making a difference in the obesity epidemic: the case for ... · weight loss disproportionately...

2/10/2017

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© American Academy of PAs. All rights reserved. These materials may not be duplicated without the express written permission of AAPA.

Making a Difference in the Obesity Epidemic: The Case

for PA Leadership

Karli Burridge, MMS, PA-C


Financial Disclosures

• Health Scripts Ambassador- Orexigen


Learning Objectives

After the completion of this presentation, participants should be able to:

– Recognize overweight and obesity as chronic diseases

– Describe an approach to screening patients, making a diagnosis, and evaluating potential

complications

– Summarize an overall approach to care, including the roles of behavioral interventions,

pharmacotherapy, and bariatric surgery

– Identify specific competencies required to manage obesity and overweight

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Obesity is a Chronic Disease

“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 Medicine Association

Obesity Medical Association. Obesity Algorithm. http://obesitymedicine.org/obesity-algorithm/


“ACQUIRING OBESITY IS NOT A

PERSONAL CHOICE, BUT A DISEASE

WITH SERIOUS HEALTH

CONSEQUENCES.”The Obesity Society

Position Statement: Obesity and Disability. January 2015. http://www.obesity.org/obesity/advocacy/obesity-care/obesity-disability.


Why Should Obesity be Considered a Chronic Disease?

Like Crohn’s disease, diabetes, asthma, chronic obstructive pulmonary disease, arthritis,

epilepsy, Parkinson’s disease, multiple sclerosis, and heart disease:

• Obesity impairs normal bodily function

• Obesity has characteristic signs and symptoms

• Obesity is associated with morbidity and mortality

• Obesity is a disease state with multiple pathophysiological aspects

• Obesity can be managed but not cured. Management requires a range of interventions.

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Implications of Designating Obesity as a Disease

• Shifts care to an evidence-based chronic disease model

• Encourages more resources for research, prevention, and treatment

• Increases reimbursement for obesity care

• Improves medical education

• Has potential to reduce weight stigma

Kyle TK. Endocrinol Metab ClinN Am. 2016; 45: 511–520.


Obesity Trends* Among U.S. Adults

BRFSS, 1995(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19%




No Data <10% 10%–14% 15%–19% ≥20%

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No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%




No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%


Prevalence of Self-Reported Obesity Among U.S. Adults by

State and Territory, BRFSS, 2015¶ Prevalence estimates reflect BRFSS methodological changes started in 2011. These estimates should not be compared to prevalence estimates before 2011.

*Sample size <50 or the relative standard error (dividing the standard error by the prevalence) ≥ 30%.

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Prevalence of Self-Reported Obesity Among Non-

Hispanic Black Adults, by State and Territory, BRFSS,

2012-2014



Prevalence of Self-Reported Obesity Among Hispanic

Adults, by State and Territory,

BRFSS, 2012-2014



Body Mass Index (BMI)

• Weight (kg)/[height (m)]2

• A high BMI can indicate high body fatness. BMI can be used as a screening tool, but BMI

alone is not diagnostic of the body fatness or health of an individual.

• <18.5 kg/m2: Underweight

• 18.5 to 24.9 kg/m2: Normal or healthy weight

• 25.0 to 29.9 kg/m2: Overweight

• ≥30.0 kg/m2: Obese

There is no BMI category for “morbid obesity,” and this term stigmatizes patients and

can be a barrier to discussion.

CDC. https://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/

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Burden of Obesity: Projected Obesity-Related

Health Care Costs

The U.S. could save $611.7 billion in health

care costs by 2030 if the BMI of the average

adult were reduced just 5%.

Robert Wood Johnson Foundation. http://healthyamericans.org/assets/files/TFAH2013FasInFatReportFinal%209.9.pdf


Psychosocial Burden of Obesity

• Stigma/Weight Bias1

– People with obesity face bias at work, school, and when receiving health care

– People with obesity earn less and receive fewer promotions than non-overweight counterparts in comparable

positions

– In a survey of 2,449 women with overweight or obesity, 69% said they had experienced bias from physicians

• Depression 1,2

• Anxiety 1,2

• Eating disorders 2

• Poor body image 1,2

• Suicidality 1

1. Yale Rudd Center. http://www.uconnruddcenter.org/files/Pdfs/Rudd_Policy_Brief_Weight_Bias.pdf. 2. Sarwer DB, et al. Endocrinol Metab ClinN Am . 2016;45: 677–688.


Obesity is a Complex, Multifactorial Disease

Obesogenic environment Hedonic input

Genetics Gut hormonesAdipose Tissue Medications

http://www.uconnruddcenter.org/files/Pdfs/Rudd_Policy_Brief_Weight_Bias.pdf

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Genetics and Obesity

Borjeson M. Acta Paediatr Scand. 1976;65:279-287.


Willer CJ, et al. Nat Genet. 2009;41:25-34.

Impact of Risk Alleles on Average BMI

Average B

MI (kg

/m2)

24.5

27.5

27.0

26.5

26.0

25.5

25.0

Nu

mb

er o

f in

div

idu

als

3000

2000

1000

0

Weighted number of risk alleles

≤3 ≥134 5 6 7 8 9 10 11 12


The Discovery of the EpidemicTrends in adult overweight, obesity, and extreme obesity among adults age 20 to 74 years:

United States. 1960–1962 through 2009–2010

National Health and Nutrition Examination Survey 1988-1994, 1999-2000, 2001-2002, 2003-2004, 2005-2006, 2007-2008, and 2009-2010.

www.cdc.gov/nchs/data/hestat/obesity_adult_11_12/obesity_adult_11_12.htm

40

30

20

10

0

Perc

ent

Overweight

Obese

Extremely Obese

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Environmental Factors

• Easy availability of cheap, energy-dense, highly palatable food. Lack of availability of

affordable, healthy food (food deserts).

• Work, play, and transportation environments that promote sedentary behavior and require

low levels of activity. Lack of safe places to be physically active.

• Epigenetic factors and nutritional programming

• Gut microbiota

• Stress, sleep deprivation

• Medications (eg, insulin, TZDs, sulfonylureas, antipsychotics, antidepressants)

• Social contagion

• Adenovirus 36

• Many more!


Food Intake is Not Simply a Cognitive

Function• Central nervous system

– Homeostatic system: hunger

and satiety

– Reward system: overrides to

produce food intake even in

absence of hunger

– Central regulation of energy

expenditure

• Peripheral signals

– Leptin from fat

– GLP-1, GIP, PYY, OXM from

small intestine

– Pancreatic polypeptide,

amylin, insulin from pancreas

– Ghrelin from stomach


Weight Loss Disproportionately Affects Appetite

Leptin

PYY

CCK

Insulin

Amylin

Ghrelin

Subjective

appetite

Mean (±SE) changes in weight from baseline to week 62. The weight loss program was started at week 0 and completed at week 10.

Sumithran P, et al. N Engl J Med. 2011;365:1597-1604.

8-10 18 26 36 44 52 62

Week

95

90

85

80

0

0

Week 10Weight -14%Leptin -65%

Week 62Weight -9%Leptin -35%

Completers

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Physiology of Reduced Obese State:

Metabolic Adaptation Drives Weight Regain

The metabolic handicap: reduction in energy expenditure disproportionate to weight reduction

Schwartz A, Doucet E. Obes Rev. 2010;11:531-547.

Mr. Smith220 pounds

needs2200 kcal/day

Loses weight to200 pounds

Needs1830 kcal/day

Mr. Jones200 pounds

needs2000 kcal/day

≠Smith Jones


Pulmonary Disease• Abnormal function

• Obstructive sleep apnea

• Hypoventilation syndrome

Nonalcoholic Fatty

Liver Disease• Steatosis

• Steatohepatitis

• Cirrhosis

Gall Bladder Disease

Gynecologic Abnormalities• Abnormal menses

• Infertility

• Polycystic ovary syndrome

Osteoarthritis

Skin

Gout

Idiopathic Intracranial

Hypertension

Stroke

Cataracts

Cardiovascular Disease• Coronary artery disease

• Atherosclerosis

• Hypertension

• Myocardial disease

• Heart failure

• Atrial fibrillation

Type 2 Diabetes

Pancreatitis

Certain Cancers

Phlebitis

• Venous stasis

• Venous thromboembolism


Pathogenesis of Obesity: Comorbidities

• Burden of fat mass

• Organ infiltration by fat, especially the muscle and liver

• Location of fat mass: portal vascular system

• Products of adipose tissue (adipokines)

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Adipose Tissue

Adipsin

Resistin

Angiotensinogen TNFα

TNF ß

IL6

EGF PAI-1

FFA

Prostaglandins

Insulin

Estrogen

Adiponectin

Leptin CRP-1

Cortisol

The link between pathophysiology of obesity and associated comorbid conditions

Products of Adipose Tissue

Hypertension

Thrombosis

Inflammation

Type 2 diabetes

DyslipidemiaArthritis (OA and RA

Stroke Heart attack

PVD

Asthma Sleep apnea

Fatty liver diseaseInsulin resistance

Cancer


Benefits of Weight Loss

• Patients do not need to achieve their ideal weight to achieve health benefits

• Modest weight loss of 5% to 10% of initial body weight produces health benefits

• Even a 5% weight loss has been shown to improve beta-cell function and adipose tissue,

liver, and muscle insulin sensitivity

Magkos F, et al. Cell Metabolism. 2016; 23:591-601.


Diabetes Prevention Program: Every Kilogram

Lost

Reduced Risk of Diabetes

Change in weight from baseline (kg)

0-10 -5 +5

Dia

bet

es I

nci

den

ce r

ate

per

1

00

per

son

-yea

rs

10

20

15

5

0

Adapted from Hamman RF, et al. Diabetes Care. 2006; 29:2102-2107.

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Modest Weight Loss Has Benefits, with

Greater Weight Loss Associated with Greater

Benefit• Measures of glycemia1

• Triglycerides and HDL cholesterol1

• Systolic and diastolic blood pressure

• Hepatic steatosis measured by MR-spectography2

• Measures of feeling and function:

– Symptoms of urinary stress incontinence5

– Measures of sexual function6,7

– Quality of life measures (IWQOL)8

• NASH Activity Score measured on biopsy3

• Apnea-hypopnea index4

• Reduction in CV events, mortality, remission of T2DM

1. Wing RR, et al. Diabetes Care. 2011;34:1481-1486.2. Lazo M, et al. Diabetes Care. 2010;33:2156–2163.3. Promrat K, et al. Hepatology. 2010;51:121–129.4. Foster GD, et al. Arch Intern Med. 2009;169:1619–1626.

5. Phelan S, et al. J Urol. 2012;187:939-944.6. Wing R, et al. Diab Care. 2013;36:2937-2944.7. Wing R, et al. J Sex Med. 2010;7:156-165.8. Crosby, Manual for the IWQOL-LITE Measure.www.qualityoflifeconsulting.com.

-3.0%

-5.0%

-10.0%

-15.0%


Diet

Components of an Effective Obesity Management Program

Medications

Or

Surgery

Physical Activity

Behavioral Therapy

Alamuddin N, et al. Endocrinol Metab Clin North Am. 2016 ; 45:565-580.


Behavioral Skills to Support Dietary Changes and Increased

Physical Activity

• Behavioral skills that should be cultivated in people engaged in a weight management

program include:

– Self monitoring

– Stimulus control

– Problem solving

– Goal setting

– Relapse prevention

Alamuddin N, et al. Endocrinol Metab Clin North Am. 2016 ; 45:565-580.

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Pharmacotherapy


FDA-Approved Pharmacotherapy for the Treatment of Obesity

• Phentermine: Generic and branded generics (Adipex-P®, Lomaira™)

• Orlistat (Xenical®/alli®)

• Lorcaserin (Belviq® and Belviq®SR)

• Phentermine/topiramate ER (Qsymia®)

• Bupropion SR/Naltrexone SR (Contrave®)

• Liraglutide 3.0mg (Saxenda®)


Pharmacotherapy Criteria

With ≥1 comorbidity

(e.g., HTN, DM, dyslipidemia)

With no comorbidities

BMI: <18.5 18.5-26.9 ≥ 27.0-29.9 ≥ 30.0 >35 >40

www.cdc.gov/healthyweight/assessing/bmi/adult_bmi

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Estimated Weight Loss with Approved Medications

Phentermine Orlistat Lorcaserin Phentermine/Topiramate ER

Naltrexone SR/Bupropion SR

Liraglutide 3.0 mg

5.1% at 28 wks

15 mg daily

3.1% at 1 yr

120 mg TID

6.6% at I yr

7.5/46 mg daily

4.8% at 56 wks

16/180 mg BID

3.6% at I yr

10 mg BID

5.4% at 56 wks

3 mg daily injection

Saunders KH, et al. Endocrinol Metab Clin North A. 2016;45:521-538.


Bariatric Surgery Criteria

38

With ≥1 obesity-

associated comorbidities(eg, diabetes, obstructive

sleep apnea)

With no comorbidities

BMI: <18.5 18.5-24.9 25.0-29.9 30.0-34.9 >35 >40

www.cdc.gov/healthyweight/assessing/bmi/adult_bmi


FDA-Approved Devices

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Vagal Blocking Therapy (VBLOC)

• Delivers high-frequency electrical pulses to induce intermittent suppression of neural

communication between the brain and stomach

• Some components of the system are internal and some are external

• FDA-approved for patients with a BMI of 40 to 45 kg/m2 or a BMI of 35 to 39.9 kg/m2 and 1 or

more obesity-related comorbidity

US Food and Drug Administration. http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/DeviceApprovalsandClearances/Recently-ApprovedDevices/ucm430696.htm


VBLOC

Image courtesy of US Food and Drug Administration


Intragastric Balloon Systems

• Balloon occupies space in the stomach to help patients lose weight

• Intragastric balloon systems are FDA-approved for patients with a BMI of 30 to 40 kg/m2 who

have been unable to lose weight through diet and exercise. Patients using a balloon system

should be in a clinician-supervised diet and exercise plan.

• Temporary system removed after 6 months

• Three types are available: a single balloon system, a dual balloon system, and a swallowable

balloon system

US Food and Drug Administration. http://www.fda.gov/medicaldevices/productsandmedicalprocedures/deviceapprovalsandclearances/recently-approveddevices/ucm457416.htm

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Single Intragastric Balloon

Image courtesy of US Food and Drug Administration


Most Common Bariatric Surgery Procedures

Restrictive

Approximately 75% of

the stomach is resected

Sleeve Gastrectomy

Malabsorptive and

Restrictive

Small stomach pouch created

(30mL); small intestine

bypassed

Roux-en-Y Gastric Bypass

196,000 total bariatric procedures performed annually.

Adjustable Gastric Band

Restrictive

Inflatable, adjustable

band placed around

upper part of the

stomach


Currently Available Treatments:

Risks and Efficacy

Lower risk

Higher risk

Lower efficacy Higher efficacy

BPD-DS

Devices

Pharma

Diets

VLCD

Lapband Sleeve

Roux-en-Y bypass

VLCD: very low calorie diet; BPD-DS: Biliopancreatic diversion with duodenal switch

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Obesity: PAs Taking the Lead


Why a National Quality Improvement Initiative on Obesity?

AAPA has a strategic imperative to:

Mobilize PAs to make a collective impact on a national scale

Improve PA quality of care related to major public health issues

Distinguish PAs as leaders in care of specific diseases

Establish the profession (and AAPA) as patient centric and issue oriented

Why Obesity?

• ~2/3 of all patients seen by PAs are affected by overweight and obesity

• PAs are trained as generalists, present in all specialties, and uniquely positioned to diagnose

and treat obesity

• No other profession has “stepped up to the plate”


“A Framework for PA Intervention for Overweight and Obesity”

• Obesity should be recast as a

chronic disease with a focus on

prevention and treatment

• PA Algorithm– Screen all patients using BMI (take

ethnically adjusted anthropomorphic

measures into account)

– Evaluate and document obesity-related

complications

– Formulate a patient-centered approach

to treatment that includes primary,

secondary, and tertiary interventions

Herman L, et al. JAAPA. 2015; 28:29-33

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A Comprehensive Online Obesity Curriculum on Learning

Central

Topics will include:

• New Approaches to Adult Obesity and Overweight

• Evaluating the Patient who has Overweight or Obesity

• Lifestyle Interventions: Counseling and Physical Activity

• Nutrition

• Pharmacologic Therapy

• Bariatric Surgery and Endoscopic Devices

• Implementing Practice Changes to Support Effective Obesity Management Lifestyle

Interventions


PA Competencies in the Management of Overweight and

Obesity

• Understanding the model of obesity as a chronic disease as the foundation of

approaches to management

• Recognizing the physiologic, genetic, and environmental factors contributing to obesity

• Conducting patient screening and workup, including the identification of comorbidities

• Initiating productive conversations with patients about their weight

• Developing a plan of care

• Connecting with community resources

• Facilitating patient self-management

• Coordinating care among the patient, community resources, and other healthcare

professionals

• Addressing business needs to to support an obesity practice


Summary

• Obesity is a chronic disease. It is caused by environmental and other factors driving expression of this phenotype on the background of genetic risk.

• Body weight and body fat distribution are biologically regulated. When weight loss is attempted, biologic and physiologic responses slow metabolism, increase hunger, decrease satiety, and make individuals more sensitive to rewarding food.

• Obesity drives morbidity and mortality by the following mechanisms: lipotoxicity, visceral adiposity, fatty infiltration of organs, and the burden of excess fat mass.

• Treatment modalities are becoming more effective and safer

• PAs have an opportunity to engage all aspects of the disease from prevention to management of obesity-related complications

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Done With This Session?

Text LEAVE to 22333 and this will remove you from the room or leave the

website if using a smartphone or tablet


Questions?For more CME and resources visit www.aapa.org/obesity

[email protected]

http://www.aapa.org/obesity

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