Obesity Diagnosis & Management: A Primer for Primary Care Providers

Kara Elena Schrader, DNP, FNP-CAssistant Professor-Health ProgramsMSU College of Nursing

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• Identify the pathophysiologic mechanisms associated with obesity

• Recognize the condition of obesity as a chronic illness

• Prioritize obesity management in the care of obesity related chronic conditions

• Apply evidenced guidelines for the assessment, diagnosis and management of obesity within the primary care setting

Objectives

Obesity is a Chronic Condition

“Obesity is defined as a chronic, relapsing, multi-factorial, neurobehavioral disease, wherein an increase in body fat

promotes adipose tissue dysfunction and abnormal fat mass physical forces, resulting in adverse metabolic, biomechanical,

and psychosocial health consequences.” Obesity Management Association

“Acquiring obesity is not a personal choice, but a disease with serious health consequences.”

The Obesity SocietyObesity is not a disorder

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Obesity as a Chronic Disease

CDC definition of chronic disease“Conditions that last 1 year or more and require ongoing medical attention or limit activities of daily living or both.”

Mosby’s Medical Dictionary, 2009“Any disorder that persists over a long period and affects physical, emotional, intellectual, vocational, social, or spiritual functioning. “

4CDC, 2018

Obesity in Primary Care

20% of adults in US have obesity Only 55% have been formally diagnosed Prevalence: Non-Hispanic Asian adults: 12%

Non-Hispanic black adults: 39.1% Hispanic:33% Non-Hispanic white: 29.3% Michigan: 32% all adults

5County Health Rankings & Roadmaps, 2020;

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Obesity Pathophysiologic

Factors

Obesity Pathophysiologic Factors: Hormonal

Gut: Ghrelin: “hunger hormone”, stimulates appetite, secreted in stomach Glucagon-like Peptide-1 (GLP-1): delays gastric emptying, improves glycemic control,

reduces appetite; secreted in small and large intestine Peptide YY: increases the feeling of satiety, levels lower in persons with obesity, secreted

in small intestine (responds to food) Cholecystokinin: increases feeling of satiety, secreted in small intestine

Pancreatic: Insulin: rises with glucose; promotes fat storage and stimulates hunger, inflammation Amylin: increases the feeling of satiety

Adipose tissue: Key endocrine organ in obesity pathology and complications Leptin: increases with higher levels of adipose tissue; suppresses appetite, regulates

energy and neuroendocrine function Adiponectin: decreases insulin resistance; some protection from CVD Pro-inflammatory cytokines

7Tartof, SY, et al;., 2020; Lee, Lee & Choue, 2013; Lenard & Berthoud 2009

Obesity Pathophysiologic Factors:Co-existing conditions that can induce or contribute

Insulin resistance: worsens weight gain Depression: one can cause the other

(bidirectional) Obstructive Sleep Apnea: can be caused by

obesity but can contribute to weight gain

8Rjan, et al.., 2017; Ong, et al., 2013

Obesity Pathophysiologic Factors: Environment

Availability of food Busy lifestyle Processed, unhealthy foods cheap Physical activity safety

9Lake A. & Townshend,2006

Obesity Pathophysiologic Factors: Genetics

Over 100 genetic variants that have been shown to be involved with obesity

No single gene found to be the cause of obesity Many genetic disorders are associated with obesity all

involving different gene and chromosomes arrangements (Prader-Willi, Melanocortin 4 Receptor Deficiency)

Continues to be studied Epigenetics: “alterations in gene expression without

alternation in genetic code.” external and environmental factors effecting genes

10Bays, et al., 2020; van Dijk, 2015

Obesity Pathophysiologic Factors: Medications

Anti-seizure meds Anti-psychotics Beta-blockers Anti-virals for HIV Corticosteroids Chemotherapy

Insulin, TZDs, sulfonylureas

Contraceptives Anti-histamines

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Obesity pathophysiologic factors: Microbiome

Bacteria in the gut >100 types Regulates metabolism Inflammatory effects associated with obesity

12D’Argenio, 2015

Obesity pathophysiologic factors: Senses

Reaction to food as a physiologic response Hunger caused by desire to eat to feel

pleasure rather than regulate energy needs

13Ziauddeen, 2015

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OBESITY RELATED CONDITIONS

Obesity Related Conditions

Hyperlipidemia, hyperglycemia, DM2, HTN, GERD, insulin resistance, PCOS, cholelithiasis, worsening of inflammatory disorders (OA, atherosclerosis), asthma (adiposity immune and endocrine responses)

Higher risk of cancers: gallbladder, gastric, liver, colon, esophagus, pancreas, ovarian, breast (post-menopausal), renal, multiple myeloma, non-Hodgkin's lymphoma, leukemia

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Bays, 2020; Lauby-Secretan, et al., 2016; Lauby-Secretan, 2016;

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ASSESSMENT/DIAGNOSIS OF OBESITY

Assessment of Obesity BMI Measures excess weight Definition varies with guideline organization Does NOT measure excess adipose tissue Cannot differentiate between lean body mass and excess

adiposity Is used for original screen Does not necessarily assess cardiometabolic risk

17AACE, 2016; AACE 2019; Bays, et al., 2020

Assessment of Obesity

Waist Circumference Most efficient and cost effective method to assess central

adiposity and disease risk

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Central Adiposity:Women: >35 inches (>88 cm)Men: >40 inches (>102 cm)

*Asian Women: >31.3 inches (>80 cm)*Asian men: >35 inches (>90 cm)

AACE, 2016; AACE 2019; Bays, et al., 2020

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Clinical diagnosis of Obesity AACE, 2019

Assessment of obesity Assess history

Weight history Dietary intake (foods, fluids) Physical activity Sleep

Physical Exam: HR, BP, RR Parotid glands (enlarged with purging/vomiting) Thyroid Dental (decay with purging/vomiting) Shape of face and appearance of neck/upper back (swollen can be sign of Cushing's) Screen for OSA and neck circumference if indicated Liver Skin: purple striae, skin tags, acanthus nigricans, hirsutism Joints (osteoarthritis) Depression screen

20AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS (AACE) AND AMERICAN COLLEGE OF ENDOCRINOLOGY (AACE), 2016

Lab Assessment for Causes or Obesity Related Conditions

Thyroid studies (TSH, FT4 if indicated) A1C Fasting lipids Liver enzymes Renal function

21AACE/ACE, 2016

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MANAGEMENT

Management: Nutrition

Minimize highly processed foods, sweetened beverages and/or energy-dense beverages (soda, juice)

Encourage whole foods: protein, healthy fats, vegetables, leafy greens, fruits, nuts, legumes, whole grains

Encourage high fiber complex carbs Assist in reading labels Nutritionist referral if available: Medical Nutrition Therapy (MNT) Quality of calories more important that quantity Must find a eating plan that is mutually agreed upon and

sustainable Adherence is best predictor of success

23AACE/ACE 2016; Bays, 2020

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Diet Description Benefits Disadvantages

DASH Balanced diet with the emphasis on vegetables, whole grains, low sat fats, sweets. Low sodium

Reduces risk of DM2Wt lossLowers BP

Mediterranean Balanced diet with emphasis on plant based (whole intact grains); olive oil primary source of fat; fish, daily in low to moderate amts; low red meat, and rare concentrated sweets

Reduces risk of DM2A1C reductionReduced triglyceridesReduced risk for CV events

Low fat Low carb veggies, beans, fruits, whole intact grains; nonfat dairy, fish, egg whites; 13-20% protein, with 70-77% complex carbs

Wt lossLowers BP

High protein (“paleo”)Based upon pre-historic diets

Lean meats, fish (including shell fish), veggies, eggs, nuts/berries; Avoiding grains, dairy, salt and refined fats; no sugar

Not enough evidence for benefit

Lack of whole grains and dairy

AACE, 2020

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Diet Description Benefits Disadvantages/Cautions

Low and very low carb (Ketogenic—”keto”; Atkins, South Beach))

Low carb veggies; animal fat, oils, butter and protein from many sources; Berries; No starchy foods or sugar; no pasta, rice potatoes, etc.; Many different definitions of low carb;

Reduces A1CWt lossLower BPIncreased HDL and lower triglyceridesCan be adaptable for long term sustainability

Possible reduced needed vitamins and minerals; Reduction in fiber causing constipation; Can raise LDL;

Intermittent Fasting

Twice weekly 24 hour fasts (beginning at dinner time)

Wt loss Fat loss, muscle gainIncreased insulin sensitivity (lowers glucose, A1C)Lower BP

Inappropriate for persons with DM; the elderly; those with history of eating disorders such as anorexia or bulimia; avoid in pregnancy and breast feeding; Need guidance of health care professional

AACE, 2020; Cabo & Mattson, 2020

Management: Physical activity

Evaluate readiness and mobility Medical testing if concerned about cardiac or resp. risk Assess available options for physical activity Encourage creativity! Utilize behavior change theories PT may be an option to assist if obesity related

osteoarthritis Physical activity is for wellness…cannot lose weight with

physical activity alone. DIETARY CHANGES ARE NEEDED FOR WEIGHT LOSS

26AACE/ACE 2016; Bays, 2020

Management: Physical activity

150 minutes of moderate intensity physical activity per week PLUS 2 days of strength training

To prevent weight regain, need to increase minutes! 420 minutes of moderate activity (210 vigorous) per

week

Physical activity is the most important factor to prevent weight regain

27AACE/ACE, 2016; Bays, 2020

Management: medications

FDA guidelines BMI >30 BMI >27 with one or more weight related complications (DM2,

hyperlipidemia, HTN or co-morbid condition—OSA) Consider other factors when deciding upon meds

• Other metabolic conditions• Lack of satiety• Cravings• Hunger

Assess for contraindications and possible medication reactions Discuss options Frequent monitoring essential (face to face at least monthly for first 3

months) If no response after 12 weeks with highest available or tolerable dose, D/C

and try another med.

28Bays, 2020; AACE, 2016

Management: medications

Phentermine: (no long term studies re: mean loss published) Targets specific neurons in the hypothalamus and suppresses hunger,

cravings Dosing is determined by brand used Schedule IV, abuse potential Contraindicated: CVD, glaucoma, drug addiction, ETOH use and agitation

Orlistat: (mean loss: 6.1%/1 year) Reduced absorption of fat by the inhibition of pancreatic and gastric

lipases Improves insulin sensitivity, lowers glucose, improves lipids, BP Given with each meal containing fat up to 3 times a day Educate about need for vitamin supplement Contraindications: Malabsorption syndrome, cholestasis,

29Bays, 2020

Management medications

Locaserin OFF MARKET 2/2020 Phentermine/Topiramate (mean loss 9.8%/1 year) Suppresses appetite/cravings Improves lipids, glucose, waist circumference Daily dosing with gradual titration If weight loss <5% within 12 weeks at the highest

dose=D/C Contraindications: CVD, glaucoma, drug addiction, ETOH

use and agitation Need to taper with D/C

30Bays, 2020

Management medications

Naltrexone/bupropion: (mean loss: 5.4%/1 year) Each component works together to activity hypothalamus neuron responsible for satiety Improves lipids, glucose, waist circumference, fasting insulin Dosing once daily and titrating weekly to max of 2 tabs BID D/C if weight loss <5% within 12 weeks Contraindications: uncontrolled HTN, hx seizure disorder, bulimia/anorexia history, history of

suicidal behavior Liraglutide: (mean loss: 8.0%/1 year)

GLP-1 analog, reduced appetite (slows gastric emptying) Improves inflammatory markers, beta-cell function, lipids, glucose, waist circumference,

fasting insulin GI side effects if titrated too quickly Daily SQ injection, anytime D/C if weight loss <4% within 16 weeks Contraindications: personal or family history of thyroid cancer

31Bays, 2020

Management: Bariatric Procedures

Metabolic procedures: Laparoscopic sleeve gastrectomy

• Decreases stomach size to 25%• Changes gut hormones and bacteria to improve satiety, suppress

hunger and improve glucose metabolism• Good for those with obesity related metabolic disease• Not for persons with severe GERD/Barrett’s• Average loss by year 3: 21%• Hospital stay: 1-2 days, recovery 1-2 weeks• Anatomy of small intestine maintained---less nutrient depletion

though micronutrient supplements still recommended

32Bays, 2020

Management: Bariatric Procedures

Metabolic procedures Laparoscopic Roux-en-Y Gastric Bypass

• Small gastric pouch created by splitting top of stomach from remaining stomach; pouch capacity 15-20 ml

• Changes gut hormones and bacteria to improve satiety, suppress hunger and improve glucose metabolism

• Good for persons with high BMIs and with additional obesity related conditions (DM2, HTN, OSA, NAFLD, GERD)

• More complex procedure, greater risk of complications• Hospital stay 1-4 days, recovery 1-2 weeks• Weight loss in 1 year approx. 35%• Micronutrient supplements needed

33Bays, 2020

Management: Bariatric Procedures

Metabolic procedures Biliopancreatic diversion with duodenal switch

• Small pouch created by removing portion of the stomach and then bypass the small intestine

• Changes gut hormones and bacteria to improve satiety, suppress hunger and improve glucose metabolism

• Enhances GLP-1 and decreases absorption of fat/calories• Greatest weight loss of all the surgeries (>35% at 3 years)• Only for BMI >50 or if DM2 and obese• Not commonly done in US due to difficulty and possible

complications• Higher protein, nutritional deficiencies

34Bays, 2020

Management: Bariatric surgery

Non-metabolic procedures Laparoscopic adjustable gastric band

• Restrictive• Inflatable, adjustable band placed around upper part of stomach

which creates small pouch to decrease capacity of stomach• Capacity controlled by inflating band with saline through accessible

port • Used to be popular choice, no longer as popular due to unsuccessful

weight loss• Average loss with appropriate use: 15% at year three• Outpatient procedure, is reversible• Lowest risk of nutrient deficiency though patients still are instructed

to take specific vitamins

35Bays, 2020

Management: Bariatric Procedures

Other non-metabolic procedures Intragastric balloon system Vagal blocking device

36Bays, 2020

Post Bariatric Procedure Guidelines are provided for eating post-op

Always need dietician collaboration Usually start with low sugar, clear liquids and gradually add thicker fluids Foods introduced slowly Education for pt. includes:

• Stop eating when full• Eat foods with high levels of protein and eat these first• 6-8 glasses water per day between meals (none 30” prior or following meal)• Chew slowly and thoroughly (2-3 minutes between bites)• 5 servings fruits/veggies daily• Avoid high sugar/fat foods---dumping syndrome• Avoid carbonated beverages• ETOH is absorbed more quickly and have greater effect—best to avoid• Avoid gum and use of a straw—air enters stomach pouch• Persons with gastric banding should avoid fibrous foods (asparagus) and sticky foods that swell like

pastas, rice, breads etc. Can block stoma Education from dietician needed for micronutrient supplement and monitoring Plan of care helpful for collaboration between bariatric center and primary care

37Bays, 2020

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COMMENTS ON BIAS

Obesity Stigma

Weight stigma is seen in all aspects of our life Great prejudice in our society which is not typically challenged

Long term consequences of stigma: anxiety/depression, low self esteem, poor body image, social rejection, negative impact on academic performance, binge eating, avoiding physical activity

Obesity bias occurs Work: Hiring, promotions, wage differences, reasons for termination Education: negative attitudes toward children affected by obesity as

early as preschool; stigmatization continues into high school and college; excluded from social activities; bias by educators

Healthcare: negative attitudes by all healthcare professionals

39Obesity Action Coalition, 2017

Obesity Stigma

Stopping and preventing stigma Examine own attitude regarding weight Educate self and others about the stigma and bias that occurs Challenge others when stigmatizing comments are made Language: “people first” “the person with obesity” instead of “that obese person”

• “My patient that has obesity” instead of “my obese patient”• Define obesity as a chronic illness instead of shifting blame on the person

Office:• Waiting room: open arm chairs and firm couches (300#), adequate space between

chairs (6-8”), weight sensitive reading materials with healthy lifestyle message, adequate sized doorways so allow large wheelchairs to pass

• Provide: large sized gowns, large BP cuffs, sturdy armless chairs, wide exam tables• Scale that will measure over 350 and is accessible, scale should be in private

location and educate staff about confidentiality• Reading materials:

40Obesity Action Coalition, 2017

References American Association of Clinical Endocrinologists and American College of Endocrinology. (2016). Clinical practice guidelines for

comprehensive medical care of patients with obesity. Executive summary. Endocrine Practice; 22 (7): 842-884. DOI:10.4158/EP161365.GL

American Association of Clinical Endocrinologists and American College of Endocrinology. (2019) Treatment algorithm for the medical care of patients with obesity slide deck. . Retrieved from https://www.aace.com/disease-state-resources/nutrition-and-obesity/treatment-algorithms/treatment-algorithm-medical-care

American Association of Clinical Endocrinologists and American College of Endocrinology. (2020). Individualizing weight loss therapy slide deck. Retrieved from https://www.aace.com/sites/default/files/2020-04/Individualizing%20Wt%20Loss%20Therapy_FINAL_v1x.pdf

American Association of Nurse Practitioners (2018). Obesity education for the primary care NP: Pharmacologic therapy. Retrieved from AANP CE Center.

Bays HE, Seger & McCarthy W. (2020). Obesity Algorithm 2020: Important principles for the effective treatment of patients with obesity. Obesity Medicine Association. www.obesityalgorithm.org

Centers for Disease Control and Prevention. (2017). Adult Obesity Prevalence Maps. https://www.cdc.gov/obesity/data/prevalence-maps.html

Cabo, R. & Mattson, M. (2029). Effects of intermittent fasting on health, aging and disease. New England Journal of Medicine, 381, 2541-2551. DOI: 10.1056/NEJMra1905136

County Health Rankings and Roadmaps. (2020). Adult obesity: Michigan. https://www.countyhealthrankings.org/app/michigan/2020/measure/factors/11/map

Lake A. & Townshend T. (2006). Obesogenic environments: exploring the built and food environments. Journal Soc Promot Health; 126(6). 262-267. DOI:10.1177/1466424006070487

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References Lee, H., Lee, IS, Choue, R. (2013). Obesity, inflammation and diet. Pediatric Gastroenterol Hepatol Nutr,

16(3), 143-152. doi: 10.5223/pghn.2013.16.3.143

Lenard, N. & Berthoud, H. (2009). Central and peripheral regulation of food Intake and physical activity: pathways and genes. Obesity; Suppl. 3: S11-22. doi: 10.1038/oby.2008.511

Lauby-Secretan, B., Scoccianti, C., Loois, D., Grosse, Y., Bianchini, F. (2016). Body Fatness and Cancer —Viewpoint of the IARC Working Group. N Engl J Med; 375:794-798DOI: 10.1056/NEJMsr1606602

Obesity Action Coalition. (2017). Understanding obesity stigma. https://4617c1smqldcqsat27z78x17-wpengine.netdna-ssl.com/wp-content/uploads/UOS_1-26-18-wo-bleed.pdf

Ong CW, O’Driscoll DM, Truby H, Naughton MT & Hamilton GS. (2013). The reciprocal interaction between obesity and obstructive sleep apnea. Sleep Med Rev; 17(2): 123-131. doi: 10.1016/j.smrv.2012.05.002.

Tartof SY., Qian, L., Hong, V. Wei, R., Nadjafi, R., Fischer, H…Zhuoxin, L,(Aug 12, 2020). Obesity and mortality among patients diagnosed with COVID-19: Results from an integrated health care organization. Ann Intern Med. Published online ahead of print. M20-3742; https://doi.org/10.7326/M20-3742

van Dijk SJ, Tellam RL, Morrison JL, Muhlhausler, BS., & Molloy PL. (2015). Recent developments on the role of epigenetics in obesity and metabolic disease; Clin Epigenetics; 7: 66. DOI: 10.1186/s13148-015-0101-5.

Ziauddeen H, Alonso-Alonso M, Hill JO, Kelley M, Khan NA. (2015). Obesity and the neurocognitive basis of food reward and the control of intake. Adv Nutr; 6(4): 474-486. DOI: 10.3945/an.115.008268

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