Obesity & Metabolic Syndrome: Fat Brothers in Arms By: Dr. Samuel N. Grief, MD Assistant...

Obesity & Metabolic Syndrome: Fat Brothers in Arms

By: Dr. Samuel N. Grief, MDAssistant Professor and Nutrition Educator

University of Illinois at Chicago Dept. of Family Medicine

Nov.11, 2003

Goals/Objectives

• 1. Review BMI

• 2. Definitions of obesity/metabolic syndrome

• 3. Billing codes for obesity/metabolic syndrome

• 4. Treatment of obesity

• 5. Conclusion

Body Mass Index (BMI)

• BMI defined as: Weight (kg)Height (m2)

• BMI replaces the Metropolitan Life height/weight tables.

• BMI correlates significantly with body fat, morbidity and mortality.

• May be an overestimate in very muscular individuals.

Body Mass Index Chart

WEIGHT

100 105 110 115 120 125 130 135 140 145 150 155 160 165 170 175HEIGH

T5’0” 20 21 21 22 23 24 25 26 27 28 29 30 31 32 33 345’1” 19 20 21 22 23 24 25 26 26 27 28 29 30 31 32 335’2” 18 19 21 22 22 23 24 25 26 27 27 28 29 30 31 325’3” 18 19 20 21 21 22 23 24 25 26 27 27 28 29 30 315’4” 17 18 20 21 21 21 22 23 24 25 26 27 27 28 29 305’5” 17 17 19 20 20 21 22 22 23 24 25 26 27 27 28 295’6” 16 17 19 19 19 20 21 22 23 23 24 25 26 27 27 285’7” 16 16 18 19 19 20 20 21 22 23 23 24 25 26 27 275’8” 15 16 17 18 18 19 20 21 21 22 23 24 24 25 26 275’9” 15 16 17 18 18 18 19 20 21 21 22 23 24 24 25 26

5’10” 14 15 17 17 17 18 19 19 20 21 22 22 23 24 24 255’11” 14 15 16 17 17 17 18 19 20 20 21 22 22 23 24 246’0” 14 14 16 16 16 17 18 18 19 20 20 21 22 22 23 246’1” 13 14 15 16 16 16 17 18 18 19 20 20 21 22 22 236’2” 13 13 15 15 15 16 17 17 18 19 19 20 21 21 22 226’3” 12 13 14 14 15 16 16 17 17 18 19 19 20 21 21 226’4” 12 13 13 14 15 15 16 16 17 18 18 19 19 20 21 21

Body Mass Index Chart

WEIGHT

180 185 190 195 200 205 210 215 220 225 230 235 240 245 250HEIGH

T5’0” 35 36 37 38 39 40 41 42 43 44 45 46 47 48 495’1” 34 35 36 37 38 39 40 41 42 43 43 44 45 46 475’2” 33 34 35 36 37 37 38 39 40 41 42 43 44 45 465’3” 32 33 34 35 35 36 37 38 39 40 41 42 43 43 445’4” 31 32 33 33 34 35 36 37 38 39 39 40 41 42 435’5” 30 31 32 32 33 34 35 36 37 37 38 39 40 41 425’6” 29 30 31 31 32 33 34 35 36 36 37 38 39 40 405’7” 28 29 30 31 31 32 33 34 34 35 36 37 38 38 395’8” 27 28 29 30 30 31 32 33 33 34 35 36 36 37 385’9” 27 27 28 29 30 30 31 32 32 33 34 35 35 36 37

5’10” 26 27 27 28 29 29 30 31 32 32 33 34 34 35 365’11” 25 26 26 27 28 29 29 30 31 31 32 33 33 34 356’0” 24 25 26 26 27 28 28 29 30 31 31 32 33 33 346’1” 24 24 25 26 26 27 28 28 29 30 30 31 32 32 336’2” 23 24 24 25 26 26 27 28 28 29 30 30 31 31 326’3” 22 23 24 24 25 26 26 27 27 28 29 29 30 31 316’4” 22 23 23 24 24 25 26 26 27 27 28 29 29 30 30

Definition of Obesity Using Body Mass Index

Classification BMI (kg/m2)Underweight < 18.5

Normal Weight 19 - 24.9

Overweight 25 - 29.9

Class I Obesity 30 -34.9

Class II Obesity 35 - 39.9

Class III Obesity 40NHLBI Clinical Guidelines on the Identification, Evaluation and Treatment of Overweight and Obesity in Adults-

the Evidence Report. Obesity Research 1998:(suppl.) 53S.

Increase in the Prevalence of Obesity in Adults (Aged 20-74)

20.623.2

13.4

28.630.2

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5

10

15

20

25

30

35

White Black Mexican

Pre

vale

nce

(%

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MalesFemales

Flegal KM et al. Overweight and obesity in the US- Prevalence and Trends. 1960-1994. Int J Obesity 1998;22: 39-47.

Body Fat Distribution

• People store body fat in two general ways; either above or below the waist.

• In both men and women, excess intra-abdominal adipose tissue correlates strongly with cardiovascular disease, dyslipidemia, hypertension, stroke and type 2 diabetes.

• Documenting body fat distribution, in conjunction with BMI, is important to assess risk.

Prevalence of Metabolic Syndrome

• 22% of US adults have the metabolic syndrome

• 43.5% rate among US adults aged 60-69

• Mexican Americans had the highest prevalence of the metabolic syndrome (31.9%)

JAMA, January 16, 2002, Vol.287, No.3, pp. 356-359

Definition of Metabolic Syndrome

• At least three of the following five criteria:• 1. Abdominal obesity: waist circumference > 102

cm in men and > 88cm in women;• 2. Hypertriglyceridemia: > or = to 150mg/dl• 3. Low HDL: <40 mg/dl in men, <50 in women• 4. High BP: > or = 130/85 mm Hg• 5. High FBS: > or = 110 mg/dl

JAMA, January 16, 2002, Vol.287, No.3, pp. 356-359

Billing for Obesity/Metabolic Syndrome

• ICD-9 codes: 278.00, 278.01 and 277.9• Code whenever possible• Expect reimbursement for obesity more

often than not• Metabolic syndrome not as well-known

among insurance companies• Conclusion: The more you bill, the more

likely we all get paid for our services

Case Presentation

• 36 y.o. Hispanic female presents for annual gyne and pap exam. Hx of mild intermittent asthma on albuterol. States she would like to lose weight; has tried Atkins diet which worked initially, but she missed the carbs!

• ROS: Regular menses, G2P2, vision normal, does notice occasional green-brown nipple d/c bilaterally for about one year.

Case Presentation

• O/E: Height 5’6”, Weight 238.5 lbs

• BMI: 42

• Waist circumference 38 inches

• BP: 130/88

• Rest of exam normal.

Case Presentation

Labs: • Cholesterol 140• Triglycerides 190 • HDL 27• LDL 75• Glucose 115• TSH 1.13• Prolactin 12.7• LFTs, rest of chem panel wnl.

Case Presentation

• Diagnoses:• Mild intermittent asthma AND• Morbid obesity• Hypertriglyceridemia• Hyperglycemia• Elevated blood pressure

OR

Metabolic Syndrome

Case Presentation

• Treatment Plan:

• Dietary advice (diet diary, nutrition counseling, etc.)

• Prescription weight loss medicine

• Exercise prescription

• Follow-up in one month

Body Fat DistributionWaist Circumference

• Measured at the mid-point between the iliac crest and the lower rib.

• Correlates strongly with intra-abdominal adipose tissue as assessed by CT and MRI.

• Upper body obesity defined as a waist circumference: – > 40 inches for men – > 35 inches for women

Obesity-Related Co-Morbidities

• CVD, HTN, type 2 diabetes, dyslipidemia• Ischemic stroke• Respiratory problems• Gallbladder disease• Arthritis (DJD)• Cancer• Sleep apnea• Gynecological irregularities

Health Benefits of Weight Loss

• Weight loss of 5% to 10% in obese individuals with type 2 diabetes, HTN or dyslipidemia results in:– Improved glycemic control– Reduced blood pressure– Improved lipid profile

• Goldstein DJ. Int J Obesity 1992;15:397-415. Wing RR, et al. Arch Int Med 1987;147:1749-1753

Etiology of Obesity Dietary Intake

• Increased caloric intake by 220 calories from1970 to 1990. – Increased portion sizes (“super-size”)– Increased frequency of eating outside the home– Fat-free foods perceived as low calorie or

calorie free– Increased fast food consumption

Ernst N. Am J Clin Nutr 1997;66(suppl):965S-72S.

Increased Portion Sizes

Etiology of ObesityPhysical Activity

Increased use of labor saving devices.

Decrease in the energy cost of everyday activities.

Etiology of Obesity Labor Saving Devices

• Tele-commutingPersonal computers• Cellular phones Internet / E-mail• Food deliveries E-Commerce• Escalators/elevators Pay per view movies• Computer games Moving sidewalks

• Drive-in windows Garage door openers• Intercoms Remote controls

Treatment of Obesity

• Behavioral

• Pharmacological

• Surgical

• Self help programs and books

Treatment of ObesityPharmacological Therapy

• Pharmacological interventions to facilitate weight loss and behavior change include:– Enhancing satiety– Decreasing fat absorption– Increasing energy expenditure– Decrease appetite

Orlistat (Xenical): Mechanism of Action

• Activity occurs in the stomach and small intestine.

• Inhibits gastric and pancreatic lipases.• 30% of ingested fat is unabsorbed and

excreted.• Minimal systemic absorption.• Low-fat diet ( 30%) required to minimize

side effects.

Orlistat (Xenical)Summary of Research Findings

-4.6

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-10.2-12

-10

-8

-6

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Time (years)

% W

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PlaceboOrlistat

Sjostrom L et al. Lancet 1998;352:167-172.

Orlistat (Xenical)Summary of Reported Adverse

EventsAdverse Events Overall Incidence

(% of Patients)Oily spotting 26.6Flatus with discharge 23.9Fecal urgency 22.1Oily stool 20.0Oily evacuation 11.9Increased defecation 10.8Fecal incontinence 7.7

Orlistat (Xenical)Prescribing Information

• 120 mg TID with meals containing fat.• Patients should be on a nutritionally balanced,

low-fat diet (< 30%) to minimize side effects. • Prescribe multivitamin to be taken at least two

hours before or after the medication.• Orlistat is contraindicated for pregnant or lactating

women, and those with chronic malabsorption syndromes or cholestasis.

Sibutramine (Meridia) Mechanism of Action

• Serotonin and norepinephrine re-uptake inhibitor SNRI).

• Animal research data shows drug reduces body weight by:– Decreasing food intake in rats– Stimulates thermogenesis in rats

Sibutramine (Meridia)Summary of Reported Adverse

EventPercent (%) of Patients

Adverse Event Placebo (n = 884) Sibutramine (n=2068)Dry mouth 4 17Anorexia 4 13Constipation 6 12Insmnia 5 11Appetite increase 3 9Dizziness 4 7Nausea 3 6Package insert data, Sibutramine, 1998.

Sibutramine (Meridia) Prescribing Information

• For patients with BMI > 30 or > 27 in the presence of risk factors.

• 5 to 15 mg per day.• Not for patients on SSRIs (e.g. Paxil, Zoloft,

Prozac)• Not for patients with poorly controlled

hypertension, history of coronary artery disease, CHF, arrhythmia or stroke.

• Regular BP and heart rate monitoring required.

Surgical Treatment of Obesity

• Patient selection criteria– BMI > 40 or > 35 for those with weight related co-morbidities.– History of failed conservative weight loss approaches.– No substance abuse and/or psychiatric disorders.

• Surgical options– Vertical banded gastroplasty (VBG)– Gastric bypass (GBP)

• Outcomes– Weight loss is 25% to 35% of initial weight.– Weight loss is generally well maintained.– Significant improvement in co-morbidities.

Weight Change New Criteria for Success

• According to the Institute of Medicine’s report, Weighing the Options: – Successful long-term weight control by our definition

means losing at least 5% of body weight and keeping it below our definition of significant weight loss for at least one year.

– Weight loss of only 5% to 10% of body weight may improve many of the problems associated with overweight, such as high blood pressure and diabetes.Thomas P (ed). Weighing the Options. Washington, DC: IOM, National Academy Press,1995

Reasons for Abandoning Ideal Weight with Significantly

Overweight People• Most cannot achieve ideal weight, even

with most aggressive approaches.

• Most cannot maintain losses >15% of initial body weight without surgery.

• Losses of 5% to 10% of body weight are associated with significant health improvements.

Helping Patients Accepts More Modest Weight Loss

• Be clear about what treatment can and cannot do.

• Discuss biological limits.

• Focus on non-weight outcomes.

• Be empathetic about dissatisfaction with weight and shape.

THANK YOU!

• Have a good night!