Thinking Like an Obesity Physician: Nutrition and Weight Loss Strategies for PCOS - ACOOG
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Nutrition and Weight Thinking Like an Loss Strategies for PCOS Obesity Physician: Nutrition and Weight Loss Strategies for PCOS Carolynn Francavilla Brown, MD, FOMA Family Medicine and Obesity Medicine Green Mountain Partners for Health and Colorado Weight Care DoctorFrancavilla@gmail.com
Goals Nutrition and Weight Loss Strategies in PCOS Feel comfortable offering brief but focused nutrition counseling to women with PCOS Understand appropriate weight loss goals for PCOS Be aware of pros and cons of popular diet strategies
Obesity Treatment Pillars of Obesity Management What does an obesity physician do? Identify Underlying Causes of Obesity Utilize Medications Advise Exercise Nutrition Counseling Behavior Modification
Underlying Causes
Relationship of PCOS and Obesity
PCOS is a heterogenous disease state with
different phenotypes
PCOS has different criteria by different expert
groups
ACOG Practice Bulletin No. 194: Polycystic Ovary Syndrome.
(2018). Obstetrics & Gynecology, 131(6),158.
Underlying Causes
Relationship of PCOS and Obesity
Overweight or obesity affects approximately
60–80% of PCOS patients
Approximately 70% of women with PCOS have
insulin resistance
Women with PCOS who have obesity or are
lean both show increased incidence of insulin
resistance
Identifying insulin resistance: A1C, fasting
glucose, glucose tolerance test (75g 2 hour
glucose tolerance test), HOMA-IR (fasting
glucose to insulin ratio), acanthosis nigricans on
exam
R. Azziz, L. A. Sanchez, E. S. Knochenhauer et al., “Androgen excess in women: experience with over
1000 consecutive
patients,” Journal of Clinical Endocrinology and Metabolism, vol. 89, no. 2, pp. 453–462, 2004.
Deugarte, C., Bartolucci, A., & Azziz, R. (2005). Prevalence of insulin resistance in the polycystic ovary
syndrome using the homeostasis model assessment. Fertility and Sterility, 83(5), 1454–1460. doi:
10.1016/j.fertnstert.2004.11.070
Underlying Causes
Goals of Weight Loss in PCOS
Many women with PCOS have improvement in
cycles, fertility and insulin resistance from modest
weight loss, but not all.
What should be the weight loss goal?
5-10% weight loss
If symptoms have not been reduced with a 10%
weight loss, additional weight loss is unlikely to
improve symptoms and other treatment modalities
should be maximized.
Prevent weight gain for women at normal weight
with PCOS Guzick, D. S., Wing, R., Smith, D., Berga, S. L., & Winters, S. J. (1994). Endocrine consequences of weight
loss in obese, hyperandrogenic, anovulatory women. Fertility and Sterility, 61(4), 598–604. doi:
10.1016/s0015-0282(16)56632-1
Huber-Buchholz, M.-M. (1999). Restoration of Reproductive Potential by Lifestyle Modification in Obese
Polycystic Ovary Syndrome: Role of Insulin Sensitivity and Luteinizing Hormone. Journal of Clinical
Endocrinology & Metabolism, 84(4), 1470–1474. doi: 10.1210/jc.84.4.1470
Underlying Causes
Why is weight loss (and maintenance) so hard?
Adaptive thermogenesis
Ø Decreased energy expenditure with weight loss
Ø Most studies show it does not fully restore to normal with weight regain
Ø Maintenance of a 10% or greater reduction in body weight in lean or obese
individuals is accompanied by an approximate 20%-25% decline in 24-hour
energy expenditure
This decrease in weight maintenance calories is 10–15% below what is predicted
solely on the basis of alterations in fat and lean mass
Biggest Loser Study. Mean RMR after 6 years was ~500 kcal/d lower than expected
based on the measured body composition changes and the increased age of the
subjects
Increase appetite
Increased Ghrelin, PYY, CCK, Amylin (hunger signals) with weight loss=hunger which
resolves with weight loss
Leptin (fullness signal) decreases
It’s not WILL POWER!
Int J Obes (Lond). 2010 October ; 34(0 1): S47–S55. doi:10.1038/ijo.2010.184
Obesity (Silver Spring). 2016 August ; 24(8): 1612–1619. doi:10.1002/oby.21538.
Medications Anti-Obesity Medications Phentermine (and other sympathomimetic amines) Orlistat Naltrexone/Bupropion ER (Contrave) Phentermine/Topiramate ER (Belviq) Liraglutide (Saxenda) Current recommendations to use medications LONG TERM as needed Should achieve a 5% weight loss by 12 weeks of medication
Medications
Metformin
Not a first line for hirsutism, anovulation, or
fertility
Utilized frequently for treatment of insulin
resistance and obesity, so consider if
either of these is present
Helps insulin resistance, weight ovulation,
improvement of symptoms
Dose 1500-2000mg daily
Neil F. Goodman, Rhoda H. Cobin, Walter Futterweit, Jennifer
S. Glueck, Richard S. Legro, and Enrico Carmina (2015)
AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS,
AMERICAN COLLEGE OF ENDOCRINOLOGY, AND
ANDROGEN EXCESS AND PCOS SOCIETY DISEASE STATE
CLINICAL REVIEW: GUIDE TO THE BEST PRACTICES IN THE
EVALUATION AND TREATMENT OF POLYCYSTIC OVARY
SYNDROME - PART 2. Endocrine Practice: December 2015,
Exercise
Exercise and PCOS
Guidelines for everyone 150-300 minutes a week of
moderate intensity physical activity
Patients who lose weight and keep it off are
exercising and average of 60 minutes a day, with
the most common exercise being walking
Create an “Exercise Prescription”
Any movement is good for health
Physical Activity Guidelines for Americans, 2nd Editions. Accessed at:
https://health.gov/paguidelines/second-
edition/pdf/Physical_Activity_Guidelines_2nd_edition.pdf
National Weight Control Registry Retrieved from http://www.nwcr.ws/Research/default.htmNutrition General Approaches to Dietary Advice Ask permission to discuss weight -Consider if patient has or had an eating disorder (ED) -Screening tools- EDDS, EAT, QEWP-R, BEDS7. -“Are there times when you feel like you eat out of control?”-If concern for ED If present refer to therapist, psychiatrist or obesity specialist that you know is comfortable with ED.
Nutrition General Approaches to Dietary Advice Find out what they are currently eating -24 hour recall -“Typical day” -Food journal Why? -Low hanging fruit like sweet drinks, alcohol, snacks, sweets, fastfood, restaurant food -Preferences- eating pattern, homemade food, restaurant food, packaged food -Lack of patient confidence if you tell them to do what they are already doing -Already eating pretty healthy? Is there binge eating present? Do you need to consider a medication or step up care to someone else like and obesity physician or RD
Nutrition General Approaches to Dietary Advice What is a calorie?
Nutrition
There is no good evidence that one type of
diet is superior to another for women with
PCOSMediterranean Diet
Summary: pattern of eating high in fruits, vegetables, whole grains,
beans, nuts, and seeds, olive oil, and moderate wine consumption.
It generally includes low to moderate amounts of fish, poultry, and
dairy products, with little red meat.
Pros: Cons:
• Better studied than • No specific
most diets “Mediterranean Diet”,
• Improved overall really a pattern of
mortality, CVD, eating associated with
cancer, Alzheimer’s, health
Parkinsons • In of itself does not
lead to weight loss,
need calorie goal to
with it
Adherence to Mediterranean diet and health
status: meta-analysis.
Sofi. BMJ (Clinical research ed.) Volume: 337 (2008)
ISSN: 0959-8138 Online ISSN: 1756-1833Plant Based Diet
Summary: (Vegan, Lacto-Ovo Vegeterian, Lacto Vegeterian)
Avoidance of Beef, lamb, poultry, seafoods. May avoid eggs or
dairy.
Pros: Cons:
• Appears to be • Long-term effects of diet
cardio-protective are difficult to separate
• May reduce risk of from those associated
with a vegetarian diet
cancers
like regular exercise,
avoidance of tobacco
and alcohol products
• Without calorie or
macronutrient goals may
not lead to weight loss
• Many plant-based foods
favored by average
person are also high
glycemic (potato, rice,
pasta, chips, crackers,
Rao, V., & Al-Weshahy, A. (2008). Plant-based diets and control of
lipids and coronary heart disease risk. Current Atherosclerosis
tortillas)
Reports, 10(6), 478–485. doi: 10.1007/s11883-008-0075-2
• Deficiencies in b12, vit D
and omega 3s if not
supplementedKetogenic Diet
Summary: Diet very low in carbohydrates, leading body to burn fat
as a fuel source producing ketones as a result
Pros: Cons:
• Rules of diet are • Often high in saturated
clear- limit carbs to fat, red meat (though
20-40g daily does not have to be)
(depending on • Long term adherence
protocol) • Weigh regain when
• Getting into ketosis diet is stopped
suppresses
appetite making it
easier to stick to
• Improved insulin
resistance quicklyPaleolithic Diet
Summary: based upon presumed dietary pattern in the Paleolithic
Period excludes grains, legumes, dairy, and ultra-processed foods.
Pros: Cons:
• Limits processed • Lots of paleo “junk
food food” and processed
• Encourages food available now
vegetables and • Not calorie restricted-
fruit so doesn’t always lead
to weight lossMeal Replacement
Programs
Summary: (Optavia, Nutrisystem, Optifast, etc) Pre-made meals,
protein bars and shakes make up majority of calories
Pros: Cons:
• Strong structure • Transition to more “real
• Easy food” can be a
• High protein, challenge, can lead to
calorie controlled yo-yo dieting
• Weight loss very • Highly processed food
likely to occur if
program is followedIntermittent Fasting
Summary: Caloric intake is limited to part of the day. Recommend
fasts start at 14-16 hours and sometime extend to 72 or more hours.
Pros: Cons:
• Eating less often • Can worsen poor
exposes patient to eating patterns, over
less insulin eating in eating
• Appears to reduce window
diabetes, heart • Still need guidelines of
disease, cancer an what can be eaten
neurodegenerative
disease
• May limit total
calories eaten per
day
Cabo, R. D., & Mattson, M. P. (2019). Effects of
Intermittent Fasting on Health, Aging, and
Disease. New England Journal of Medicine, 381(26),
2541–2551. doi: 10.1056/nejmra1905136Nutrition
Nutrition Summary
What do these plans have in common?
o Increasing vegetables and produce
o Structure- reduce calories or
carbohydrates
o Decreasing processed foodsNutrition
If you have 5 minutes or less to discuss nutrition
The best diet for weight loss is the one a patient
will stick to!
What fits with the patient’s lifestyle, culture,
interests and experience
The physical and psychological tendencies
Plants are good for you!
But too much fruit does not help with weight
loss, eat more veggies- 1 serving of fruit a day
For most plans give a calorie goal- 1200 is a
reasonable target for most women, can use
an online calculator to help patients set a
goal Source:Bays HE, McCarthy W, Christensen S, Wells S, Long J, Shah
NN, Primack C. Obesity Algorithm eBook, presented by the
Obesity Medicine Association. www.obesityalgorithm.org. 2019.
https://obesitymedicine.org/obesity-algorithm/ (Accessed
January 28, 2020)Nutrition
If you have 5 minutes or less to discuss nutrition
Calorie Goal:Nutrition
If you have 5 minutes or less to discuss nutrition
Protein Fat Carbs
Bread
Meat Butter Grains
Egg White Egg yolk -Wheat
-Rice
Soy Fat on meat -Corn
Some dairy -Oats
Cheese
(greek yogurt,
Crackers
cottage Oils
Chips
cheese) Nuts
Potato
Protein shakes Avocado
Sweets
and bars Desserts
Fruit
VeggiesBehavior Change
General Approaches to Behavior Change
Stimulus Control: portion control, limiting
snacking/grazing, removing trigger foods
Cognitive Restructuring: realistic weight goals
and body image, change relationship with
foods, let go of all or nothing mentality
Self- Monitoring: logging (apps like
myfitnesspal or loseit, pen and paper)
Support/Accountability: therapist, obesity
physician, personal trainer, support group,
structured program (weight watchers, etc)
Source:Bays HE, McCarthy W, Christensen S, Wells S, Long J, Shah
NN, Primack C. Obesity Algorithm eBook, presented by the
Obesity Medicine Association. www.obesityalgorithm.org. 2019.
https://obesitymedicine.org/obesity-algorithm/ (Accessed
January 28, 2020)Bariatric Surgery
Bariatric Surgery Requirements
BMI ≥ 40, or more than 100 pounds overweight
BMI ≥ 35 and at least one or more obesity-
related co-morbidities such as type II
diabetes, hypertension, sleep apnea and
other respiratory disorders, non-alcoholic fatty
liver disease, osteoarthritis, lipid abnormalities,
gastrointestinal disorders, or heart disease.
Inability to achieve a healthy weight loss
sustained for a period of time with prior weight
loss efforts. (usually 3-6 months for insurance
purposes) Who is a Candidate for Bariatric Surgery?: Patients: ASMBS. (n.d.). Retrieved February 22, 2020,
from https://asmbs.org/patients/who-is-a-candidate-for-bariatric-surgery
Escobar-Morreale, H. F., Botella-Carretero, J. I., Álvarez-Blasco, F., Sancho, J., & Millán, J. L. S.
(2005). The Polycystic Ovary Syndrome Associated with Morbid Obesity May Resolve after
Weight Loss Induced by Bariatric Surgery. The Journal of Clinical Endocrinology &
Metabolism, 90(12), 6364–6369. doi: 10.1210/jc.2005-1490Billing
Billing for Obesity Counseling
Can add code 99401 for 15 minutes of
nutrition counseling for obesity in addition
to your E&M code for management at
visit
Modifier 25 on E&M Code (i.e. 99214)
Document what you spent the 15 minutes
counseling on
Some suggest a “separate note” to
document thisSummary Summary ✭60-80% of women with PCOS have overweight or obesity ✭Obesity is a risk factor for diabetes, heart disease, cancer and other disease states ✭Treatment of weight in women with PCOS can improve PCOS symptoms ✭A 5-10% weight loss often improves PCOS symptoms in addition to reducing disease risks from obesity ✭The best diet is the diet a patient can stick with!
You can also read
