ADDRESSING OBESITY IN PRIMARY CARE Capella Crowfoot Lapham, FNP-C, - - PowerPoint PPT Presentation

ADDRESSING OBESITY IN PRIMARY CARE

Capella Crowfoot Lapham, FNP-C, DNP for the Nurse Practitioners of Oregon Annual CME Conference 10/13/2018

▪ Take a breath ▪ Review trends in obesity prevalence ▪ Describe current Clinical Practice Guidelines

for treating obesity

▪ Review available pharmaceuticals for treating

• besity

▪ Describe the risks of weight loss ▪ Propose a population health approach to

treatment of obesity

▪ BMI is obtained by dividing weight in kilograms by height in

meters squared.

▪ Normal weight: BMI greater than 18 to 24.9 kg/m2 ▪ Overweight: BMI greater than 25 to 29.9 kg/m2 ▪ Obesity class I: BMI of 30 to 34.9 kg/m2 ▪ Obesity class II: BMI of 35 to 39.9 kg/m2 ▪ Obesity class III (severe obesity): BMI greater than 40 kg/m2 (or

>35 kg/m2 in the

▪ Presence of comorbidities)

▪ BMI classifications for Asian and South Asian people:

▪ overweight as BMI between 23 and 24.9 kg/m2 ▪ obesity as a BMI of greater than 25 kg/m2.13

(Smith & Smith, 2016)

Sturm & An, 2014. CA: A Cancer Journal for Clinicians.

Sturm & An, 2014. CA: A Cancer Journal for Clinicians.

Sturm & An, 2014. CA: A Cancer Journal for Clinicians.

Sturm & An, 2014. CA: A Cancer Journal for Clinicians.

▪ The population is roughly divided in thirds for each category:

“normal weight”, overweight, and obese

▪ All social groups regardless of race, income, socioeconomic

group, level of education, or geographic region have experienced increased rates of obesity

▪ Those groups with greatest rate of prevalence and/or increase

are:

▪ Recent immigrants of any race ▪ Asian immigrants with a college education ▪ American Indians, African Americans, and Hispanics ▪ Females 40-59 years old of any race ▪ People with less education and/or less income

(Ogden, Carroll, Kit, & Flegal, 2014; Singh, Siahpush, Hiatt, & Timsina, 2011; Sturm & An, 2014)

▪ According to a large systematic review and meta-analysis obesity is associated with all-

cause mortality

All-cause Mortality Hazard Ratio by BMI

(Flegal, Kit, Orpana, & Graubard, 2013)

▪ Obesity is associated with a 4-7 year reduction in life

expectancy

▪ BMI > 35.0 is has a 2x risk of cardiovascular disease ▪ 80% of those with diabetes are overweight or obese ▪ Being obese raises the risk of diabetes by a factor of 7 ▪ About 6% of cancers are estimated to be attributed to

• verweight and obesity

▪ In trauma patients, those with obesity have a 45% greater

risk of mortality

(Peeters, et al, 2003; Fruh, 2017; Hruby & Hu, 2015)

▪ Tobacco is leading cause of death in US ▪ Adiposity-based chronic disease costs the healthcare

system double that of tobacco

▪ In a study of 30,000 Mayo clinic adult employees and

retirees, smoking was associated with 20% increase in annual costs while those with BMI >40 had 50% greater annual costs

(Spieker & Pyzocha, 2016)

▪ People living in counties with higher PCP supply have

20% less risk of obesity

▪ Only 30% of overweight and 42% of obese patients

report receiving advice to lose weight

(Jones & Sundwall, 2016; Gaglioti, et al, 2016)

▪ 36 year old white female with BMI 46 ▪ Clinically fits PCOS with irregular periods, facial hair, truncal obesity ▪ Has metabolic syndrome: 3/5 of the following:

▪ Waist circumference > 35 (>40 for men), TG’s >150, HDL <50 (<40 for men), BP > 130/85,

• r FBG >100

▪ Desires pregnancy but no conception after 4 years of marriage ▪ Unable to stick to any diet plan or exercise, “I make goals but just can’t stay

committed”

▪ Joint statement from the National Heart, Lung, and Blood Institute, the American

Heart Association, and the American College of Cardiology

▪ Screen BMI annually ▪ Use BMI >25 as cut-off for intervention, waist circumference can indicate if greater risk ▪ Discuss risk of cardiovascular disease, diabetes, and all-cause mortality with all patients

with BMI over 25

▪ Recommend weight loss of 3-5% of body weight ▪ Prescribe a calorie-restricted diet ▪ Recommend a comprehensive lifestyle program ▪ Recommend bariatric surgery to those with BMI>40 and >35 if having related

comorbidity

(Jensen, et al., 2013) https://www.nhlbi.nih.gov/health-topics/managing-

• verweight-obesity-in-adults

▪ American Association of Clinical Endocrinologists and American College of

Endocrinology CPG

▪ Improve adiposity-related complications rather than focus on weight-loss

▪ Screen BMI annually, use BMI >25 as cutoff ▪ Screen those patients for increased waist circumference, pre-diabetes, increased blood

pressure, and elevated lipids

▪ In physical exam and history assess for cardiovascular risk factors, NAFLD, PCOS,

infertility, OSA, asthma, OA, urinary stress incontinence, GERD, depression

▪ Dietary changes, increased physical activity, weight loss of 5-10%, and appropriate

medications will produce clinically relevant improvements in adiposity-based chronic disease (ABCD)

▪ Refer those with BMI >40 or BMI >35 and serious comorbidity to bariatric surgery

(Garvey, et al., 2016) https://www.aace.com/files/guidelines/ObesityExecutiveSu mmary.pdf

▪ Comprehensive life-style program:

▪ Face-to-face, individual or group ▪ Weekly visits for 6 months with an additional year of follow-up ▪ Focus on modifying eating and physical activity habits ▪ Several commercial programs have demonstrated efficacy: ▪ Weight watchers, Jenny Craig, and Nutrisystem (Wadden, et al, 2012) ▪ 10 year follow up typically shows weight was regained but lower

prevalence of comorbidities

▪ The one the patient can do.

▪ Successful weight-loss is directly correlated with the rate of

adherence to the dietary plan

▪ Head-to-head trials of low-fat, low-carb, low-glycemic,

ketogenic diets show that although some have more rapid short-term effect, similar long-term outcomes

▪ Select dietary advice to support comorbidities

(Wadden, et al, 2012)

▪ Physical Activity Recommendations:

▪ 30 minutes 5 days per week for adults ▪ 60 minutes daily for children and <2 hours per day screen-time

▪ Weight loss through exercise requires hours of high-intensity

exercise

▪ However, increased physical activity is associated with long-

term success in avoiding weight regain

(Wadden, et al, 2012)

▪ MyPlate concept:

▪ Can be used to teach basic nutritional concepts ▪ To assist diabetics to adjust meals based on CBG results ▪ To assist in maintaining balanced diet while reducing

portions

▪ For children parents can learn about health portion sizes

at:

https://www.healthychildren.org/english/healthy- living/nutrition/pages/default.aspx

▪ Physical Activity Vital Signs tool provides longitudinal information

▪ How many days during the past week have you performed physical

activity where your heart beats faster and your breathing is harder than normal for 30 minutes or more?

▪ How many days in a typical week do you perform activity such as this? ▪ Scored as days this week / typical week: 0/0 to 7/7

▪ HEVS: Health Eating Vital Signs provides information that is highly

associated with excess BMI and are amenable to discussion in a clinic visit

▪ Questions focus on restaurant/fast food, soda, juice/punch, vegetables,

fruit, breakfast

(https://www.researchgate.net/publication/260214360_Healthy_Eating_Vital_Sign_A_New_Assessment_Tool _for_Eating_Behaviors)

▪ 5A model: shown to improve provider communication with patient

regarding obesity

▪ Assess risk, current behavior, and readiness to change ▪ Advise change of specific behaviors ▪ Agree and collaboratively set goals ▪ Assist in addressing barriers and securing support ▪ Arrange for follow-up

(https://bmchealthservres.biomedcentral.com/articles/10.1186/1472-6963-10-159)

▪ Psychosocial-life events focused history helps build tailored

interventions:

▪ Patient can often chart their weight gain based on significant life

events:

▪ Smoking cessation, pregnancy or menopause, change in marital status or new

job

▪ Post-illness or when initiating a new medication

(Kushner & Ryan, 2014)

▪ Reduced mortality with increased BMI:

▪ For ages 65-74 ideal BMI 27-30 for all-cause mortality and 25-35

for cardiovascular mortality

▪ However, higher BMI has increased risk for DM, OA,

disability, and some fractures

▪ Weight loss is associated with increased function and

improved lab values, however:

▪ Focus on adequate nutrition when reducing calories ▪ Important that include muscle strengthening activity in

comprehensive weight loss plan

▪ Utilize 2 measures to diagnose diabetes since higher

prevalence of conditions that compromise HgbA1C accuracy

(Rothberg & Halter, 2015; Kalish, 2016)

▪ Share health promotion information for metabolic health with every

patient

▪ Ask permission to discuss BMI ▪ Emphasize the importance of metabolic health over weight ▪ Brainstorm strategies to assist patient in achieving physical activity

and dietary recommendations

▪ Set small goals and celebrate small achievements

▪ 69 year old Hispanic female with chronic conditions, BMI 34.0 ▪ DM2 that is controlled through dietary changes, occasionally checks CBG at home ▪ OA: takes celecoxib and gabapentin, can’t walk much due to knee pain

▪ History of harmful weight-loss drugs:

▪ Sheep thyroid extract used in the 1890’s—cardiac arrhythmias and

deaths

▪ 2,4-dinitrophenol was population in 1930’s until connected to fatal

hyperthermia and agranulocytosis

▪ Amphetamine was used during the 1950’s in a “Rainbow” pill

regimen that mixed amphetamine with digitalis, diuretics, laxatives, thyroid extracts, and barbiturates

▪ Fen-phen (fenfluramine and phentermine), heavily marketed in the

1990’s resulted in valvular heart disease

(Daneschvar, et al, 2016)

Consider medication for patients determined to lose weight.

(Golden, 2016)

▪ Lorcaserin (Belviq): serotonin agonist (5-HT)

▪ Dose: 20mg daily. ▪ Suppresses appetite ▪ Schedule IV: higher doses can induce hallucinations and euphoria ▪ As a serotonergic drug, potentially fatal interactions with SSRI/SNRI,

MAOI’s, triptans, buproprion, dextromethorphan, and St. John’s Wort.

▪ Orlistat (Xenical, Alli): lipase inhibitor

▪ Dose: 120mg. Take orally with each fat-containing meal. ▪ A low-fat diet is desirable since side effects are worse with higher fat

content of foods

▪ Disrupts absorption of other medications and fat soluble vitamins ▪ Monitor renal function, do not use in those with malabsorption

syndrome

(Golden, 2017; Daneschvar, et al, 2016)

▪ Phentermine-topiramate (Qsymia): stimulates noradrenaline,

dopamine, serotonin

▪ Dose: 3.75/23mg, 7.5/46mg. Titrate dose over 2 weeks. ▪ Schedule IV drug, due to abuse potential of phentermine ▪ Monitor mood, electrolytes, creatinine, and glucose levels ▪ Interactions with MAOI, oral contraceptives, CNS depressants, and

non-potassium sparing diuretics

▪ Naltrexone-buproprion (Contrave): opioid receptor antagonist

and inhibitor of dopamine and noradrenaline uptake

▪ Dose: 8/90mg daily and can titrate over 4 weeks to 16/180mg BID ▪ Monitor mood, blood pressure, and heart rate ▪ Interacts with MAOI’s, other drugs that lower the seizure threshold,

• ther dopaminergic drugs, and those that use the CYP liver enzymes

(Golden, 2017; Daneschvar, et al, 2016)

▪ Liraglutide (Saxenda): glucagon-like peptide receptor agonist

▪ Dose: 3mg daily SQ injection, initial dose 0.6mg and titrate weekly

to full dose

▪ Slow titration mitigates GI side effects ▪ Decreased cardiovascular mortality in adults with T2D using

liraglutide / slight risk of pancreatitis

▪ Do not use in patients with personal or family history of medullary

cancer (Golden, 2017; Daneschvar, et al, 2016)

▪ Phentermine: daily dose of 15-37.5mg or 8mg TID ▪ Schedule IV drug: short-term use only (12 weeks) due to

abuse potential and adverse events

▪ Do not prescribe with MAOI’s, SSRI/SNRI’s, other stimulants,

• r drugs that increase seizure risk.

▪ Do not prescribe to those with anxiety, cardiovascular

disease, hyperthyroidism, history of drug abuse, glaucoma,

• r during pregnancy and breastfeeding

▪ Pregnancy is contraindicated for ALL weight-loss medication

▪ Topiramate: monthly pregnancy test recommended

▪ Select medication based on comorbidities:

▪ Use liraglutide for those with prediabetes or diabetes ▪ Use buproprion for those with depression or tobacco use

▪ All produce:

▪ Improved lipid profile ▪ Reduced progression to diabetes in prediabetic patients

(Golden, 2017; Daneschvar, et al, 2016)

▪ Consider alternatives where available:

Category Obesogenic Alternatives Neuroleptics Thioridazine, haloperidol,

• lanzapine, quetiapine,

risperidone, clozapine Ziprasidone, aripiprazole Antidepressants Tricyclics, paroxetine, mirtazapine Protriptyline, buproprion, nefazodone Anticonvulsants Valproate, carbamazepine, gabapentin Topiramate, lamotrigine, zonisamide Antihistamines Cyproheptadine Inhalers, decongestants Beta/adrenergic blockers Propranolol, doxazosin ACE, CCB Steroid hormones Contraceptives, glucocorticoids, progestational steroids Barrier methods, NSAIDS

(Kushner & Ryan, 2014)

▪ 35 year old female, white, with college degree ▪ A high-energy professional patient who reports working up to 20 hour shifts. Her

current BMI is 33.0

▪ She reports success reducing from 140 to 120 pounds using phentermine in the

• past. She is interested in using phentermine again.

▪ She describes different diets she has tried: keto-diet, metabolism correcting diet,

Weight Watchers.

▪ She confesses that she is a sugar-addict, is capable of eating sugar snacks all day

and living on Redbull.

▪ Capacity:

▪ Do you have access to intensive lifestyle programs? ▪ Do you have staff trained to counsel patients for weight loss? ▪ >60% of Oregonians have BMI >25: do we have the capacity to provide

intensive lifestyle programs for everyone who needs them?

▪ Both psychological harm and physical harm

▪ Dieting produces future risk of obesity

▪ Odds of obesity increased by 1.9, 2.9, and 3.2 times for those who were

• n a diet once, more than once, and always

▪ Body shame and preoccupation

▪ Join the Health at Every Size community at: https://haescommunity.com/

▪ 95% of people who successfully lose weight, regain it all in 10

years

▪ Weight loss creates a negative energy balance which activates

physiologic process to regain the weight

(Siahpush, et al, 2015; Bacon & Aphramor, 2011; Rogge & Gautam, 2017; Guo & Garvey, 2016)

▪ Uncertainty regarding cardiovascular benefit:

▪ Is it weight loss or the behavioral changes that produce

reduced prevalence of cardiovascular and metabolic disease?

▪ Presence of metabolic risk factors are significantly

stronger predictors of poor outcomes regardless of weight

▪ Weight is not a SMART goal:

▪ Addressing behaviors that support metabolic health is more

effective

(Siahpush, et al, 2015; Bacon & Aphramor, 2011; Rogge & Gautam, 2017; Guo & Garvey, 2016)

▪ Discuss metabolic health with ALL patients ▪ Behavior focus with PAVS and HEVS tool ▪ Food insecurity assessment and address issues of access ▪ Support patients interested in weight loss with evidence based

nutrition information

▪ Support patients of all sizes with metabolic risk factors with

appropriate dietary recommendations

▪ Rates of disease between groups provides evidence to the

cause:

a population wide increase in obesity and overweight BMI among diverse demographic groups in the US population points to an environmental cause that is common to the whole population (Sturm & An, 2014; Rose, 2008).

▪ Environmental causes include:

▪ Cheap plentiful food and increasingly sedentary lifestyle ▪ Shifts in supply over last 100 years mirror shifts in consumption

patterns to higher amounts of meat and sugar

▪ Postulated mechanisms through exposure to antibiotics and

environmental toxins

▪ Prevalence is predicted by

population mean

▪ Heavily investing in tertiary

prevention will not prevent new cases

▪ Incremental change across

many individuals result in significant population shifts

Physiologic and behavioral norms within a population exist on a continuum:

• Individuals at the extreme ends

are simply the extension of the norm

▪ Individual and choice-based strategies benefit those of higher

socioeconomic class

▪ Avoid increasing racial and socioeconomic disparities by

environmental, macro-level modifications:

▪ Restricting sales of unhealthy foods in schools ▪ Increasing mandatory PE time ▪ Directing industry-wide reductions in caloric density ▪ Encouraging urban design to increase green space and bike paths ▪ Giving tax credits to businesses that offer comprehensive wellness

programs

(Backholer, et al, 2014)

▪ A 1% reduction in national mean BMI would prevent 2

million new cases of type 2 diabetes, 1.5 million new cases of heart disease, and 100,000 cases of cancer per year

▪ Soft drink consumption represents 13% of caloric intake

per capita in the US: a 1-cent per ounce tax could cut consumption by 15%

▪ Lowering prices for nutrient-rich foods and raising

prices for nutrient-poor foods has been shown to shift purchasing patterns

(Jones & Sundwall, 2016; Wang, et al, 2012; Andreyeva, et al, 2010)

CONCLUSION

▪ Primary care:

▪ Focus on health behaviors that support metabolic health ▪ Normalize excess BMI and provide realistic expectations of weight loss ▪ Address food insecurity and access to opportunities for physical activity

▪ Public health:

▪ Support taxation of unhealthy foods ▪ Provide information to policy makers ▪ Participate in local government and urban planning

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