5 As of Obesity Management
Shahebina Walji, MD, CCFP
Clinical L ecturer, University o f Calgary
Medical Director, Calgary Weight Management Centre
www.cwmc.ca
s.walji@cwmc.ca
Objectives
•
Review Key Principles of Obesity Management
•
Become Familiar with the 5As of Obesity Management™
•
Better understand the etiological factors contributing to obesity
•
Increase ability to create a patient focused care plan to help with weight management
How does obesity affect your patient’s life?
Leger Survey, 2011
Patient experience:
• 50% state that weight has had a negative impact on relationships with friends, family and/or spouses.
• 55% have low self-­esteem
• 33% withdraw from social situations
• 75% have tried to lose weight for over 11 years.
• 25% have tried countless times to lose weight
• Less than 20% receive help their from physician. Why?
• Information seldom helpful
• Physicians lack sensitivity
• Patients want more support in self-­management, tailored strategies and reliable resources
Leger Survey, 2011
As a physician, what is your role in obesity management?
What makes managing obesity so challenging for physicians?
Weight Management Today: What we’ve been doing wrong…
• Obesity has been viewed by many clinicians as a homogeneous condition amenable to simply “eating less and moving more”. • We have not consistently been distinguishing between different causes or stages of obesity.
• Reality: People seeking weight-­loss support often present with a range of barriers, including mental health issues, chronic pain and family or social issues.
Key Principles of Obesity Management Photo c ourtesy of t he Canadian Obesity Network
Key Principles of Obesity Management
•
Obesity is a Chronic (Progressive) Medical Condition
•
Obesity management is about improving health and well-being, not
simply about reducing numbers on the scale
•
Early intervention is about addressing root causes and removing
roadblocks
•
Success looks different for everyone
•
A patient’s “best” weight may never be an “ideal” weight.
Case: John
54 year old business man, married with 2 children
Vitals: BMI (today): 38
BMI (2012): 36
BP: 134/80
PMHx: Impaired Glucose Tolerance, Hypertension
FHx: hypertension (both parents), T2 DM (sister)
Case: John
HPI
Onset of weight gain in 40’s, corresponding to move to Calgary for work
Current job involves ++ travel, lunch, and sometimes dinner meetings
Previously active in recreational hockey;; since move and new job, has no time
Progressive weight increase in last 12 years or so
No previous attempts at weight loss
PMx
Impaired glucose tolerance 1 yr ago
Hypertension x 5 yr
Medications
Atenolol
FHx
Obesity: mother, father, sister
Hypertension – mother + father
Diabetes -­ sister
ROS/Lifestyle Assessment
Skips breakfast most days
Lunch and some dinners out
No time for exercise (previously active in sports)
Alcohol: 1-­2 servings per night on weekdays;; 6 per night on weekends
How would you start a conversation with John about his weight?
Possible Questions….
Are you concerned about the impact that your weight might be having on your health?
Does your weight cause you any medical or personal difficulties?
What types of changes to see you happening in your life if you do lose weight?
Can we talk about your weight today?
John:
“I honestly don’t have time to worry about my weight right now.”
“I am nowhere as heavy as my father was. I haven’t really thought about my weight as being all that related to my health. Do you have any concerns, doc?”
“Yes, I am so frustrated! I want to lose weight, it feels like an impossible task. I am ready to do anything!!What do you suggest?”
Medical Perspective
How worried am I about the patient’s health across 3 dimensions?
• Metabolic
• Mechanical
• Emotional
Is there anything we need to prioritize before even thinking about
weight reduction?
What are the factors that are making weight management difficult
and how can we reduce these barriers?
1. Obesity Class and Waist Circumference
2. Obesity Stage
•
Associated Health Conditions
3. Barriers to Weight Management
4. Readiness
Obesity Class:
BMI Classification
WHO Classification:
•
•
•
Based on a patient’s BMI
Gives us information about the SIZE of the patient.
Does not provide information about the patient’s current health status
Underweight
<18.5
Normal Range
18.5-­‐24.9
Overweight
25.0-­‐29.9
Obesity
•
Class 1
30.0-­‐34.9
•
Class 2
35.0-­‐39.9
•
Class 3
40.0 +
Waist Circumference:
•
Gives us more information about visceral adiposity, which may be a better marker of health/disease
Waist Circumference Threshold
European
♂ > 94 cm ♀> 80 cm
Asian & Hispanic
♂ > 90 cm ♀> 80 cm
Obesity Stage:
EOSS: Edmonton Obesity Staging System
INCREASED HEALTH RISK…INCREASED INTENSITY OF INTERVENTION
Sharma et al. A Proposed Clinical Staging System for Obesity. International Journal of Obesity (2009) 1-­7
Edmonton Obesity Staging System. http://www.albertahealthservices.ca/ps-­ww-­eoss-­tool.pdf
Obesity Stage: JOHN
MHx:
• IGT
• HTN
EOSS: Edmonton Obesity Staging System
INCREASED HEALTH RISK…INCREASED INTENSITY OF INTERVENTION
Sharma et al. A Proposed Clinical Staging System for Obesity. International Journal of Obesity (2009) 1-­7
Edmonton Obesity Staging System. http://www.albertahealthservices.ca/ps-­ww-­eoss-­tool.pdf
Barriers to Weight Management
Readiness
10-­‐POINT SCALE QUESTIONS:
On a scale of 1-­‐10…
•
How important is it to you to manage your weight at this time? 9/10
•
How ready are your to manage your weight at this time? 7/10
•
How confident are you that you can manage your weight without support? 2/10
•
How confident are you that you can manage your weight with support? 8/10
Summary: John
Obesity Class:
Class 2
Obesity Stage: Stage 2
Barriers:
• Genetics
• Medication/Alcohol
• Social
• Knowledge
Readiness:
Ready and Confident with Support
Obesity is a chronic & often complex condition
Obesity is a CHRONIC Medical Condition
% Weight loss
20 – 30 %
liraglutide
? 8-­‐10 %
orlistat
3-­‐8 %
Psychological
MEDICATIONS:
Approved in Canada:
• Orlistat
• Liraglutide
Not approved for weight loss in Canada:
• Locaserin
• Phentermine-­Topiramate
• Naltrexone-­Bupropion
Orlistat: Mechanism of Action
Intestinal lumen
Gl Lipase +
Orlistat
Micelle
Lymphatics
Fatty Acids
Monoglycerides
Bile acids
30% of dietary fat is
not absorbed
Mucosal cell
ADVISE: Liraglutide Mechanism of Action
Energy Balance
3rd
ventricle
Liraglutide
POMC
NPY/ AGRP
Hypothalamus
Hypothalamus
Increase Satiety Decrease Hunger
POMC, proopiomelanocortin;; NPY, neuropeptide Y;; AGRP, agouti-­related peptide
Secher A et al., J. Clin. Invest. 2014;; 24(10): doi:10.1172/JCI75276.
Bariatric Surgery:
1. MOST EFFECTIVE TREATMENT FOR OBESITY
2. ACHIEVES GREATEST AMOUNT OF SUSTAINABLE WEIGHT LOSS
3. CAN BE RESTRICTIVE OR MALABSORPTIVE OR BOTH
Laparoscopic Adjustable Gastric Banding
Vertical Sleeve Gastrectomy
Gastric Bypass
How much will Patients Risk for Surgery?
• Boston: Wee et al, JAMA Surgery
• 600 individuals seeking bariatric surgery
• 85% will accept 7% mortality risk with surgery
• 1/10 will accept 10% mortality risk
• Patient Expectations: 40% initial weight loss
**Efficacy of Surgery**
• 20-­30% loss of initial weight
• Up to 30% patients will experience substantial weight regain.
• 25% state they would be disappointed if they did not lose at least 25% initial weight
JOHN
• Obesity as a chronic condition
• Health Risks associated with weight: HTN, IGT
• Benefits of modest weight loss
• Etiologies +/-­ Barriers
ALL TREATMENT OPTIONS
NUTRIONAL TIPS For Goal Setting
1. Keep a detailed food journal
2. Eat a big balanced breakfast within 1 hour of waking
3. Try to consume 3 balanced main meals separated by balanced snacks
4. Eat as close to the farm as possible
5. Be mindful of calories from beverages;; set specific limits
6. Portion control: portion plate, smaller plate, veggies first
7. Have a strategy for cravings
JOHN
Assessment Summary
Obesity Class: Class 2
Obesity Stage: Stage 2
Agreed Upon Plan
•
No interest in surgery or obesity medications
•
Revisit BP medications
Barriers:
• Genetics
• Medication
• Social
• Knowledge
•
Alcohol: Alternate water with alcohol on •
Put on pedometer and track steps daily
Readiness:
• Ready & Confident with Support
•
Consider education re: glycemic control
•
Follow up!!
weekends to halve his intake
•
Eat something in AM – anything – within 1 hour of waking