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Principles of Weight Principles of Weight ManagementManagement

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R.Daniel Braun,MDR.Daniel Braun,MD

Indiana U. School of MedicineIndiana U. School of Medicine

Goals of Obesity TherapyGoals of Obesity Therapy

Old goal: Reduction to “Ideal” WeightOld goal: Reduction to “Ideal” Weight Most significantly obese individuals can Most significantly obese individuals can

not achieve “Ideal” weight.not achieve “Ideal” weight. Most cannot maintain large weight loss.Most cannot maintain large weight loss. Frustrating to patients and physiciansFrustrating to patients and physicians

Goals of Obesity TherapyGoals of Obesity Therapy

New Goal: Reduction to a HEALTHIER New Goal: Reduction to a HEALTHIER Body WeightBody Weight

Weight loss of as little as 5-15% of Weight loss of as little as 5-15% of initial weight improves many Obesity-initial weight improves many Obesity-related co-morbiditiesrelated co-morbidities

Most patients can achieve and maintain Most patients can achieve and maintain weight losses of 10-15% of initial weight losses of 10-15% of initial weightweight

Long Term Behavioral RxLong Term Behavioral Rx

Study Maximum Loss Loss last Treatment visit

Perri 14% @ wk 20 13% @ wk 72

Viegener 9% @ wk 26 9% @ wk 52

Wadden 14% @ wk 52 12% @ wk 78

Wing 13% @ wk 26 10% @ wk 52

Long Term Pharmacotherapy

Study Maximum Loss Loss last Treatment visit

Andersen 15% @ wk 26 11% @ wk 52

Finer 12% @ wk 8 17% @ wk 34 14% @ wk 52Guy-Grand 11% @ wk 34 10% @ wk 52

Weintraub 16% @ wk 34 15% @ wk 54 11% @ wk 156

Challenges in Weight Challenges in Weight ManagementManagement To facilitate patient and provider To facilitate patient and provider

acceptance of modest weight loss goalsacceptance of modest weight loss goals To develop treatment models for long To develop treatment models for long

term careterm care To demonstrate the benefits of weight To demonstrate the benefits of weight

managementmanagement

Definition of OverweightDefinition of Overweight

Body Mass IndexBody Mass Indexwt(Kg)/ht(m) 2 orwt(Kg)/ht(m) 2 orwt(lb)/ht(in) 2 X 70 3wt(lb)/ht(in) 2 X 70 3

BMI < 27 = Normal weightBMI < 27 = Normal weightBMI 27-30 = OverweightBMI 27-30 = OverweightBMI 31-39 = ObeseBMI 31-39 = ObeseBMI >39 = Morbidly ObeseBMI >39 = Morbidly Obese

Scope of ProblemScope of Problem

300,000 Excess deaths per year due to 300,000 Excess deaths per year due to ObesityObesity

51 % of Population in U.S has BMI>3051 % of Population in U.S has BMI>30 58% of Females in U.S. have BMI>3058% of Females in U.S. have BMI>30

Phenotype of ObesePhenotype of Obese1. Family is more likely to be overweight.2. Poorer fitness than the lean, and lesser

tendency to exercise.3. Age group at onset: infant, teen, or adult4. Immigrants or those becoming westernized

in their own natural surroundings tend tobecome overweight.

5. Many efforts and failures to lose weight.Many excuses for not being able to changehabits or weight.

6. Overeating (binge eating) typically understress.

Goals of TreatmentGoals of Treatment

Induce and maintain weight lossInduce and maintain weight loss Reduce obesity related co-morbiditiesReduce obesity related co-morbidities Help patients adopt a healthy lifestyleHelp patients adopt a healthy lifestyle Improve patient satisfaction with Improve patient satisfaction with

outcome.outcome.

Benefits of Weight LossBenefits of Weight Loss

Decreased glucoseDecreased glucose Decreased insulinDecreased insulin Decreased triglyceridesDecreased triglycerides Decreased LDL CholesterolDecreased LDL Cholesterol Decreased blood pressureDecreased blood pressure Decreased uric acidDecreased uric acid Increased HDL CholesterolIncreased HDL Cholesterol Improved quality of lifeImproved quality of life

Phases of TreatmentPhases of Treatment

Patient evaluationPatient evaluation Treatment decision and selectionTreatment decision and selection Goal settingGoal setting Induction of weight lossInduction of weight loss Maintenance of weight lossMaintenance of weight loss Long term weight managementLong term weight management

Patient EvaluationPatient Evaluation

MedicalMedicalHistory and physicalHistory and physicalEkg, blood chemistry panel, waist and Ekg, blood chemistry panel, waist and

hip hip circumferencescircumferences

BehavioralBehavioralMood, social support, psychopathologyMood, social support, psychopathologyPatient readiness, stress, time Patient readiness, stress, time

availabilityavailability

Treatment Decision and Treatment Decision and SelectionSelection

BMI Category Health Risked based on BMI

<25 Minimal25>27 Low27<30 Moderate30<35 High35<40 Very High>40 Extremely High

Presence of a co-morbid condition or other risk factorjumps patient to next level of risk based on BMI.

Shapeup America

Treatment Decision and Treatment Decision and SelectionSelection

Health Risk Treatment Options

Minimal & Low Healthful eating &/or moderate deficit diet, Increased physical activityLifestyle change

Moderate All of above plus low calorie diet

High & Very High All of above plus pharmacotherapyor very low calorie diet (VLCD)

Extremely High All of above plus surgical intervention

Goal SettingGoal SettingDream Weight What you would like to weigh.

Happy Weight A weight you would be happy with.

Acceptable Weight Less than above but “OK”

Disappointed Less than current, but more thanWeight above.

Goal SettingGoal Setting

60 women mean age 40 years, BMI of 36.3

Current Weight 99.1 kgDream Weight 61.4 kg (-38%)Happy Weight 68 kg (-31%)Acceptable Weight 74 kg (-25%)Disappointed Weight 82 kg (-17%)

Goal SettingGoal Setting

Weight Goal % Achieving

Dream Weight 0%

Happy Weight 9%

Acceptable Weight 24%

Disappointed Weight 20%

Less than Disappointed 47%

Foster et.al. J Consult Clin Psychol, 1996

Induction of Weight LossInduction of Weight Loss

Identify Components of Treatment (Diet, Identify Components of Treatment (Diet, activity, lifestyle modification, activity, lifestyle modification, Pharmacotherapy, etc.Pharmacotherapy, etc.

Provide overview of course of initial Provide overview of course of initial treatment including duration, schedule of treatment including duration, schedule of visits, and probable resultsvisits, and probable results

Identify treatment provider’s and patient’s Identify treatment provider’s and patient’s responsibilities for behavior changeresponsibilities for behavior change

Maintenance of Weight LossMaintenance of Weight Loss

Break maintenance into “semesters” Break maintenance into “semesters” and schedule regular visitsand schedule regular visits

Identify diet, activity, and life style Identify diet, activity, and life style goals for each visitgoals for each visit

Increase social support and new Increase social support and new activitiesactivities

Provide “lapse” counseling as neededProvide “lapse” counseling as needed

Long-Term Weight ControlLong-Term Weight Control

Establish weight and health criteria and Establish weight and health criteria and a schedule for monitoring thema schedule for monitoring them

Determine when treatment should be Determine when treatment should be re-initiated and approach to be usedre-initiated and approach to be used

Alleviate patients shame and guilt Alleviate patients shame and guilt concerning weight regainconcerning weight regain

Predictors of Weight LossPredictors of Weight Loss

Body WeightBody Weight Resting Metabolic RateResting Metabolic Rate Self Efficacy (Says Yes I can do that)Self Efficacy (Says Yes I can do that) Good AttendanceGood Attendance Early Weight LossEarly Weight Loss

Predictors of Greater Weight Predictors of Greater Weight LossLoss Longer TreatmentLonger Treatment PharmacotherapyPharmacotherapy Supervised Physical ActivitySupervised Physical Activity Lifestyle ModificationLifestyle Modification

Characteristic of Weight Loss Characteristic of Weight Loss MaintainersMaintainers

Exercises RegularlyExercises Regularly Monitors weight Regularly (Daily even)Monitors weight Regularly (Daily even) Eats Low fat diet tailored to food Eats Low fat diet tailored to food

preferencespreferences Has problem focused coping skillsHas problem focused coping skills Monitors fat intake periodically (Food diary Monitors fat intake periodically (Food diary

esp when weight starts up)esp when weight starts up) Takes medication on regular basisTakes medication on regular basis

Caloric Energy BalanceCaloric Energy Balance

Body weight remains same when: Caloric Body weight remains same when: Caloric Intake = Caloric ExpenditureIntake = Caloric Expenditure

Intake (we all know about thatIntake (we all know about that Expenditure Expenditure

1.Resting Metabolic Rate=(60-70%) 1.Resting Metabolic Rate=(60-70%) ExpenditureExpenditure

2.Thermic Effect of Food= (5-10%) 2.Thermic Effect of Food= (5-10%) ExpenditureExpenditure

3.Physical Activity = rest of Expenditure3.Physical Activity = rest of Expenditure

DietDiet

Careful Training in :Careful Training in :Selection of lower fat foodsSelection of lower fat foodsModified food guide pyramidModified food guide pyramidIncrease fruits & vegetablesIncrease fruits & vegetablesLower fat preparation techniquesLower fat preparation techniquesEstimation of portion sizeEstimation of portion size

_diet_diet

Moderate deficitModerate deficit(- 500 Kcal/day) 1200-1500 for (- 500 Kcal/day) 1200-1500 for

women &women &1400-2000 for men1400-2000 for men

Low calorieLow calorie(- 800-1200 Kcal/ day)(- 800-1200 Kcal/ day)

Very low calory diet (VLCD)Very low calory diet (VLCD)(< 800 Kcal/ day)(< 800 Kcal/ day)

Energy Deficit CalculationEnergy Deficit Calculation

Calculate REE (Resting Energy Expenditure)Calculate REE (Resting Energy Expenditure)REE = {9.99 * Wt.(Kg)} + {6.25 * Ht. (Cm.)} REE = {9.99 * Wt.(Kg)} + {6.25 * Ht. (Cm.)} --{4.92 * Age} =Kcal/day{4.92 * Age} =Kcal/day

Multiply REE by activity factor (AF)Multiply REE by activity factor (AF)AF = 1.6 for males and 1.5 for femalesAF = 1.6 for males and 1.5 for females

Subtract 500 from Result. This = Subtract 500 from Result. This = recommended caloric intake and will result recommended caloric intake and will result in loss of 1 pound per week.in loss of 1 pound per week.

ExerciseExercise

Not enough by itselfNot enough by itself Hard to Succeed without itHard to Succeed without it 30 min/day (3-7 days/week)30 min/day (3-7 days/week)

Behavior ModificationBehavior Modification

Identify barriers to changing eating and Identify barriers to changing eating and exercise patternsexercise patterns

Once identified, change and modify Once identified, change and modify those barriersthose barriers

Involves identifying reasons for Involves identifying reasons for inappropriate eating and exercise and inappropriate eating and exercise and changing themchanging them

Pharmacologic Management of Pharmacologic Management of ObesityObesity

Goal: To help obese patients achieve Goal: To help obese patients achieve a reduction in food intake and a higher a reduction in food intake and a higher level of energy expenditure, not for 3 level of energy expenditure, not for 3 months or 3 years, but for a lifetime.months or 3 years, but for a lifetime.

History of Obesity History of Obesity PharmacotherapyPharmacotherapy 1930’s1930’s ScolexScolex 1950’s1950’s Amphetamines Sold by MD’s Amphetamines Sold by MD’s 1960’s1960’s PhenethylaminesPhenethylamines

Amphetamine-like agents (Not addictive)Amphetamine-like agents (Not addictive) 1970’s1970’s Drug abuse transformationDrug abuse transformation

Controlled Substances actControlled Substances act 1980’s1980’s Market dried up (Stigma)Market dried up (Stigma) 1990’s1990’s Introduction of New AgentsIntroduction of New Agents

Break three month barrierBreak three month barrier

LeptinLeptin

Protein produced by the Protein produced by the obob gene gene Obese humans have higher Obese humans have higher

concentrations than non obese concentrations than non obese counterparts counterparts NEJM NEJM 1996;334:292-2951996;334:292-295

Phase I clinical trialsPhase I clinical trials began late 1996began late 1996

SibutramineSibutramine

Developed as Antidepressant & ObesityDeveloped as Antidepressant & ObesityInhibits monoamine reuptakeInhibits monoamine reuptakeLacks anticholinergic activityLacks anticholinergic activityNo diabetic problem exacerbationNo diabetic problem exacerbation

Phase I & II trials Adv. EffectsPhase I & II trials Adv. EffectsInsomnia,irritability, tachycardiaInsomnia,irritability, tachycardiaHTN in Afro.-Amer. (3-4Torr in whites HTN in Afro.-Amer. (3-4Torr in whites

& & 20Torr in Afro.-Amer.20Torr in Afro.-Amer.

Orlistat/HydrolipistatinOrlistat/Hydrolipistatin

Potent gut irreversible lipase inhibitorPotent gut irreversible lipase inhibitorPancreatic lipase divides FFA from glycerolPancreatic lipase divides FFA from glycerol

Reduces triglyceride and cholesterol absorptionReduces triglyceride and cholesterol absorptionEliminated in fecesEliminated in feces

Lowers Cholesterol (4-11%) & LDL (5-10%)Lowers Cholesterol (4-11%) & LDL (5-10%) Not dependant on amt fat or fiber ingestedNot dependant on amt fat or fiber ingested 120 mg TID [ac, during, or pc]120 mg TID [ac, during, or pc]

Cholecystokinin-8 AgonistsCholecystokinin-8 Agonists

Sulfated carboxy-terminal of cholecystokininSulfated carboxy-terminal of cholecystokinin CCK-8released in response to food intakeCCK-8released in response to food intake Generates satiety signalGenerates satiety signal CCK-8 is a peptide. Cannot be given orally or IVCCK-8 is a peptide. Cannot be given orally or IV Agonists block endogenous CCK-8 breakdown Agonists block endogenous CCK-8 breakdown

by tripeptidyl peptidase II (TPPII)by tripeptidyl peptidase II (TPPII) Duration of action too short for efficacy; Duration of action too short for efficacy;

looking for other analogueslooking for other analogues

Initial Weight Loss Response Predicts Initial Weight Loss Response Predicts Long Term ResponseLong Term Response

Those who lose 4# in 1st 4 weeks Those who lose 4# in 1st 4 weeks (78%)(78%)

Mean weight loss = 22 #Mean weight loss = 22 #60% lost 10% of initial weight60% lost 10% of initial weight

Those who do not lose 4# in 1st 4 Those who do not lose 4# in 1st 4 weeksweeks

Mean weight loss = 6 #Mean weight loss = 6 #Only 10% lost 10% of initial weightOnly 10% lost 10% of initial weight

For Those Who Don’t Lose For Those Who Don’t Lose WeightWeight Reassess:Reassess:

Understanding and compliance with diet. Understanding and compliance with diet. physical activity, and drug regimenphysical activity, and drug regimenAccuracy of weight recordingsAccuracy of weight recordingsPossible Fluid retention (salt intake, etc)Possible Fluid retention (salt intake, etc)Changes in medical conditionChanges in medical conditionMotivation for changeMotivation for changeSocial and personal stressSocial and personal stressIs the provider of health care the root of the Is the provider of health care the root of the problem ?problem ?

For Those Who Don’t Lose Weight For Those Who Don’t Lose Weight and There is no Cause Except and There is no Cause Except Noncompliance with Diet & ExerciseNoncompliance with Diet & Exercise Consider changing medicationConsider changing medication consider referral to:consider referral to:

DietitianDietitianBehavioral counselorBehavioral counselorExercise professionalExercise professionalWeight WatchersWeight Watchers

Reconsider goal: i.e. simple maintenance or a Reconsider goal: i.e. simple maintenance or a rest from weight loss effortsrest from weight loss efforts

Discuss surgical options if medically or Discuss surgical options if medically or psychologically indicatedpsychologically indicated

Obesity SurgeryObesity Surgery

Vertical Banded GastroplastyVertical Banded Gastroplasty238 patients averaging 245% of 238 patients averaging 245% of

IBWIBWlost to average of 140% of IBWlost to average of 140% of IBWAfter 6 years averaged 150% of After 6 years averaged 150% of

IBWIBW

Am.J Surg 1989;157:150-155