the chronic disease of obesity in the u.s. · the chronic disease of obesity in the u.s. faculty....

THE CHRONIC DISEASE OF OBESITY

IN THE U.S.

FACULTY

Angela Golden DNP, FNP-C,

FAANP

DISCLOSURES

• Angela Golden• Novo Nordisk: Speaker and Advisory Bureau• Takeda/Lundbeck: Speakers bureau • Sanofi: Advisory board

LEARNING OBJECTIVES

Identify key recommendations and strategies from current clinical guidelines for the management of obesity

Compare the safety, efficacy, and pharmacokinetic profiles of anti-obesity medications

Identify best practices for selecting, initiating, and advancing appropriate pharmacological therapies for patient-specific management of obesity

OVERVIEWObesity and its Consequences

PREVALENCE OF OVERWEIGHT AND OBESITY IN ADULTS

• People who have overweight classification 35.2%

• People with obesity –36.5%

https://nccd.cdc.gov/dnpao_dtm/rdPage.aspx?rdReport=DNPAO_DTM.ExploreByLocation&rdRequestForwarding=Form

Obesogenic Medications

PhysiologicEnvironmental

Genetic

Golden A. Obesity. In A. Hollier (Ed.) 2016:281-285Locke A, et al. Nature. 2015; 518(7538):197-206

Heritable traits Chromosomal abnormalities

Endocrine disrupting chemicals

Low macronutrient /high calorie foods

Medications causing weight gain

Altered microbiome GI/CNS regulation of hunger

+ satiety hormones

?GI, gastrointestinal; CNS, central nervous system

THE COMPLEXITY OF APPETITE

REGULATION

Dietrich MO, et al. Nat Rev Drug Disc. 2012;11(9):675-691Suzuki K, et al. Exp Diabetes Res. 2012;2012:824Murray S, et al. Nat Rev Endocrinol. 2014;10:540-552

GLP-1 = glucagon-like peptide 1CCK = cholecystokininYY = peptide YYFFA = free fatty acidsAA = amino acids

Repr

inte

d by

per

miss

ion

from

Mac

milla

n Pu

blish

ers L

td: N

at R

ev D

rug

Disc

. 201

2;11

(9):6

75-6

91;

perm

issio

n co

nvey

ed th

roug

h C

opyr

ight

Cle

aran

ce C

ente

r, In

c.

GABA = γ-aminobutyric acid, AgRP = agouti-related protein, NPY = neuropeptide, α-MSH = alpha-melanocyte-stimulating hormone, POMC = pro-opiomelanocortin, CART = cocaine and amphetamine-regulated transcript, MC4 = melanocortin 4 receptor

OVERWEIGHT AND OBESITY CLASSIFICATION

Body Mass Index (BMI) in kg/m2

Overweight Class 1 Obesity Class 2 Obesity Class 3 Obesity25-29.9 30-34.9 35-39.9 ≥40

≥35 w/comorbidities

Waist CircumferenceMen Abdominal Obesity Women Abdominal Obesity >/ = 40 inches (>102 cm) >/ = 35 inches (>88cm)

Waist circumference cut-points differ by ethnicity

Endocrine Society Pre-obesity: 26 kg/m2

Garvey WT, et al. Endocr Pract 2016;22 Suppl 3:1-20Apovian CM, et al. J Clin Endocrinol Metab 2015;100:342-62.

OBESITY-RELATED COMPLICATIONS

• Nonalcoholic fatty liver disease

• Polycystic ovary syndrome• Female infertility• Male hypogonadism• Obstructive sleep apnea• Asthma• Osteoarthritis• Depression

• Diabetes risk, metabolic syndrome, and prediabetes

• Type 2 diabetes• Dyslipidemia• Hypertension• Cardiovascular disease and

cardiovascular disease mortality

• Urinary stress incontinence

Garvey WT, et al. Endocr Pract 2016;22 Suppl 3:1-203; Bays HE, Seger JC, Primack C, McCarthy W, Long J, Schmidt SL, Daniel S, Wendt J, Horn DB, Westman EC: Obesity Algorithm, presented by the Obesity Medicine Association. www.obesityalgorithm.org. 2016-2017.

The adverse health consequences of increased body fat (especially visceral fat) are not just ‘comorbidities’ or

‘associated risk factors’.

OBESITY-RELATED COMPLICATIONS

Obesity is a

complex, multifactorial,

chronic disease

Obesity is defined as a chronic, relapsing, multi-

factorial, neurobehavioral

disease, wherein an increase in body fat promotes adipose

tissues dysfunction and abnormal fat mass

physical forces, resulting in adverse metabolic, biomechanical, and psychosocial health

consequences. Bays HE, Seger JC, Primack C, McCarthy W, Long J, Schmidt SL, Daniel S, Wendt J, Horn DB, Westman EC: Obesity Algorithm, presented by the Obesity Medicine Association. www.obesityalgorithm.org. 2016-2017.

RATIONALE FOR WEIGHT LOSS

Jensen MD, et al. Circulation 2014;129:S102-S138

Obesity is associated with a significant increase in mortality and

many health risks

The higher the BMI, the greater the risk of morbidity and mortality

CLINICAL VIGNETTE: EVALUATION

MEET PAMELA

42 years oldWorks part-time as a bankerLives with her husband and 2 daughtersHas tried multiple times to lose weightTried phentermine in past for weight loss but did not tolerate the side effects (“felt jittery”)Has not reached her weight goal

http

://w

ww

.ob

esity

act

ion.

org/

wp

-con

tent

/up

loa

ds/

Ob

esity

Act

ion_

Portr

aits

_-37

5.jp

g©

Obe

sity

Actio

n Co

aliti

on

COMMUNICATION: USING THE 5AS

Ask Permission to discuss weight

Explore readiness for

change

Assess BMI, waist circumference, obesity stage

Explore drivers + complications

of excess weight

AdviseHealth risks of

obesity + benefits of weight loss

Long-term strategy + treatment

options

Agree Expectations + targets

Behavioral changes

Assist Identify barriers to optimal

healthCreate follow-

up plan

Vallis M, et al. Can Fam Physician 2013 59:27-31.

ASKING WITH PEOPLE FIRST LANGUAGE

• People First: Remove the Word “Obese” from Your Dictionary and Language

• Avoid labeling it = bias and discrimination

http://stopobesityalliance.org/wp-content/themes/stopobesityalliance/pdfs/STOP-Provider-Discussion-Tool.pdf

LANGUAGE

Suggestions From Stop Obesity Alliance• Would it be okay if we discussed your weight?”• “Our measurement indicate that you are carrying excess

weight. This can be unhealthy for you and strain your body. If you’re interested we can talk about creating a plan of action together.”

http://stopobesityalliance.org/wp-content/themes/stopobesityalliance/pdfs/STOP-Provider-Discussion-Tool.pdf

EVALUATION PARAMETERSHistory: weight, activity, nutrition, family

• Complete blood count (CBC), fasting lipid panel, fasting glucose, HbA1c, liver function tests, vitamin D, thyroid stimulating hormone (TSH)

Laboratory studies

• Examples: sleep apnea, depression

Assess + treat obesity-related comorbidities

• Measure weight + height to calculate BMI • Waist circumference for patients w/ BMI >25kg/m2

• Blood pressure

Physical exam

Jensen MD, et al. Circulation 2014;129:S102-S138; Garvey WT, et al. Endocr Pract 2016;22 Suppl 3:1-203

PAST MEDICAL HISTORY + DIAGNOSTICS

Sleep Apnea: intermittent use of CPAP

GERD: treated with protonix

Osteoarthritis both knees: takes intermittent ibuprofen

Reproductive barrier: IUD

Mild depression and anxiety: treated successfully with citalopram

ETOH: drinks socially—1 glass of wine/week. No illicit drugs.

No history of seizures, hypertension, heart disease, or pancreatitis

BMI 29 kg/m2

CMP, CBC,TSH noncontributory

TC= 245

LDL = 134

TG = 173

HgbA1C = 5.8

PHQ9 = 4

BMI, body mass index; CMP, comprehensive metabolic panel; CBC, complete blood count; TSH, thyroid stimulating hormone; TC, total cholesterol; LDL, low-density lipoprotein; TG, triglycerides; HbA1c, glycated hemoglobin; PHQ9, Patient Health Questionnaire

PAMELA’S PERSPECTIVE

I’ve tried to lose weight many, many times—at

least 6 or 7. Sometimes I do lose weight, but I always

gain it back again. I’m getting real frustrated.

I’ve been overweight since I was 17. I’m always thinking about food, especially sweets and snacks. I find it hard to curb my cravings—instead of eating only a few chips, I usually end up eating the

whole bag.

© Obesity Action Coalition

EVALUATION SUMMARY

Next steps?

Weight gain Regain

CravingsPrediabetes

DepressionGERD

Osteoarthritis

GUIDELINE RECOMMENDATIONS Best Practice Strategies

GUIDELINE RECOMMENDATIONS

Similarities1-3

Individualized eating plans

Counseling patients to increase physical activity

Behavioral interventions

Medication may be appropriate for some patients

Referral to an obesity specialist or surgery may be appropriate

New Focus

Differences1

Endocrine Society paradigm shift toward pharmacologic therapy over no therapy at all for patients:

With a history of unsuccessful weight lost and maintenance

Who meet label indications

1. Apovian CM, et al. J Clin Endocrinol Metab 2015;100:342-62.2. Garvey WT, et al. Endocr Pract 2016;22 Suppl 3:1-203.3. Jensen MD, et al. Circulation 2014;129:S102-S138

THERAPEUTIC GOALS

Weight loss of 5%-10% of body

weight

Reduce obesity-associated

complications within 6 months

Improve patient health and

quality of life

Jensen MD, et al. Circulation 2014;129:S102-S138; Garvey WT, et al. Endocr Pract 2016;22 Suppl 3:1-203.;Yanovski SZ, et al. JAMA 2014;311:74-86; Apovian CM, et al. J Clin Endocrinol Metab 2015;100:342-62

Reduces sleep apnea, depression

Improves physical function

Reduces CVD risk factorsPrevents/delays T2DMImproves osteoarthritis

CLINICAL VIGNETTE: EVIDENCE BASED MANAGEMENT STRATEGIES

GUIDELINE-RECOMMENDED COMPREHENSIVE LIFESTYLE THERAPY*

Meal Plan Physical Activity BehaviorEnergy deficit ≥500kcal/day

Low-carbLow-fat

VolumetricHigh proteinVegetarian

MediterraneanDASH

Self-monitoringGoal settingEducation

Problem-solving strategies

Stimulus controlStress reduction

Counseling

Individualized

Increase leisure time physical

activity

Decrease sedentary time

↑ >150 mins/week on 3-5 separate days

Jensen MD, et al. Circulation 2014;129:S102-S138.Garvey WT, et al. Endocr Pract 2016;22 Suppl 3:1-203.Mozaffarian D. Circulation. 2016 Jan;133(2):187-225.

*Alone or with adjunctive therapies

Track progress:Daily activity logsPedometer logsTraining metrics

TECHNOLOGY TO SUPPORT WEIGHT LOSS

Applications to log nutrition and physical activity

Body-weight scales w/feedback

Wearable technology

Websites

Social media

Dobkin BH. Curr Opin Neurol 2013 26:602-608. Chou WY, et al. Transl Behav Med 2014 4:314-323. Jakicic J, et al. JAMA 2016;316:1161-1171

NEXT STEPS


Explore readiness to change

Continue lifestyle therapy

Agree on weight loss goal of 5-7% of

Pamela’s current weight

Consensus to discuss medication

options

Think:Motivational Interviewing & Shared Decision Making

WHICH THERAPY WOULD YOU RECOMMEND ADDING TO PAMELA’S

LIFESTYLE PLAN?

A. Orlistat B. Phentermine/topiramate ER (Qsymia)C. Naltrexone/bupropion ER (Contrave)D. Phentermine E. Liraglutide (Saxenda)F. Lorcaserin (Belviq)

PHARMACOLOGIC THERAPYTherapy Options, Factors to Consider When Selecting Therapy, and Efficacy/Safety Evidence

FDA-APPROVED SHORT-TERM ANTI-OBESITY THERAPIES

https://dailymed.nlm.nih.gov/dailymed/index.cfm; Bray GA, et al. Circulation2012;125:1695-703Apovian CM, et al. J Clin Endocrinol Metab 2015;100:342-62

Generic Drug*

Dose Contraindications Side Effects

Phentermine 8mg-37.5mg Anxiety disorder, CVD, hypertension, MAO inhibitors, glaucoma, hyperthyroidism, seizures, pregnancy/breastfeeding, drug abuse history

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

Diethylpropion 25 mg or 75 mg, SR

Phendimetrazine 17.5-70 mg or 105 mg, SR

Benzphetamine 25-50 mg

*Mechanism of action = Sympathomimetic—noradrenergic causing appetite suppression

https://dailymed.nlm.nih.gov/dailymed/index.cfm

PHENTERMINE• US Drug Enforcement Agency scheduled drug

• Risk for addiction• Not indicated for long term use

• 13 weeks by label

Endocrine Society allows for possible long term use: No CVD No psychiatric/substance abuse history Has been informed about therapies that are approved

for long-term use Document off-label use in patient’s medical record No clinical significant increase in pulse/BP when taking

phentermine Demonstrates significant weight loss with phentermine Start at 7.5 or 15 mg/d—dose escalate if not achieving

significant weight loss Monitor monthly during dose escalation

Apovian CM, et al. J Clin Endocrinol Metab 2015;100:342-62

FDA-APPROVED ANTI-OBESITY THERAPIES

https://dailymed.nlm.nih.gov/dailymed/index.c

Generic Drug Mechanism of ActionOrlistat (oral) Pancreatic lipase inhibitor—impairs

gastrointestinal energy absorption, causing excretion of approximately 30% of ingested triglycerides in stool

Lorcaserin(oral)

Highly selective serotonergic 5-HT2C receptor agonist causing appetite suppression

Phentermine/ topiramate-ER (oral)

Noradrenergic + GABA-receptoractivator, kainite/AMPA glutamate receptor inhibitor causing appetite suppression

Liraglutide (subcutaneous injection)

GLP-1 receptor agonist

Naltrexone/bupropion ER (oral)

Opioid receptor antagonist; dopamine and noradrenaline reuptake inhibitor

LONG-TERM EFFICACY FOR ANTI-OBESITY MEDICATIONS

Therapy Length of Trial Total WeightLoss

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%

LeBlanc E, et al. Ann Intern Med 2011;155:434; Vilsbøll T, et al. BMJ 2012;344:d7771 ; Bray GA, et al. Lancet 2016;387:1947-56*Pi-Sunyer X, et al. New Engl J Med 2015; 373: 11-22

GENERAL CONSIDERATIONS IN PHARMACOLOGIC INITIATION

Apovian CM, et al. J Clin Endocrinol Metab 2015;100:342-62.

Pharmacologic interventions may be helpful as adjuvant therapy with lifestyle interventions for patients

with BMI ≥30 kg/m2 or ≥27 kg/m2 with comorbidities.

Different patients respond to different medications- If one option does not work, consider others

Discontinue medication in patients who do not respond with weight loss of at least 5% at 12 weeks

Avoid in pregnancy - Pregnancy tests at baseline- Consider a disclosure signature

5 STEP STRATEGY FOR THERAPY SELECTION

Safety

Co-morbidities

Patienthistory

Cost + insurance

Side effects


Dose Frequency

Efficacy Side Effects Contraindications

60 mg OTC

120 mg TID within 1 h of fat-containing meal

Mean weight loss ranged from 3.9%-10.2% at year 1 in 17 RCTs (120mg TID)

↓ BP, TC, LDL-C, fasting glucose at 1 year

Slows risk of progression to T2DM

Oily spotting, cramps, flatus with discharge, fecal urgency, fatty oily stool, increased defecation, fecalincontinence

Chronic malabsorption syndrome, pregnancy,breastfeeding, cholestasis, some medications (ex. warfarin, antiepileptic agents, levothyroxine, cyclosporine)

ORLISTAT

Practical Considerations

Consider fat-soluble multivitamin Limit fat intake to 30% of calories Counsel on risk of GI adverse events

LexicompBragg R, et al. J Am Assoc Nurse Pract 2016;28:107-15; Kahan S. Am J Manag Care. 2016;22:S186-S196

Dose Frequency Efficacy Contraindications Side Effects Initiate

treatment at 3.75 mg/23 mg for 2 weeks

Increase to 7.5 mg/46 mg

Escalate to 11.25mg/69mg for 2 weeks then to max 15 mg/92 mg

10% weight loss with treatment vs 2% placebo

Improved cardiometabolicmarkers

Reducedprogression to T2DM

Pregnancy and breastfeeding, hyperthyroidism, glaucoma, use of monoamine oxidase inhibitors

Paresthesiasdizziness, taste alterations,insomnia, constipation,dry mouth, elevation in heart rate, memory or cognitive changes

PHENTERMINE-TOPIRAMATE ER

Practical Considerations Titrate dose at initiation and discontinuation Drug Enforcement Agency Schedule IV drug Risk Evaluation and Mitigation Strategy Counsel about risk for mood disorders, suicidal thoughts Taper highest dose every other day for 1 week if

discontinuation is necessaryLexicompBragg R, et al. J Am Assoc Nurse Pract 2016;28:107-15; Kahan S. Am J Manag Care. 2016;22:S186-S196

Dose Frequency

Efficacy Contraindications Side Effects

Weekly titration by 0.6mg over 5 weeks to target dose of 3.0mg

Mean weight loss 9% at 1 year

Reduced progression to T2DM in patients with prediabetes

Reduced risk of weight regain at 1 year

Medullary thyroid cancer history, multipleendocrine neoplasia type 2 history, history of pancreatitis,pregnancy, breastfeeding

Nausea, vomiting, diarrhea, constipation, hypoglycemia in patients with T2DM, increased lipase, increased heart rate, pancreatitis

LIRAGLUTIDE

Practical Considerations Injectable administration FDA approved for use in adults with BMI > 30kg/m2 or BMI

> 27 kg/m2 with at least one complication. Risk Evaluation and Mitigation Strategy (medullary thyroid

carcinoma, acute pancreatitis)


Dose Frequency Efficacy Contraindications Side Effects

10 mg twice daily

ER 20mg daily

Average weight loss 8%-10%

Improvedcardiovascular risk factors

Improved HbA1c in patients with T2DM

Reduced risk of developing T2Dm in patients with prediabetes

Pregnancy, breastfeeding

Caution withserotoninergic agents (due to risk of serotonin syndrome)

Avoid in patients w/severe hepatic or renal insufficiency, valvular heart disease

Headache, dizziness, fatigue, nausea, dry mouth, cough, and constipation

Patients w/T2DM, back pain, cough, hypoglycemia

LORCASERIN

Practical Considerations Schedule IV Drug ER is slowly absorbed and lasts throughout the day Independent effect on lowering HgbA1c


Dose Frequency Efficacy Contraindications Side Effects

Initiate8mg/90mg x 1 week

Weekly escalation to target dose of 32mg/360 mg (2 tablets BID)

Weight loss of 8.2% vs 1.4% (placebo)

Improvedcardiometabolicparameters

Fewer cravings Lowered HbA1c

in patients with T2DM

Uncontrolled hypertension, seizure disorder, anorexia or bulimia, drug or alcohol withdrawal, chronic opioid use, monamine oxidase inhibitors

Nausea, constipation, headache, dizziness, vomiting, insomnia, dry mouth

Transient increase in blood pressure

NALTREXONE-BUPROPION ER

Practical Considerations Titrate dose on initiation Monitor blood pressure Monitor closely for depression


MONITORING PROGRESS

MEASURING SUCCESS

At week 16 (includes titration period) Pamela has lost 2% of her baseline weight and her HbA1c remains 5.8%.

What would be your next management step?

• Initiate 8mg/90mg x 1 week• Escalate to target dose of 32mg/360

mg• Weekly follow up monitoring

Begin therapy with naltrexone-bupropion

• ≥5% of baseline body weight at 3 months

Effective response to therapy

• 5%-10% overall reduction of risk for T2DM, HTN, CVD

Improvement in cardiovascular risk

markers

INEFFECTIVE RESPONSE TO THERAPY

If no clinical improvement after 12 weeks with one anti-obesity medication, consider:

Increasing anti-obesity medication dose, if applicable

Alternative anti-obesity medicationO

R

Bray GA, et al. Lancet 2016;387:1947-56. Apovian CM, et al. J Clin Endocrinol Metab 2015;100:342-62.

CONSIDERATIONS FOR SWITCHING PAMELA’S THERAPY

LORCASERIN? • No history of CVD but

borderline high LDL/TC• Caution w/SSRI• Monitor for depression

LIRAGLUTIDE?• HbA1c remains elevated• No family history of thyroid or

pancreatitis

MAINTAINING WEIGHT LOSS

1. Apovian CM, et al. J Clin Endocrinol Metab 2015;100:342-62.2. Thomas JG, et al. Am J Prev Med. 2014;46(1):17-23

Weight regain typically occurs when medication is stopped1

• Self-monitoring• Weight loss of >2kg in 4 weeks• Frequent/regular attendance at weight loss program• Self-belief that weight can be controlled

Successful weight maintenance includes:2

Maintaining weight loss is made difficult by the reduction in energy expenditure that weight loss induces

Adaptive responses to weigh

loss promotes

weight regain.

Fall in energy expenditure

Increase in appetite

Dysfunctional hormonal system

Physiology of Weight Regain

Repr

inte

d by

per

miss

ion,

Cop

yrig

ht C

lear

ance

Cen

ter,

Inc.

Apo

vian

CM

, et a

l. J

Clin

End

ocrin

ol M

etab

20

15;1

00:3

42-6

2

Apovian CM, et al. J Clin Endocrinol Metab 2015;100:342-62 Sumithran P, et al. New Engl J Med. 2011;365:1597-1604.

OBESITY SPECIALIST REFERRAL--CONSULTATION

Weight loss <5% at 3 months with approved

medication

Safety or tolerability issues

Patient-centered concerns

Apovian CM, et al. J Clin Endocrinol Metab 2015;100:342-62. Jensen MD, et al. Circulation 2014;129:S102-S138.

BARIATRIC SURGERY

Apovian CM, et al. J Clin Endocrinol Metab 2015;100:342-62 Rubino F, et al. Diab Care 2016;39:861-877

BMI ≥40 kg/m2 if surgical risk is acceptable

BMI ≥35 kg/m2 if >1 obesity-related disease

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

Inability to achieve + sustain healthy weight loss with prior weight loss efforts

PAMELA AT FOLLOW-UP

WITH LIRAGLUTIDE

She has visited 10 times in 6 months for intensive behavioral

therapy and monitoring.


AT FOLLOW-UP WITH LIRAGLUTIDE (CONT.)

Lost 8% baseline weight HbA1c = 5.4% Sleep apnea is minimal No longer requires ibuprofen for osteoarthritis Walking 10,000 steps/day, 5 days/week Hiking with friends on weekends Signed up for a charity 5K

Provider F/U Close follow-up Continue to prescribe medication with lifestyle Pregnancy prevention plan Close follow-up

KEY TAKE AWAYS

Adapted from http://www.obesitynetwork.ca/5As

Obesity is a chronic and often progressive condition

Obesity management is not about simply reducing numbers on the scale

Early intervention means addressing root causes and removing roadblocks

Success is different for every individual

A patient’s ‘best’ weight may never be an ‘ideal’ weight

NO SHAME, NO BLAME

REFERENCE SECTION

REFERENCES• 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.

• Bays HE, Seger JC, Primack C, McCarthy W, Long J, Schmidt SL, Daniel S, Wendt J, Horn DB, Westman EC: Obesity Algorithm, presented by the Obesity Medicine Association. www.obesityalgorithm.org. 2016-2017.Bragg R, Crannage E. Review of pharmacotherapy options for the management of obesity. J Am Assoc Nurse Pract. 2016;28(2):107-115.

• Bray GA, Fruhbeck G, Ryan DH, Wilding JP. Management of obesity. Lancet. 2016;387(10031):1947-1956.

• Bray GA, Ryan DH. Medical therapy for the patient with obesity. Circulation. 2012;125(13):1695-1703.

• Chou W-yS, Prestin A, Kunath S. Obesity in social media: a mixed methods analysis. Translational Behavioral Medicine. 2014;4(3):314-323.

• Dietrich MO, Horvath TL. Limitations in anti-obesity drug development: the critical role of hunger-promoting neurons. Nat Rev Drug Discov. 2012;11(9):675-691.

• Dobkin BH. Wearable motion sensors to continuously measure real-world physical activities. Current Opinion in Neurology. 2013;26(6):602-608.

• Flegal KM, Kruszon-Moran D, Carroll MD, et al. Trends in Obesity Among Adults in the United States, 2005 to 2014. JAMA. 2016;315(21):2284-2291.

• 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.

REFERENCES

• Fruh, S. (2017). Obesity: Risk factors, complications, and strategies for sustainable long‐term weight management. Journal of the American Association of Nurse Practitioners, 29(S1):S3-S14.

• Golden, A. (2017). Current pharmacotherapies for obesity: A practical perspective. Journal of the American Association of Nurse Practitioners, 29(S1):S43-S52.

• Golden A. Obesity. In A. Hollier (Ed.), Clinical Guidelines in Primary Care. pp. 281-285, 2016.• 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.

• 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.

• Kahan SK. Overweight and Obesity Management Strategies. Am J Manag Care 2016;22:S186-S196.• LeBlanc E, O’Connor E, 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(7):434

• 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.

• Mozaffarian D. Dietary and Policy Priorities for Cardiovascular Disease, Diabetes, and Obesity: A Comprehensive Review. Circulation. 2016;133(2):187-225.

• Murray S, Tulloch A, Gold MS, Avena NM. Hormonal and neural mechanisms of food reward, eating behaviour and obesity. Nat Rev Endocrinol. 2014;10(9):540-552.

REFERENCES• 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.• Ritten, A., & LaManna, J. (2017). Unmet needs in obesity management: From guidelines to clinic.

Journal of the American Association of Nurse Practitioners, 29(S1):S30-S42.• Rogge, M., & Gautam. B. (2017). Biology of obesity and weight regain: Implications for clinical

practice. Journal of the American Association of Nurse Practitioners, 29(S1):S15-S29.• Rubino F, Nathan D, 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(6):861-877.• Sumithran P, Prendergast LA, Delbridge E, et al. Long-Term Persistence of Hormonal Adaptations

to Weight Loss. New England Journal of Medicine. 2011;365(17):1597-1604.• Suzuki K, Jayasena CN, Bloom SR. Obesity and Appetite Control. Experimental Diabetes Research.

2012;2012:824305• Vallis M, Piccinini–Vallis H, Sharma AM, Freedhoff Y. Modified 5 As: Minimal intervention for obesity

counseling in primary care. Canadian Family Physician. 2013;59(1):27-31.• Vilsboll T, Christensen M, Junker AE, et al. Effects of glucagon-like peptide-1 receptor agonists on

weight loss: systematic review and meta-analyses of randomised controlled trials. BMJ. 2012;344:d7771.

• Yanovski SZ, Yanovski JA. Long-term drug treatment for obesity: a systematic and clinical review. JAMA. 2014;311(1):74-86.

the chronic disease of obesity in the u.s. · the chronic disease of obesity in the u.s. faculty....

Documents