010

Definitions of Overweight and Definitions of Overweight and ObesityObesity

BMI = weight in kg/height in metersBMI = weight in kg/height in meters2 2

(weight in lb/height in inches(weight in lb/height in inches22)*703)*703

Overweight- BMI 25-29.9Overweight- BMI 25-29.9

Obesity- BMI Obesity- BMI >> 30 30

Extreme obesity- BMI Extreme obesity- BMI >> 40 40

Waist CircumferenceWaist Circumference

Increases risk when increased with BMI Increases risk when increased with BMI 25-3525-35– Men >102 cm (40 in)Men >102 cm (40 in)– Women > 88 cm (35 in)Women > 88 cm (35 in)

Prevalence of Overweight and Prevalence of Overweight and ObesityObesity

19901990– Overweight- 55.9%Overweight- 55.9%– Obesity- 22.9%Obesity- 22.9%

20002000– Overweight-64.5%Overweight-64.5%– Obesity- 30.5%Obesity- 30.5%

Associated Risk FactorsAssociated Risk Factors

DiabetesDiabetes

HypertensionHypertension

High cholesterolHigh cholesterol

AsthmaAsthma

ArthritisArthritis

Obstructive sleep apneaObstructive sleep apnea

Poor health statusPoor health status

Health BurdenHealth Burden

Second leading cause of premature Second leading cause of premature mortality after smokingmortality after smoking

300-400,000 deaths per year 300-400,000 deaths per year

Benefits of weight lossBenefits of weight loss

Little evidence that interventions reduce Little evidence that interventions reduce morbidity or mortalitymorbidity or mortality

Weight loss does improve glucose control, Weight loss does improve glucose control, lipid levels and blood pressurelipid levels and blood pressure

Goals of weight loss and Goals of weight loss and managementmanagement

Prevent further weight gainPrevent further weight gain

Reduce body weightReduce body weight

Maintain lower body weight long-termMaintain lower body weight long-term

Weight loss guidelinesWeight loss guidelines

Reasonable goal- 10% decrease in weight Reasonable goal- 10% decrease in weight over 6 monthsover 6 monthsRequires a decrease of 300-500 calories Requires a decrease of 300-500 calories per day up to BMI of 35per day up to BMI of 35Requires a decrease of 500-1000 calories Requires a decrease of 500-1000 calories per day for BMI > 35per day for BMI > 35Weight loss will usually plateau after 6 Weight loss will usually plateau after 6 monthsmonthsMaintenance is difficultMaintenance is difficult

Sedentary LifestyleSedentary Lifestyle

Independent risk factor for cardiovascular Independent risk factor for cardiovascular and all cause mortalityand all cause mortality

Hypertension, insulin resistance, elevated Hypertension, insulin resistance, elevated glucose and dyslipidemia all improve with glucose and dyslipidemia all improve with exerciseexercise

Physical ActivityPhysical Activity

30 minutes on most days recommended30 minutes on most days recommended

For most individuals, will not produce For most individuals, will not produce significant weight loss alonesignificant weight loss alone

Walking briskly for 30-45 minutes will Walking briskly for 30-45 minutes will consume 100-200 caloriesconsume 100-200 calories

Target heart rate: (220-age)*0.6 to 0.9Target heart rate: (220-age)*0.6 to 0.9

USPSTFUSPSTF

Recommends clinicians screen all adult Recommends clinicians screen all adult patients for obesity and offer intensive patients for obesity and offer intensive counseling and behavioral interventions to counseling and behavioral interventions to promote weight loss for obese adultspromote weight loss for obese adults

Found insufficient evidence to determine Found insufficient evidence to determine whether counseling patients to promote whether counseling patients to promote physical activity leads to increased physical activity leads to increased physical activity in adultsphysical activity in adults

MedicationsMedications

May consider if diet and exercise not May consider if diet and exercise not successfulsuccessful

Should have BMI> 30 or >27 with risk Should have BMI> 30 or >27 with risk factorsfactors

Consider stopping if < 2 kg weight loss Consider stopping if < 2 kg weight loss after 4 weeksafter 4 weeks

Long-term effectiveness uncertain and Long-term effectiveness uncertain and many patients discontinuemany patients discontinue

SibutramineSibutramine

Blocks reuptake of norepinephrine and Blocks reuptake of norepinephrine and serotoninserotoninSide effects include increased blood Side effects include increased blood pressure, heart rate, headache, insomnia, pressure, heart rate, headache, insomnia, dry mouthdry mouthShould not be used for patients with Should not be used for patients with uncontrolled hypertension or significant uncontrolled hypertension or significant cardiovascular diseasecardiovascular diseaseDose- 10-15 mg/dayDose- 10-15 mg/dayEffectiveness- average weight loss 5%Effectiveness- average weight loss 5%

OrlistatOrlistat

Lipase inhibitorLipase inhibitor

Side effects include loose and more Side effects include loose and more frequent stoolsfrequent stools

Dose- 120 mg tidDose- 120 mg tid

Effectiveness- average weight loss 5%Effectiveness- average weight loss 5%

Combined therapy no more effective, Combined therapy no more effective, weight loss limited to 10%weight loss limited to 10%

Weight loss surgeryWeight loss surgery

Very successful in some patientsVery successful in some patients

Gastric bypass used at UVAGastric bypass used at UVA

Indications- unsuccessful medical weight Indications- unsuccessful medical weight loss with BMI > 40 or BMI > 35 with loss with BMI > 40 or BMI > 35 with complicationscomplications

Five A’sFive A’s

Ask- BMI as a vital signAsk- BMI as a vital sign

Advise- provide brief feedbackAdvise- provide brief feedback

Assess- motivation and stage of changeAssess- motivation and stage of change

Assist- help patients who wish to lose Assist- help patients who wish to lose weight develop a planweight develop a plan

Arrange follow-upArrange follow-up

Dietary counseling for other Dietary counseling for other conditionsconditions

Elevated cholesterolElevated cholesterol

Cardiovascular diseaseCardiovascular disease

HypertensionHypertension

DiabetesDiabetes

Mediterranean DietMediterranean Diet

Only diet shown to decrease cardiovascular Only diet shown to decrease cardiovascular morbidity and mortalitymorbidity and mortality

RR 0.3-0.5 vs regular or “heart-healthy diet” RR 0.3-0.5 vs regular or “heart-healthy diet” (30% fat, 10% saturated fat, 300 g cholesterol/d)(30% fat, 10% saturated fat, 300 g cholesterol/d)

250-300 g fruit, 125-150 g vegetables, 25-50 g 250-300 g fruit, 125-150 g vegetables, 25-50 g nuts/daynuts/day

400-500 g whole grains, legumes, rice/d400-500 g whole grains, legumes, rice/d

+/- fish several times a week+/- fish several times a week

3-4 servings of monounsaturated fat/d3-4 servings of monounsaturated fat/d

ReferencesReferences

CLINICAL GUIDELINES ON THE IDENTIFICATION, EVALUATION, AND TREATMENT OF OVERWEIGHT AND OBESITY IN ADULTS – http://www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns.pdf

US PREVENTIVE SERVICES TASK FORCE– http://www.ahcpr.gov/clinic/uspstfix.htm

MEDITERRANEAN DIETMEDITERRANEAN DIET– Circulation 1999;99:779Circulation 1999;99:779