Obesity - American Academy of Family Physicians
Transcription
Obesity - American Academy of Family Physicians
ACTIVITY DISCLAIMER The material presented here is being made available by the American Academy of Family Physicians for educational purposes only. This material is not intended to represent the only, nor necessarily best, methods or procedures appropriate for the medical situations discussed. Rather, it is intended to present an approach, view, statement, or opinion of the faculty, which may be helpful to others who face similar situations. Obesity The AAFP disclaims any and all liability for injury or other damages resulting to any individual using this material and for all claims that might arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. Every effort has been made to ensure the accuracy of the data presented here. Physicians may care to check specific details such as drug doses and contraindications, etc., in standard sources prior to clinical application. This material might contain recommendations/guidelines developed by other organizations. Please note that although these guidelines might be included, this does not necessarily imply the endorsement by the AAFP. Myra Muramoto, MD, MPH CME041 Tuesday, 3:20-4:20 p.m., Location: 145AB CME042 Wednesday, 12:30-1:30 p.m., Location: 146AB This CME session is supported by an educational grant to the AAFP from Eisai Inc. FACULTY DISCLOSURE It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflict of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity. The following Faculty in a position to control content relevant to this session has disclosed the following relevant financial relationships: Myra Muramoto, MD, MPH, Sanofi-Aventis (pharmaceuticals) Stock/Bond Holdings The content of my material/presentation in this CME activity will not include discussion of unapproved or investigational uses of products or devices. Biography Professor and Sr. Vice Head of Family and Community Medicine, University of Arizona College of Medicine; Professor of Public Health, University of Arizona College of Public Health; Practices at the Abrams Center Family Medicine Center; founding Director of the Quit & Win Tobacco Free Living Program; founding co-Director of the Clinical Weight Loss Program. Assembly Sessions - Endocrine: Obesity, CME041, CME042 Dr. Muramoto practices with the University of Arizona Health Network (UAHN), serving an ethnically and racially diverse patient population with a focus on chronic disease treatment and prevention through lifestyle change. Dr. Muramoto has been teaching for 26 years. This is her first year speaking at the Assembly. Learning Objectives 1. Screen patients using BMI to determine whether they are overweight or obese 2. Devise collaborative care plans that involve intensive, multicomponent behavioral interventions, including behavioral management activities 3. Assess risks and benefits of medications as an adjunct to lifestyle changes in patients who have not lost at least 1.11 lbs (0.5 kg)/ week after 3 – 6 months of implementing lifestyle changes alone. 4. Establish a multidisciplinary, patient-centered strategy to manage bariatric treatment options for obese patients; including patient education, evaluation, coordination of care and follow-up support. Presentation Agenda • • • • • • • • Obesity: epidemic of a chronic disease Obesity treatment = chronic disease management Screening for obesity/overweight The 5 A’s of obesity management Specific behavioral intervention strategies Risks and benefits of weight loss medications Additional practice resources Practice recommendations & questions 1 Obesity Trends* Among U.S. Adults BRFSS, 1985 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) OBESITY: EPIDEMIC OF CHRONIC DISEASE Learning Objective: Screen patients using BMI to determine whether they are overweight or obese No Data <10% 10%–14% Source: Behavioral Risk Factor Surveillance System, CDC. Obesity Trends* Among U.S. Adults BRFSS, 1986 Obesity Trends* Among U.S. Adults BRFSS, 1987 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% Source: Behavioral Risk Factor Surveillance System, CDC. (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% Obesity Trends* Among U.S. Adults BRFSS, 1988 Obesity Trends* Among U.S. Adults BRFSS, 1989 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% Source: Behavioral Risk Factor Surveillance System, CDC. 10%–14% Source: Behavioral Risk Factor Surveillance System, CDC. (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% Source: Behavioral Risk Factor Surveillance System, CDC. 2 Obesity Trends* Among U.S. Adults BRFSS, 1990 Obesity Trends* Among U.S. Adults BRFSS, 1991 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data Source: Behavioral Risk Factor Surveillance System, CDC. <10% Obesity Trends* Among U.S. Adults BRFSS, 1993 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% <10% 10%–14% 15%–19% 15%–19% Obesity Trends* Among U.S. Adults BRFSS, 1995 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data 10%–14% Source: Behavioral Risk Factor Surveillance System, CDC. Obesity Trends* Among U.S. Adults BRFSS, 1994 Source: Behavioral Risk Factor Surveillance System, CDC. 15%–19% Source: Behavioral Risk Factor Surveillance System, CDC. Obesity Trends* Among U.S. Adults BRFSS, 1992 Source: Behavioral Risk Factor Surveillance System, CDC. 10%–14 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% Source: Behavioral Risk Factor Surveillance System, CDC. 3 Obesity Trends* Among U.S. Adults BRFSS, 1996 Obesity Trends* Among U.S. Adults BRFSS, 1997 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data 15%–19% Source: Behavioral Risk Factor Surveillance System, CDC. <10% <10% 10%–14% 15%–19% ≥20% (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% <10% 10%–14% 15%–19% ≥20% 15%–19% ≥20% Obesity Trends* Among U.S. Adults BRFSS, 2001 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data 10%–14% Source: Behavioral Risk Factor Surveillance System, CDC. Obesity Trends* Among U.S. Adults BRFSS, 2000 Source: Behavioral Risk Factor Surveillance System, CDC. ≥20% Obesity Trends* Among U.S. Adults BRFSS, 1999 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data 15%–19% Source: Behavioral Risk Factor Surveillance System, CDC. Obesity Trends* Among U.S. Adults BRFSS, 1998 Source: Behavioral Risk Factor Surveillance System, CDC. 10%–14% (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25% Source: Behavioral Risk Factor Surveillance System, CDC. 4 Obesity Trends* Among U.S. Adults BRFSS, 2002 Obesity Trends* Among U.S. Adults BRFSS, 2003 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data ≥25% Source: Behavioral Risk Factor Surveillance System, CDC. <10% 10%–14% 15%–19% 20%–24% ≥25% <10% 10%–14% 15%–19% 20%–24% 15%–19% 20%–24% 25%–29% ≥30% Obesity Trends* Among U.S. Adults BRFSS, 2007 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) <10% 10%–14% Source: Behavioral Risk Factor Surveillance System, CDC. Obesity Trends* Among U.S. Adults BRFSS, 2006 No Data ≥25% (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data Source: Behavioral Risk Factor Surveillance System, CDC. Source: Behavioral Risk Factor Surveillance System, CDC. 20%–24% Obesity Trends* Among U.S. Adults BRFSS, 2005 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) <10% 15%–19% Source: Behavioral Risk Factor Surveillance System, CDC. Obesity Trends* Among U.S. Adults BRFSS, 2004 No Data 10%–14% 25%–29% ≥30% (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30% Source: Behavioral Risk Factor Surveillance System, CDC. 5 Obesity Trends* Among U.S. Adults BRFSS, 2008 Obesity Trends* Among U.S. Adults BRFSS, 2009 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) ≥30% No Data Source: Behavioral Risk Factor Surveillance System, CDC. <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30% Source: Behavioral Risk Factor Surveillance System, CDC. Obesity Trends* Among U.S. Adults BRFSS, 2010 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30% Source: Behavioral Risk Factor Surveillance System, CDC. 34 Source: Behavioral Risk Factor Surveillance System, CDC. Obesity Related Chronic Diseases Use blank slide for large graphs and graphics. 35 • • • • • • • • • • • Diabetes Mellitus Type II Cardiovascular disease Metabolic Syndrome Nonalcoholic fatty liver disease Gallstones Pancreatitis Obstructive Sleep Apnea Pulmonary emboli Osteoarthritis Gout Cancer: breast, colon, uterus…… Source: Behavioral Risk Factor Surveillance System, CDC. 6 Questions/Poll Everywhere • Should obesity be treated as a chronic disease? OBESITY: A CHRONIC RELAPSING CONDITION Learning Objectives: Devise collaborative care plans that involve intensive, multicomponent behavioral interventions, including behavioral management activities Obesity: a Chronic Condition Obesity is a long‐lasting condition that can be controlled but not cured. It often begins in childhood. Obesity = chronic disease: • Duration longer than a year, has exacerbations and remissions • Associated with functional limitations • Need for on‐going medical care and patient self‐management Think: obesity treatment = chronic disease management: • • • • • • Better control = longer remissions & fewer, less severe exacerbations Regular monitoring by patient and clinician Collaborative care plans Intensive multicomponent behavioral interventions Action plan for detection/early intervention of exacerbations Assist and encourage patient self‐management Overall Obesity Management Goals Overall GOALS of obesity management: • Improve patient health • Improve quality of life • Improve body weight/composition (reduce fat mass, preserve lean mass Reframe Success SCREENING FOR OBESITY AND OVERWEIGHT Learning Objective: Screen patients using BMI to determine whether they are overweight or obese 7 AAFP Recommendations Calculate BMI • Screen all adults for obesity using BMI. – Offer or refer patients with BMI > 30 to intensive multicomponent behavioral interventions. • Screen children > 6 yrs for obesity – Offer or refer to comprehensive, intensive behavioral interventions if BMI >85th percentile for age. BMI Calculator • Kilograms/Meters Formula: weight (kg) / [height (m)]2 = BMI • Pounds/Inches Formula: weight (lb) / [height (in)]2 x 703 = BMI BMI < 35: Measure Waist Circumference • Top of iliac crest • Indicates abdominal adiposity • Predicts risk independent of BMI HIGH RISK Men: > 102 cm (>40 in.) Women: >88 cm (>35 in.) >5x RISK of multiple CVD risk factors BMI for Age Charts BMI for Age Calculator 8 Questions/Poll Everywhere • Should the physician ask the patient for permission to discuss weight? 5 A’S OF OBESITY MANAGEMENT Learning Objective: Devise collaborative care plans that involve intensive, multicomponent behavioral interventions, including behavioral management activities 5 A’s for Evaluation & Management of Obesity • • • • • Ask Assess Advise Agree Assist/Arrange ASK: Permission • Permission to talk about body weight – – – – Patient‐centered Principal of Motivational Interviewing Facilitates patient‐driven behavior change Facilitates non‐judgmental conversation about weight “Are you concerned about your weight and its effect on your health and quality of life?” “Would it be alright if we discussed your weight?” Vallis, et al. Can Fam Physician 2013 59:27‐31. 51 ASK: Explore Readiness to Change • Motivational interviewing approach • Establishes where the patient is with their weight • Helps physician avoid working harder than the patient on weight “How ready are you to work on your weight?” ASSESS: Obesity Severity BMI Classification of overweight/obesity: • Overweight = BMI 25 – 29.9 • Class 1 = BMI 30 – 34.9 (obesity) • Class 2 = BMI 35 – 39.9 (severe obesity) • Class 3 = BMI > 40 (extreme obesity) • Super obesity = BMI > 50 Waist Circumference Risk Level: • HIGH RISK: Men: > 102 cm (>40 in.) Women: >88 cm (>35 in.) 54 9 ASSESS: Complications & ASSESS: Complications & Comorbidities, Barriers to Management Comorbidities, Barriers to Management • Complete medical history and physical exam The 4 M’s of Obesity • Mental: • Mechanical • Metabolic • Monetary – PMhx, PShx, FMhx – Preventive health • Weight–focused history – Previous weight loss treatment – Nutrition history – Physical activity • Diagnostic studies as indicated Sharma AM. Obesity reviews. (2010) 11,808‐809. Mental Complications & Comorbidities, Barriers to Management • • • • • • • Depression Anxiety Other behavioral health issues Cognitive issues Sleep issues Inadequate knowledge Unrealistic expectations for treatment Sharma AM. Obesity reviews. (2010) 11,808‐809. Mechanical Complications & Comorbidities, Barriers to Management • • • • • • • • • Sharma AM. Obesity reviews. (2010) 11,808‐809. Metabolic Complications & Comorbidities, Barriers to Management • • • • • • • • • • Nutritional deficiencies Insulin resistance/metabolic syndrome Type 2 Diabetes Dyslipidemia Hypertension Steatohepatosis Gout Gall bladder disease Polycystic Ovary Syndrome & Infertility Medications causing weight gain Sharma AM. Obesity reviews. (2010) 11,808‐809. Osteoarthritis, other musculoskeletal problems Chronic pain Obstructive sleep apnea, Restrictive hypoventilation Esophageal reflux Urinary incontinence Intertrigo Venous thrombosis Lymphedema Monetary Complications & Comorbidities, Barriers to Management • • • • • • • • Low education and/or income Unemployment and/or disability Life/health Insurance Bariatric furniture or aids Oversized clothing Diet products Weight loss treatment programs Surgery Sharma AM. Obesity reviews. (2010) 11,808‐809. 10 Metabolic Syndrome Diagnostic Criteria Any 3 of these 5 criteria: • Waist Circumference: • Steroid hormones • Antidiabetic drugs: – > 130 mm Hg systol. – > 85 mm Hg diast. – or drug tx for HTN – Some insulins – Sulfonylureas – Thiazolidinediones – esp. atypicals – Lithium • Elevated fasting glucose – > 100 mg/dl – Or drug Tx for hyperglycemia • Reduced HDL‐C – < 40 mg/dl (or drug tx for HDL‐C) • Rapid assessment Questionnaire: – AAFP’s AIM‐HI Fitness Inventory • Food/beverage diary – Food diary – at least 7 days record EVERYTHING – Measure/weigh portions – Paper or smart phone • Purpose: Assess eating patterns, Identify high impact foods Assess patient motivation Patient learns important skill for weight management ADVISE: Health Risks of Excess Weight – “Control” vs. “Cure” – “Healthy Lifestyle” vs. “Dieting” – “Best Weight” vs. “Ideal Weight” – – – – • Antiretrovirals • Antidepressants – – – – Propranolol Prazocin Clonidine Nisoldipine Tricyclics MAO inhibitors Some SSRIs Some antiserotonin agents – Highly active protease inhibitors – diphenhydramine ASSESS: Nutrition/Food Intake Emphasize: • Benefits of modest weight loss (5‐7%) • Benefits of physical activity • Need for long‐term management plan • Reframe thinking: • Antihypertensives • Antihistamines 61 – – – – – Valproic acid – Carbemazepine – Gabapentin • Antipsychotics • Elevated Triglycerides – > 150 mg/dl – or drug tx for TGs • Antiseizure drugs – Glucocorticoids – Estrogens, progestins • Elevated BP – Men: > 102 cm (40 in) – Women: >88 cm (35 in) Common Medications that May Promote Weight Gain Leslie WS, Hankey CR, Lean MEJ. Q J Med 2007; 100:395–404; Malone M. Ann Pharmacother 2005;39:2046‐55. ASSESS: Physical Activity • Rapid assessment questionnaire: – AAFP’s AIM‐HI Fitness Inventory • Current level/type of leisure physical activity • Risks to increasing physical activity? • Enjoyable physical activities – organized or informal? – alone or with others? – Inside or outdoors? • Opportunities and barriers for being more active? • Goal: increase caloric expenditure “Dieting” vs. “Healthy Lifestyle” • Dieting = the smallest number of calories and the greatest amount of exercise that a patient can tolerate. • Healthy Lifestyle = the smallest number of calories and greatest amount of exercise that a patient can enjoy. • “Best Weight” = the weight the patient can attain while still enjoying their life. Freedhoff, Sharma, 2010. Canadian Obesity Network.Toronto, Canada. 11 ADVISE: Diet & Physical Activity • The “best diet” has fewer calories than current diet, that the patient can enjoy and follow long‐term • To lose weight, MUST change diet – Quantity and/or quality of calories • To maintain weight loss – must increase physical activity – Caloric requirements decrease with weight loss • Diet Types: – Low fat – Low carbohydrate – Very low calorie Low-Fat Diet • Fat restricted to 20‐35% of total calories, sometimes less • Weight loss: – After 6 months, the same as low‐carbohydrate • Metabolic Effects: – May reduce fasting glucose and insulin – Moderate decreases LDL‐C, HDL‐C • Risks: – Hunger control may be more difficult – Significant increase in carbohydrates without sufficient weight loss could increase glucose, insulin, TGs and reduce HDL‐C Freedhoff and Sharma, 2010. Canadian Obesity Network. Toronto, Canada. Low-Carbohydrate Diet • 50‐ 150 grams of carbohydrate/day (sometimes less) • Weight loss: – first 6 months, modestly greater weight loss than low‐fat – After 6 months the same as other calorie restricted diets • Metabolic effects: – – – – Reduced fasting glucose, insulin, TGs Increased HDL‐C May increase LDL‐C May reduce BP • Risks: carbohydrate cravings Very Low Calorie Diet • 400‐ 800 calories/day – Commonly use commercially prepared formulas – Need physician supervision • Weight loss: more rapid that low fat or low carb • Metabolic effects: – Reduces fasting glucose, insulin, TGs & BP; may decrease LDL‐C – May increase HDL‐C • Risks include: – Fatigue, nausea, diarrhea, constipation, hair loss, cold intolerance – Kidney and gall stones, gout – Insufficient mineral intake ‐> palpitations, dysrhythmias, muscle cramps ADVISE: Other Treatment Options • Lifestyle – Nutrition – Exercise – Behavioral programs • Lifestyle + Weight loss medications – Meal replacements + medications – Very Low Calorie Diets + Supplements + medications • Weight loss surgery REQUIRES: – Long‐term lifestyle change for long‐term success – Life‐long medical follow‐up Adapted from Obesity Algorithm®, 2013‐2014 American Society of Bariatric Physicians® 12 AGREE: Management Plan and Goals • Realistic weight‐loss expectations/targets – Lose 1 to 2 lbs/week – Goal: 10% of initial body weight over 6 months – Best weight vs. Ideal weight • Behavioral changes – Dietary – Physical Activity • Written agreement/goals ASSIST: Diet Changes ASSIST/ARRANGE: • • • • Provide diet plan Provide physical activity guide/exercise Rx Use motivational interviewing Provide intensive behavioral intervention – Year 1: 12‐26 visits – Patient education resources – Behavioral change tools • AAFP Practice Resource: Americans in Motion – Healthy Interventions ASSIST: Cut Portion Sizes & Record Foods Identify 10 favorite/common foods Apply CAMES Approach • Cutting portion size • Adding healthful foods • Moving eating time • Eliminating foods • Substituting foods • “Calibrate”: Measure foods and drink for 2‐3 days • Food diaries increase weight loss success – Paper journal – Smart phone apps – AIM‐HI Food & Activity Journal • NHLBI website: “Portion Distortion” interactive quiz Mckight TL. “Obesity Management in Family Practice” 2006 Springer, New York. 13 ASSIST: Physical Activity • Low impact exercise prescription – Walking – Swimming – Bicycling/ stationary bike • Initial Goal: 150 minutes/week • Self‐monitoring tools – Pedometer – Smart‐phone apps – Activity trackers Warburton DE, Nicol CW, Bredin SS: CMAJ 2006 174:801‐809. ASSIST: Intensive Behavioral ASSIST: Physical Activity Rx Therapy • AIM‐HI Fitness Prescription – Opportunity – Goal – Dose – Benefits Physical Activity, Healthy Eating, Emotional Well‐being • FITT – – – – • Year 1: 12‐26 sessions – CMS covers up to 22 session IBT/12 months • Suggested schedule: – – – – Weekly x 1 month Q 2 weeks x 2 ‐ 6 months Monthly x 7‐12 months Total 20 visits Frequency (# times/week) Intensity (level of effort) Time (minutes/session) Types of Activity (restrictions/ not‐recommended ARRANGE: Follow-up, Referrals • Follow‐up appointments for – Intensive behavioral treatment (12‐26 sessions/year) – Medication adjustments – Monitoring for weight regain RISKS AND BENEFITS OF WEIGHT LOSS MEDICATIONS • Arrange referrals as indicated – – – – Dietitian Behavioral health provider Bariatric medicine provider Bariatric surgery program Learning Objective: Assess risks and benefits of medications as an adjunct to lifestyle changes in patients who have not lost at least 1.11 lbs (0.5 kg)/ week after 3 – 6 months of implementing lifestyle changes alone. 14 Questions/Poll Everywhere Pharmacotherapy • Indications: • Which of these medications is not approved for long‐ term use in obesity treatment? – – – – – a. Phentermine b. Orlistat c. Combination topiramate/phentermine extended release d. Lorcaserin e. Metformin – BMI > 30, or BMI > 27 + 1 comorbidity – Patients who have not lost at least 1.11 lbs (0.5 kg)/ week after 3 – 6 months of implementing lifestyle changes alone • FDA Approved – Short‐term use (< 12 weeks) – Long term use • Off label medications 86 Phentermine, Diethylpropion, Phendimetrazine, Benzphetamine • Noradrenergic sympathicomimetics: suppress appetite • Not approved for long‐term use • Phentermine efficacy: 6.3 kg total, 3.6 kg more than placebo (over 36 weeks) • Adverse effects: – Dysrhythmias, HTN, chest pain, insomnia Orlistat (Xenical) • Inactivates gastric & pancreatic lipase: Blocks fat absorption • Weight loss efficacy: – 12 months: lost 2.5 ‐ 3.4 kg more that behavioral intervention alone – 24 months: lost 2.5 – 3.3 kg additional weight – 4 years: lost average of 2.7 kg (~ 2.4% of IBW) • Improvements in: – Blood pressure – Insulin resistance, – Lipid levels • Contraindications: – – – – Advanced/symptomatic CAD; Uncontrolled HTN Hyperthyroid Glaucoma Concurrent TCA or recent MAOi use • Adverse effects: – Diarrhea, abdominal cramping, fecal incontinence, oily spotting, flatus Yanovski. JAMA. 2014;311(1):74‐86. Phentermine + Topiramate (Qsymia) • Reduced appetite • Weight loss efficacy: – 1 yr: 8.1 – 10.2 kg (7.8% ‐ 9.8% IBW) – 2 yrs: 9.3 – 10.5% • Improvements in: BP, lipids, HgB A1c, inflammatory biomarkers, waist circumference • Contraindications: pregnancy, glaucoma, hyperthyroid, recent MAOi use • Adverse effects: Parathesias, dizziness, dry mouth, constipation, dysgusia, increases HR, insomnia, • Teratogen (topiramate) – FDA required REM strategy Lorcaserin (Belviq) • Selective serotonin 5HT2C agonist – promotes satiety • Weight loss efficacy: – 1 yr: 3.2 kg (3.2% IBW) more than placebo – 2 yrs: lost 3.2 kg more than placebo • Improvement in: – BP, LDL‐C, TGs, HgbA1c • Adverse effects: – Headache, nausea, fatigue, dizziness – ? Valvulopathy, HTN (post‐approval monitoring) 15 Metformin (off-label) • Improves insulin sensitivity • Off label use for weight loss: – In pre‐diabetes, insulin resistant states, – To reduce weight gain with antipsychotics • 3 kg more weight loss over placebo in patients taking antipsychotics • Weight loss effect is small – limited usefulness as monotherapy – helpful if other indications for use Americans in Motion Healthy Interventions ADDITIONAL PRACTICE RESOURCES Learning Objective: Establish a multidisciplinary, patient‐centered strategy to manage bariatric treatment options for obese patients; including patient education, evaluation, coordination of care and follow‐up support. Canadian Obesity Network • Fitness Inventory Questionnaire • Fitness Rx pad • Food & Activity Journal • Patient handouts • Portion Tools • Children’s books • DVD • Spanish materials CDC Weight Management Research to Practice Series National Institute of Diabetes and Digestive and Kidney Diseases • Summaries of research evidence – – – – – Portion size Fruits & vegatables Sugar sweetened beverages Low‐energy dense foods Away from home foods • Patient handouts • Patient tools 16 Practice Recommendations • Measure and record BMI at each visit for all adults and adolescents. • Implement the 5 A’s of obesity management – – – – – Ask Assess Advise Agree Assist/Arrange Contact Myra Muramoto, MD, MPH Email: [email protected] • Provide intensive behavioral therapy of 12‐26 visits over first year 17