yale medical school cme

8/6/2019 Yale Medical School CME

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OWCHOnline Weight management Counseling

program for Healthcare providers

Module 1:

Rationale for Lifestyle & WeightManagement Counseling

Yale-Griffin Prevention Research Centerwww.yalegriffinprc.org

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Summary of Modules

Module 1provides an overview of the obesityepidemic and explains the importance of lifestylecounseling to promote health.

Module 2provides guidance for nutrition and physicalactivity prescriptions for weight management andoptimum health.

Module 3 reviews theories of behavior modification.

Module 4presents the Pressure System Model, abehavior change construct tailored to, and tested in, theprimary care setting.

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Obesity The Problem

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World Pandemic

According to the WHO, 1.6 billion adults worldwidewere overweight in 2005.

At least 400 million adults were obese.

At least 20 million children


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World Pandemic

The United States can be regarded as the epicenter ofthis global pandemic.

Overweight and obesity affects 65%-80% ofAmerican adults, and a rising proportion of children.

Obesity is a major, modifiable risk factor for type 2diabetes and cardiovascular disease.

Katz DL. (2007) Nutrition in Clinical Practice. Lippincott Williams & Wilkins

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According to the CDCs Behavioral Risk Factor SurveillanceSystem (BRFSS):

In 1995, obesity prevalence in each of the 50 states was less than20%.

In 2000, 28 states had obesity prevalence rates less than 20%.

In 2005, 4 states had obesity prevalence rates less than 20%.

In 2007, 1 state (Colorado) had obesity prevalence rate less than20%.

www.cdc.gov/nccdphp/dnpa/obesity/index.htm7

Obesity Trends Among U.S.

Adults


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1998

Obesity Trends* Among U.S. AdultsBRFSS,1990, 1998, 2007

(*BMI 30, or about 30 lbs. overweight for 54 person)

2007

1990

No Data


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Increase in Prevalence (%) of Overweight and

Obesity Among U.S. Adults

Overweight(BMI > 25)

Obesity(BMI > 30)

1976 - 1980 47.0 15.0

1988 - 1994 55.9 23.2

1999 - 2000 64.5 30.9

2001 - 2002 65.7 31.3

2003 2004 66.2 32.9

CDC national center for health statistics


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Increase in Overweight Prevalence (%)

Among U.S. Children & Adolescents

AGE 1971 -1974

1976 - 1980 1988 - 1994 1999 - 2000 2001 2002 2003 - 2004

2 5 5 5 7.2 10.3 10.6 13.9

6 - 11 4 6.6 11.3 15.1 16.3 18.8

12 - 19 6.1 5 10.5 14.8 16.7 17.4

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CDC, National Center for Health Statistics, National Health and Nutrition Examination

Survey


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12Lifestyle Counseling- The Why


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Cost of Obesity Related Illness inthe U.S.

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Average $Cost

1987 2002 % Increase

NormalWeight

$1,512 $2,210 46 %

Obese $1,784 $3,454 94 %

% Difference15 % 36 % 48 %


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Cost of Obesity in theU.S.

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Definitions of Overweight and

Obesity

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Children

Growth charts show the weight status categories used withchildren and teens.

www.cdc.gov/nchs/about/major/nhanes/growthcharts/charts.htm

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Weight Category Percentile RangeUnderweight


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Medical Conditions Associated

with Obesity

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Health Effects of Obesity

Medicare reclassified obesity as a chronic disease in July, 2004. Evidence shows that obesity and Type 2 diabetes are inflammatory

states.

Co-morbidities concurrent with obesity lead to increased morbidityand mortality.

Prevalence of high blood pressure, high cholesterol and low HDLescalates with increasing BMI.

A 10% weight loss can improve some co-morbidities including type2 diabetes and hypertension. Surgical removal of adipose tissuedoes not improve metabolic parameters.

http://obesity1.tempdomainname.com/subs/fastfacts/Health_Effects.shtml

Spiegelman . Adipocytes as regulators of energy balance and glucose homeostasis. Nature:2006 vol:444; 7121:847 -53

N Engl J Med. 2004;350:2542-2544, 2549-2557


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Obesity and Mortality

Obesity is associated with increased overall mortality.

Mortality was found to be lowest at BMI of 22.5-25.

Each 5 kg/m(2) higher BMI was on averageassociated with about 30% higher overall mortality.

Whitlock G, Lewington S, Sherliker P, et al. Body-mass index and cause-specific mortality in 900 000 adults: collaborative analyses of 57

prospective studies. The Lancet 2009; 373 iss:9669:1083 -96

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Obesity = Increased Risk

Endometrial, colorectal, prostate, pancreatic, breast,esophageal and renal cell cancers

Hypertension, cardiovascular disease, DVT, CVA

Osteoarthritis, rheumatoid arthritis, gout, carpal tunnelsyndrome, low back pain

Type 2 Diabetes; Gall bladder disease Menstrual abnormalities, infertility, stress incontinence

Asthma, sleep apnea, respiratory impairment

The incidence of co-morbidities related to obesity and overweight. BMC Public Health 2009, Mar25:9:88

Callee et al. Obesity, recreational physical activity, and risk of pancreatic cancer in a large U.S.Cohort. Cancer Epid Biomarkers Prev, 2005 Feb;14(2):459-66

Callee et al. Body mass index, weight change, and risk of prostate cancer in the Cancer PreventionStudy II Nutrition Cohort. Cancer Epid Biomarkers Prev. 2007 Jan;16(1):63-9.

A prospective study of waist circumference and body mass index in relation to colorectal cancerincidence. Cancer Causes Control. 2008 Sep;19(7):783-92

Callee et al. The role of body weight in the relationship between physical activity and endometrialcancer: results from a large cohort of US women. Int J Cancer. 2008 Oct 15;123(8):1877-82

Maguire M. Impact of obesity on women's health. Fertility and Sterility, May 2009 Vol 91, Issue 5.

American Obesity Association 21


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Prevalence of Medical Conditions by BMIfor Men

MedicalCondition

Body Mass Index18 24.9 25 29.9 30 34.9 40

Prevalence Ratio (%)

Type 2 Diabetes 2.03 4.93 10.10 10.65Coronary HeartDisease

8.84 9.60 16.01 13.97

High BloodPressure

23.47 34.16 48.95 64.53

Osteoarthritis 2.59 4.55 4.66 10.04Source: NHANES III, 1988 - 1994.


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Prevalence of Medical Condition by BMIfor Women

MedicalCondition

Body Mass Index18.5 24.9

25 29.9 30 34.9 40

Prevalence Ratio (%)

Type 2 Diabetes 2.38 7.12 7.24 19.89

Coronary HeartDisease

6.87 11.13 12.56 19.22

High BloodPressure 23.26 38.77 47.95 63.16

Osteoarthritis 5.22 8.51 9.94 17.19

Source: NHANES III, 1988 - 1994.

s ac ors or es y


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s ac ors or es yAssociated Disease

Non-modifiable Risk Factors: Age men over 45, women over 55 or after menopause.

Gender greater risk for men than women who are pre-menopausal.

Family History - first degree blood relative who experiences heartdisease or stroke before the age of 55 years in a male and 65 years in afemale.

Modifiable Risk Factors:

Physical inactivity

Poor nutritional habits

High cholesterol High blood pressure

Diabetes mellitus

Cigarette smoking

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Class BMI (kg/m

2

) Normal WaistCircumference Increased WaistCircumference

Underweight


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Nutrition and Physical

Activityin Weight Management

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Energy Balance

Although genetics and the environment are

contributing factors in deterring body fat mass

accumulation, energy balance is of paramount

importance in weight regulation. If intake is too high obesity will develop.

Maintaining an appropriate energy balance of food

intake and physical activity is a crucial preventivemeasure.

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Hofbauer KG. Molecular pathways to obesity. International Journal of Obesity 2002; 16: S18- S27. Current Trends in Weight Management: What Advice Do We Give to Patients? Clinical Diabetes Volume 26,

Number 3, 2008


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Physical Activity and aHealthful Diet

A healthful diet and physical activity are crucial components of weightloss/control.

Recent research shows 76% of US adults had inadequate fruit &vegetable intake and 65% did not exercise.

Eating well and being active have been linked to the prevention of co-morbidities related to obesity and weight gain, such as diabetes and themetabolic syndrome.

Interventions during the phase of insulin resistance, particularlysupervised weight loss, mitigate cardiovascular risk and preventdiabetes.

Behavioral changes for long-term adherence are key components.

Balasubramanian BA, Cohen DJ, Clark EC, Isaacson NF. Practice-level approaches for behavioral counseling and patienthealth behaviors. Am J Prev Med; 2008 Nov;35:S407-13.

Hu FB et al. NEJM. 2001;345:790-7

Magkos et al. Management of the Metabolic Syndrome and Type 2 Diabetes Through Lifestyle Modification. Annu. Rev. Nutr. 2009.

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DPP Lif l M difi i


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DPP - Lifestyle ModificationArm

Goals of the lifestyle modification intervention:

achieve 150 minutes of physical activity per

week and a weight loss of > 7%.

Participants were encouraged to consume a

healthy low-calorie, low-fat diet (based on the

Food Guide Pyramid and the National Cholesterol

Education Program) and to engage in moderate

intensity physical activity (e.g., brisk walking).

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DPP - Results

The incidence of diabetes was 11.0, 7.8, and

4.8 cases per 100 person-years in the placebo,

metformin, and lifestyle group respectively.

The lifestyle group reduced the incidence of

diabetes by 58%, and metformin by 31% incomparison to the placebo.

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Cumulative Incidence of Diabetes-


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34Lifestyle Counseling- The Why

0 1 2 3 4

0

10

20

30

40

Percent developing diabetes

All participants

All participants

Years from randomization

C

umula

tiveincidence

(%)

Placebo

Metformin

Lifestyle

Type 2 Diabetes PreventionRisk reductionRisk reduction

31% by metformin31% by metformin

58% by lifestyle58% by lifestyle

The DPP Research Group, NEJM 346:393-403, 2002

Cumulative Incidence of Diabetes-DPP


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DPP

Prevalence of Metabolic Syndrome

53% of participants were determined to have metabolic

syndrome at baseline.

Lifestyle intervention and Metformin reduced

development of the syndrome in the remainingparticipants (lifestyle intervention 38%; Metformin

23%).

Conclusion: Lifestyle changes may reverse metabolic

syndrome and diabetes risk.

Orchard T, Temprosa M, Goldberg R. The effect of metformin and intensive lifestyle intervention on the metabolic syndrome: the Diabetes Prevention

Program randomized trial. Annals of Internal Medicine:2005 vol:142 iss:8 pg:611 -9

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ATP III Th M t b li S d


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ATP III: The Metabolic Syndrome

Diagnosis is established when >3 of these risk factors are present

- Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults.JAMA 2001;285:2486-2497.- http://www.nhlbi.nih.gov/guidelines/cholesterol/

Risk Factor Defining LevelAbdominal obesity(Waist circumference)MenWomen

>102 cm (>40 in)>88 cm (>35 in)

TG >150 mg/dL

HDL-CMenWomen

110 mg/dL


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Fi i h Di b t P ti St d


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Finnish Diabetes Prevention StudyDoes Treating Metabolic Syndrome

Make a Difference?

522 middle-aged, overweight adults, (BMI 31) 172 men and 350 women Mean duration 3.2 years

Intervention Group: Individualized counseling to Reduce body weight and reduce dietary fat & saturated fat Increase dietary fiber and physical activity

Control Group Usual care; annual physical exam General dietary and exercise advice at baseline

Tuomilehto J et al. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. NEJM 2001; 344:

1343-1350.

F nn s D a etes Prevent on Stu y-


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F nn s D a etes Prevent on Stu yResults

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Goals Intervention Control P value

% of subjects

Wt reduction>5%

43 13 0.001

Fat intake< 30% energy

47 26 0.001

Sat fat15 g/1000 kcal 25 12 0.001

Exercise > 4hr/wk

86 71 0.001


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Benefit of Treating the Metabolic Syndrome

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InterventionIntervention

After 4After 4

years years

risk ofrisk of

diabetesdiabetes

reduced byreduced by58%58%

11%11%

23%23%

((615615

CI)CI)

(1729(1729

CI)CI)

InterventionIntervention ControlControl

% with Diabetes% with DiabetesTuomilehto J et al. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects

with impaired glucose tolerance. NEJM 2001; 344: 1343-1350.


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Metabolic Syndrome:

Benefits of Weight Loss

Reverses insulin resistance, lowers metabolic

syndrome and diabetes incidence in children andadults.

Lowers systolic and diastolic blood pressure,

glucose levels, cholesterol and TG.

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Savoye M et al. Effects of a weight management program on body composition and metabolic parameters in overweight children. JAMA 2007;2697- 2704.

Case CC et al. Impact of weight loss on the metabolic syndrome. Diabetes, Obesity, and Metabolism 2002; 4: 407-414.

Set Point Theory and Weight


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Set Point Theory and WeightLoss

The set point theory emphasizes that the body has ahomeostatic feedback system for controlling its fat stores.

Homeostatic mechanisms are an adaptation of the bodysmetabolic rate to maintain fat stores and body weight.

A reduction in the consumption of calories without addingphysical activity will result in a decline in the RestingMetabolic Rate (RMB), thus inhibiting weight loss.

Combining physical activity and caloric restriction is thebest way to achieve sustainable weight loss.

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Weinsier RL. Do Adaptive changes in metabolic rate favor weight regain in weight-reduced individuals? An examination of the set pointtheory. Am J Clin Nutr 2000; 72: 1088-1094.

Wang et al. Weight regain is related to decreases in physical activity during weight loss. Med Sci Sports Exerc. 2008 Oct;40(10).

Ph i l A ti it


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Physical Activity A large body of scientific evidence has shown that physical activity

has a protective effect against numerous chronic diseases and mortality. Sufficient physical activity = at least moderately active for 30 minutes

or more on most days of the week.

This amount of exercise can decrease risk of metabolic syndrome.

Resistance training 2 days/week is recommended to promote lean bodymass and muscle strength.

Health care providers can play an important role in encouraging

physical activity. www.cdc.gov/nccdphp/sgr/pdf/sgrfull.pdf;

Jakicic JM, Marcus BH, Gallagher KI, et al. Effects of exercise duration and intensity on weight loss in overweight, sedentary woman.

JAMA 2003; 290: 1323-1330.

Blair S, LaMonte M, Nichaman M.The evolution of physical activity recommendations: how much is enough? Am J Clin Nutr. 2004; 79 (5)

Verghese J, Lipton RB, Katz MJ, et al. Leisure activities and risk of dementia in the elderly. NEJM 2003; 348: 2508-2516.

Ainsworth BE, Youmans CP. Tools for physical activity counseling in medical practice. Obesity Research 2002; 10: 69S- 78S.

Johnson J, Slentz C, Houmard J, et al. Exercise training amount and intensity effects on metabolic syndrome. Am J Cardol; 2007 Dec 15;100(12):1759-66.

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http://www.cdc.gov/nccdphp/sgr/pdf/sgrfull.pdfhttp://www.cdc.gov/nccdphp/sgr/pdf/sgrfull.pdfhttp://www.cdc.gov/nccdphp/sgr/pdf/sgrfull.pdfhttp://www.cdc.gov/nccdphp/sgr/pdf/sgrfull.pdf


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Physical Activity has a Protective Effect

against:Hypertension (SR of RCTs)Diabetes mellitus (Cs, RCTs, D)Dyslipidemia (Cs, RCTs, D)Obesity (Cs, RCTs, D)Myocardial infarction (Cs, D)

Stroke (Cs, D),Claudication (SR of RCTs)Depression (SR of RCTs)Cognitive dysfunction (Cs, D)Osteoporosis (SR of RCTs)Arthritis (SR of RCTs)

Chronic low back pain (SR of RCTs)

Recurrent falls (SR of RCTs)Hip fracture (Cs)Breast cancer (SR of Cs, D)Colon cancer (SR of Cs, D)Chronic fatigue (RCTs)

Fibromyalgia (RCTs)Sleep disorders (RCTs)Gallbladder stones (Cs, D)Diverticulosis (Cs)Prostate hypertrophy (Cs, D)Sexual dysfunction (RCTs)

Levels of evidence:

SR- systematic review RCTs- randomized controlled trialsCs- Cohort studies D- Dose-dependent effect

Physical Activity: Protective


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Physical Activity: ProtectiveMechanisms

Peripheral vasodilation (by nitric oxide)

Enhanced sensitivity to insulin

Increased HDL cholesterol Increased endogenous thrombolysis

Improved musculoskeletal stability

Enhanced cognitive function Improved mood

Gene regulation

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Physical Activity Prolongs Life

Physical activity or smoking cessation has been found to lower the mortality rate by 50% and increase survival rates by 10 years.

In comparison, Coronary Artery Bypass Graft (CABG) or catheterization prolongs life for a half a year.

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Yusuf S. Effect of coronary artery bypass graft surgery on survival: overview of 10-years results from randomized trial by the Coronary Artery Bypass Graft Surgery Trialists

Collaboration. Lancet 1994; 344: 563-570.

Van de Werf. Access to catheterization facilities in patients admitted with acute coronary syndrome: multinational registry study. BMJ 2005; 330: 441-447.

Doll R. Mortality in relation to smoking: 50 years observations on male British doctors. BMJ 2004; 328: 1519-1527.

H t i St di


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Hypertension Studies:

A meta-analysis by Whelton (2002) has shown that

aerobic exercise is associated with a significant reductionin mean systolic and diastolic blood pressure (-3.84mmHg and -2.58 mm Hg respectively).

The reduction was seen in both normotensive andhypertensive patients alike. An increase in aerobic

physical activity should be considered an importantcomponent of lifestyle modification for prevention andtreatment of high blood pressure.

According to the JNC7, aerobic physical activity isrecommended for pre-hypertension and hypertension

stages I and II. In overweight hypertensive patients, a combined exerciseand weight-loss intervention has been shown to decreaseSBP and DBP by 12.5 and 7.9 mm Hg, respectively.

Whelton SP, Chin A, Xin X, He J. Effect of aerobic exercise on blood pressure: A meta-analysis of randomized, controlled trials. Annals ofInternal Medicine 2002; 136: 493-506.

Appel L, Champagne C, Harsha D. Effects of comprehensive lifestyle modification on blood pressure control: main results of the

PREMIER clinical trial. JAMA; 2003 Apr 23-30;289(16):2083-93. www.nhlbi.nih.gov/guidelines/hypertension/

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Physical Activity and Cancer

Current research supports the beneficial role of physical activity

and exercise in reducing the risk for developing breast cancer

and preventing or attenuating disease and treatment-related

impairments.

An inverse association exists between physical activity and

colon cancer in both men and women.

Overweight or obesity increases risk of endometrial, breast,

prostate, and colorectal cancers.

Reigle B, Wonders K. Breast cancer and the role of exercise in women. Methods Mol Bio. 2009;472:169-89.

Wolin K, et al. Physical activity and colon cancer prevention: a meta-analysis. Br J Cancer; 2009 Feb 24;100(4):611-6.

www.cdc.. gov/cancer/dcpc/prevention/

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Lifestyle Counseling

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Barriers to Lifestyle Counseling

Lack of time within patient-provider encounter.

Lack of knowledge and training in behavioral counseling.

Lack of financial incentives.

Unavailability of easily administered counseling tools.

Katz DL et al. Impact of an educational intervention on internal medicine residents' physical activity counseling: The Pressure System Model.Journal ofEvaluation in Clinical Practice. In Press.

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Patient-Provider Encounter

Americans average 2.7 office visits per person per year, withmost (60%) occurring in a primary care setting.

Patients regard physicians as a resource for preventive healthinformation and recommendations.

Many patients would like their doctor to focus more onprevention.

Patients counseled by primary care physicians to make lifestylechanges and who target a specific change are more likely tomake an attempt and to be successful.

Calfas et al., PACE+ for adults, 2002

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Examples of Successful


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Examples of SuccessfulPrograms

The Green Prescription Intervention

PACE+

The Pressure System Model (PSM)

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PACE+


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PACE+ for Adolescents

A primary care-based physical activity and nutritional counseling programusing an interactive computer program and focusing on provider counseling totarget one physical activity behavior and one nutritional behavior in need ofchange.

Results showed significant improvement over a 4 month period:

Decreased fat consumption

Increased fruit and vegetable intake

Increased physical activity

Adolescents who set an a-priori goal of behavior change were more likely tochange behaviors than those who did not set such goals.

Patrick K et al. A multicomponent program for nutrition and physical activity change in primary care: PACE+ for adolescents. Arch Pediatr Adolesc Med 2001; 155: 940- 946.

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The Pressure System Model Study


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e essu e Sys e ode S udy(PSM)

A controlled trial evaluated the impact of an educationalintervention on clinician physical activity counseling behaviorand their patients physical activity levels using the PSM in a

busy primary care setting.

At a 6 and 12 month follow-ups, patient physical activityincreased significantly from baseline, compared to no change inthe control.

At 12 months, the intervention clinicians provided physicalactivity counseling 1.5 more times than they did at baseline. Incomparison, no change was observed in residents in the control.

Katz DL, Shuval K, Comerford BP, Faridi Z, Njike VY. Impact of an educational intervention on internal medicine residents'

physical activity counselling: the Pressure System Model. J Eval Clin Pract. 2008 Apr;14(2):294-9 59


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Summary of Module 1

There is strong evidence associating sedentary lifestyle

and weight gain to increased morbidity and mortality.

Weight loss and control have enormous potential healthbenefits.

Lifestyle counseling in primary care can effectively

encourage healthful dietary and physical activity patterns.

The next module provides the information needed to

provide an exercise prescription and offer constructive

nutritional guidance.

yale medical school cme

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