Current Obesity Management in Primary Care

Current Obesity Management in Primary Care
By:Eileen L. Seeholzer, M.D., M.S.

Obesity Defined

· Traditionally defined as a weight 20% greater than ideal body weight
· Severe obesity or morbid obesity is defined traditionally defined as a weight 100% greater than ideal body weight

Fat Distribution
Upper-body obesity or abdominal obesity or androgenic obesity: An independent risk factor for diabetes mellitus, cardiovascular disease, hypertension, arthritis, menstrual irregularities and gallbladder disease
(Diabetes mellitus is thirty times higher in highest waist-to-hip ratio (whr)compared to lowest quartile whr)
Clinical Guidelines on the Identification, Evaluation and Treatment of overweight and Obesity in Adults

Body Mass Index Chart
Scope of the problem in the U.S.
Increased Risk for Adult Obesity
* Gender/Ethnicity: Women, blacks, Hispanics and Native Americans
* Family History
* Childhood Obesity
* In lower socioeconomic status
* Sedentary lifestyle
* Increased time-spent watching TV
Local Public Health Data
Associated Medical Problems
Renal: Proteinuria/glomerulosclerosis, CRF
Dermatologic: intertrigo, venous stasis, cellulitis, hidradenitis suppurativa, acanthosis nigricans
Psychiatric: depression, binge eating disorder, night eating syndrome
GU: stress incontinence, PCOS, infertility, pregnancy risk
Rheumatologic: DJD- knee, hip, low back pain
General: fatigue, pain, disability, lower socio- economic status, poorer quality of life
Obesity associated Increased Risks in Pregnancy
* Gestational Diabetes
* Hypertension
* Disordered breathing/Obstructive Sleep Apnea
* Cesarean section rate (RR1.5-1.8)
* Congenital heart defects (OR 1.4-2.0)
* Spina Bifida (OR 3.5)
* Omphalocele (OR 3.3)
* Increased levels of leptin, crp and tnf-alpha

Birth Weight and Obesity
* LBW and (<2000gm)OR2.16 and high birth weight (>4000gm)OR 1.53 increased gestational DM risk
* LBW associated with increased overweight adolescence
* Prolonged breast feeding associated with lower rates of adult obesity
Metabolic Syndrome
Three or more of the following present:
* Abdominal obesity(>102cm M/88cm F)
* Elevated triglycerides (>150mg/dl)
* Low HDL (<40 for men mg/dl; <50 for mg/dl for women)
* Hypertension
* High fasting blood sugar
Neuroendocrine Environment
* Leptin/Leptin receptor resistance (at VMH)
* TNF-α, IL-6, adiponectin (aconitase theory – decreased cellular ATP,increased FFA and glucose, Wlodek, et. Al. 2003)
* CRP
* Dopamine, serotonin, norepinephrine
* Low growth hormone levels observed
* Higher cortisol levels sometimes seen
Ghrelin and Peptide YY
Impact of Weight Loss on Risk Factors
Obesity Treatment Pyramid
Diet
Physical Activity
Lifestyle Modification
Pharmacotherapy
Surgery
Non-Pharmacologic Treatments
Components of Basic Program
* Diet Recommendations
* Exercise Recommendations
* Behavior Therapy
* Regular f/u in maintenance phase
Behavior therapy
Combined therapy
Time (mo)
Assessing Weight Loss Readiness
* Motivation:
* Stress level:
* Psychiatric issues:
* Time availability:
Patient seeks weight reduction
Results from Non-pharmacologic Programs
Pharmacologic Treatments
Other Agents
Experimental Agents - Phase 3
Medications That May Promote Weight Gain
* Antipsychotics: risperidone, clonazepine, olanzepin
* Antidepressants: Tri-cyclics, SSRI
* Antiepileptics: valproic acid, gabapentin, carbemazepine
* Lithium
* DM treatments: Sulfonylureas, insulin
* Progestin steroids
* Cortisone
* Antihistamines
* Beta blockers
Surgical Treatment
Surgical Outcomes
Improvement in Comorbid Conditions s/p Gastric Bypass
Common longer-term Complications after Gastric Bypass
Screening For Obesity in Adults
Weight Management Clinic
Obesity Treatment Guidelines

Current Obesity Management in Primary Care.ppt