Medical Treatment Options for Obesity

Options for
Jennifer DeBruler, M.D.
Medical Director
Advocate Weight Management
Board Certified Internal Medicine
October 2012
Goals for this presentation…
 Discuss low fat diet, Mediterranean diet, Paleo diet
 Discuss exercise recommendations for weight loss and
 Discuss medication options for treatment of obesity
 Provide an office tool to help patients loss weight
– Dietary Guideline for Americans 2010
• US Department of Agriculture
– Decrease saturated fat
– Consume >45% from carbohydrate
– Once size fits all approach only fits a minority of
the population
Jeff S. Volek, PhD, RD
Re-Examining the Role of
The Low Fat Era
The increase in calories during the obesity
epidemic was largely due to carbohydrate
Jeff S. Volek, PhD, RD
Saturated Fat & the Diet Heart
 We know decreased SFA intake leads to increased
carb intake which can lead to metabolic syndrome
then diabetes and ultimately heart disease
 Is it true that increased SFA intake causes increased
plasma LDL and heart disease?
Jeff S. Volek, PhD, RD
What happens to a carbohydrate?
 Eat Carbohydrate, it goes into blood glucose
and is broken down to glycogen and oxidized
 Too much carbohydrate leads to glycogen
and excess carbohydrate fuels lipogenesis
(fat synthesis)
Plasma Saturated Fat
 Predicts Heart disease
Br Med J 1982;285993-6
Am J Epidemiolo. 1995;142: 469-76
Nut Metab Crdiovasc Dis 2003;13:256-66
Am Heart J 2008; 156:965-74
 Predicts Diabetes
AJCN. 2003; 78:91-8
Diabetologia. 2005; 48:1999-2005
AJCN. 2007; 86:189-97
AJCN. 2010; 92:1214-22
Dietary Saturated Fat and Heart Disease
3 Recent Meta-Analyses
FollowUp (yr)
Skeaff & Miller. Dietary fat and
coronary heart disease:
summary of evidence from
prospective cohort and
randomized controlled trials
Ann Nutr Metab, 2009. 55(1-3):
p. 173-201.
No association between
SFA intake & CHD
Jakobsen, et al., Major types of
dietary fat and risk of coronary
heart disease: a pooled
analysis of 11 cohort studies.
Am J Clin Nutr, 2009. 89(5): p.
Increased SFA intake
not associated w/CHD
Siri-Tarino et al., Meta-analysis
of prospective cohort studies
evaluating the association of
saturated fat with
cardiovascular disease. Am J
Clin Nutr, 2010. 91 (3): p. 53546.
No association b/t SFA
intake & CVD, CHD or
If you decrease SF, it matters what you
replace it with.
 Replacing 5% of SFA with carbohydrates
increase coronary events.
 It increases your relative risk of CAD
Jakobsen et al. AJCN , Feb 2011
 When it comes of SFA, you are not what you eat
 Consumption of carbohydrate at levels that exceed a
persons ability to directly oxidize them contributes to
increased circulation SFA
 Instead of telling everyone to restrict dietary saturated fat
a more rational and effective strategy would be to focus
on ways to help people find their “right” level of
 For people with insulin resistance, a low carb lifestyle
can have a profoundly beneficial effect on a metabolic
risk factors including SFA
Jeff S. Volek, PhD, RD
Mediterranean Diet
 Large quantities of minimally processed,
fresh, plant-based foods (fruit, vegetables,
whole grains, seeds and nuts)
 Olive oil is principal source of dietary fat
 Low consumption of red meat and dairy
 Red Wine in low to moderate amounts with
 45% Carbohydrate
 Low glycemic load
Minich DM, et al. Nutr Rev Vol 66(8): 429-444.
Mediterranean Diet
Lyon Diet Heart Study
 Prospective secondary prevention in 605
subjects for 5 years
 Subjects randomized to
– Mediterranean diet with 40% fat, 45% carbs
– ADA Step 1 Diet with 25% fat, 60% carbs
De Lorgeril M. Circulation. 1999; 99: 779-785.
Mediterranean Diet
Lyon Diet Heart Study
 Study halted after 27 months due to
excess mortality in the AHA Step 1 Diet
– Total mortality (cardiac + non-cardiac) 72%
– Cardiovascular events (MI, CHF, PE) 47%
De Lorgeril M. Circulation. 1999; 99: 779-785.
Mediterranean Diet
Lyon Diet Heart Study
 The Mediterranean diet dramatically reduced heart
attack and overall mortality compared to the AHA diet
 No change in serum lipids, BP, BMI
 Key difference: Mediterranean diet modifies
De Lorgeril M. Circulation. 1999; 99: 779-785.
Mediterranean Diet
Lyon Diet Heart Study
 Mediterranean diet includes nutrients known to decrease
inflammatory mediators (crp, IL-6, WBC)
– Omega 3- EFA, DHA-EPA
– Gamma Tocopherol
– Flavenoids, coumarins anthyrocyanin
 Med. Diet excludes nutrients that increase inflammatory
– Omega 6-EFA, linoleate and arachidonate
– Iron
– Trans fat: increase CRP
– Alpha tocopherol: reduces gamma tocopherol (Vit E)
Mediterranean Diet
 Great for moderately obese, 20-30 pounds
 Not concerned with rapid weight loss
 For patients who want to use diet to prevent
or treat co-morbids,
– e.g. Metabolic syndrome, diabetes, CAD
The Paleo Diet
 Typical food in the Western Diet were
virtually unknown in ancestral human diets
Breads, cereals, rice, and pasta
Dairy Products
Added Salt
Refined vegetable oil
Refined sugars, except honey
Processed Meats
Cordain et al. Am J Clin Nutr 2001;71:682-92
The Paleo Diet
 Eat like the cavemen eat
– Fresh Veggies
– Nuts/Seeds
– Healthful Oils
– Fresh fruits
– Fish/seafood
– Grass produced meats
The Paleo Diet
 Typical Hunter-Gatherer Diet
– Animal food energy 55%
• Hunted animal 27.5%
• Fished animal 27.5%
• No processed meats
• No dairy food
– Plant food energy 45%
• No cereal grains
• Minimally processed fresh fruits, veggies, seeds & nuts
– No Processed Foods
Cordain et al. Am J Clin Nutr 2001;71:682-92
The Paleo Diet
 Nutrient differences between:
– wild vs. cultivated plant food
More fiber
Less sugar
Slightly greater minerals
Vitamin content similar
The Paleo Diet
 Seems like a lot of cholesterol in this diet?
 Dietary cholesterol has a minimal influence
on serum cholesterol.
– Lowering dietary cholesterol from 491 mg (paleo) to
300mg (recommended) drops serum cholesterol by
4.5 mg/dl
– Lowering dietary cholesterol from 491 mg (paleo) to
219 mg (food pyramid) drops serum cholesterol by 6
– Cutting dietary cholesterol from 491mg to 219 mg
would reduce a high cholesterol 240 to 234 or 2.5%
Schonfeld G et al. J Clin Invest 1982;69:1072-80
The Paleo Diet
 High protein diet is more effective than high
carbohydrate diet in causing weight loss
– After 6 mo – high protein/low fat group had lost
average of 19.6 lbs
– After 6 mo – high carb/low fat group had lost an
average of 11.2 lbs
 Similar studies have replicated results
Baba NH et al. 1999
Torbay N et al. 2002
Johnston CS et al. 2002
Parker B et al., 2002
Weigle DS et al, Am J Clin Nutr 2005
Exercise Recommendations
 General Health Benefit
– Moderate aerobic exercise 150 min/wk (about 30
minutes 5x/wk) + strength training
 Prevention of Weight Gain
– 150-250 minutes per week
– 150-300 minutes per week
 Prevention of Weight Regain
– 200-300 minutes per week
– 300-420 minutes per week
– Donnelly JE. Med Sci Sports Exerc. 2009
USDHHS. PA Guidelines for Americans. 2008
Medical Clearance for Physical Activity
 ACSM Guidelines for Risk Stratification
– Men>45, women>55 w/2 or more risk factors
– Risk factors include:
• FHx of MI in 1st degree relative M<55, F<65
• Smoking in last 6 mo
• Hypertension
• Abnormal lipids
• Impaired Fasting Glucose
• BMI ≥ 30
• Sedentary Lifestyle
– Plan to exercise at >60% of max, vigorous
– Consider Stress testing
Thompson WR, Ed. ACSM’s Guidelines for Exercise Testing & Prescription, 2010
Medications for Weight Loss
 Sympathomimetic effect
 Works at the hypothalamus and limbic system
 Appetite suppressant effect
 Meta-analysis of phentermine and diethylproprion
– 3.6 kg additional weight loss at 6 mo for phentermine
– 3 kg additional weight loss at 6 mo for diethylpropion
Li, A. Ann Intern Med. 2005.
Medication for Weight Loss
 Short term adjunct in a regimen of weight
reduction involving lifestyle changes in
management of adult obesity
 BMI ≥ 30 or ≥ 27 with comorbid condition
 Contraindication – advanced arteriosclerosis,
CAD, mod/severe HTN, hyperthyroid, glaucoma,
agitated states, history of known drug abuse,
Medication for Weight Loss
 Adverse Effects
– CV: palpitations, tachycardia, primary pulm
– CNS: restlessness, dizziness, insomnia, HA
– GI: dry mouth, diarrhea, constipation
– Endocrine: impotence, change in libido
Medication for Weight Loss
 Gastric and pancreatic lipase inhibitor
 Inhibits uptake of up to 1/3 ingested fat
 Needs to be used in accordance with low-fat,
calorie controlled diet.
Medication for Weight Loss
 May be used long-term up 4 yrs for weight loss or for
weight loss maintenance in adult obese patients
 Pediatric indication: 12-16 y/o obese adolescents
 Should be accompanied by vitamin supplementation
 Common SE: fecal soiling, dyspepsia, flatulence,
vitamin malabsorbtion, elevated liver enzymes
 Rare SE: severe liver injury
 Contraindication: cholestasis, malabsorbtion syndrome,
liver disease
Medication for Weight Loss
 Biguanide: reduces hepatic glucose
production and improves insulin sensitivity
 Induces modest weight loss initially
 Improves fertility in PCOS patient
 Lost 8 kg more weight over 24 wks than
Lee A. Obes Res. 1998
Medication for Weight loss
GLP-1 Agonists
Exenatide, liraglutide
Enhances glucose dependent insulin release
Suppress inappropriate glucagon release
Delays gastric emptying
Reduction in food intake directly acting on
Medication for Weight Loss
GLP-1 Agonist
 Great medication for DM treatment and
weight loss
 Works synergistically with carbohydrate
controlled diet
 Nausea common, usually self-limited
 Watch out for pancreatitis
Medication for Weight Loss
 Dopamine and norepinephrine reuptake
 Tx major depression, smoking cessation,
 Do not use in bulimic patients, may lower
seizure threshold
Medication for Weight Loss
 Works centrally as an appetite suppressant
 Only anti-depressant with consistent weight
loss effect
 May blunt weight regain in smoking cessation
Medication for Weight Loss
 Phentermine & topiramate ER (Qsymia)
– BMI ≥ 30 or ≥ 27 with comorbid
– Synergistic with Phentermine
• Increased satiety through reduced GI motility
• Increased taste aversion
• Reduced calorie intake
– SE: increased HR, paresthesias, metabolic
– TBD when released
Medication for Weight Loss
 Phentermine & topiramate ER (Qsymia)
– Caution: women of reproductive age
Cleft palate in 1st trimester
Women must be on OCP
Avoid with glaucoma
 Studies show 5-10 kg weight loss
Medication for Weight Loss
 Lorcaserin (Belviq)
– Activates the seratonin 2C receptor
– Works at centrally acting satiety receptors
– Caution:
• Valvular HD, CHF, HTN
• Men with predisposition to erection more than
4 hrs (sickle cell, MM, Leukemia) or deformed
– 3.7% weight loss, 7kg.
Office Tool
Thank you

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