Medical
Treatment
Options for
Obesity
Jennifer DeBruler, M.D.
Medical Director
Advocate Weight Management
Board Certified Internal Medicine
October 2012
Goals for this presentation…
 Discuss low fat diet, Mediterranean diet, Paleo diet
 Discuss exercise recommendations for weight loss and
mantainence
 Discuss medication options for treatment of obesity
 Provide an office tool to help patients loss weight
– Dietary Guideline for Americans 2010
• US Department of Agriculture
• www.dietaryguidelines.gov
– Decrease saturated fat
– Consume >45% from carbohydrate
– Once size fits all approach only fits a minority of
the population

Jeff S. Volek, PhD, RD
Re-Examining the Role of
Carbohydrate
The Low Fat Era
The increase in calories during the obesity
epidemic was largely due to carbohydrate
intake.

Jeff S. Volek, PhD, RD
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 disease
 Is it true that increased SFA intake causes increased
plasma LDL and heart disease?

Jeff S. Volek, PhD, RD
What happens to a carbohydrate?
 Eat Carbohydrate, it goes into blood glucose
and is broken down to glycogen and oxidized
 Too much carbohydrate leads to glycogen
and excess carbohydrate fuels lipogenesis
(fat synthesis)
Plasma Saturated Fat
 Predicts Heart disease
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Br Med J 1982;285993-6
Am J Epidemiolo. 1995;142: 469-76
Nut Metab Crdiovasc Dis 2003;13:256-66
Am Heart J 2008; 156:965-74
 Predicts Diabetes
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AJCN. 2003; 78:91-8
Diabetologia. 2005; 48:1999-2005
AJCN. 2007; 86:189-97
AJCN. 2010; 92:1214-22
Dietary Saturated Fat and Heart Disease
3 Recent Meta-Analyses
Study
Pooled
Cohort
Studies
Baseline
Cohort
(n)
FollowUp (yr)
Interpretation
Skeaff & 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.
28
280,000
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. 53546.
21
347,747
5-23
No association b/t SFA
intake & CVD, CHD or
stroke
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 CAD
Jakobsen et al. AJCN , Feb 2011
Conclusion
 When it comes of SFA, you are not what you eat
 Consumption of carbohydrate at levels that exceed a
persons ability to directly oxidize them contributes to
increased circulation SFA
 Instead 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
carbohydrate
 For people with insulin resistance, a low carb lifestyle
can have a profoundly beneficial effect on a metabolic
risk factors including SFA

Jeff S. Volek, PhD, RD
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 fat
 Low consumption of red meat and dairy
 Red Wine in low to moderate amounts with
meals
 45% Carbohydrate
 Low glycemic load

Minich DM, et al. Nutr Rev Vol 66(8): 429-444.
Mediterranean Diet
Lyon Diet Heart Study
 Prospective secondary prevention in 605
subjects for 5 years
 Subjects randomized to
– Mediterranean diet with 40% fat, 45% carbs
– ADA Step 1 Diet with 25% fat, 60% carbs
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De Lorgeril M. Circulation. 1999; 99: 779-785.
Mediterranean Diet
Lyon Diet Heart Study
 Study halted after 27 months due to
excess mortality in the AHA Step 1 Diet
– Total 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.
Mediterranean Diet
Lyon Diet Heart Study
 The Mediterranean diet dramatically reduced heart
attack and overall mortality compared to the AHA diet
 No change in serum lipids, BP, BMI
 Key difference: Mediterranean diet modifies
inflammation

De Lorgeril M. Circulation. 1999; 99: 779-785.
Mediterranean Diet
Lyon Diet Heart Study
 Mediterranean diet includes nutrients known to decrease
inflammatory mediators (crp, IL-6, WBC)
– Omega 3- EFA, DHA-EPA
– Gamma Tocopherol
– Flavenoids, coumarins anthyrocyanin
 Med. Diet excludes nutrients that increase inflammatory
mediators
– Omega 6-EFA, linoleate and arachidonate
– Iron
– Trans fat: increase CRP
– Alpha tocopherol: reduces gamma tocopherol (Vit E)
Mediterranean Diet
 Great for moderately obese, 20-30 pounds
overweight
 Not concerned with rapid weight loss
 For patients who want to use diet to prevent
or treat co-morbids,
– e.g. Metabolic syndrome, diabetes, CAD
The Paleo Diet
 Typical food in the Western Diet were
virtually unknown in ancestral human diets
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Breads, cereals, rice, and pasta
Dairy Products
Added Salt
Refined vegetable oil
Refined sugars, except honey
Processed Meats
Alcohol
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Cordain et al. Am J Clin Nutr 2001;71:682-92
The Paleo Diet
 Eat like the cavemen eat
– Fresh Veggies
– Nuts/Seeds
– Healthful Oils
– Fresh fruits
– Fish/seafood
– Grass produced meats
The Paleo Diet
 Typical Hunter-Gatherer Diet
– Animal food energy 55%
• Hunted animal 27.5%
• Fished animal 27.5%
• No processed meats
• No dairy food
– Plant food energy 45%
• No cereal grains
• Minimally processed fresh fruits, veggies, seeds & nuts
– No Processed Foods
–
Cordain et al. Am J Clin Nutr 2001;71:682-92
The Paleo Diet
 Nutrient differences between:
– wild vs. cultivated plant food
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Smaller
More fiber
Less sugar
Slightly greater minerals
Vitamin content similar
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/dl
– Lowering dietary cholesterol from 491 mg (paleo) to
219 mg (food pyramid) drops serum cholesterol by 6
mg/dl
– Cutting 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;69:1072-80
The Paleo Diet
 High protein diet is more effective than high
carbohydrate diet in causing weight loss
– After 6 mo – high protein/low fat group had lost
average of 19.6 lbs
– After 6 mo – high carb/low fat group had lost an
average of 11.2 lbs
 Similar studies have replicated results
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Baba NH et al. 1999
Torbay N et al. 2002
Johnston CS et al. 2002
Parker B et al., 2002
Weigle DS et al, Am J Clin Nutr 2005
Exercise Recommendations
 General Health Benefit
– Moderate aerobic exercise 150 min/wk (about 30
minutes 5x/wk) + strength training
 Prevention of Weight Gain
– 150-250 minutes per week
– 150-300 minutes per week
 Prevention of Weight Regain
– 200-300 minutes per week
– 300-420 minutes per week
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– Donnelly JE. Med Sci Sports Exerc. 2009
USDHHS. PA Guidelines for Americans. 2008
Medical Clearance for Physical Activity
 ACSM Guidelines for Risk Stratification
– Men>45, women>55 w/2 or more risk factors
– Risk factors include:
• FHx of MI in 1st degree relative M<55, F<65
• Smoking in last 6 mo
• Hypertension
• Abnormal lipids
• Impaired Fasting Glucose
• BMI ≥ 30
• Sedentary Lifestyle
– Plan to exercise at >60% of max, vigorous
– Consider Stress testing
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Thompson WR, Ed. ACSM’s Guidelines for Exercise Testing & Prescription, 2010
Medications for Weight Loss
Phenylethylamines
 Sympathomimetic effect
 Works at the hypothalamus and limbic system
 Appetite suppressant effect
 Meta-analysis of phentermine and diethylproprion
– 3.6 kg additional weight loss at 6 mo for phentermine
– 3 kg additional weight loss at 6 mo for diethylpropion
–
Li, A. Ann Intern Med. 2005.
Medication for Weight Loss
Phenylethylamines
 Short term adjunct in a regimen of weight
reduction involving lifestyle changes in
management of adult obesity
 BMI ≥ 30 or ≥ 27 with comorbid condition
 Contraindication – advanced arteriosclerosis,
CAD, mod/severe HTN, hyperthyroid, glaucoma,
agitated states, history of known drug abuse,
pregnancy
Medication for Weight Loss
Phenylethylamines
 Adverse Effects
– CV: palpitations, tachycardia, primary pulm
HTN
– CNS: restlessness, dizziness, insomnia, HA
– GI: dry mouth, diarrhea, constipation
– Endocrine: impotence, change in libido
Medication for Weight Loss
Orlistat
 Gastric and pancreatic lipase inhibitor
 Inhibits uptake of up to 1/3 ingested fat
 Needs to be used in accordance with low-fat,
calorie controlled diet.
Medication for Weight Loss
Orlistat
 May be used long-term up 4 yrs for weight loss or for
weight loss maintenance in adult obese patients
 Pediatric indication: 12-16 y/o obese adolescents
 Should be accompanied by vitamin supplementation
 Common SE: fecal soiling, dyspepsia, flatulence,
vitamin malabsorbtion, elevated liver enzymes
 Rare SE: severe liver injury
 Contraindication: cholestasis, malabsorbtion syndrome,
liver disease
Medication for Weight Loss
Metformin
 Biguanide: reduces hepatic glucose
production and improves insulin sensitivity
 Induces modest weight loss initially
 Improves fertility in PCOS patient
 Lost 8 kg more weight over 24 wks than
placebo
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Lee A. Obes Res. 1998
Medication for Weight loss
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GLP-1 Agonists
Exenatide, liraglutide
Enhances glucose dependent insulin release
Suppress inappropriate glucagon release
Delays gastric emptying
Reduction in food intake directly acting on
hypothalamus
Medication for Weight Loss
GLP-1 Agonist
 Great medication for DM treatment and
weight loss
 Works synergistically with carbohydrate
controlled diet
 Nausea common, usually self-limited
 Watch out for pancreatitis
Medication for Weight Loss
Bupropion
 Dopamine and norepinephrine reuptake
inhibitor
 Tx major depression, smoking cessation,
ADHD
 Do not use in bulimic patients, may lower
seizure threshold
Medication for Weight Loss
Bupropion
 Works centrally as an appetite suppressant
 Only anti-depressant with consistent weight
loss effect
 May blunt weight regain in smoking cessation
Medication for Weight Loss
 Phentermine & topiramate ER (Qsymia)
– BMI ≥ 30 or ≥ 27 with comorbid
– Synergistic with Phentermine
• Increased satiety through reduced GI motility
• Increased taste aversion
• Reduced calorie intake
– SE: increased HR, paresthesias, metabolic
acidosis
– TBD when released
Medication for Weight Loss
 Phentermine & topiramate ER (Qsymia)
– Caution: women of reproductive age
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Cleft palate in 1st trimester
Women must be on OCP
Avoid with glaucoma
Hyperthyroidism
MAOI’s
 Studies show 5-10 kg weight loss
Medication for Weight Loss
 Lorcaserin (Belviq)
– Activates the seratonin 2C receptor
– Works at centrally acting satiety receptors
– Caution:
• Valvular HD, CHF, HTN
• Men with predisposition to erection more than
4 hrs (sickle cell, MM, Leukemia) or deformed
penis
– 3.7% weight loss, 7kg.
Office Tool
Thank you