Frustrating Plateaus & Post Operative Weight Gain

Transcription

1 Frustrating Plateaus & Post Operative Weight Gain Christopher Still, DO, FACN, FACP Director, Center for Nutrition & Weight Management & Geisinger Obesity Research Institute Geisinger Health Care System Did the PATIENT fail the surgery or did the SURGERY fail the patient 1

2 Most Common Bariatric Surgery Procedures Roux-en-Y Gastric Bypass (57%) Malabsorptive & Restrictive Bypass a portion of the small intestine and create a 15-30cc stomach pouch Adjustable Gastric Banding (37%) Restrictive Place implantable device around upper most part of stomach Sleeve Gastrectomy (6%) Restrictive Resect approximately three-fourths of the stomach 260,000 procedures annually, 90% laparoscopic Weight Regain Following Surgery: NOT uncommon A weight gain of % from their lowest weight is common and patients should be prepared Usually occurs after ~ 12 months of surgery Continued accountability and follow-up provides greater chance for early intervention. Usually diagnose problem by history /weight graph 2

3 SS 57 year old female PMH DM, HTN, OSA and depression s/p lap gastric bypass November, 2002 Uneventful post operative course with weight loss of 76% of EBW at 2 years. SS Presents for yearly check up with 42 pound weight gain over the past 8 months. 3

4 Graph of 42 Pound Weight Gain 45 year old female MJ PMH DM, OSA, HTN, Depression, NSH S/P Lap RYGB 2002 with uneventful postoperative course Presents with 80 pound weight Gain over last 7 months. 4

5 MJ Recent evaluation in ED for severe epigastric pain and reflux symptoms No showed last appt (too embarrassed to come) MJ 5

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7 Depression Anatomical Defect G-G fistula Dilated anastomosis Dietary Intake Eating Pattern Composition WEIGHT Metabolism RMR Medications Exercise Time Compliance Depression Anatomical Defect G-G fistula Dilated anastomosis Dietary Intake Eating Pattern Composition WEIGHT Metabolism RMR Medications Exercise Time Compliance 7

8 Gastro-Gastro Fistula Not that common More rapid weight gain S/S of esophageal reflux common DX: UGI/ CT scan with oral contrast MJ 8

9 Depression Anatomical Defect G-G fistula Dilated anastomosis Dietary Intake Eating Pattern Composition WEIGHT Metabolism RMR Medications Exercise Time Compliance Dietary Indiscretion Most Common cause of weight re-gain following bariatric surgery Usually occurs ~ months after surgery Change from 2 to 3 meals per day to more of a grazing pattern Macronutrient composition changes from protein to more carbohydrates Soft calories predominate Small bowel adaptation 9

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11 Depression Anatomical Defect G-G fistula Dilated anastomosis Dietary Intake Eating Pattern Composition WEIGHT Metabolism RMR Medications Exercise Time Compliance Physical Activity / Energy Expenditure Decrease in muscle mass following rapid weight loss Decrease in REE Decrease in physical activity 11

12 Depression Anatomical Defect G-G fistula Dilated anastomosis Dietary Intake Eating Pattern Composition WEIGHT Metabolism RMR Medications Exercise Time Compliance Depression after Bariatric Surgery Not uncommon Often patients self medicate with food Grazing eating pattern with increase CHO consumption Screen with objective depression inventory Avoid weight stimulating medications Encourage support group participation Break grazing cycle with short term liquid diet 12

13 Depression Anatomical Defect G-G fistula Dilated anastomosis Dietary Intake Eating Pattern Composition WEIGHT Metabolism RMR Medications Exercise Time Compliance Prescription Medications that May Promote Weight Gain Antidiabetics Antipsychotics Antidepressants Antiepileptics Steroids Antihistamines 13

14 Depression Anatomical Defect G-G fistula Dilated anastomosis Dietary Intake Eating Pattern Composition WEIGHT Metabolism RMR Medications Genetics Microbiota Int. Perm. Exercise Time Compliance Correlation of excess weight loss with number of obesity alleles 14

15 Gut Microbiota and Geight Gain in Humans Future Microbiol Jan;7(1): The relationship between gut microbiota and weight gain in humans. Angelakis E, Armougom F, Million M, Raoult D. Source Unité des Rickettsies, URMITE -CNRS UMR 6236 IRD 198, IFR 48, Université de la Méditerranée, 27 Bd Jean Moulin, Marseille Cedex 05, France. Abstract The human gut microbiota is a metabolic organ that is determined by a dynamic process of selection and competition. Age, dietary habits and geographical origin of people have an important impact on the intestinal microbiota. The role of the microbiota is still largely unknown, but the bacteria of the gut flora do contribute enzymes that are absent in humans and play an essential role in the catabolism of dietary fibers. Germ-free mice provide a complementary approach for characterizing the properties of the human gut microbiota. Recently, microbial changes in the human gut were proposed to be one of the possible causes of obesity. This review summarizes the latest research on the association between microbial ecology and host weight. Intestinal Permeability & Obesity JPEN J Parenter Enteral Nutr Sep;35(5 Suppl):14S-20S. Epub 2011 Aug 1. Intestinal permeability, obesity-induced inflammation, and liver injury. Frazier TH, DiBaise JK, McClain CJ. Source Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Louisville School of Medicine, Louisville, Kentucky 40202, USA. thfraz01@louisville.edu Abstract Obesity and its metabolic complications are major health problems in the United States and worldwide, and increasing evidence implicates the microbiota in these important health issues. Indeed, it appears that the microbiota function much like a metabolic "organ," influencing nutrient acquisition, energy homeostasis, and, ultimately, the control of body weight. Moreover, alterations in gut microbiota, increased intestinal permeability, and metabolic endotoxemia likely play a role in the development of a chronic low-grade inflammatory state in the host that contributes to the development of obesity and associated chronic metabolic diseases such as nonalcoholic fatty liver disease. Supporting these concepts are the observations that increased gut permeability, low-grade endotoxemia, and fatty liver are observed in animal models of obesity caused by either high-fat or highfructose feeding. Consistent with these observations, germ-free mice are protected from obesity and many forms of liver injury. Last, many agents that affect gut flora/permeability, such as probiotics/prebiotics, also appear to affect obesity and certain forms of liver injury in animal model systems. Here the authors review the role of the gut microbiota and metabolic endotoxemia-induced inflammation in the development of obesity and liver injury, with special reference to the intensive care unit setting. 15

16 Treatment Plan To consider UGI to evaluate neo-stomach, G-G fistula, and anastomosis. Break CHO cycle with 2 week liquid diet and again introduce protein, vegetables and fruits while limiting soft CHO calories Screen for depression // Review medications Water intake Weekly weigh-ins Encourage re-enrollment in Getting back on track* support groups Consider appetite suppressant medication Obesity Medications Under FDA Review Status At-a-Glance Belviq Qsymia Contrave Arena Pharmaceuticals Lorcaserin October 23, 2010 Denied FDA Advisory Board May 10, 2012 Approved FDA Advisory Board Vivus, Inc. Phentermine and topiramate February 22, 2012 Approved FDA Advisory Board July 17, 2012 FDA APPROVAL Orexigen Therapuetics Bupropion and naltrexone February 1, 2011 Denied FDA Advisory Board 2014 PDUFA June 27, 2012 FDA APPROVAL PDUFA = Prescription Drug User Fee Act Authorizes FDA to collect fees from companies that produce certain human drug and biological products. Since the passage of PDUFA, user fees have played an important role in expediting the drug approval process

17 Antiobesity Drugs Recently FDA Reviewed, Rejected, or Approved: Qsymia Powell AG, Apovian CM, Aronne LJ. Clin Pharmacol Ther Jul;90(1): Expected Weight Loss with Currently Approved and Investigational Drugs Qsymia Contrave Belviq Powell AG, Apovian CM, Aronne LJ. Clin Pharmacol Ther Jul;90(1):

18 CONCLUSION Weight re-gain is common and should be expected Education PRE-operatively that regular follow up will decrease risk of weight regain Weekly weigh-ins Encourage support groups* Encourage adequate protein intake Encourage regular exercise Don t be judgmental 36 18