Treatment of Obesity SAJIDA AHAD MERCY GENERAL SURGERY

Treatment of Obesity SAJIDA AHAD MERCY GENERAL SURGERY

Objectives 1. Learn classification and evaluation of overweight and obese patient 2. Discuss impact of voluntary weight loss on morbidity and mortality 3. Review resources for treatment of obesity in primary care setting 4. Update on bariatric surgery

Why care about obesity? Obesity is a global public health concern Prevalence of obesity in the United States: 35% among men and 40% among women Compared to 25 years ago when less than 15% of the nation was considered obese The obesity epidemic has placed an economic burden on the US health care system

In 2013, obesity was officially recognized as a disease state by the American Medical Association World Health Organization (WHO) defines body mass index (BMI)as follows Normal = 18.5 to 24.9 Overweight =25 to 29.9 Obese >30 class I =30 to 34.9 class II =35 to 39.9 class III = 40 and above

Classification and evaluation of overweight and obese patients Clinical classification Size and number of fat cells In adults, upper limits of the total of normal fat cells range from 40-60 billion The number of fact cell increase most rapidly during late childhood and puberty The number of fat cells can increase 3-5 fold with obesity occurs in childhood or adolescence Hypertrophic obesity Large fat cells correlate with android or truncal fat distribution This condition is often associated with metabolic disorders such as glucose intolerance, dyslipidemia, hypertension and coronary artery disease

Fat distribution Fat distribution is important because increased visceral fat predict the development of health risks better than total body fat Waist circumference CT MRI

Waist circumference(wc) WC has been shown to be a strong correlate of intra-abdominal adipose tissue in diverse race/ethnic groups WC is very strongly related to total adiposity and Visceral adiposity Visceral fat is associated with many metabolic risk factors, metabolic syndrome, diabetes, and CAD cutoff values for WC (90 cm for men and 83 cm for women) that are equivalent to a BMI of 25 kg/m2 might represent appropriate action levels for counseling patients to limit further weight gain

Natural history of obesity Individuals can become overweight at any age One third of the overweight adults do so before age 20 Predictors of weight gain Incidence of diabetic mother R mother who smoked Overweight parents Overweight in childhood Lower education or income group Cessation of smoking Sedentary lifestyle Low metabolic rate Lack of maternal knowledge of child s sweets eating habits Recent marriage Multiple births

Cost of obesity The economic cost of obesity The cost-effectiveness of treatment modalities

Economic cost of obesity Direct Medical Cost -direct treatment of obesity and related disease e.g. DM and HTN -include medications and surgical procedures Direct Non Medical Cost -expense of health education -expense of maintaining healthy life style -preventing obesity -not paid for by healthcare systems Indirect Cost -time lost from employment -time lost by family and friends

Cost of Obesity (contd) In USA, estimated cost of obesity ranges from $26.6 to $ 70 Billion Upto 7 % of annual healthcare expenditures Majority of the cost is treating obesity related conditions rather than obesity itself Cost to employers Medical charges for obese employees 69% higher than non obese employees Obese employees use twice as many sick leave days as normal weight employees Cost to individuals Shorter life expectancy Lower health related quality of life Cost of weigh management and control($66 billion market)

Cost effectiveness of obesity interventions A physician weight loss advice is associated with both fewer calories and fat intake and more exercise to lose weight Weigh WatchersTM might be cost-effective because of its demonstrated effectiveness and the moderate cost Medically supervised programs are expensive, but achieve more weight loss than Weight Watchers in the best scenario Although there is insufficient evidence for the effectiveness of weight loss of inexpensive self-help programs and Internet-based programs, they are potentially cost-effective if the weight loss goal can be achieved

Voluntary weight loss voluntary weight loss is considered central to the clinical and public health response to prevent obesity Barriers 1. Perceived ineffective 2. Epidemiological concern with increased mortality 3. Broad ramifications more than a 1/3 adults and more than 2/3 obese adults are trying to lose weight at any given time huge potential of interventions to positively affect health or, waste resources

Strategies for voluntary weight loss used by patients most people have a weight loss goal of <10 kg, but about one-fourth would like to lose 15 kg or more only one-fifth report the recommended combination of eating fewer calories and exercising >150 min/wk other methods used skipping meals (17%) attending special programs (7%) eating special products (22%) taking supplements or diet pills (14%) fasting(3%) purging (3%)

structured weight loss programs advantage of providing stronger evidence about the cause and effect, dose response, and clinical utility of weight loss interventions limitation is that it frequently test interventions that are either not practical in the real world and/or do not reflect the real ways that people in the community go about weight loss Unknown net effect in the population

Effect on diseases Weight loss affect long-term disease incidence and mortality most direct and important effects on insulin sensitivity, glucose tolerance, blood pressure, lipid parameters, and inflammatory factors A 5 kg reduction in weight causes Drop of 4 mmhg systolic blood pressure Drop of 3 mmhg of diastolic blood pressure Decrease of 5 to 8 mg/dl of total and low-density lipoprotein (LDL) cholesterol Decrease of 18 mg/dl of triglyceride Weight loss reduces left ventricular hypertrophy, resting heart rate, increases stroke volume and cardiac output, improves coagulation and fibrinolytic factors, reduces angina symptoms, and consistently improves functional status Decrease in inflammatory markers Improvement in HbA1c

Is short term weight loss beneficial? most people who try to lose weight regain weight on average, one-third of peak weight loss is regained in the year following weight loss unclear whether the physiological benefits are maintained over a longenough period of time to reverse preexisting pathology and thus influence long-term health outcomes weight loss is associated with increased bone loss, decreased lean muscle mass, gallstone development, and perhaps, decreased immunity associated with multiple weight loss attempts The reduction in bone loss may be offset by increased physical activity, but concerning in older adults

Strong and consistent evidence relates intentional weight loss to reduced incidence of diabetes among high-risk individuals Intentional weight loss has been consistently associated with reduced incidence of hypertension and improved control of blood pressure Weight loss may reduce disability and improve mobility and functioning in daily living among older populations Increasing evidence suggests that intentional weight loss reduces overall mortality and possibly CVD incidence

Obesity and Primary Care Obesity is one of the most common medical problem seen by Primary Care Physicians these patients are also more likely to present with other diseases, e.g., hypertension, dyslipidemia, type 2 diabetes, metabolic syndrome In practice, however, obesity is underrecognized and undertreated in the primary care setting Failure to adequately identify the overweight and mildly obese patient, however greater recognition for the moderately to severely obese patient less than half of obese adults are being advised to lose weight by health care professionals

Office-Based Obesity Care Health care system geared to treating acute care problems rather than chronic conditions Obesity is a chronic condition

Physical environment Equipment Materials Tools Protocols Accessibility and comfort, space, reading and educational material Large BP cuffs, large gowns, Step stools, higher limit scales Educational handouts on diet, exercise, medications, surgery, www.choosemyplate.gov Pre-visit questionnaires, Fitness trackers, apps Return visit, medications, referral to surgery,dietitian and psychologists

Treating obesity Measure height and weight BMI Measure waist circumference assess comorbidities Look for causes of obesity including the use of medications Is the patient ready and motivated to lose weight? If the patient is not ready to lose weight, urge weight maintenance and manage the complications If the patient is ready, agree with the patient on reasonable weight and activity goals and document Involve other professionals(dietitians, therapists, structured programs)

Guide to selecting treatment Treatment 25-26.9 27-29.9 30-34.9 Diet, exercise, behavior therapy With comorbidities With comorbidities 35-39.9 >40 + + + Pharmacotherapy + + + Surgery With comorbidities +

Pharmacotherapy Antiobesity pharmacotherapy should be considered as an adjunct to diet and behavioral modification facilitates weight loss or promote long-term weight maintenance Potentially treat comorbid conditions associated with obesity, including prediabetes, type 2 diabetes mellitus (T2D), obstructive sleep apnea, hypertension, and dyslipidemia expected weight loss from obesity pharmacotherapy is 5% to 10% of total body weight (TBW) For patients with severe obesity (class III), multiple medications, in addition to surgical intervention may be considered

Phentermine Phentermine was approved by the FDA in 1959 Most commonly prescribed short-term (up to 12 weeks) medication for weight loss Phentermine is primarily Standard adult dose is up to 37.5 mg daily before breakfast Use lowest effective dose first side effects: dizziness, dry mouth, difficulty sleeping, and irritability

Orlistat Approved in 1999 by the Orlistat alters fat digestion by inhibiting gastric and pancreatic lipases, causing approximately 30% fecal fat excretion Prescribed 3 times a day at a dosage of 120 mg to be taken with meals A lower-dose formulation containing 60 mg per capsule is available over the counter and sold under the brand name Alli Side : bloating, flatulence, flatus with discharge, and fecal incontinence reduces the absorption of fat-soluble vitamins(a, D, E, K), a multivitamin supplement is advised when treating with this agent

Lorcaserin(Belviq) Approved by the FDA in 2012 for long-term weight management Selective serotonin 2c receptor agonist decreases food consumptionand promotes satiety by selectively activating the 5HT-2c receptor on anorexigenic POMC neurons located in the hypothalamus daily dose of 10 mg twice a day Side effects : headaches, dizziness, and nausea, hypoglycemia(reduction in diabetic medication dosage may be needed)

PHENTERMINE/TOPIRAMATE (QSYMIA) Approved by the FDA in 2012 Phentermine increases norepinephrine in the hypothalamus, enhancing POMC neuron pathway signaling to increase alpha-msh, which binds to melanocortin 4 receptor and suppresses appetite The exactmechanism of action for weight loss with topiramate is not known 4 dosages: 3.75/23mg (starting dose) 7.5/46mg (treatment dose) 11.25/69mg 15/92 mg (maximumdose a stepwise approach, starting at 3.75/23 mg once daily for 2 weeks before increasing to the recommended dose of 7.5/46 mg once daily Further titration to a maximum dose of 15/92 mg once daily may be considered for individuals who do not achieve 3%weight loss after 12 weeks. If 5% weight loss is not achieved after 12 weeks at 15/92mg per day, then phentermine/topiramate ER dose should be gradually reduced for discontinuation

Qsymia(contd) Side effects: paresthesias,dizziness, dysgeusia, and dry mouth Inform women of reproductive age about the increased risk of congenital malformation during the first trimester of pregnancy

Liraglutide(Saxenda) Glucagon-like peptide-1 (GLP-1) agonist cause glucose-dependent insulin secretion from pancreatic beta cells to lower glucose levels, suppression of glucagon secretion, and slowing of gastric emptying FDA approved in 2014 Dose up to 3.0 mg once daily Side effects: nausea, vomiting, hypoglycemia and diarrhea, increased lipase, abdominal pain,

NALTREXONE /BUPROPION (CONTRAVE FDA approved in 2014 Given the known individual effects of naltrexone and bupropion on addiction (alcohol and smoking, respectively), a fixed combination was hypothesized to induce weight loss through sustained modulation of central nervous system reward pathways

Gelesis Each capsule contains thousands of proprietary, biocompatible hydrogel particles synthesized with starting materials that are Generally Recognized as Safe by the FDA capsules are taken before a meal with water, after which the small particles within the capsules hydrate and expand in the stomach and small intestine,triggering several important satiety and glycemic control mechanisms built-in safety features: (a) the volume it creates is limited by the amount of water consumed (b) the hydrated particles, which are 2 mm in size, do not cluster or stick together and have similar elasticity (rigidity) as ingested food (c) the particles partially degrade in the colon, releasing absorbed water Pilot Human Study initiation is planned in 2019

Bariatric Surgery at Mercy Medical Center Numbers Sleeve gastrectomy :113 Gastric Bypass: 22

Before 325.3 LBS

After 175 LBS

Program Start Date December 26, 2016 SUCCESS STORIES Program Start Weight 325.3 lbs Starting BMI 54.13 Sleeve Gastrectomy May 30, 2017 Current Weight 175 lbs Current BMI 28 Total Weight Loss 150.3 lbs Starting Pant Size 26 Current Pant Size 10/12 Before After

Before 258 LBS

After 150 LBS

Program Start Date July 10, 2017 SUCCESS STORIES Program Start Weight - 258 lbs Starting BMI 43.6 Sleeve Gastrectomy November 28, 2017 Current Weight 150 lbs Current BMI 25.08 Total Weight Loss 108 lbs Starting Pant Size 18/20 Current Pant Size 6/8

Before 442 LBS

After 325.2 LBS

Program Start Date September 29, 2016 SUCCESS STORIES Program Start Weight - 442 lbs Starting BMI 56.75 Sleeve Gastrectomy April 18, 2017 Current Weight 325.2 lbs Current BMI 40.65 Total Weight Loss 116.8 lbs Before After

320 LBS Before

After 135 LBS

Success Stories Program Start Date March 30, 2017 Program Start Weight - 320 lbs Starting BMI 54.08 Sleeve Gastrectomy September 20, 2017 Current Weight 135 lbs Current BMI 23.19 Total Weight Loss 185 lbs