Physical Activity and Weight Management

Julie Hagel, Pharm.D.

September 24, 2003

U.S. Obesity Statistics

127 million adults: overweight or obese 2nd leading cause of preventable death Responsible for 5-7% of annual national

health care expenditure $117 billion in healthcare costs:

includes direct and indirect costs

U.S. Obesity Statistics

43.6% women, 28.8% men attempt weight loss

$30 billion spent annually on weight loss products

A need and an opportunity

National Institutes of Health (NIH) notes that few healthcare

providers play a role in management of

obesity

Barrier or Benefit?

No 3rd-party coverage

Who has time / space?

Scope of practice? Costs Competition

Pathophysiology of Obesity

Chronic medical condition Energy intake exceeds energy

expenditure Factors involved

Genetic and physiological Environmental Cultural and socioeconomic

Health Consequences of Obesity

Hypertension Dyslipidemias Type 2 diabetes Cardiovascular

disease Stroke Gallstones

Degenerative joint disease

Sleep apnea Respiratory disease Some types of

cancer Hyperuricemia/gout

Getting started……

NHLBI Obesity Education Initiative Treatment of overweight or obese person

is two step process Assessment Management

Requires lifelong effort!

Assessment:Weight & Obesity

Body Mass Index (BMI) Waist circumference Risk factors Readiness to lose weight

Assessment: BMI

Body Mass Index:

Wt in Kg

Ht in meters squared

or

Weight in Lb x 703

Ht in inches squared

BMI

BMI Ranges

Normal: 18.5 to 24.9 Overweight: 25.0 to 29.9 Class I obesity: 30.0 to 34.9 Class II obesity: 35.0 to 39.9 Class III obesity: 40.0 or greater

(extreme obesity)

Assessment: Waist Circumference

Regardless of weight or calculated BMI, waist circumference marks increased risk Men: >40 inches Women: >35 inches

Measure right above the upper hip bone at the top of the iliac crest with tape measure parallel to floor

Fat Distribution

Apple Android shape, typically in males Fat store seen in abdomen

Pear Gynecoid shape, typically in females Fat store seen in buttocks, hips, thighs

Assessment: Risk Factors

Very high absolute risk Established coronary heart disease Other atherosclerotic diseases Type 2 diabetes Sleep apnea

Increased risk Osteoarthritis, gallstones, stress

incontinence, gynecological abnormalities

Assessment: Risk Factors

High absolute risk if three or more of the following: Hypertension Cigarette smoking High LDL cholesterol Low HDL cholesterol Impaired fasting glucose Family history of early cardiovascular disease Age

Male > 45 Female > 55

Assessment: Readiness

Motivation Previous attempts Potential barriers Support system

Assessment: Tools

Scale and Height measurement

Calculator or Chart On-line calculator

(Search engine: “BMI Calculator”)

Tape measure

Weighing In

Can be performed by patient for self- monitoring Recommend once weekly

Scale in pharmacy Document patient progress

Body Fat Analysis

Normal range Men: 12-15% (>25% indicator for obesity) Women: 20-25% (>30% indicator for obesity)

Measuring techniques Hydrostatic weighing- mainly used in research Bioimpedance Near-infrared spectroscopy Body fat calipers

Management

Goals Reduce and maintain body weight Prevent future weight gain Promote healthy lifestyle

Therapies

Must be individualized Can include:

Dietary therapy Physical activity Behavior therapy Combination of above Pharmacotherapy-eligible high risk patients Surgery- extreme obesity

It doesn’t happen overnight….

NHLBI guidelines Initial goal: 10 percent reduction in body

weight Weight should be lost at rate of 1-2 pounds

per week

Consequences associated with losing weight too fast

Dietary Therapy

Modify diet to achieve a decrease is caloric intake

Must adopt long term nutritional adjustments

Avoid very low calorie (<800 kcal /day) content diets

Ensure that all daily recommended dietary allowances are met

Key Counseling Points

Learn energy values of different foods Read and understand nutrition labels Monitor food consumption

Reduce portion size Use dietary recall or food diary

Use new habits with food purchasing and preparation

Physical Activity

Has direct and indirect benefits Crucial for weight maintenance Evaluation before starting Recommendation is 60 minutes of

moderate intensity most days of week Build activity level slowly over period of

time

Key Counseling Points

Keep track of physical activity and chart weekly progress

Effects of increased activity add up; small increases = benefit

Step counters may help motivate Reduce sedentary time Build physical activity into each day

Behavior Therapy

Strategies to provide tools for overcoming barriers Consider attitude and past history Develop partnership with patient Set realistic goals

Behavior Modification Techniques

Self-monitoring Stimulus control Stress management Relapse prevention Social support

Pharmacotherapy

May be used as adjunctive therapy in BMI > 30 BMI > 27 + risk factors

Continue diet, physical activity and behavior therapy

Pharmacologic Interventions Agents approved for short term use only

Phentermine, diethylpropion, benzamphetamine

Increase NE in brain Usually prescribed 8-12 weeks Contraindications: hypertension, advanced

arteriosclerosis, cardiovascular disease, hyperthyroidism, glaucoma, agitated states, history of drug abuse, patients taking MAOI, tricyclic antidepressants

Pharmacologic Interventions Serotonergic Agents

Inhibits reuptake serotonin + NE + dopamine in brain

sibutramine (Meridia®); dosed once daily with or without food

Induces feeling of satiety Adverse effects include dry mouth, constipation,

headache, insomnia Contraindicated in cardiovascular disease, past

history of stroke Caution: Hypertension- monitor BP early

Pharmacologic Interventions

Pancreatic Lipase Inhibitor Blocks digestion of ~30% dietary fat orlistat (Xenical®); dosed 3 times daily

during or up to 1 hour after meal (with fat) GI side effects Can minimize GI side effects with a low fat

(<30% fat) high fiber diet

Pharmacologic Interventions

OTC weight loss medications No FDA approved OTC ingredients Many products that claim to promote

weight loss Ephedra

Currently under FDA investigation Stimulant properties: potential to cause

increased blood pressure, MI, stroke, seizures, especially in high doses

Surgery

Reserved for patients in whom other treatments have failed AND who have clinically severe obesity

Now what do you do?

Behavioral approaches: Develop a therapeutic relationship Determine patient readiness Partner with patient / facilitate “buddies”

Goal: Increase energy expenditure through planned and unplanned physical activity and decrease energy intake

Three levels of management

Level I Entry level Educate patients re:

health risks of obesity and health benefits of increased physical activity and weight

loss

Distribute literature Offer Digi-Walkers®, exercise bands, etc. Get to know the weight loss drugs & community

resources very well

Three levels of management

Level II Add all or some of the following: Medical quality scale and height tape/bar Assess health risks: BMI and waist circumference Referral relationships w/ other providers Incorporate weight management strategies into

disease management programs (e.g. HTN/DM) Documentation system Marketing

Three levels of management

Level III Health-oriented weight loss and physical activity

improvement as a focal point of pharmacy practice Pharmacist is facilitator, motivator, educator Dedicated assessment room and classroom Program fee: primarily private pay Small group or individual counseling Marketing of screenings and classes

Useful Resources

www.nhlbi.nih.gov/about/oei/Obesity Education Initiative

www.obesity.orgAmerican Obesity Association

www.d.umn.edu/student/loon/soc/phys/par-q.htmlPhysical Activity Readiness Questionnaire (PAR-Q)

Conclusion

Obesity is recognized as a disease Obesity and lack of physical activity

present significant health risks Few providers are involved in weight

management A screening and management program

is a viable pharmacy practice option