Obesity Treatment. A Brief Overview. Presented by:

Transcription

1 Obesity Treatment A Brief Overview Presented by: Lana G. Nelson, DO, FACOS Medical Director of Metabolic and Bariatric Surgery Norman Regional Health System

2 Obesity Treatment Objectives Problem of obesity Causes of obesity Treatment options Clinicians role in addressing obesity

3 The Problem More than 30% of adults are overweight and another 30% are obese Obesity continues to rise- 50% obesity rate by 2030? Epidemic rates Not always recognized or acknowledged Projected that the generation being raised today may have a shorter lifespan than we do

4 Defining Obesity:The Body Mass Index

5 Obesity Prevalence 2014

6 Medical Impacts of Obesity Sleep apnea Asthma Dyspnea Infertility Menstral irregularities Polycystic ovaries Incontinence Impotence Cholelithiasis GERD/Reflux NASH Cirrhosis Cancer: Prostate Breast Uterine Cervical Colon Depression Anxiety CVA Intertrigo Panniculitis Cephalgia HTN LEE Heart disease Dyslipidemia Venous ulcers DVT/PE Diabetes Metabolic Syndrome Osteoarthritis Joint pain DDD Gout

7 Causes of Obesity-Behavioral Lack of willpower Excess eating Poor food choices Liquid calories Lack of exercise/physical activity

8 Causes of Obesity-Genetic Rare causes Common forms More than 30 genes identified Multiple variants Impacts co-morbidities Predisposition, not destiny

9 Causes of Obesity-Enviromental Food availability Food deserts Processed foods High calorie food and drinks Physical activity Sedentary jobs Eating schedules Sleep health Local stressors

10 Obesity and Ethnicity Obesity rates high in blacks (50% higher) Hispanics (21% higher) Mexican Americans Lower physical activity Difference in cultural norms Limited access to healthy foods Asians experience metabolic derangements at lower BMI

11 Oklahoma State Meal Fried okra, squash, cornbread, barbecue pork, biscuits, sausage and gravy, grits, corn, strawberries, chicken fried steak, pecan pie, and black-eyed peas.

12 Causes of Obesity-Medications Diabetes meds Psych agents Antipsychotics Anti-seizure meds Steroids Hormones Antihistamines Beta blockers

13 We need a new approach

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15 Treatment considerations BMI and treatment Diet, behavior, physical activity Medications With comorbidities Surgery - - Intragastric balloon or LAGB with comorbidities Intragastric balloon or others with comorbidities LAGB, RNY, LSG, BPDDS

16 Dietary Options: Induction and Maintenance VLCD/LCD Low fat Calorie restriction Flexitarian/Vegetarian/Plant-based Mediterranean

17 Short-term medications FDA-Approved Drug Mechanism of Action Comments Phentermine (Adipex, Suprenza) Noradrenaline/dopamine releasing stimulator Schedule IV drug Phendimetrazine (Bontril) Diethylproprion (Tenuate) Benzphetamine (Didrex) Noradrenaline/dopamine releasing stimulator Noradrenaline/dopamine releasing stimulator Noradrenaline/dopamine releasing stimulator Schedule IV drug Schedule III drug Schedule III drug

18 Long term medications FDA-Approved Drug Mechanism of Action Comments Orlistat (Xenical) (Alli OTC) Phentermine/Topiramate (Qysmia) Lorcaserin (Belviq) Bupropion/Naltrexone (Contrave) Approved for long-term use in 1999, Pancreatic lipase inhibitor blocks fat absoprtion Noradrenaline releasing + modulator of ɣ aminobutyric acid (GABA)/ carbonic anhydrase inhibition Selective 5-HT 2C receptor agonist Inhibitor of dopamine and noradrenaline reuptake + µ opiate antagonist Approved July 2012 Q and Me Patient support Approved June 2012 Believe Support Approved Sept 2014 Scale Down Program Liraglutide (Saxenda) GLP-1 agonist Approved December 2014 SaxendaCare

19 Weight loss from other meds Medication Indicated Uses Comments Metformin Type 2 diabetes PCOS Rare liver toxicity Sitagliptin (Januvia) Type 2 diabetes Decreases appetite Exenatide (Byetta) Type 2 diabetes Injectable Pramlintide (Symlin) Type 2 diabetes Injectable

20 Weight loss from other meds Medication Indicated Uses Comments Lisdexafetamine (Vyvanse) Metreleptin (Myalept) ADHD, BED Leptin disorder Injectable Bupropion Depression Avoid in bipolar disease Topiramate Zonisamide (Zonergan) Seizures, Migraines Mood disorders Seizures Mood disorders May produce neurological side effects Few studies Bupropion Depression Avoid in bipolar disease

21 Exercise Counseling Chronic exercise alters habits toward healthy fooddecreases appetite and calorie consumption Increases brown fat Enhances resting energy expenditure Lowers energy storage set point Decreases cardiovascular disease Increases insulin sensitivity Improves mood and energy

22 % Change % Change Aerobic Exercise Alone Results in Weight Loss: Midwest Exercise Trial Males Total Weight Fat Mass Fat-Free Mass Females Total Weight Fat Mass Fat-Free Mass +0.5 vs vs -5.2 kg Supervised 5 days a week/10 months Donnelly et al. Obesity (2013), E

23 Surgical Treatment of Obesity NIH guidelines FDA guidelines Insurance guidelines Endoscopic and laparoscopic therapies Multiple mechanisms of action

24 Contraindications to bariatric surgery High operative risk Active substance abuse Active nicotine abuse Untreated or uncontrolled psychiatric disease Inability to understand or comply with expected changes

25 Endoscopic Surgery Endoscopic sleeve Intragastric balloon Short term device Short term results Long term impact unknown Orbera and ReShape 8-10% of body weight loss $7000+

26 Laparoscopic Bariatric Surgery Gastric bypass, gastric sleeve, duodenal switch and Lap-band Indicated for BMI over 35 with co-morbidities, or over 40 Significant weight loss and reduction in cardiovascular risk factors Metabolic side effects Frequently covered by insurance, including Medicare Early intervention is best Investigational in BMI with diabetes

27 US Bariatric surgery trends Total 173, , , ,000 RNY 37.5% 34.2% 26.8% 23.1% Band 20.2% 14% 9.5% 5.7% Sleeve 33% 42.1% 51.7% 53.8% BPD DS 1% 1% 0.4% 0.6% Revision 6% 6% 11.5% 13.6% Other 2.3% 2.7% 0.1% 3.2%

28 Roux-en-Y Gastric Bypass

29 Roux-en-Y Gastric Bypass Advantages: Rapid, consistent weight loss Sustained weight loss Immediate impact on diabetes High improvement in obesity related health problems Long term data available Curbs hunger Disadvantages: Invasive Dumping syndrome Nutrition deficiencies Marginal ulcer No NSAID's

30 Gastric Sleeve

31 Gastric Sleeve Advantages: No re-rerouting No dumping syndrome Able to take NSAIDS No foreign material Curbs hunger May proceed to gastric bypass or DS if weight loss is inadequate Disadvantages: Not reversible May worsen reflux Medium term data

32 Adjustable Gastric Band

33 Adjustable Gastric Band Advantages: Reversible No Malabsorption Least invasive Outpatient procedure quicker return to work Plication improves wt loss Disadvantages: Higher maintenance Possible higher cost May worsen reflux or dilate esophagus Possibility of re-operation: slip, erosion, leak, flipped port Weight loss variable More effective for lower BMI

34 Duodenal Switch/SIPS

35 Duodenal Switch/SIPS Advantages: Best weight loss Best comorbidity resolution No marginal ulcers Able to continue NSAIDS No dumping Disadvantages: Higher malabsorption- esp fat soluble More BMs and Flatus Technically more difficult Higher initial morbidity/mortality Higher BMI pts/severe DM Follow up most important- need reliable pt

36 Risk of Weight Loss Surgery Early: Death DVT/PE Bleeding/transfusion Injury to adjacent organs Pneumonia Atalectasis Infection Leakage/perforation Obstruction/blockage Late: Hypoglycemia Nutritional deficiencies Osteopenia/porosis Transfer addiction Suicide Hernia formation Need for additional surgery Marginal Ulcer formation Stricture

37 Procedure Comparison SIPS Bypass Sleeve Adjustable Band Consistent weight loss Yes Yes Yes Variable NSAID Yes No Yes Yes Controls hunger Yes Yes Yes Variable Reversible No Yes No Yes Diabetes improvement Yes Yes Yes Variable Improves reflux Variable Yes Variable Variable

38 Early Post-operative Medications Crushable, liquid, and non ER/SR Rapid adjustment of DM meds- use metformin, insulin, and ultimately incretins Avoid sulfonyureas and meglitinides Continue B blockers, reduced dose and IR Continue statins

39 Long term monitoring Monitor labs annually for mal-absorptive (CBC, CMP, Prealbumin, Iron/Ferritin, B12/Folate, Vit D/iPTH, selectively A1C, zinc, copper, lipids, thiamine, Vit A Bone density scan 2 years post op for malabsorptive Check with bariatric surgeon before stopping supplements Be suspicious of abominal complaints Address weight gain quickly and agressively

40 Routine vitamins SIPS Bypass Sleeve Adjustable Band MVI x2 x2 x2 x1 B Complex Yes Yes Yes No Calcium Citrate Yes Yes Yes Variable B12 Yes Yes Yes No Vitamin D ADEK PRN PRN PRN Iron Yes Yes No No

41 Pregnancy after Weight Loss Surgery Safer when mom is metabolically healthier Weight loss and nutritional intake have stabilized Consider nutrition labs prior to conception Nutrition counseling At least 18 months after surgery

42 Clinicians Role Recognize the problem Avoid discrimination Reinforce need for change Enable patients who want to change Monitor progress Keep patients accountable Provide positive reinforcement Be an example

43 Obesity is a complex disease Multiple contributors to obesity: physiological, environmental, genetic, behavioral, psychological, medications Multi-modal treatment options: diet therapy, medication, behavior modification, lifestyle intervention, exercise counseling, surgery Requires multidisciplinary evaluation and treatment No one therapy is effective for all, and many may require combination therapy

44 Questions?