how to use the flip chart

HOW TO USE THE FLIP CHART• Obesity is a complex chronic disease that may make it difficult for patients to lose weight and to maintain

weight loss. Talking to patients about their weight status can raise their awareness about how weight affects health and well-being as well as motivate and help patients achieve success.

• Conversations about weight can be difficult for patients and providers. • Weight bias and stigma may be barriers to communication. • Patients may feel reluctance or shame when talking about their weight. • Providers may have difficulty in knowing how to broach the topic of weight management with their patients.

• The flip chart is designed to help you more easily discuss obesity and weight management issues with your patients. There is a provider-facing side, and a patient facing side.

• The following communication tips can make conversations about weight easier. • Listen to your patient. • Ask for the patient’s permission before you discuss weight and weight-related health problems.1 • Obesity is a highly charged word. Patient-friendly terms include:2.3 —Weight, unhealthy weight, excess weight, weight problem.• The evidence-based 5As model supports discussions about weight.4 You can use the 5A topics to help

patients identify, describe, and achieve their lifestyle and health goals.

The 5As of Obesity Management4

1 http://obesity.aace.com/files/obesity/toolkit/initiating_obesity_talk.pdf 2 Obesity Action Coalition. Weight bias in healthcare. https://issuu.com/oacywm/docs/weight-bias-in-healthcare/1?e=7752303/1891883 3 Volger S, Vetter ML, Dougherty M, et al. Patients’ preferred terms for describing their excess weight: discussing obesity in clinical practice. Obesity. 2012;20(1):147-150. 4 Vallis M, Piccinini-Vallis H, Sharma AM, Freedhoff Y. Clinical review: modified 5 As: minimal intervention for obesity counseling in primary care. Can Fam Physician 2013 59:27-31.

1 ASK

2 ASSESS

3 ADVISE

4 AGREE

5 ASSIST

• Ask for permission to discuss weight• Explore readiness for change

• Assess obesity class and stage• Assess for drivers, complications, and barriers

• Advise on obesity risks• Explain benefits of modest weight loss• Explain need for long-term strategy• Discuss treatment options

• Agree on realistic weight-loss expectations• Focus on behavioral goals (SMART) and health outcomes• Agree on treatment plan

• Address drivers and barriers• Provide education and resources• Refer to appropriate provide• Arrange follow-up

American Association of Nurse Practitioners

FACULTY

Frances M. Sahebzamani, Ph.D., ARNP, FAANP

H. Lee Moffitt Cancer Center and Research Institute

Team Member Medical Clinic

Healthy Weight and Cardiovascular Risk Reduction Program

Tampa, Florida

Geraldine M. Budd

PhD, RN, FNP-BC, FAANP

Professor and Assistant Dean

Widener University

Harrisburg, Pennsylvania

STAFF

Sue Ellen Gondran, DNP, APRN, FNP-BC

Nurse Practitioner Education Specialist

This educational material was developed by the American Association of Nurse Practitioners, www.aanp.org, in cooperation with Thistle Editorial, LLC www.thistleeditorial.com

Design by Kat&Dog Communications, Austin, TX

Let’sTalk Weight & Your Well being

An educational toolbox to help manage weight and achieve better health

Supported by Novo Nordisk, Inc.

TABLE OF CONTENTSOVERVIEW

Adult Obesity Facts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1The DISEASE of Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Defining Adult Overweight and Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3How Does the Body Control Weight? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4When the Body is “Out of Balance” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Aim for a Healthier Weight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

WEIGHT MANAGEMENTGetting Ready for Better Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

LIFESTYLE TOOLSDeveloping New Lifestyle Skills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Learning New Habits for a Healthier Weight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Mindful Eating . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

MEAL PLANNING TOOLSMeal Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Consider the Calories/Hunger Scale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

PHYSICAL ACTIVITY TOOLSPhysical Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13All Types of Physical Activity are Helpful . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14

MEDICATION TOOLSAnti-obesity Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15There are 2 Main Types of Anti-obesity Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16What are the Benefits of Anti-obesity Medications? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

SURGICAL TOOLSWeight Loss Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18Types of Weight Loss Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19If You are Thinking about Weight Loss Surgery... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

SUMMARYConsider Your Healthcare Provider as Your Partner for Better Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21

RESOURCESRESOURCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

OVERVIEW

Adult Obesity Facts

Points to Emphasize:

Obesity is a chronic disease that is increasing in prevalence in the United States and around the world.

• Overweight and obesity affects 69% of adults ≥20 years1

• Obesity affects 35% of adults ≥20 years

• Obesity affects 17% of youth (2-19 years)1

• More women are affected by obesity than men (40% vs 35%)1

• One third of women of childbearing age (20-29 years) are affected by overweight and obesity1

• Obesity increases the risk of many conditions—type 2 diabetes mellitus, hypertension, cardiovascular disease, stroke, osteoarthritis, sleep apnea and respiratory problems.2-6

1 Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the United States, 2011-2012. JAMA 2014;311:806-14.2 Guh DP, Zhang W, Bansback N, Amarsi Z, Birmingham CL, Anis AH. The incidence of co-morbidities related to obesity and overweight: a systematic review and meta-analysis. BMC public health. 2009;9:88.3 Bhaskaran K, Douglas I, Forbes H, dos-Santos-Silva I, Leon DA, Smeeth L. Body-mass index and risk of 22 specific cancers: a population-based cohort study of 5.24 million UK adults. Lancet. 2014;384(9945):755-765.4 Li C, Ford ES, Zhao G, Croft JB, Balluz LS, Mokdad AH. Prevalence of self-reported clinically diagnosed sleep apnea according to obesity status in men and women: National Health and Nutrition Examination Survey, 2005-2006. Prev Med. 2010;51(1):18-23.5 Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the United States, 2011-2012. JAMA. 2014;311(8):806-814.6 Ng M, Fleming T, Robinson M, et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980–2013: a systematic analysis for the Global Burden of Disease Study 2013. The Lancet. 2014;384(9945):766-781.

1 World Health Organization (WHO). Obesity and overweight. 2015. http://www.who.int/mediacentre/factsheets/fs311/en/. 2 Locke AE, Kahali B, Berndt SI, et al. Genetic studies of body mass index yield new insights for obesity biology. Nature. 2015;518(7538):197-206.3 Mechanick JI, Hurley DL, Garvey WT. Adiposity-Based Chronic Disease as a New Diagnostic Term: American Association of Clinical Endocrinologists and the American College of Endocrinology Position Statement. Endocr Pract 2016.

The DISEASE of Obesity


• Obesity/overweight:

— Is a multi-factorial, chronic disease that makes it difficult for people to lose weight and leads to increased risk for other diseases.

— Involves excess adipose tissue as a result of an imbalance between energy intake and energy expenditure.1

— Is not solely a lifestyle or behavioral issue. The onset of obesity involves genetic, metabolic, and environmental factors that contribute to its complex pathophysiology.

— Is more complicated than total calories consumed and expended.2

Additional Information:

• The terminology used to describe obesity is evolving. Adiposity-based chronic disease (ABCD) is a new term.3

• The key elements of ABCD to support the care and management of patients who have overweight/obesity are as follows:

— Lifestyle modifications to promote overall health;

— A comprehensive approach to weight loss strategies;

— Management of adiposity-based complications that is tailored to the individual cultural, ethnic and socio-economic characteristics of patients; and

— Long-term support for weight management.

1 Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults. Circulation. 2014;129(25 suppl 2):S102-S138.2 Garvey WT, Mechanick JI, Brett EM, et al. American Association of Clinical Endocrinologists and American College of Endocrinology Comprehensive Clinical Practice Guidelines for Medical Care of Patients with Obesity. Endocr Pract. 2016;22 Suppl 3:1-203.

Defining Adult Overweight and Obesity


• Use the following markers to screen patients for adiposity:

— Body mass index (BMI): the higher the BMI, the greater the risk of morbidity and mortality1

— Waist circumference: an indirect measure of central adiposity that correlates with visceral fat and provides information about cardiometabolic risk

— Weight-related complications or diseases


• The American Association of Clinical Endocrinologists classifies overweight and obesity as follows:2

Classification of Overweight and Obesity by BMI and Waist Circumference

Classification BMI Waist Circumference and Health Risk

BMI kg/m2 Comorbidity Risk Men ≤40 in (102cm)Women ≤35 in (88cm)

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

Underweight <18.5 Low but other problems

Normal weight 18.5-24.9 Average

Overweight 25-29.9 Increased Increased High

Obese Class I 30-34.9 Moderate High Very high

Obese Class II 35-39.9 Severe Very high Very high

Obese Class III ≥40 Very severe Extremely high Extremely high

1 Suzuki K, Jayasena CN, Bloom SR. Obesity and appetite control. Exp Diabetes Res. 2012;2012:8242 Murray S, Tulloch A, Gold MS, Avena NM. Hormonal and neural mechanisms of food reward, eating behavior and obesity. Nat Rev Endocrinol. 2014;10:540-5523 Bray GA, Fruhbeck G, Ryan DH, Wilding JP. Management of obesity. Lancet. 2016;387(10031):1947-1956.4 Chapman CD, Benedict C, Brooks SJ, Schioth HB. Lifestyle determinants of the drive to eat: a meta-analysis. Am J Clin Nutr. 2012;96(3):492-497.5 Apovian CM, Aronne LJ, Bessesen DH, et al. Pharmacological management of obesity: an endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2015;100(2):342-362.

How Does the Body Control Weight?


• Energy intake (food) fuels energy expenditure (physical activity).

• The body tries to achieve balance between energy intake and energy expenditure (energy homeostasis) by complex interactions and feedback loops involving the brain, the gut, and other organs, including fat cells (adipocytes).1-2

• Energy balance can be upset by:

— Increased intake (e.g., high-fat, high-calorie diet)

— Decreased expenditure (e.g., sedentary lifestyle)

• Genetic, environmental, metabolic, and behavioral factors affect the balance between energy intake and energy expenditure over an extended period.3-4


• Energy homeostasis involves:5 — Central nervous system:

Hypothalamus receives signals from the body about the presence of too much or too little food, as well as its absorption rate. CNS uses these signals to control how nutrients are metabolized and how the mind decides when and what to eat.

— Cellular feedback loop: Adipocytes secrete hormones in response to CNS signaling. These hormones are involved in regulating glucose, lipid, and steroid metabolism, as well as coagulation, blood pressure, and hunger. Short-term signals about nutrient availability circulate in a feedback loop between the brain and other organs (i.e. the periphery—the gut, pancreas, liver, muscle, adipose tissue). Feelings of hunger and fullness (satiety) drive appetite through hormones and special proteins (neuropeptides) that carry messages to the brain about nutrient surpluses or deficits in the body.

— Reward pathways: Hypothalamus processes information from reward pathways associated with pleasure (sight, smell, taste of food). These pathways may override energy balance processes and influence the physiologic regulation of hunger and satiety.

Environmental Factors that Affect Balance Behavioral Factors that Affect Balance

*Obesogenic environment:—marketing of energy-dense foods—increased availability of these foods—increased portion size—stress that triggers compensatory food intake

*Other factors contribute to obesity:—epigenetics—certain drugs are associated with weight gain (e.g. for treating diabetes, depression, pain, hypertension, GERD, asthma, mood disorders)

*Chronic exposure to obesity-promoting behaviors:—alcohol abuse—sleep deprivation—excessive screen time—decreasing physical activity

*Exposure to these behaviors increases the drive to eat via neurobehavioral mechanisms that affect memory, reward signals, and inhibit control

1 Bays HE, Abate N, Chandalia M. Adiposopathy: sick fat causes high blood sugar, high blood pressure, and dyslipidemia. Future Cardiology. 2005;1(1):39-592 Stenholm S, Harris TB, Rantanen T, Visser M, Kritchevsky SB, Ferrucci L. Sarcopenic obesity: definition, cause and consequences. Curr Opin Clin Nutr Metab Care. 2008;11(6):693-7003 Lago F, Dieguez C, Gomez-Reino J, Gualillo O. Adipokines as emerging mediators of immune response and inflammation. Nat Clin Pract Rheumatol. 2007;3(12):716-724.4 Lidell ME, Betz MJ, Enerback S. Brown adipose tissue and its therapeutic potential. J Intern Med. 2014;276(4):364-377.

When the Body is “Out of Balance…”


• The body stores excess energy in adipose tissue (fat).

• The type of adipose tissue and where it is stored in the body plays a role in how weight accrues, and increases the risk for other conditions.1

• As people age, the balance between body fat and muscle mass shifts2

— Body fat increases and muscle mass decreases.

— Visceral fat tends to increase.

— Physical inactivity, hormonal changes, and other physiological factors speed up this shift in balance between body fat and muscle.


• White adipose tissue is the main type of adipose tissue and is the body’s main energy store.

— It is metabolically active and functions as an endocrine organ system associated with energy metabolism, feeding control, inflammatory response, and cardiovascular function.3

— Problems with the functioning of white adipose tissue lead to many adverse health conditions (e.g., atherosclerosis, insulin resistance and diabetes, rheumatoid arthritis, osteoarthritis, kidney disease, liver disease).

• Brown adipose tissue (BAT) is metabolically active tissue that is mostly found in the neck, shoulders, and spine.4

— BAT transfers energy from food into heat and increases energy output.

— As people age, having BAT can protect against adiposity.

• Beige adipose tissue is a subcutaneous type of brown fat.4

— When exposed to cold, beige adipose tissue can be recruited to convert white fat into energy-burning brown fat, and reduce adiposity.

1 Gustafson B, Smith U. Regulation of white adipogenesis and its relation to ectopic fat accumulation and cardiovascular risk. Atherosclerosis.241(1):27-35.2 Mechanick JI, Hurley DL, Garvey WT. Adiposity-Based Chronic Disease as a New Diagnostic Term: American Association of Clinical Endocrinologists and the American College of Endocrinology Position Statement. Endocr Pract 2016.3 Yuen MM, Earle RL, Kadambi N, et al. A systematic review and evaluation of current evidence reveals 236 obesity-related disorders (ObAD). Poster T-P-3166. Presented at The Obesity Society Annual meeting at ObesityWeekSM 2016, Oct 31-Nov 4, New Orleans, LA. www.obesityweek.com

Aim for a Healthier Weight


• Excess abdominal/central adiposity is an independent predictor of cardiovascular risk factors and multiple comorbidities.1

• Central adiposity correlates with visceral fat, which promotes insulin resistance and inflammation.

— Inflammation worsens insulin resistance, which causes other mechanisms that worsen inflammation.

— This feedback loop contributes to diseases such as diabetes, cardiovascular disease, and cancer.

• Weight loss can improve physical and psychological health, reduce inflammation and insulin resistance, and reduce the risk of disease and disability.


• Overweight/obesity can cause dysfunction in adipose tissue (adiposopathy):

• Hypersecretion of pro-inflammatory, pro-atherogenic, and pro-diabetic adipocytokines.

• These adipocytokines contribute to organ-specific and biomechanical conditions:2

Biomechanical Cardiometabolic OtherGastroesophageal reflux disease (GERD)Asthma/respiratory diseaseOsteoarthritisSleep apneaUrinary incontinence

DyslipidemiaHypertensionPrediabetesDiabetesNon-alcohol fatty liver disease

Androgen deficiencyCancerGallstone diseaseDepression & anxietyPolycystic ovary syndrome

Obesity-Related Complications

There are 236 recognized complications.3

1 Cefalu WT, Bray GA, Home PD, et al. Advances in the Science, Treatment, and Prevention of the Disease of Obesity: Reflections From a Diabetes Care Editors’ Expert Forum. Diabetes Care. 2015;38(8):1567-1582.2 Messier SP, Gutekunst DJ, Davis C, DeVita P. Weight loss reduces knee-joint loads in overweight and obese older adults with knee osteoarthritis. Arthritis & Rheumatism. 2005;52: 2026–20323 Arthritis Foundation. Osteoarthritis Fact Sheet. http://www.joionline.net/pdf/OAFactSheet.pdf. Accessed May 21, 20174 Garvey WT, Mechanick JI, Brett EM, et al. American Association of Clinical Endocrinologists and American College of Endocrinology Comprehensive Clinical Practice Guidelines for Medical Care of Patients with Obesity. Endocr Pract. 2016;22 Suppl 3:1-203.5 Apovian CM, Aronne LJ, Bessesen DH, et al. Pharmacological management of obesity: an endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2015;100(2):342-362.

Getting Ready for Better Health


• Losing a small amount of weight—3%— can reduce complications and produce successful health outcomes.1

• The primary therapeutic endpoint of an obesity treatment regimen is to improve obesity-related complications, not to achieve a preset decline in body weight.2

• Set clear goals with patients—they may desire greater short-term weight loss than is realistic.

• Select treatment goals based on disease stage and severity of complications.

— Normal weight: prevent overweight/obesity

— Overweight: prevent weight gain or promote weight loss to prevent complications

— Obese Class I-III: promote weight loss to reduce complications, prevent progression, and reduce risk

• Individualize treatment for obesity-related conditions via behavioral interventions for lifestyle change, pharmacotherapy, and/or bariatric surgery.3-4

Developing New Lifestyle Skills


• Lifestyle management is the foundation for improving obesity-related disease, reducing adiposity, and improving patient quality of life.1

• The presence and severity of obesity-related complications are the primary determinants for selecting treatment modality and the intensity of therapy.

• The decision to recommend lifestyle therapy alone or combined with pharmacotherapy or bariatric surgery depends on the severity of each patient’s adiposity or obesity-related complications.2


• Patients with the following should be evaluated for obesity-related complications:2

— BMI >25 kg/m2 (BMI >23 kg/m2 in certain ethnic groups)

• Medical history: including history of present illness, medication history, family history

• Weight-related history: life events and past episodes of weight gain or weight loss, diet and activity, weight loss readiness

• Review of systems: assessment for comorbidities/obesity-related complications

• Physical examination: BMI, waist circumference, blood pressure, assess for obesity-related complications

• Laboratory evaluations: as per guideline recommendations. If not done within last year, perform A1C and/or fasting glucose for diabetes, thyroid stimulating hormone levels, lipid panel, liver enzymes to assess for NAFLD and/or creatinine to assess for kidney function, if appropriate.

1 Garvey WT, Mechanick JI, Brett EM, et al. American Association of Clinical Endocrinologists and American College of Endocrinology Comprehensive Clinical Practice Guidelines for Medical Care of Patients with Obesity. Endocr Pract. 2016;22 Suppl 3:1-203.2 Kushner RF. Clinical assessment and management of adult obesity. Circulation. 2012;126(24):2870-2877.

Learning New Habits for a Healthier Weight


• Lifestyle modifications alone may be appropriate for patients with overweight (pre-obesity) or obesity who have no clinically significant obesity-related complications.1

• Help patients develop new lifestyle skills and accomplish goals by providing step-by-step instruction on:

— Meal plans to reduce total energy intake

— Increasing the volume and intensity of physical activity

— Behavioral skills to support adherence to lifestyle + pharmacologic interventions

• Cultivating the following behaviors can support lifestyle changes and help patients achieve and maintain weight loss: 2,3,4

— Realistic goal setting

— Personal motivation to change

— Prompt self-monitoring of behavior

— Using available social support

— Self-belief that weight can be controlled


• Dietary restrictions and/or physical activity can help to achieve weight loss, but over the long term, many people regain weight.5

• Caloric restriction triggers several biological adaptations designed to prevent starvation and/or preserve weight:6

— Circulating levels of hormones (e.g., ghrelin, leptin) do not return to levels recorded before diet-induced weight loss.

— Weight loss induces reduction in resting energy expenditure, and less energy expenditure is required with physical activity because muscle efficiency is greater.

— Certain behaviors may also contribute to weight regain.

Motivational interviewing is an effective strategy to support goal-oriented communication. Learn more at:http://obesity.aace.com/files/obesity/toolkit/motivational_interviewing.pdf

1 Apovian CM, Aronne LJ, Bessesen DH, et al. Pharmacological management of obesity: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2015;100(2):342-362.2 Olander EK FH, Williams S et al. What are the most effective techniques in changing obese individuals’ physical activity self-efficacy and behaviour: a systematic review and meta-analysis. Int J Behav Nut Phys Activity. 2013;10(29).3 Ali MK, Echouffo-Tcheugui J, Williamson DF. How effective were lifestyle interventions in real-world settings that were modeled on the Diabetes Prevention Program? Health Aff. 2012;31(1):67-75.4 Thomas JG, Bond DS, Phelan S, Hill JO, Wing RR. Weight-loss maintenance for 10 years in the National Weight Control Registry. Am J Prev Med. 2014 Jan;46(1):17-235 Greenway FL. Physiological adaptations to weight loss and factors favouring weight regain. Int J Obes (Lond). 2015;39(8):1188-1196.6 Sumithran P, Prendergast LA, Delbridge E et al. Long-Term Persistence of Hormonal Adaptations to Weight Loss. New England Journal of Medicine 2011;365:1597-1604.

Mindful Eating


• Some people who are trying to manage weight think they are hungry when they may be feeling sad, bored, stressed, excited, or scared.

• People who eat in response to stress, emotions, or physical cues (e.g., responding to TV ads) may overeat.1

• Mindful eating is a way to empower patients.


• Highly palatable food (e.g. foods with fat or sugar) can activate the brain reward system and reinforce the need to eat more palatable food.

• Repeated stimulation of the reward pathways by eating highly palatable food can lead to neurobiological adaptation and increase compulsive overeating.2-3

Principles of Mindful Eating:4

• With practice, mindfulness cultivates the possibility of freeing yourself of reactive, habitual patterns of thinking, feeling, and acting.

• Mindfulness promotes balance, choice, wisdom, and acceptance of what is.

• Learning to be aware of physical hunger and satiety cues to guide your decision to begin eating and to stop eating.

• Allows a person to be aware of and reflect on the effects caused by unmindful eating.

How do you recognize mindful eating?

• Do you remember your last meal?

• What was the flavor, the taste, the texture?

• Do you remember why you made the food choice?

1 http://www.joslin.org/info/how-to-use-a-hunger-scale.html2 Torres SJ, Nowson CA. Relationship between stress, eating behavior, and obesity. Nutrition. 2007;23:887-8943 Ada, TC, Epel ES. Stress, eating, and the reward system. Physiology & Behavior. 2007;91:449-458.4 The Center for Mindful eating: http://thecenterformindfuleating.org/IntroMindfulEating

Meal Planning


• A negative energy balance is important for achieving weight loss.

—Caloric restriction is more important than the type of plan.

—AACE guidelines recommend meal plans that support an energy deficit of 500-750 kcal/day.1

• Many meal plans support weight loss regimens (e.g., low carb, low-fat, volumetric, high protein, vegetarian, Mediterranean, DASH).

• Dietary recommendations include:

—Reduced intake: refined carbohydrates, processed meats, and foods high in sodium and trans fat, high fructose corn syrup

—Moderate intake: unprocessed red meats, poultry, eggs, and milk

—Higher intake: fruits, nuts, fish, vegetables, vegetable oils, minimally processed whole grains, legumes, and yogurt.2 Some of these foods are high in fat. Use in small amounts to achieve recommended caloric intake.


• The Mediterranean diet (containing olive oil, nuts, vegetables, and fish) has many benefits in addition to favorable effect on weight:3

— Palatable for long-term adherence

— Reduced fasting blood glucose and better glycemic control among patients with diabetes

— Higher persistent weight loss at 6 years, vs low-fat or low-carb meal plans

— Lower mortality rates

• Low-calorie plans are typically 1,200-1,800 kcal/day

• Very low-calorie plans (<800 kcal/day) may be appropriate for selected patients.

—These plans are associated with the potential for health complications (e.g., gallstones) and should only be used where trained providers and close medical monitoring is available.

1 Garvey WT, Mechanick JI, Brett EM, et al. American Association of Clinical Endocrinologists and American College of Endocrinology Comprehensive Clinical Practice Guidelines for Medical Care of Patients with Obesity. Endocr Pract. 2016;22 Suppl 3:1-203.2 Mozaffarian D. Dietary and Policy Priorities for Cardiovascular Disease, Diabetes, and Obesity: A Comprehensive review. Circulation. 2016 Jan;133(2):187-225.3 Shai I SD, Henkin Y et al. Weight loss with a low-carbohydrate, Mediterranean, or low-fat diet. New Engl J Med. 2008;359(3):229-241.

Evidence-Based Nutritional Strategies

*self-selected diet *dietitian involvement *diet diary*set daily caloric restriction*portion control

*breakfast *meal replacements*treat eating disorders*group visits/support *diet prescription

*Resources- educational handouts - professional, community and internet resources- sample meals

Consider the Calories/Hunger Scale


• The FDA has an updated Nutrition Facts label based on new scientific information. The label reflects the link between diet and chronic diseases such as obesity and heart disease. The new label should help consumers make better informed food choices. Use of the new label is mandated by July 26, 2018.1,2

1 US Food and Drug Administration. Changes to the Nutrition Facts Label. https://www.fda.gov/Food/GuidanceRegulation/GuidanceDocumentsRegulatoryInformation/LabelingNutri-tion/ucm385663.htm. Updated April 25, 2017. Accessed May 19, 2017. 2 https://www.fda.gov/downloads/food/ingredientspackaginglabeling/labelingnutrition/ucm511646.pdf3 Ominchinski L. You Count, Calories Don’t. 1992. London: Hodder and Stoughton

• The Hunger Scale can help people control eating and lessen the chance of ‘mindless eating’.3

New Label/What’s Different1

Physical Activity


• All types of physical activity are beneficial.

• Physical activity is any bodily movement produced by skeletal muscle that results in energy expenditure—e.g., climbing stairs, gardening, walking the dog

• Exercise is a type of physical activity that involves planned and structured bodily movement to increase caloric expenditure—e.g., jogging, lap swimming, resistance training

• Engaging in or increasing physical activity and exercise improves:1

— Weight loss and maintenance

— Metabolic, musculoskeletal, CV, pulmonary, mental, and sexual health

• Counsel patients to set goals to engage in or increase physical activity according to current guideline recommendations.1

• Intensity: able to be physically active and talk comfortably

• Frequency: ≥3-4 times per week

• Motivation: engage in a regular schedule of different activities, partner with someone, use a reward system

1 Garvey WT, Mechanick JI, Brett EM, et al. American Association of Clinical Endocrinologists and American College of Endocrinology Comprehensive Clinical Practice Guidelines for Medical Care of Patients with Obesity. Endocr Pract. 2016;22 Suppl 3:1-203.

All Types of Physical Activity are Helpful


• To maintain weight, the Centers for Disease Control (CDC) recommends one of the following each week:1

— 150 minutes of moderate-intensity aerobic activity (i.e., brisk walking, light swimming)

— 75 minutes of vigorous activity (e.g., soccer, jogging, cycling)

— An equivalent mix of the two each week.

• Adults also need muscle-strengthening activities at least 2 days per week (e.g., resistance or strength training)

• Aerobic activity of 240 to 300 minutes per week may add additional benefits to reduced calorie intake.

• Other physical activity guidelines:

— 200-300 mins/week for weight loss maintenance (i.e. ‘you lost weight and want to stay at your new, healthier weight).2

— ≥150 mins/week as part of comprehensive lifestyle intervention for weight loss2

• Individualize physical activity treatment planning.

— Assess patients for comorbidities and degree of sedentary lifestyle before starting physical activity.

— Advise patients to start slowly.

• Technology-based and other tools can help patients track activity progress.3

— Social media: post activity to enhance accountability and get physical activity advice from others

1 Centers for Disease Control and Prevention. How much physical activity do adults need? 2015. https://www.cdc.gov/physicalactivity/basics/adults/index.htm. Accessed May 18, 20172 Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults. Circulation. 2014;129(25 suppl 2):S102-S138.3 Jakicic J, Davis KK, Rogers RJ et al. Effect of wearable technology combined with a lifestyle intervention on long-term weight loss: The IDEA randomized controlled trial. JAMA. 2016;316(11):1161-1171.

Anti-Obesity Medications


• Approved anti-obesity medications may help improve complications, enhance adherence to behavior changes, and promote long-term weight maintenance.

• Compared with lifestyle alone:

— More patients (>50%) can achieve weight loss goals of 5%-10% with medications and lifestyle

— Clinically significant improvements include: blood pressure, triglycerides, HDL, measures of glycemic control, and risk reduction for progression to type 2 diabetes.1

• Patients may be candidates for medications in the following circumstances:

— Lifestyle therapy alone does not meet health goals

— Progressive weight gain

— No clinical improvement in obesity-related complications

— Weight regain following lifestyle alone

— BMI 27-29.9 kg/m2 with obesity-related complications

— BMI ≥30 kg/m2

• Select the weight loss therapy that will most likely prevent or improve obesity-related complications.

• Review the following:

— Treatment goals and drug efficacy for mean weight loss

— Risks and benefits: adverse events, drug-drug interactions

— Patient acceptance of medication side effect profiles

— Cost

1 Wadden TA BR, Womble LG, et al. Randomized Trial of Lifestyle Modification and Pharmacotherapy for Obesity. N Engl J Med 2005;353:2111-2120.

There are 2 Main Types of Anti-Obesity Medications


• Monitor patients regularly (initially every 4-6weeks) for degree of weight loss, risk markerimprovement (e.g., CVD, diabetes), titrationschedules if necessary, and side effectsaccording to each agent’s recommendedprescribing schedule.1

• If patients do not respond to a weight loss medication 3-4 months after starting treatment(≥5% loss of body weight), consider thefollowing:1

— Increase dose of weight loss medication

— Switch weight loss medication


• There are 4 short-term medications that are currently approved for weight management (Table). 2,3,4

FDA Approved Short-term Medication (12 weeks)

Drug Category Target, and System EffectSympathomimetic CNS causing appetite suppression,

Insomnia, palpitations, tachycardia, dry mouth, taste alterations, dizziness, tremors, headache, diarrhea, constipation, vomiting, gastrointestinal distress, anxiety, restlessness, increased blood pressure

• There are 5 medications that are currently approved for long-termweight management and maintenance as an adjunct to lifestyle therapy (Table).5

• These drugs affect appetite and support adherence with a reducedcalorie diet.6

Drug Category Target, and System Effect

Pancreatic lipase inhibitor GI: Alters fat absorption

Serotonin agonist CNS: Stimulates serotonin type 2c receptor, suppresses appetite, promotes satiety

Sympathomimetic/antisiezure CNS: Affects POMC neurons, suppresses appetite, may cause early satiety, decreases binge eating behavior7

GLP-1 agonist Regulates appetite/satiety, lowers body weight through decreased food intake; Slows gastric emptying

Opioid antagonist/dopamine + norepinephrine reuptake inhibitor CNS: Stimulates POMC neurons, suppresses appetite + food cravings

1 Bragg R, Crannage E. Review of pharmacotherapy options for the management of obesity. J Am Assoc Nurse Pract. 2016;28(2):107-115.2 Bray GA, Ryan DH. Update on obesity pharmacotherapy. Ann N Y Acad Sci. 2014;1311:1-13. 3 Hurt RT, Edakkanambeth Varayil J, Ebbert JO. New pharmacological treatments for the management of obesity. Curr Gastroenterol Rep. 2014;16(6):394. 4 Yanovski SZ, Yanovski JA. Long-term drug treatment for obesity: a systematic and clinical review. JAMA. 2014;311(1):74-86. 5 https://dailymed.nlm.nih.gov/dailymed/index.cfm6 Smith SR WN, Anderson CM, et al Multicenter, placebo-controlled trial of lorcaserin for weight management. N Engl J Med. 2010;363(3):245-256.7 Berkman ND, Brownley KA, Peat CM, Lohr KN, Cullen KE, Morgan LC, Bann CM, Wallace IF, Bulik CM. Management and Outcomes of Binge-Eating Disorder. Comparative Effectiveness Review No. 160. (Prepared by the RTI International–University of North Carolina Evidence-based Practice Center under Contract No. 290-2012-00008-I.) AHRQ Publication No. 15(16)-EHC030-EF. Rockville, MD: Agency for Healthcare Research and Quality; December 2015. www.effectivehealthcare.ahrq.gov/reports/final.cfm.

FDA Approved Long-term Medication

What are the Benefits of Anti-Obesity Medications?


Weight Loss Associated with Long-Term Anti-Obesity Medications 1-5

Therapy Length of Trial

Total Weight Loss

Mean Weight

Loss

Orlistat ≥1 year -5.3 kg -6.1%

Lorcaserin 1 year -5.8 kg -5.8%

Phentermine/topiramate

≥1 year -10.2 kg - 9.8%

Bupropion/naltrexone ≥1 year -6.1 kg -5.4%

Liraglutide ≥1 year -8.4kg -8.0%

Advantages and disadvantages of

available long-term anti-obesity

medications2,6

Drug Advantages Disadvantages

Pancreatic lipase inhibitor→

• Nonsystemic• Long-term data available• Excretion of ~ 30% of TG in stool• May need to lower diabetes medications

• Side effect profile• Supplement with fat soluble vitamins• Take 1 hour before each meal

Serotonin agonist→• Side effect profile• BID or ER qd formulation• Long-term data available

• Caution with use with SSRIs

Sympathomimetic/antisiezure• Improved cardiometabolic biomarkers• May reduce binge eating behavior6

• Long-term data available

• Teratogen• Titrate dose at initiation and discontinuation

Opioid antagonist/dopamine + norepinephrine reuptake inhibitor

• Food addiction/cravings• Long-term data available

• Side effect profile• Titrate dose at initiation and discontinuation

GLP-1 agonist• Improvement in A1C, lipids, Blood pressure• Long-term data available

• Injectable• Side effect profile: nausea most common • Monitor: medullary thyroid cancer, pancreatitis

1 LeBlanc E OCE, Whitlock EP, et al Effectiveness of primary care-relevant treatments for obesity in adults: A systemic evidence review for the US Preventive Services Task Force. Ann Intern Med 2011;155:434.2 Apovian CM, Aronne LJ, Bessesen DH, et al. Pharmacological management of obesity: an endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2015;100(2):342-362.3 Vilsbøll T, Christensen M, Junker AE, Knop FK, Gluud LL. Effects of glucagon-like peptide-1 receptor agonists on weight loss: systematic review and meta-analyses of randomised controlled trials. BMJ 2012;344:d7771.4 Bray GA, Fruhbeck G, Ryan DH, Wilding JP. Management of obesity. Lancet 2016;387:1947-56.5 Pi-Sunyer X, Astrup A, Fujioka, K, et al. A randomized, controlled trial of 3.0 mg of liraglutide in weight management. New Engalnd Journal of Medicine 2015; 373: 11-22.6 Berkman ND, Brownley KA, Peat CM, Lohr KN, Cullen KE, Morgan LC, Bann CM, Wallace IF, Bulik CM. Management and Outcomes of Binge-Eating Disorder. Comparative Effectiveness Review No. 160. (Prepared by the RTI International–University of North Carolina Evidence-based Practice Center under Contract No. 290-2012-00008-I.) AHRQ Publication No. 15(16)-EHC030-EF. Rockville, MD: Agency for Healthcare Research and Quality; December 2015. www.effectivehealthcare.ahrq.gov/reports/final.cfm.

Weight Loss Surgery


• Bariatric surgery can be an effective treatment option for severe obesity.1-10

— Results in significant weight loss

— Is more effective at improving diabetes in the short term (up to 2 years) than nonsurgical interventions (diet, exercise, other behavioral interventions, and medications).

• Bariatric surgery may be indicated in the following scenarios:

— BMI ≥ 40 kg/m2 if surgical risk is acceptable

— BMI 35.0-39.9 kg/m2 if >1 obesity-related disease

— BMI 30-34.9 kg/m2 for T2DM and/or metabolic syndrome

1 Rubino F Nathan DM, Eckel RH, et al. Metabolic Surgery in the Treatment Algorithm for Type 2 Diabetes: A Joint Statement by International Diabetes Organizations. Diab Care 2016;39:861-877.2 Mechanick JI, Youdim A, Jones DB, et al. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient--2013 update: cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery. Obesity. 2013;21 Suppl 1:S1-27.3 Choi J, Digiorgi M, Milone L, et al. Outcomes of laparoscopic adjustable gastric banding in patients with low body mass index. Surg Obes Relat Dis 2010; 6(4):367-71.4 Gianos M, Abdemur A, Fendrich I, et al. Outcomes of bariatric surgery in patients with body mass index <35 kg/m2. Surg Obes Relat Dis 2012; 8(1):25-30.5 Aarts E, DoganK, Koehestanie P, et al. Long-term results after laparoscopic adjustable gastric banding: a mean fourteen year follow-up study. SOARD 2014; 10(4): 633-640.6 Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta analysis. JAMA. 2004;292(14):1724–1737.7 Thodiyil P, Rogula T, Matter S, Schauer P. Management of Complications After Laparoscopic Gastric Bypass. In William B. Inabnet, Eric J. DeMaria & Sayeed Ikramuddin. Laparoscopic Bariatric Surgery. Lippincott Williams & Wilkins, October 2004. 8 Podnos Y, Jimenez J, Wilson S, et al. Complications After Laparoscopic Gastric Bypass. Arch Surg. 2003;138(9):957-961.9 Lalor P, Tucker O, Szomstein S, Rosenthal R. Complications after laparoscopic sleeve gastrectomy. SOARD 2008; 4(1): 33-38. 10 Fischer L, Hildebrandt C, Bruckner, et al. Excessive weight loss after sleeve gastrectomy: a systematic review. Obes Surg. 2012 May;22 (5):721-31.

Types of Weight Loss Surgery


• Surgery requires referral to a surgeon with expertise in laparoscopic bariatric procedures

— The surgeon will discuss the different types of bariatric surgery approaches recommended for the patient

— Insurance coverage for specific bariatric procedures

— Lifestyle changes that are necessary to fully benefit from bariatric surgery

— Nonsurgical treatment options for diabetes and other metabolic conditions

If your patients are considering bariatric surgery, discuss the potential benefits and adverse effects of bariatric surgery.

Advantages + Disadvantages of Bariatric Procedures1

PROS ConsExpected loss

% EBW at two years

Optimally suited for

patients with:Other comments

Roux-en-Y Gastric Bypass (RYGB)

Greater improvement in metabolc disease

Increased risk of malabsorptive complications over sleeve

60-73% Higher BMI, GERD, Type 2 DM

Largest data set, more technically challenging than LAGB, VSG

Vertical Sleeve Gastrectomy(VSG)

Improves metabolic disease; maintains small intestinal anatomy; micronutrient deficiencies infrequent

No long term data 50-70% Metabolic diseaseCan be used as the first step of staged approach; most common based on 2014 data

Laparoscopic Adjustable Gastric Banding (LAGB)

Least invasive; removable

25-40% 5 year removal rate internationally

30-50% Lower BMI; no metabolic disease

Any metabolic benefits achieved are dependent on weight loss

1 Rubino F Nathan DM, Eckel RH, et al. Metabolic Surgery in the Treatment Algorithm for Type 2 Diabetes: A Joint Statement by International Diabetes Organizations. Diab Care 2016;39:861-877.

If You are Thinking about Weight Loss Surgery...


• Discuss the need to select an experienced surgeon for best surgical outcomes.1

• Studies show surgery reduces a person’s risk of premature death by 30-40%.2,3

• Gastric bypass patients may improve life expectancy by 89%.2,3

1 John D. Birkmeyer, M.D., Jonathan F. Finks, M.D., Amanda O’Reilly, R.N., M.S., Mary Oerline, M.S., Arthur M. Carlin, M.D., Andre R. Nunn, M.D., Justin Dimick, M.D., M.P.H., Mousumi Banerjee, Ph.D., and Nancy J.O. Birkmeyer, Ph.D., for the Michigan Bariatric Surgery Collaborative New England Journal of Medicine 2013; 369:1434-1442.2 Sjöström. L., et al. (2007). Effects of bariatric surgery on mortality in Swedish obese subjects. New England Journal of Medicine. 357 pp. 741-752.3 Adams, T. D., et al. (2007). Long-term mortality after gastric bypass surgery. New England Journal of Medicine. 357 pp. 753-761.4 Kral JG, Kava RA, Catalano PM, Moore BJ. Severe obesity: The neglected epidemic. Obesity Facts. 2012;5:254-269

Disease and Conditions of Severe Obesity that Obesity Surgery May Prevent, Resolve, Improve4

Type 2 diabetes Cancers Breast Colorectal Endometrial Esophageal Kidney Ovarian Pancreatic Prostate

Cardiovascular Hypertension Coronary artery disease Dyslipidemia Pulmonary embolism Stroke

AsthmaOsteoarthritis Chronic back pain Sleep apnea Esophagitis Infectious disease Infertility

Obstetric complicationsOperative risk Liver cirrhosis Thrombosis Poor quality of life


SUMMARY

Point to Emphasize:

Talking with your health care provider about making a treatment plan is a strong predictor of successful weight loss.

Explore appropriate lifestyle

and medical treatment options and make plans

that meet individual patient needs

Set goals for short term and

long term

Build trust through shared decision-making

Initiate a collaborative conversation about weight management with patients1-4

Emphasize the importance of a

patient’s perspective, experiences, and

feelings about past weight changes

1 Centers for Medicare and Medicaid Services. Decision memo for intensive behavioral therapy for obesity (CAG-00423N). https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?&NcaName=Intensive%20Behavioral%20Therapy%20for%20Obesity&bc=ACAAAAAAIAAA&NCAId=253 Accessed May 21, 20172 Pollak KI, Østbye T, Alexander SC, et al. Empathy goes a long way in weight loss discussions. J Fam Pract. 2007;56(12):1031-1036.3 Vallis M, Piccinini-Vallis H, Sharma AM, Freedhoff Y. Modified 5 As: minimal intervention for obesity counseling in primary care. Can FamPhysician. 2013;59(1):27-31.4 Bardia A, Holtan SG, Slezak JM, Thompson WG. Diagnosis of obesity by primary care physicians and impact on obesity management. Mayo Clin Proc. 2007;82(8):927-32.

RESOURCES

Specialist Referral

Obesity SpecialistIf weight loss is ineffective (<5% at 3 months) or if there are safety or tolerability issues at any time, guidelines recommend that the medication be discontinued and alternative medications or referral for alternative treatment approaches be considered.

Other SpecialistsPatients may also be referred to mental health professionals, endocrinologists, sleep specialists, nutritionists, registered dietitians, psychologists, and exercise physiologists for additional support if necessary

Obesity specific tools to support diagnosis, evaluation, and management AACE Obesity Resource Center: http://obesity.aace.com/obesity-resource-toolkit

American Obesity Association: http://www.obesity.org

Obesity Action Coalition: http://www.obesityaction.org/educational-resources

Obesity Society: http://www.obesity.org/publications/clinical-resources http://www.obesity.org/resources/facts-about-obesity/resources-for-consumers

Community Health Association of Mountain/Plain States (CHAMPS) Obesity Resource List http://champsonline.org/tools-products/clinical-resources/diseasecondition-specific-resources/overweight-and-obesity-treatment-and-prevention-resources

Obesity Support Group for Bariatric Surgery http://www.obesityhelp.com/

Diabetes PreventionPreventing Diabetes: https://www.cdc.gov/diabetes/home/index.html

American Diabetes Association: meal planning, exercise, weight loss, complications: http://www.diabetes.org

General Lifestyle Advice Heart Health and Healthy Living: https://healthyforgood.heart.org/

Healthy Food Choices: https://www.choosemyplate.gov/

American Dietetic Association: http://www.eatright.org/

The Center for Mindful Eating: http://thecenterformindfuleating.org

Center for Disease Control Healthy lifestyle: www.cdc.gov/obesity/

RESOURCES

UpToDate Weight Loss Treatments:

http://www.uptodate.com/contents/weight-loss-

treatments-beyond-the-basics?source=search_

result&search=obesity+patients&selectedTitle=9~150

Go to https.//www.AANP.org Click Education Tab

Select Education Tools and ResourcesSelect Obesity

for additional resource information.