Disclosures. Objectives. Impact of Obesity in Primary Care Practice and What To Do About It. Intuitive Surgical. Consultant

Transcription

1 Disclosures Intuitive Surgical Consultant Stephen Archer, MD, FACS, FASMBS Director, Bariatric Surgery, St. Charles Medical Center Bend, OR Grand Rounds June 15, Objectives Impact of Obesity in Primary Care Practice and What To Do About It Recognize the role obesity plays in the pathogenesis and epidemiology of common problems such as diabetes, cancer, etc. Describe the impact of medical treatments for treating obesity including interactions and side effects. Review bariatric surgery indications and results with respect to common ailments in primary care practice Discuss prevention strategies

2 Prevalence of Self-Reported Obesity Among U.S. Adults by State and Territory, BRFSS, 2016 Obesity Trends 6 Trend In Obesity Rate in Oregon Oregon WIC Kids 2-4 y.o. Obesity Rates Diabetes Rates 8

3 Body Mass Index vs. Mortality Relative Mortality Rate Exponential Increase in Risk High risk Medium risk Low risk BMI How Did We Get Here? Source: NIH, NEJM, What is the furthest you can be from a Big Mac in the United States? How did we get here? We don t move as much 107 Miles

4 What Causes Obesity? Top 10 Family Practice Diagnoses Genetic predisposition Obesity gene Physiologic Hormones: ghrelin Decreased stretch receptors Loss of satiety mechanism (hypothalamus) Behavioral Family tradition Food to comfort child Addiction! Socioeconomic! Cultural views! Fast Food Nation! Psychosocial! Coping mechanism (i.e. stress, abuse)! Societal! Technology has decreased energy expenditure! Fast food--starting in school Hypertension ension Hyperlipidemia pidemia Diabetes es Back pain Anxiety y Obesity y Allergic rhinitis Reflux esophagitis Respiratory Problems Hypothyroidism 2018 Practice Fusion, Inc. 14 Co-morbidities of Obesity Spiritual Morbidity of Obesity Diabetes Heart disease Hypertension Hyperlipidemia Asthma Sleep apnea Gallstones Steatohepatitis Urinary incontinence Acid reflux Arthritis and gout Infertility and PCOS High risk pregnancy DVT/PE Depression Immobility Cancer Breast Colorectal Prostate Endometrial Accident prone Rashes All the medical stuff, but also Isolation We get sick when we are alone and we get better when connected. Food Addiction 16

5 Oxidative stress is increased in metabolic syndrome and type 2 diabetes mellitus (T2DM) and this appears to underlie the development of cardiovascular disease, T2DM and diabetic Pathway complications. to Increased T2DM oxidative stress appears to be a deleterious factor leading to insulin resistance, dyslipidemia, β-cell dysfunction, impaired glucose tolerance and ultimately leading to T2DM Two Hit Theory: Genes + Environment 1 2* Obesogenic Environment World J Diabetes Apr 15; 6(3): World J Diabetes Apr 15; 6(3): Closed Loop NAFLD and Metabolic Syndrome Adipocytes Not simply storage cells Metabolically active Pro-inflammatory World J Gastroenterol Sep 28; 23(36): The fields of immunology and metabolism are rapidly converging on adipose tissue. During obesity, many immune cells infiltrate or populate in adipose tissue and promote a low-grade chronic inflammation. Studies to date have suggested that perturbation of inflammation is critically linked to nutrient metabolic pathways and to obesity-associated complications such as insulin resistance and type 2 diabetes. Annu Rev Nutr Aug 21; 32:

6 Treatment of Obesity When you treat obesity you are treating the underlying problem for the morbidities Relationship to food and life is fundamental Education for patients Advocacy for the public health Medications Surgery Orlistat (Xenical) Weight Loss Medications Lipase inhibitor, reduced absorption of fat by 30% Lorcaserin (Belviq), Stimulates 5-HT (serotonin) 2C receptors on anorectic POMC neurons close to fenfluramine, but not quite, decreased appetite, induces satiety Phentermine/Topiramate (Qsymia) Centrally acting appetite suppressant (phentermine) and increased energy utilization/inhibition of appetite Bupropion/Naltrexone (Contrave) Dopamine/norepi uptake inhibitor (stimulates POMC) + opioid receptor antagonist Liraglutide (Saxenda) GLP-1 agonist similar to other meds for T2D, induces satiety 21 Drugs. 2015; 75(9): Weight Loss Medications Medication Mechanism of Action Side Effects Interaction/Warnings Cost/month* Note An Aside Orlistat (Xenical) Lipase inhibitor, 30% less fat absorbed Diarrhea, oily stools, etc Avoid w cyclosporin, Add MVI $ Lorcaserin (Belviq) 5-HT (serotonin) 2C agonist, POMC neurons: anorexia/ satiety Phentermine/ Centrally acting Topiramate anorectic, increased (Qsymia) metabolism, satiety Buproprion/ Dop/NE uptake Naltrexone inhibitor (POMC) + (Contrave) opioid receptor agonist constipation, cough, dizziness, dry mouth, fatigue, nausea constipation, dizziness, dry mouth, taste changes, insomnia constipation, dizziness, dry mouth, headache, increased BP, tachycardia, liver damage Serotonin syndrome possible w other antidepressants? heart valve issues Avoid w glaucoma/ hyperthyroidism. Exacerbate HTN, mania, arrhythmias BIRTH DEFECTS Can t use w opioids, increased suicidal thoughts, avoid during etoh withdrawal $ Safe long term $ Safe long term, taper off prior to surgery, Controlled so monthly Rx. $250 Safe long term use, $ w coupon taper off. (components If emergency ordered separately surgery, fentanyl much less) must be used. Hypothalamic pro-opiomelanocortin piom (POMC) neurons promote satiety. Cannabinoid noid receptor 1 (CB1R) is critical for the central regulation of food intake.... The Pomc gene encodes both the anorexigenic peptide α-melanocyte-stimulating hormone, and the opioid peptide β-endorphin. Liraglutide (Saxenda) GLP-1 agonist, satiety and anorexia Injection only, nausea, diarrhea, constipation, and pain, headache, tachycardia possible role in pancreatitis $ FDA approved for 12 weeks only *Coupons often available from drug companies Hypothalamic pro-opiomelanocortin (POMC) neurons promote satiety 24

7 Probability of Achieving 5% Weight Loss and Possibility of Adverse Events Case For/Against Bariatric Surgery For Against Decreased mortality Expensive Resolution of diabetes, HTN Weight regain up to 20% etc Unpredictable results Improved quality of life Complications Halo effect in families Higher death rate from suicide Safe Addiction transfer <1% leak rate Significant weight gain occurs continuously in patients after reaching.5% mortality ty rate the nadir weight following gastric Best treatment t currently bypass. Despite this weight gain, the long-term mortality remains low at available 3.1%. JAMA Jun 14; 315(22): How Bariatric Surgery Works 28

8 Current Most-Used Bariatric Techniques Leak Test in the OR Leak is one of several possible life threatening complications Vertical Sleeve Gastrectomy Roux-en-Y Gastric Bypass Restrictive Remove approximately threefourths of the stomach Malabsorptive & Restrictive Bypass a portion of the small intestine and create a 15-30cc stomach pouch Long Term Results Gastric Bypass Very Low Calorie Diet +/- Behavioral Modification 5 Weight change (kg) Very-low-calorie diet Modified diet plus behavior therapy Very-low-calorie diet plus behavior therapy intervention Years after intervention 4 5

9 Oncologic Model of Obesity Care Neoadjuvent medical therapy prior to surgery? Surgery Adjuvent therapy at the nadir of weight loss or before? Summit BMC has added an internist to bariatric program Firefighting vs. Prevention I do obesity treatment. You probably do too. We are standing on the edge of a fire How do we prevent the fire? Obesity Prevention Real food not processed food, prepared at home Know your farmer and rancher or be your own farmer Advocate for better school lunches Zero sugar sweetened beverages (Believe that Big Food is out there) Less screen, more activity Be a part of civic discussions about city and neighborhood planning (Obesogenic environment) Teach children how to eat and cook and sleep Weight loss surgery in parent may prevent transmission of obesity to their children (Arch Surg. 2011;146(10): ) Be aware of adverse childhood events (ACE s) Obesity Prevention Epigenetics (selective gene expression) Avoid prenatal weight gain Pediatrics 118(6):e Encourage breast feeding (data is +/-) Support the gut biome Example growing body of evidence indicating that common food additives can push our microbial communities in unhealthy directions, not only potentially aiding the emergence of new pathogens, but also encouraging diseases like obesity, diabete and inflammatory bowel disease. EAT. MOVE. CONNECT

10 Thank you St. Charles is accredited by the American College of Surgeons for Bariatric Surgery Summit Weight Loss is the only comprehensive (med + surg) on this side of the Cascades This is my cell phone number: I will see any obese patient for any reason, regardless of issue, regardless of what operation or where. Summit Weight Loss: Medical and Surgical Weight Management 37