Obesity Management: Effective Clinical Strategies I have nothing to disclose Alka M. Kanaya, MD Professor of Medicine, Epidemiology & Biostatistics UCSF, Advances in Internal Medicine May/June 2016 Prevalence of Obesity (BMI≥30 kg/m 2 ) Trends in Obesity 1999-2014 Ogden, NCHS, 2015 % 1
Overweight Trajectories § Communities § Government Social Norms § Worksites and Values § Public Health § Health Care § Health Care Sectors of § Agriculture § Schools and Influence § Education Child Care § Media § Home Behavioral § Land Use and Settings Transportation § Demographic § Communities Factors Individual § Foundations Factors § Psychosocial § Industry Factors Food § Gene- Physical Food & Beverage Activity Environment Beverage Intake Retail Interactions Leisure and Energy Intake § Other Energy Expenditure Recreation Entertainment Energy Balance Roadmap Question #1 The same BMI categories 1. Definitions and Outcomes 2. Clinical management should be used for determining a. The Clinic Visit overweight and obesity b. Diet in all populations? c. Exercise d. Mobile technology, Apps, wearables A. True e. Medications B. False f. Bariatric Surgery 2
Question #1 Defining Obesity The same BMI categories v “An increase in fat accumulation, to the extent that health may be adversely should be used for determining affected” overweight and obesity v BMI (kg/m 2 ) in all populations? v 1995: BMI < 18.5 Underweight 18.5 – 24.9 Healthy Weight 25 - 29.9 Overweight A. True 30 Obese ³ B. False WHO, 1995 Intl Obesity Task Force, 1997 Ectopic Fat Depots Body Shape and Size All 6 people Are 5’9” 172 lbs BMI 25.4 kg/m 2 Body Labs, NY Times, 9/3/2015 3
CHD and Stroke Outcomes Overweight & Obesity Definitions ERFC, Lancet, 2011 BMI Waist WHO-general WHO-Asian Underweight <18.5 <18.5 Normal weight 18.5 – 24.9 18.5 – 22.9 BMI Waist Overweight 25.0 – 29.9 23.0 – 27.5 Obese ≥ 30.0 ≥ 27.5 Lancet, WHO expert panel, 200 4 Metabolically Healthy Obesity? Policies and Recommendations CVD Mortality v HEDIS : adults 18-74 years, receive BMI 14 studies; 299,000 participants assessment annually at PCP visits v USPSTF : screen all adults for obesity – If BMI ≥ 30 kg/m2, offer or refer for counseling and behavioral interventions to promote weight loss v ACA : provides coverage, without cost sharing, for obesity screening and counseling on healthy eating and weight loss RR 1.47 > 15 years f/u Fan, Intl J Cardiology, 2013 4
Guidelines The Clinic Visit AACE, ACC/AHA/TOS, Endocrine Society: v Measure BMI: the fifth vital sign. v Document obesity as a problem. 1. Obesity is a chronic disease and needs long-term management. v Talk to patient about their weight, “your BMI is 2. Goal is to improve health. above a healthy range”. 3. Cornerstone is comprehensive lifestyle change. v Ask about eating habits, physical activity. 4. Initial goal is weight loss of 5-10% 5. Consider use of weight loss medication or possible v What are their goals regarding weight? bariatric surgery as addition to lifestyle therapy to v What changes are they willing to start making? promote greater weight loss and maintain weight loss. v Willing to work with a team including the PCP? Question #2 45 y.o. African American woman, no other comorbidities, BMI = 33 kg/m 2 She wants to start making dietary changes to lose weight. What type of diet would you recommend? A. Low-fat diet B. Low-carbohydrate diet C. Weight Watcher’s diet D. Any diet that she wants to try 5
Low Fat vs. Other Diets Question #2 in weight loss trials T obias, Lancet Diab & Endo, 2015 45 y.o. African American woman, no other Low-fat Vs. comorbidities, BMI = 33 kg/m 2 Low carb She wants to start making dietary changes Favors low carb -1.2 kg mean difference to lose weight. Low-fat Vs. What type of diet would you recommend? Higher fat A. Low-fat diet B. Low-carbohydrate diet No difference Low-fat C. Weight Watcher’s diet Vs. Usual diets Favors low fat D. Any diet that she wants to try -5.4 kg mean difference Favors Low-fat Favors Low Carb Low Fat vs. Other Diets Low Fat vs. Other Diets in weight loss trials in weight loss trials T obias, Lancet Diab & Endo, 2015 T obias, Lancet Diab & Endo, 2015 Low-fat Low-fat Vs. Vs. Low carb Low carb Favors low carb Favors low carb -1.2 kg mean difference -1.2 kg mean difference Low-fat Low-fat Vs. Vs. Higher fat Higher fat No difference No difference Low-fat Low-fat Vs. Vs. Usual diets Usual diets Favors low fat Favors low fat -5.4 kg mean difference -5.4 kg mean difference Favors Low-fat Favors Low Carb Favors Low-fat Favors Low Carb 6
Low-fat vs. Low Carb MA Which Named Diet is Better? v 48 RCTs of named diets evaluated v Low carb: -7.3 kg at 12 mo vs. no diet v Low-fat: -7.3 kg at 12 mo vs. no diet v Weight loss differences between individual diets were minimal Favors Low Carb v Supports recommending any diet that a -2.0 kg patient can adhere to for weight loss. Sackner-Bern stein , Plos One, 2015 Johnston, Jama, 2014 My Dietary Tips v Track what you eat (self-monitor) v Be conscious of portion sizes (plate method) v Beware of liquid calories (choose water) v More fiber (whole grains, fresh fruit/veggies) v Eat protein at each meal (legume, beans, nuts, fish, poultry…) v Small snacks between meals (nuts, fruit) v Take time to eat your meals (mindfulness) 7
Question #3 Question #3 45 y.o. African American woman, no other 45 y.o. African American woman, no other comorbidities, BMI = 33 kg/m 2 comorbidities, BMI = 33 kg/m 2 She doesn’t have time to add exercise to her She doesn’t have time to add exercise to her day. She asks whether diet or exercise is more day. She asks whether diet or exercise is more effective for weight loss? effective for weight loss? A. Diet is more effective A. Diet is more effective B. Exercise is more effective B. Exercise is more effective C. Both diet + exercise are most effective C. Both diet + exercise are most effective Diet vs. Exercise for Weight Loss Diet vs. Exercise for Weight Loss Meta-analysis of 21 trials Meta-analysis of 21 trials Comparison Weight loss, kg Fat Mass, kg Comparison Weight loss, kg Fat Mass, kg Diet vs. Exercise -2.9 (-4.2 to -1.7) -2.2 (-3.7 to -0.7) Diet vs. Exercise -2.9 (-4.2 to -1.7) -2.2 (-3.7 to -0.7) D+E vs. Diet alone -1.4 (-2.0 to -0.8) -1.6 (-2.8 to -0.5) D+E vs. Diet alone -1.4 (-2.0 to -0.8) -1.6 (-2.8 to -0.5) D+E vs. Exercise -4.1 (-5.6 to -2.6) -3.6 (-6.1 to -1.0) D+E vs. Exercise -4.1 (-5.6 to -2.6) -3.6 (-6.1 to -1.0) v Moderate quality evidence that D+E is effective for long-term obesity management v Moderate superiority of Diet over Exercise for weight loss outcomes Schwingshackl, Sys Rev, 2014 Schwingshackl, Sys Rev, 2014 8
Modest Benefit of Isolated Aerobic Exercise is Key after Weight Loss Activity in Trials of weight loss v Weight loss leads to decreases in EE (activity- related, nonexercise activity thermogenesis, and PA index) v RCT of 140 post-menopausal women who had lost 25 lbs with diet (800 kcal/day) v Group 1: aerobic trained 3/week, 40 min/day v Group 2: resistance trained 3/week v Group 3: no exercise Thorogood, Am J Med, 2011 Hunter, Med Sci Sports Exerc, 2015 Exercise is Key after Weight Loss My Exercise Tips v Weight loss leads to decreases in EE (activity- v Set exercise goals: related, nonexercise activity thermogenesis, and PA index) – Be specific: walk 30 minutes per day v RCT of 140 post-menopausal women who had – Attainable (doable): start with 3 days/week lost 25 lbs with diet (800 kcal/day) – Forgiving: Ok if I miss a day v Find a fitness buddy v Group 1: aerobic trained 3/week, 40 min/day v Mix up your routine—walk, bike, swim, dance, step v Group 2: resistance trained 3/week v Add strength training v Group 3: no exercise v Monitor your steps v All measures of EE decline after wt loss, but v Reward yourself (but not with food) either form of exercise ↑ TEE and NEAT v Bottom line : “You cannot outrun a bad diet” Hunter, Med Sci Sports Exerc, 2015 9
Existing (free) Apps v 7-minute work-out v My Fitness Pal: calorie counter and diet tracker v Lose It! v Noom Coach v Fooducate v Amwell v Calorie counter PRO MyNetDiary ($ Ip/ free Android) v Diet Assistance v Endomondo Physical Activity trackers Mobile Technologies v Mobile health interventions: – Short message service (SMS) – majority of trials – Multimedia message service (MMS) v Meta-analysis of randomized trials of mobile phone interventions with weight change outcomes – 14 trials, total of 1,337 participants (trial n=30-250) Case, Jama, 2015 Liu, Am J Epidemiology, 2015 10
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