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2/13/2017 5 Things to Know About Managing Obesity in Clinical Practice y Taraneh Soleymani, MD, FTOS Assistant Professor Department of Nutrition Sciences University of Alabama at Birmingham soltar@uab.edu Disclosure I have no financial interest or conflict of interest in I have no financial interest or conflict of interest in relation to this program/presentation. 1

2/13/2017 Objectives THING 1 Staging of Overweight and Obesity THING 2 Obesity Treatment Modalities THING 3 Diet in Weight Management THING 4 Physical Activity in Weight Management Behavioral Modification in Weight THING 5 Management THING 1 Staging of Overweight and Obesity Why is it important to do? • – Correlates with body fat – Risk estimate: Increase BMI is associated with adverse health conditions – Accurate diagnosis & documentation – Treatment selection Treatment selection • Based on Body Mass Index (BMI) – A weight-stature index, used both as a measure of obesity and malnutrition – BMI = weight (kg) / Height2 (m2) – BMI= weight (lb.) x 703/ height squared (in2) – BMI chart Relationship Between BMI and Percent Body Fat in Men and Women 70 Women 60 Men 50 Body 40 Fat Fat 30 (%) 20 10 0 0 10 20 30 40 50 60 Body Mass Index (kg/m 2 ) Adapted from: Gallagher et al. Am J Clin Nutr . 2000;72:694. 2

2/13/2017 THING 1 Staging of Overweight and Obesity • 2013 AHA/ACC/TOS Guidelines for Obesity Recommendation: – Measure height and weight and calculate BMI at annual visits or more frequently Body Mass Index Staging 18.5 – 24.9 kg/m 2 Normal range 25 – 29.9 kg/m 2 Overweight 30 – 34.9 kg/m 2 Obesity Stage I 35 – 39.9 kg/m 2 Obesity Stage II ≥ 40 kg/m 2 Extreme Stage III Does BMI give you the complete picture? • BMI does not distinguish between lean and fat mass. • It is especially less accurate in: – Elderly – Athletes – Certain ethnic groups • Waist Circumference: – Indirect measure of central adiposity correlated with visceral fat Indirect measure of central adiposity, correlated with visceral fat – Excess abdominal fat is an independent predictor of risk factors and morbidity Measurement is recommended for individuals with BMI 25 ‐ 34.9 kg/m 2 to provide • additional information on risk • It is unnecessary to measure waist circumference in patients with BMI ≥ 35 kg/m 2 because the waist circumference will likely be elevated and will add no additional risk information. • Cut points: – Women: >88 cm (>35 in) – Men: >102 cm (>40 in) Comparison of Anthropometric and Metabolic Variables and Disease Prevalence in Women With Normal vs High WC Values Within Different BMI Categories Arch Intern Med. 2002;162(18):2074-2079. doi:10.1001/archinte.162.18.2074 3

2/13/2017 Measuring Waist Circumference • Locate upper hip bone and top of right iliac crest • Place measuring tape around abdomen at level of iliac crest, abdo e at e e o ac c est, keeping it parallel to the floor • Ensure tape is snug but not compressing the skin http://www.nhlbi.nih.gov/guidelines/obesity/prctgd_c.pdf. Waist Circumference is NOT Belt Size Real waist located here = 44” Belt from college located here = 36” Assessing Obesity: BMI, Waist Circumference, and Disease Risk Disease Risk Relative to Normal Weight and Waist Circumference Men  40 in Men > 40 in BMI (kg/m 2 ) Women  35 in Women > 35 in Underweight g <18 5 <18.5 — — — — Normal 18.5-24.9 — — Overweight 25.0-29.9 Increased High Obesity Stage I 30.0-34.9 High Very high Obesity Stage II 35.0-39.9 Very high Very high  40 Extreme obesity Extremely high Extremely high Disease risk for DM2, HTN and CVD. Adapted from: Clinical Guidelines on the Identification, Evaluation and Treatment of Overweight and Obesity in Adults: the Evidence Report. Obesity research and NIH NHLBI, 6(S2), 1998. 4

2/13/2017 Ethnic Specific Values for Waist Circumference Objectives THING 1 Staging of Overweight and Obesity THING 2 Obesity Treatment Modalities THING 3 Diet in Weight Management THING 4 Physical Activity in Weight Management Behavioral Modification in Weight THING 5 Management Lifestyle Lifestyle Pharmacotherapy Surgery Modification Modification Diet Orlistat Phentermine Phentermine/ Physical Topiramate Diethylpropion Activity ER ER Behavior Lorcaserin Therapy Liraglutide Buproprion/ Naltraxone ER 5

2/13/2017 Current Approach to Obesity Treatment → Current Patient Risk LOW HIGH Treatment Options BMI Range 25–26.9 27–29.9 30–34.9 35–39.9 ≥ 40 Diet, exercise, and Potential behavioral therapy behavioral therapy + + + + + + + + + + Treatment Risk LOW With a Pharmacotherapy + + + comorbidity ↓ With a Surgery + HIGH comorbidity Complications-Centric Model for Obesity Treatment Objectives THING 1 Staging of Overweight and Obesity THING 2 Obesity Treatment Modalities THING 3 Diet in Weight Management THING 4 Physical Activity in Weight Management Behavioral Modification in Weight THING 5 Management 6

2/13/2017 Composition Calories Diet Strategies for Weight Mangement Very Low Fat Diet Low Fat Diet Moderate Fat Diet 10 ‐ 20% 20 ‐ 35% 35 ‐ 45% Total Calories from Fat Total Calories from Fat Total Calories from Fat Pritikin Dietary Guidelines for Americans Mediterranean Diet Ornish Dash Primarily plant based American Heart Association Jenny Craig Weight Watchers Nutrisystem High Protein Diet Low Carbohydrate Diet Very Low Calorie Diet > 25% 10 ‐ 30 % <800 kcal Total Calories from protein Total Calories from carbohydrate ZONE Atkins OPTIFAST HMR Ketogenic How Much Calorie to Prescribe? 1. Calculate daily caloric needs and subtract 500 ‐ 750 kcal : Basal Metabolic Rate equation ‐ Mifflin ‐ St Jeor: • Men: 10 x Weight (kg) + 6.25 x height (cm) ‐ 5 x age (y) + 5 • Women: 10 x Weight (kg) + 6.25 x height (cm) ‐ 5 x age (y) – 161 Daily Multiply Basal Metabolic Rate by Activity Factor: Caloric Caloric • Sedentary = 1 2 Sedentary = 1.2 (little or no exercise desk job) (little or no exercise, desk job) Needs • Lightly active = 1.375 (light exercise/ sports 1 ‐ 3 days/week) • Moderately active = 1.55 (moderate exercise/ sports 6 ‐ 7 days/week) • Very active = 1.725 (hard exercise every day, or exercising 2 x/day) • Extra active = 1.9 (hard exercise 2 or more times per day, or training for marathon, or triathlon, etc.) 2. Obesity Guidelines 2013: Women: 1200 – 1500 kcal/day Men: 1500 – 1800 kcal/day Bray, G. & Bouchard, C. Handbook of Obesity, Fourth Edition: Surgical Procedures in the Treatment of Obesity and its Comorbidities 7

2/13/2017 THING 3 Diet in Weight Management START BY recommending a diet that your patient is most likely to • adhere to for weight loss Keep in mind: A collaborative effort • Consider: • – Previous success and failures with a diet plan Previous success and failures with a diet plan – Current life circumstances: opportunities & barriers – Co-morbidities Educate the patient: • – Obesity is a disease – Weight management is a journey: Trial & Error – Importance of keeping a food journal THING 3 Diet in Weight Management Ask patient to be transparent about their food choices, hunger • and challenges of adhering to the diet plan. A Judgment Free Zone Monitor weight loss progress at every visit. • Keep an open mind to the possibility of changing the diet if there • is poor response. Always CHECK THE FOOD JOURNAL before determining the • need to change the diet plan. Objectives THING 1 Staging of Overweight and Obesity THING 2 Obesity Treatment Modalities THING 3 Diet in Weight Management THING 4 Physical Activity in Weight Management Behavioral Modification in Weight THING 5 Management 8

2/13/2017 Short ‐ Term Changes in Body Weight 0 -2 -4 -6 -8 -10 -12 0 Months 6 Months Control Diet Exercise Diet + Exercise Wing et al. 1998 Effect of Exercise on 24-Month Weight Loss Maintenance in Overweight Women Jakicic et al. Arch Intern Med. 2008 Physical Activity & Weight Management • Physical Activity to prevent weight gain : – 150-250 min/wk. (energy equivalent to 1200-200 kcal/wk.) Physical Activity for weight loss : • – <150 min/wk.: minimal weight loss / g – >150 min/wk.: modest weight loss 2-3 kg – >225-420 min/wk.: weight loss of 5-7.5 kg • Physical Activity to prevent weight regain : – 200-300 min/wk. – More is better ACSM Position Stand. Med Sci Sports Exerc. 2009 Feb;41(2):459 ‐ 71 9

2/13/2017 Objectives THING 1 Staging of Overweight and Obesity THING 2 Obesity Treatment Modalities THING 3 Diet in Weight Management THING 4 Physical Activity in Weight Management Behavioral Modification in Weight THING 5 Management Low-Carbohydrate vs. Low-Fat Diet 63 Participants with Obesity 154 Participants with Obesity Low- Low-Fat Low-Carbohydrat Carbohydrate Behavior modification Low-Fat 1200-1500 kcal e 20 g/day carbohydrate 25% fat Increased over time intensity has a 6 months 12 months significant impact on significant impact on -7% % -3.2% 11 % 11 % 11 % total amount of 12 months 24 months weight loss . -4.4% -2.5% 7% 7% Foster GD N Engl J Med. 2003 What is Behavior Therapy? A set of principles and techniques used to help patients ADOPT new • habits. Helps patients REPLACE maladaptive behaviors with new eating and • activity habits. • Helps patients develop a set of SKILLS to regulate their weight The goal: • – to improve eating, activity, and thinking habits that contribute to a patient’s excess weight. 10