ACHIEVING HEALTH: AGENDA: Achieving Health: A Look at Your Weight Management Options

Transcription

1 ACHIEVING HEALTH: A Look at Your Weight Management Options Achieving Health: A Look at Your Weight Management Options AGENDA: Achieving Health: A Look at Your Weight Management Options Topic 1 Behavior Modification: Changing the Direction Topic 2 Is Obesity Medication Right for Me? Topic 3 Breaking down the Surgical and Device Options 1

2 Achieving Health: A Look at Your Weight Management Options FACULTY: Christopher D. Still, DO, FACN, FACP (Moderator and Presenter) Deborah Bade Horn, DO, MPH, FOMA Samer G. Mattar, MD Behavioral Modification: Changing the Direction? Deborah Bade Horn DO MPH FOMA President, Obesity Medicine Association Medical Director, Center for Obesity Medicine & Metabolic Performance Clinical Asst. Professor, Department of Surgery University of Texas Medical School 2

3 Results Typical Obesity Remission Weight Maintenance & Metabolic Health Success & Treatment Contacts Wadden TA, et al. Obesity 2011: 19;

4 Success & Meal Replacement Use % Reduction in initial weight in ILI participants 2 MR/ wk* 1 MR Every other day* 5.5.9% % 5.7.2% % 1 MR/ day* 1-2 MRs/ day* 5.9.4% % 11.2% % *Calculated based on total annual reported usage. Wadden TA et al. Obesity 2009;17: Look AHEAD Year 1: Success and Physical Activity 0 Quartiles of minutes of weekly physical activity % Reduction in initial weight in ILI participants min 5.4.4% % 84.8 min min 57.1% % 5.9.0% % min 11.9% % 1st quartile 2nd quartile 3rd quartile 4th quartile Wadden TA. Obesity

5 Look AHEAD Year 4: Success and Physical Activity 4-5 Mets for 60-70min/d Or Approx 420min/wk Wadden TA. Obesity LookAHEAD: 10 year Physical Fitness Outcomes The Look AHEAD Research Group. Cardiovascular Effects of Intensive Lifestyle Intervention in Type 2 Diabetes. NEJM 2013;369(2):

6 Sedentary Time vs. Exercise What s in between? Owen N et al. Br J Sports Med 2014;48: Standing vs Sitting and All Cause Mortality Katzmarxyk. Med & Sci in Sports & Exerc. 46(5): , May

7 Don t just stand there or maybe - Do! Duvivier BMFM, Schaper NC, Bremers MA, van Crombrugge G, et al. (2013) PLoS ONE 8(2): e Br J Sports Med Feb;48(3):213-9 #4 Know your numbers: Physical Activity General Health Benefit Moderate aerobic exercise 150min/wk (About 30 minutes 5x/wk) + Strength Training Prevent Weight Gain & Active Weight Loss minutes per week minutes per week Prevention of Wt Regain minutes per week minutes per week Donnelly J. Am College Sports Med US Health and Human Services

8 #5 Know YOUR Numbers: Track the Data Accelerometers Smart Scales Nutritional electronic tracking Future platform connectivity Sleep Data Use Your Environment 8

9 Do it Together! Barriers Happen What s you back up plan? 9

10 #6 Rate your walkability How many places can you walk to accomplish a daily task? Can your patient create a more walkable life for yourself and your family? Dr. Horn s Neighborhood Walk Score 68 out of 100 Somewhat Walkable 10

11 A walkable life in a NON-walkable city School YMCA 2 Libraries 5 Parks Bank Traffic Court 2 Drug Stores Dry Cleaners Shopping Church 4 Grocery Stores Chocolate Bar Post Office Swimming Pool Farmer s Market >10 Restaurants Share Your Path Have Fun! 11

12 Thank You Achieving Health: A Look at Your Weight Management Options Is Obesity Medication Right for Me? Christopher D. Still, DO, FACN, FACP 12

13 Components of an Effective Obesity Management Program Surgery or Medications Behavior Modification Physical Activity Healthy Eating Pattern Wadden TA, Foster GD. Behavioral treatment of obesity. Med Clin North Am. 2000;84: Stumbo, PH, et. al. Dietary and medical therapy of obesity. Surg Clin N Am 85(2005) Why Use Medications? Medications help patients lose more weight when they are trying to diet. Medications can: reduce hunger, improve satisfaction with smaller meals, make patients resist tempting foods or foods they crave or, in the case of Xenical, help reinforce a low fat diet. 13

14 Why do we need drugs for weight loss? To help patients better adhere to their dietary plan, To help more patients achieve meaningful weight loss, To produce more weight loss so that health benefits will be greater, and To help patients sustain lost weight. General Principles of Choosing Weight Loss Medications ALL medications will be most effective when used in conjunction with a reduced calorie meal plan and increased physical activity The more you can be accountable, (food and exercise logs, daily weights, frequent follow ups*,etc), the greater weight loss. Not every medication will work on every patient Need to have REALISTIC expectations I have lost 35 pounds and hit a plateau I ve developed a tolerance to my medication and it doesn t work anymore 14

15 Phentermine/Topiramate ER (Qsymia) May help migraine headaches or chronic pain Produced most weight loss of all medications approved Has been used with patients with depression Pregnancy fetal toxicity Glaucoma HYPERthyroidism Uncontrolled blood pressure Heart problems (arrhythmias, etc) Capsules taken daily Produces ~ 12% weight loss after 1 year Lorcaserin (Belviq) Well tolerated; few side effects May help blood sugar control Should not increase blood pressure Caution with depression medications like fluoxetine (Prozac), paroxetine (Paxil), etc Tablet taken twice daily Produces ~7% weight loss after 1 year 15

16 Naltrexone SR/Bupropion SR (Contrave) Smoker Alcohol use Seizure disorder Uncontrolled blood pressure Opioid use oxycodone Tablets taken twice daily Produces ~ 9% weight loss at 1 year Liraglutide 3.0 mg Diabetic History of pancreatitis Thyroid cancer Kidney problems Injected daily Produces ~ 9% weight loss ay 1 year 16

17 Odds of Reducing Body Weight by % Categories at 1 Year with Adjunctive Medication Among those who Complete Treatment* % Phen/TPM 7.5/46 Phen/TPM 15/92 lorcaserin 10 BID bupropion/naltrexone 32/360 5% weight loss 10% weight loss liraglutide 3.0 *combined with lifestyle modification Choosing the Right Medication for the Right Patient. Do you have history of glaucoma? Qsymia and Contrave aren t the best choice for you Do you have kidney stones? Avoid Qsymia Do you have thyroid cancer or pancreatitis? Saxenda is not for you Do you take an SSRI for depression? Qysmia has been used in that patient population Do you need better blood sugar control? Saxenda and Belviq would be your best option Do you have insurance coverage? NO? Contrave has special pricing 17

18 Thank you! Breaking down the Surgical and Device Options Samer G. Mattar, MD, FACS Oregon Health & Science University 18

19 Prevalence of Self-Reported Obesity Among U.S. Adults by State and Territory, BRFSS, 2014 Prevalence estimates reflect BRFSS methodological changes started in These estimates should not be compared to prevalence estimates before *Sample size <50 or the relative standard error (dividing the standard error by the prevalence) 30%. Medical Complications of Obesity Pulmonary disease abnormal function obstructive sleep apnea hypoventilation syndrome Nonalcoholic fatty liver disease steatosis steatohepatitis cirrhosis Gall bladder disease Gynecologic abnormalities abnormal menses infertility polycystic ovarian syndrome Osteoarthritis Skin Gout Idiopathic intracranial hypertension Stroke Cataracts Coronary heart disease Diabetes Dyslipidemia Hypertension Severe pancreatitis Cancer breast, uterus, cervix colon, esophagus, pancreas kidney, prostate Phlebitis venous stasis 19

20 Operations for Morbid Obesity Gastric Restriction Combination Malabsorption Sleeve Gastrectomy Duodenal Switch RY-Gastric Bypass Gastric Banding BPD/DS Roux-en-Y Gastric Bypass Advantages Excellent excess weight loss (60-75%) Very good long-term results Solid food well tolerated Disadvantages Potential nutrient deficiencies 20

21 Adjustable Gastric Band Sleeve Gastrectomy 21

22 Appeal of Sleeve Gastrectomy Simpler operation Good safety profile. No foreign body No adjustments needed. No marginal ulcers. Mild lifelong malabsorption concerns. Satisfactory weight loss Comorbidity resolution rates equivalent to RYGB. But, shorter track record. COMPARISON OF BARIATRIC OPERATIONS n = 22,094 patients; 2738 citations Excess weight loss Operative mortality Resolution of diabetes Gastric Band Gastric Sleeve Gastric Bypass 47.5% 55% 62% 70% Duodenal Switch 0.1% 0.1% 0.5% 1.1% 47.8% 70% 83.6% 97.9% Buchwald, et al JAMA 2004;292: Brethauer et al. SOARD 2009 (4):

23 Drivers of Improved Outcomes in Bariatric Surgery Dedicated multi-disciplinary teams Comprehensive, holistic approach Improved patient selection. Improved patient evaluation. Improved patient optimization. Standardized operations. Accreditation UHC data: In-Hospital Mortality 4.5 Bariatric Surgery In-hospital Mortality by Year (N = 105,287) Deaths per 1, Year Nguyen et al. Surg Rel Obes Dis 2013; 9(2):

24 Contemporary Innovations (FDA +) Intra-gastric Balloons Contemporary Innovations (FDA+) V-Block 24

25 Intragastric Balloons Recently Approved by FDA for BMI with NO comorbidities Either swallowed or placed endoscopically. Maximum duration is 6 months. 6 mos = 25% Comorbidity improvement in 89%. Severe nausea and gastritis Ponce et al, SOARD 2015;9(2):290-5 Neuro-Regulation VBLOC Therapy FDA approved for patients with BMI induces intermittent intra-abdominal vagal blocking using high-frequency electrical energy. VBLOC delivers a charge 12 hours daily at a frequency of 5000Hz with an amplitude between 3 and 8mA at 5 minute intervals. EWL% at 18m = 24% Shikora et al J Obes 2015 in press 25

26 Contemporary Innovations Aspire Created by Segway inventor Just completed clinical trials. Designed to reduce absorption of 30% ingested calories. Expected to receive FDA approval this year. Sullivan S et al, Gastroenterology 2013;145: Contemporary Innovations Endoscopic surgery 26

27 Contemporary Innovations Surgical Single-Anastomosis Gastric Bypass Single-Anastomosis Duodenal Switch Single Anastomosis DS (SADS) Single Anastomosis Duodeno-Ileo Anastomosis (SADI) First described in 2007 Includes a SG (similar to DS) over 54F tube Preserves pylorus, but creates a loop anastomosis instead of a Roux-en-Y. 250 cm common channel Another modification is using a 40F tube and 300 cm common channel Sanchez-Pernault A et al, Obes Surg 2007;17:

28 Estimate of Bariatric Surgery Numbers Published July 2015 ASMBS total bariatric procedures numbers from based on the best estimation from available data (BOLD, ASC/MBSAQIP, National Inpatient Sample data and outpatient estimations) Total 158, , , , ,000 RNY 36.7% 37.5% 34.2% 26.8% 23.1% Band 35.4% 20.2% 14% 9.5% 5.7% Sleeve 17.8% 33% 42.1% 51.7% 53.8% BPD/DS 0.9% 1% 1% 0.4% 0.6% Revisions 6% 6% 6% 11.5% 13.6% Other 3.2% 2.3% 2.7% 0.1% 3.2% Balloons 700 V-Block 18 However, there is a Graveyard of Broken Promises 28

29 Summary Bariatric surgery has undergone remarkable evolution, since its origin in the 1950s. The popularity of WLS is due to the obesity epidemic, technical progress, and successful weight loss and safety outcomes. Our field is rich in future prospects in technological advances, and increased understanding of metabolic processes. 29