obesity management in primary care
DESCRIPTION
Obesity Management in Primary Care. Arya M Sharma, MD, PhD , DSc . ( h.c .) FRCP(C) Professor of Medicine Research Chair for Obesity Research & Management University of Alberta Medical Director Alberta Obesity Prevention & Bariatric Care Strategy Edmonton, AB, Canada www.drsharma.ca. - PowerPoint PPT PresentationTRANSCRIPT
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Obesity Management in Primary Care
Arya M Sharma, MD, PhD, DSc. (h.c.) FRCP(C)Professor of Medicine
Research Chair for Obesity Research & Management
University of AlbertaMedical Director
Alberta Obesity Prevention & Bariatric Care Strategy
Edmonton, AB, Canadawww.drsharma.ca
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Disclosures
Research Support:Heart and Stroke Foundation of Canada, Canadian
Diabetes Association, Networks of Centres of Excellence, Canada Research Chair, University Hospital Foundation and Canadian Institutes of
Health Research.
I have also received research support, consulting and/or speaking honoraria from
Abbott, Allergan, Amylin, Astra-Zeneca, Arena, Boehringer-Ingelheim, Bristol-Myer Squibb, Covidien, GSK, Johnson and Johnson, Merck, Neurosearch, Novartis, Novo-Nordisk, Sanofi-
Aventis, Takeda, Pfizer, Roche.
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Overweight
Obesity in Canada1985 2010
30% 60%Obese 20%6%
Severely Obese1% 6%
Statistics Canada 2010
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Obesity is a heterogeneous complex disorder of multiple etiologies characterized by excess body fat that threatens or affects socioeconomic, mental or physical health Sharma 2007
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The 5 As of Obesity Management• Ask• Assess• Advise• Agree• Assist
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Ask
• Ask for permission to talk about weight
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Ask Permission
• Weight is a sensitive issue. • Many patients are embarrassed or fear
blame and stigma. • Weight measurements and discussions
of weight should be conducted in a private area.
• Most patients prefer the terms ‘weight’, ‘size’ over ‘heavy’ or ‘fat’.
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Ask
• Ask for permission to talk about weight
• Be non-judgmental
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Be Non-Judgmental
• Do no blame, threaten or provoke guilt in your patient.
• Do not make assumptions about their lifestyles or motivation (your patient may already be on a diet or have lost weight).
• Acknowledge that weight management is difficult and hard to sustain
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Ask
• Ask for permission to talk about weight
• Be non-judgmental • Explore Readiness for Change
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Readiness for Change
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Assess
• BMI and Waist Circumference
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Relationship Between BMI and Percent Body Fat in Men and Women
Adapted from: Gallagher et al. Am J Clin Nutr 2000;72:694.
Bod
y Fa
t (%
)
Body Mass Index (kg/m2)
0 10 30 40 6020 50
Women
Men
0
70
10
20
30
40
50
60
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Relationship Between Visceral adipose Tissue and Waist Circumference
Pouliot MC et al.; Am J Cardiol 1994;73:460
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Assess
• BMI and Waist Circumference• Obesity Stage (EOSS)
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Edmonton Obesity Staging System (EOSS)
Stage 0
Sharma AM & Kushner RF, Int J Obes 2009
Stage 1
Stage 2
Stage 3
Stage 4
Med
ical
Men
tal
Func
tiona
l
abse
nt
abse
nt
abse
nt
pre-
clinic
al
risk f
actor
smild
mild
co-morbidity
moderate
moderateend-organ
damage
severesevere
end-stage
end-stage
end-stage
Obesity
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EOSS Predicts Mortality in NHANES III
Padwal R, Sharma AM et al. CMAJ 2011
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EOSS Predicts Mortality at Every Level of BMINHANES III
Padwal R, Sharma AM et al. CMAJ 2011
Overweight
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EOSS Distribution Across BMI CategoriesNHANES III (1988-1994)
15%
28%
47%
10%
5%
17%
64%
14%
Class II
8%
19%
59%
14%
Class I
5%14%
67%
14% EOSS Stage 0
EOSS Stage 1
EOSS Stage 2
EOSS Stage 3
Overweight
ClassIII
Padwal R, Sharma AM et al. CMAJ 2011
50 million
23 million
10 million
6 million
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Assess
• BMI and Waist Circumference• Obesity Stage (EOSS)• Root causes of weight gain
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Sharma & Padwal, Obes Rev 2009
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Edema = Positive Fluid Balance
Sharma & Padwal, Obes Rev 2009
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Fluid In Fluid Out X X?
Sharma & Padwal, Obes Rev 2009
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Energy In Energy Out X X
Sharma & Padwal, Obes Rev 2009
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Differential Approach to Obesity Assessment
Diet Metabolism Activity
Sharma & Padwal, Obes Rev 2009
100 % 60-80 % 40-20 %
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Differential Approach to Obesity Assessment
AgeGender
GeneticsHormonesSkeletal muscle
Medication
Socio-Cultural
Bio-Medical
Mental
Diet Metabolism Activity
Medication
Sharma & Padwal, Obes Rev 2009
Socio-Cultural
Bio-Medical
Mental
Medication
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Advise on
• Obesity risks
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Advise on
• Obesity risks• Benefits of modest weight loss
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Advise on
• Obesity risks• Benefits of modest weight loss• Need for long-term strategy
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Isn’t Obesity Simple?
EnergyIn
EnergyOut
+/- +/-
Energy Regulation is Complex!
Diet Exercise
Sharma AM 2007
Genetics
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Phases of Obesity Treatment
Phase I(Weight Loss)
3-6 months
Phase II(Weight-Loss Maintenance)
Indefinitely
When you stop treatment,the disease comes back!
Wei
ght
www.drsharma.ca
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Best Weight
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Advise on
• Obesity risks• Benefits of modest weight loss• Need for long-term strategy• Treatment options
– Self-monitoring– Behaviour modification– Medications– Low calorie diets– Surgery
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Agree on
• Weight loss expectations
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Treatment SuccessC
hang
e in
Wei
ght
Years
Lifestyle (LS) ~ 3-5%
LS+Surgery ~ 20-30%
LS+Pharmacotherapy ~ 5-15%
www.drsharma.ca
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Agree on
• Weight loss expectations• Behavioural goals
–Specific–Measureable–Attainable–Realistic–Timely
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Agree on
• Weight loss expectations• Behavioural goals
–Specific–Measureable–Attainable–Realistic–Timely
• Treatment plan
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Assist
• Identify drivers and barriers
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Obesity: Complications and Barriers(M, M, M & M)
Obesity
MentalMood Disorder
Anxiety DisorderAttention Deficit
DisorderSleep Disorder
Personality DisorderAddiction DisorderPsychotic DisorderCognitive Disorder
MetabolicType 2 Diabetes
DyslipidemiaHypertension
NAFLDGall Bladder Disease
PCOSInfertilityCancer
MechanicalOsteoarthritis
PainReflux Disease
Obstructive Sleep ApneaUrinary Incontinence
IntertrigoPseudotumor Cerebri
Plantar Fasciitis
MonetoryEducation
EmploymentLow Income
DisabilityLife/Health Insurance
Bariatric Furniture/AidsOversized Clothing
Weight Loss ProgramsSharma AM, Obes Rev 2010
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Assist
• Identify drivers and barriers• Provide resources
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Assist
• Identify drivers and barriers• Provide resources• Refer to program
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Adult Bariatric Clinic, RAH, 2010
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Assist
• Identify drivers and barriers• Provide resources• Refer to program• Follow-up
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Agree
Ask
Advise
AssessAssist
The 5As of Obesity Management
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My Obesity Blog: www.drsharma.ca