Case 1. Relationship Between Fat Free Mass and 24-hour Energy Expenditure

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1 Difficult Cases of Obesity Management from Clinic Dan Bessesen, MD Professor of Medicine University of Colorado Chief of Endocrinology Denver Health Medical Center Case 1 43 year old woman is seen for treatment of hypertension, type 2 diabetes, hypertriglyceridemia and degenerative joint disease. She comes in today frustrated saying that she is eating very little and yet has gained another 5 lbs since her last visit 3 months ago. She says that she must have a problem with her metabolism. Is she right? What do you say to her? What tests should you do? Relationship Between Fat Free Mass and 24-hour Energy Expenditure Weyer C, IJO 23: Obesity is associated with increased food intake

2 Lichtman, NEJM 327:1893; 1992 But what do you say/do? Ask open ended questions. Avoid the temptation to give advice Listen, empathize Reflect Keep the ball in the patient s court Goal is to come up with a defined, specific measureable plan of action. Case 2 33 year old woman had lap band surgery 1 year ago. She lost 10% of her baseline weight and was frustrated with the surgical team. She did not follow up with them and regained 3% of her baseline weight back. She comes to your office for ongoing management of her hypertension. Why didn t she lose more weight? Do you have any thoughts about how you might help her lose more weight?

3 Lap Band Lap Band Case 2 The weight loss after Lap Band is much more dependent on follow up and band adjustment. Even so, some people do not lose that much weight. Failure to lose or regain after a lap band may represent mechanical failure. Options include: Return to surgical team for band adjustment Diagnostic study (EGD or UGI) Greater focus on her diet Pharmacotherapy Revision of the operation to a RYGB

4 Case 3 47 year old woman comes to see you as a new patient for help with her chronic health problems as well as concerns over her weight. Her BMI=32 kg/m 2. She has a history of hypothyroidism and after trying a variety of medications she has been taking Armour Thyroid at a dose of 2 gr/day. On exam her bp=143/88, her p=98 bpm, her skin is warm and dry, her thyroid is small and firm, she has a fine resting tremor. Case 3 Continued She states that when she was on LT4 she had problems losing weight and was always tired. Her labs show TSH<0.01, FT4=1.35 ( ), TT3=195 (90-180) Is there evidence that LT4 does not alleviate patients symptoms? Does T3+T4 work better than T4 alone? What do you do with this patient? Patients on LT4 complain about more symptoms than controls 961 patients on thyroid hormone matched to 1922 controls with other health problems. Answered a General Health Questionnaire and a Thyroid Symptom Questionnaire (TSQ) Roughly 60% response rate Thyroid patients complained of more fatigue (p<0.001), Weight gain (p<0.001), Aches and pains (p=0.002) and clumsiness (p=0.001) Saravanan P, Clin. Endocrinol (Oxf) 2002, Nov 57:577-85

5 Rat Data on Subject Escobar-Morreale, JCEM 2005 Aug 90: reviews studies in rats and humans Physiology of T4/T3 may be different in rats Tissue levels of T4 and T3 differ in different tissues Data suggests that neither T4 alone or T3 alone restores tissue levels of T4 and T3 in rats. T4 replacement doses that normalize serum TSH and T4 in rats do not normalize tissue T3 levels in some tissues. There is no Conclusive Evidence that T4+T3 is Better than T3 alone Meta-analysis of 11 studies involving 1216 patients Combination effects on quality of life Grozinsky-Glasberg S, JCEM 2006 Jul; 91: Combination effects on fatigue But what do you do? The ethical thing to do: Beneficence, Non- Maleficence, Autonomy, Informed consent. Over-replacement increases risk of atrial arrythmias and osteoporosis (in postmenopausal women), may increase thrombotic risk Blood levels of T3 related to time of T3 dosing Biological ratio of T4 to T3 secretion is 10:1-15:1, (Armour about 3:1)

6 Case 4 48 year old woman had RYGB surgery 16 years ago. Peak wt pre-operatively was 380 lbs. She lost 140 lbs and did well for 7 years but then developed a stricture which was dilated at another institution. Since then she has gradually gained weight and developed diabetes. Why did she regain the weight? What tests do you want to do? How does this surgery work? 1. Restrict gastric volume 2. Alter the vagus nerve 3. Exclude the stomach 4. Exclude the duodenum 5. Undigested food is exposed to the ileum Roux-en-Y Gastric Bypass

7 Gastric Bypass Staple Line Dehiscence Case 4 Failure to maintain weight loss can occur, but this surgery worked initially. Old procedure left pouch and stomach in continuity and dilation procedure could have broken down this anastamotic line. Test: UGI If there is an anastamotic failure then a re-operation/ revision may restore weight loss. Vertical, Banded Gastroplasty

8 Case 5 43 year old woman comes for follow up for her weight problem. She has been going to Weight Watchers and has been using phentermine and has been exercising for 45 minutes 4 times per week. She has lost 9% of her baseline body weight but has now plateaued and despite continued efforts is not losing any more weight and now has gained 2 lbs. She is frustrated with the lack of progress and doesn t understand how she could be regaining weight. What do you say to her? What should she do? The Body Responds to Over and Underfeeding in a Manner that Restores Weight Changes in Energy Expenditure Resulting From Altered Body Weight Leibel RL, NEJM 332: , 1995

9 Effects of Weight Gain or Loss on TEE and RMR Leibel RL, NEJM 332: , 1995 Changes in Energy Expenditure Resulting From Weight Loss Persist Over Time Examined energy expenditure in subjects who had lost >10% of baseline Weight and maintained the reduced state for > 1 year. Rosenbaum M, Am J Clin Nutr Oct;88(4): Why does EE go down? Lean body mass declines. Thyroid hormone goes down. Sympathetic nervous system activity declines. Absolute amount of physical activity probably does not decline, but energy cost declines. Energy efficiency of physical activity may increase. Leptin may counteract these effects.

10 But what do you say? Reflect what the patient just told you. Empathize how frustrating that must be. Explain the relevant biology. Review the original motivations for attempting weight loss. Review the positive steps they have taken. Ask what they want to do next. Fear of death is not sustainable.. Joy of life is sustainable.. Case 6 A 34 year old woman comes to see you with concerns over her weight. She has gained 10 lbs over the last year and now has a BMI=31 kg/ m 2 She says that your recommendation that she go to Weight Watchers was not helpful and she wants to try the on line HCG diet. She wants your opinion. What do you tell her?

11 The HCG diet Albert T. Simeons, 1954 rigorously defined 500 kcal diet plus daily IM injections of HCG 125 units 6/7 days x 8 wks, claimed reduced hunger and produced fat redistribution. Randomized controlled trial by W. Asher in AJCN in 1973 suggested efficacy. Became the most widely prescribed medication in the US for weight loss in the 1970 s. A number of trials done testing efficacy. Br J Clin Pharmacol 1995, 40:237-43: Meta-Analysis of HCG Diet Br J Clin Pharmacol 1995, 40:237-43: We conclude that there is no scientific evidence that HCG causes weight-loss, a redistribution of fat, staves off hunger or induces a feeling of well-being. Therefore the use of HCG should be regarded as an inappropriate therapy for weight reduction Pharmacists and physicians should be alert on the use of HCG for Simeons therapy. The results of this meta-analysis supports a firm standpoint against this improper indication. Restraints on physicians practicing this therapy can be based on our findings.

12 HCG History of Reguation 1975: FDA requires labeling and advertising of HCG has not been demonstrated to be effective adjunctive therapy in the treatment of obesity FTC orders Simeon Weight Loss Clinics Foundation to stop claiming that their programs were safe and effective Kevin Trudeau writes Weight loss cure they don t want you to know about FTC charges result in $37million fine. But what do you say to her? This is a bad idea, you could hurt yourself. It probably won t hurt you, but I don t think that this product will help you, I think you are wasting your money. You will likely lose weight if you follow the diet. The risk is probably low. I agree with you that losing weight is a good idea. Take an MVI and Ca, we can follow your K and weight. Give it a try and let s see if it works for you. Other patients of mine have done well on this. Case 7 42 year old man had gastric bypass surgery 3 years ago. His peak pre-operative weight was 345 lbs. His weight nadir was 223 lbs and occurred 18 months post-operatively Since then his weight has gradually increased such that his current weight is 241 lbs. He is extremely worried, thinks the surgery has failed. What is likely going on? What do you tell him?

13 Weight Loss by Treatment Group in the Swedish Obese Subjects Study (SOS) Sjostrom L NEJM 2007: Weight Regain After Gastric Bypass Obesity Surg 18: , 2008 Prospective study of 782 GBPS patients form one institution Weight nadir occurred at an average of 18 months 50% of patients experienced some regain Average regain was about 8% Regain and surgical failure were higher in the super-obese Case 7 Continued He goes back to see the nutritionist and begins to work on his diet. He increases his habitual levels of physical activity and his weight stabilizes. However 2 years later (5 years post-operative) he returns and his weight is 290 lbs (pre-op weight was 345 lbs) and his diabetes is back. He is on metformin, insulin and glyburide. His hypertension is also worse and he is on lisinopril and atenolol. He is depressed and wonders what can be done.

14 Case 7 What is causing this weight regain? Behavioral Factors Alcohol or drug use Depression Decreased Self Monitoring What do you suggest? Intensification of dietary treatment (Obesity Surgery 2010, 20: )? Meal replacements? Intensification of physical activity? Medications: That May Increase Weight Anti-diabetic medications Sulfonylureas Insulin TZDs Mood Stabilizers, antipsychotics Birth Control Medications: Depo Provera Glucocorticoids: Prednisone What to do About These Medications Be aware of weight when the medication is started, have the patient weigh and have a plan if weight goes up. Choose a different medication that does not cause weight gain Choose a lower dose Weigh risks and benefits of this medication

15 Medications? Phentermine: mg/d, controlled HTN relative contraindication Xenical: mg Obesity Surgery 12: report of orlistat use with gastric band. No reports with gastric bypass Less side effects because smaller meals Bariatric Surgery Resources American Society for Bariatric Surgery International Bariatric Surgery Registry (IBSR) International Federation for the Surgery of Obesity online.com/ifso Betsy Lehman Center for Patient Safety and Medical Error Reduction: Expert Panel on Weight Loss Surgery Bariatric Surgical Guidelines American Association of Clinical Endocrinologists/the Obesity Society/ American Society for Metabolic and Bariatric Surgery Evidence based A-D recommendations 164 recommendations 777 references 83 pages long