Management of Obesity in adult

Management of Obesity in adult 52226

Introductionprevalence of obesity > 30% in adults associated with increased risk cardiovascular disease type 2 diabetescancer (i.e., liver, kidney, breast, endometrial, prostate, and colon).

Overweight and obesity are chronic diseases with behavioral origins

DefinitionBody mass index (BMI)Overweight = BMI range: 25 - 29 kg/m2, Obesity = BMI 30 kg/m2.

Body mass index (BMI)= weight(kg) height(m2)

BMI correlates with the amount of body fatBMI directly measure body fat

The National Heart, Lung and Blood Institute (NHLBI)

Waist Circumference

The NHLBI defines abdominal obesity as:Waist circumference Men > 40 inch (102 cm) Women > 35 inch (88 cm)

Measure at a level parallel to the floormidpoint between the top of the iliac crest and the lower margin of the last palpable rib in the mid axillary line.

National Heart, Lung, and Blood Institute. Classification of overweight and obesity by BMI, waist circumference, and associated disease risks. www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/bmi_dis.htm. Accessed March 1, 2013.8

Approach to Managementsignificant weight loss = 5-10%total body weight

Behavioral TreatmentPharmacotherapyBariatric Surgery

Behavioral Treatment

The goal is enable patients to monitoring and modifying their food intake increasing their physical activity recognizing and controlling cues that trigger overeating

Behavioral interventions in conjunction with dietary or drug therapy are more effective than routine care alone

TheUnited States Preventive Services Task Force( USPSTF) developed the stepwise framework known as the 5 As

The 5 As for Evaluation and Treatment of ObesityAssess Severity of obesityBMIwaist circumferenceComorbidities

Food intake and physical activityMedications that affect weight or satiety Readiness to change behavior

AdviseDiagnosis of overweight, obese, or severe obesityCaloric deficit needed for weight lossVarious types of diets Appropriateness, cost, and effectiveness of meal replacements dietary supplements over-the-counter weight aids medications surgeryImportance of self-monitoring

Agree

patient is not readydiscuss at another visit patient is motivated and ready to change develop treatment plan set weight-loss goal at 10% from baselinepatient can do surgery review options

Assistdiet plan, physical activity guide, behaviormodification guide Web resources based on patient interest or needmethod for self-monitoring (e.g., diary)Review food and activity diary on follow-up (reassess if initial goal is not met)

ArrangeFollow-up appointments to meet patient needsReferral to registered dietitian and/or behavioral specialistReferral to surgical programMaintenance counseling to prevent relapse or weight regain*helpful for patients who are ready to change

Motivational interviewingfor patients who are ambivalent or hesitant about making lifestyle changes.physicians ask questions that lead patients to identify healthy choices that they want to makegives them an opportunity for self-examination that may lead to the realization that they can do more to improve their health

Self-Monitoringimproved outcomes a key element in any successful behavioral weight-loss program

Stimulus Controlhelp long-term maintenance.Examples -eating only at the dining table -not eating while watching television -not keeping snack foods at home;

Nutrition Counselingdietary recommendations such ascontrolling portion sizes increasing fruit and vegetable decreasing saturated fat. reducedcalorie diet can result in meaningful weight loss

National Heart, Lung and Blood Institute guidelines suggest reduce caloric intake

Physical Activity

Physicians should routinely recommend regular physical activity to all patients, not only to those who are overweight or obeseThe 2008 Physical Activity Guidelines for Americans recommend 150 minutes of moderate-intensity aerobic activity per week or 75 minutes of vigorous-intensity aerobic activity per week Aerobic activity should 10 minutes per session and should be spread throughout the week

adults should increase their aerobic physical activity to 300 minutes of moderate-intensity or 150 minutes of vigorous-intensity aerobic activity per week. Adults should also engage in muscle-strengthening activities of moderate to high intensity that involve all major muscle groups on two or more days per week.

PharmacotherapyPrescription anti-obesity drugs can be useful adjuncts to diet and exercise for obese adults who have failed to achieve weight loss with diet and exercise.

Prescription weight-loss drugs are approved for patients who meet the following criteria: BMI of 30 kg/m2 or greater BMI of 27 kg/m2 or greater + an obesity-related condition hypertensiontype 2 diabetesdyslipidemia

Three prescription medications are currently approved for longterm management of obesity: orlistat (Xenical)lorcaserin (Belviq) combination phentermine-topiramate extended release (Qsymia).

Orlistat(xenical)

was approved by the Food and Drug Administration (FDA) in 1999.

The effectiveness of orlistat has been demonstrated in several randomized trials

orlistat plus behavioral interventions lost 8% of baseline weight compared with 5% in the control group after 12 to 18 months(Bray GA. Drug therapy of obesity. www.UpToDate.com. Accessed Jan. 15, 2013.)

orlistat resulted in a weight loss of 6.6 lb (3 kg) more than placebo(LeBlanc ES, OConnor E, Whitlock EP,et al. Effectiveness of primary care-relevant treatments for obesity in adults: A systematic evidence review for the U.S. Preventive Services Task Force. Ann Intern Med. 2011;15(7)5:434-447.)

Orlistat also has beneficial effects on blood pressure, insulin resistance, and lipid levels(Carter R, Mouralidarane A, Ray S, et al. Recent advancements in drug treatment of obesity. Clin Med. 2012; 12(5):456-460)

Mechanism:

The adverse effects of orlistat

diarrhea,abdominal cramping fecal incontinence oily spottingrare reports of severe liver injury

Lorcaserin(belviq)a selective serotonin(5-hydroxytryptamine, or 5-HT)subtype 2C receptor agonistreducing appetite and promoting satietyThe FDA approved lorcaserin in 2012

Lorcaserins safety and effectiveness were evaluated in three randomized, placebo-controlled, double-blind studies that were the basis for FDA approval. These trials included more than 6,000 patients and lasted at least one year. The average weight loss with lorcaserin ranged from 3% - 3.7% over placebo47% of participants lost at least 5% of their body weight, compared with 23% for placeboResponse to lorcaserin should be assessed at 12 weeks

Adverse effectfewer adverse effects than orlistatThe most common adverse effects with lorcaserin include headache, dizziness, fatigue, nausea, dry mouth, and constipation

Nonselective serotonergic agonists increased risk of serotonin-associated cardiac valvular diseasefenfluramine dexfenfluramine Theoretically, lorcaserin should not have the same cardiac effects .it is a selective agonist of serotonin receptor 2C. However, there are currently few long-term safety data

https://www.jci.org/articles/view/70678/figure/1

Serotonin Mechanisms in Heart Valve Disease

Serotonin up-regulate transforming growth factor (TGF)- in mesangial cells via G-protein signal transduction.characterized by hyperplastic valvular endocardial lesions

carcinoid syndrome46

A, Thickened and retracted aortic cusp (bold arrow) and deposits of collagen tissue at base of cusp (thin arrow) in a rat given serotoninB, Aortic valve in control ratC, Shortened, thickened, and collagen-rich cusp in serotonin-treated rat with aortic valve insufficiencyhttp://circ.ahajournals.org/content/111/12/1517/F4.expansion.html

Phentermine-Topiramate ER(qsymia)Phentermine is an appetite suppressant topiramate is an anticonvulsant act as an appetite suppressant

two large randomized, double-blind, placebo-controlled trials. (U.S. Food and Drug Administration. FDA approves weight-management drug Qsymia. www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm312468.htm. Accessed Feb. 14, 2013.)

These trials included 3,700 patients treated for up to one year. The average weight loss in patients taking phentermine-topiramate ER ranged from 6.7% (lowest dose) to 8.9% (recommended dose) over placebo.

62%of patients taking the lowest dose and 70% taking the recommended dose lost at least 5% of their body weight, compared with 20% of patients receiving placeb

slightly more effective than orlistat and lorcaserin.

effect on heart rate limit its use in patients with cardiovascular disease.

adverse effectsThe most common adverse effects with phentermine-topiramate ER include paraesthesia, dizziness, dysgeusia, insomnia, constipation, and dry mouthshould be discontinued gradually because abrupt cessation of topiramate has been associated with seizures in some patients

Sympathomimetics4 sympathomimetic agents are currently approved for short-term use as weight-loss adjuncts: phentermine diethylpropion benzphetaminephendimetrazine.

causing early satietyevidence is lacking about the long-term risks and benefitsThese agents are contraindicated in patients with coronary heart disease, hypertension, hyperthyroidism

Bariatric Surgeryconsidered in adults who have not achieved weight loss with dietary or other treatmentswho have a BMI 40 kg/m2 or BMI 35 kg/m2 + obesity-related comorbidities -hypertension- type 2 diabetes- obstructive sleep apnea)

Bariatric Surgery categorizedRestrictive procedures limit the size of the stomach. laparoscopic adjustable gastric banding vertical sleeve gastrectomy

Malabsorptive procedures restrict the size of the stomach and involve bypassing a portion of the small intestine. Roux-en-Y gastric bypass

Sustained changes in diet and exercise habits are essential following bariatric surgery

referenceCopyright 2013 American Academy of Family Physicians 11400 Tomahawk Creek Parkway Leawood, KS 66211 www.aafp.orghttp://www.asean-endocrinejournal.org/index.php/JAFES/article/view/80/381http://asean-endocrinejournal.org/index.php/JAFES/article/view/78/379http://gucdv1wwi8pslzdfpv7t0dk6.wpengine.netdna-cdn.com/wp-content/uploads/2015/12/2015-OMTF-European-Guidelines-for-Obesity-Management.pdfhttps://www.jci.org/articles/view/70678http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1850922/

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