1. Pharmacologic Treatment Considerations for the Obese Patient
Shala Swarm, FNP-BC
Cheyenne Regional Medical Center
Cheyenne Physician’s Group
Weight Loss Center

2. No Disclosures

3. Objectives
Identify three major Health Effects Obesity causes for patients and importance of addressing and treating obesity
Select at least one treatment option for obesity for patients with major health conditions

4. Metropolitan Life Insurance Table
Ideal Body and BMI
Ideal Body Weight
Metropolitan Life Insurance Table
Method to Calculate
Women = 100 lbs for 5’0” +
5 lbs for each add. inch /- 10%
Men = 110 lbs for 5’0” +
5 lbs for each add. Inch
+/- 10%
Body Mass Index
Height to Weight Ratio
Method to Calculate
BMI = Weight (pounds) X 703
Height x Height
(inches)

5. Ideal Body Weight Charts
TABLE METROPOLITAN HEIGHT AND WEIGHT TABLE According to Frame, Ages MEN Weight in Pounds (In Indoor Clothing)*
TABLE METROPOLITAN HEIGHT AND WEIGHT TABLE According to Frame, Ages 25-59
WOMEN Weight in Pounds (In Indoor Clothing)*
HEIGHT
SMALL
MEDIUM
LARGE
(In Shoes)+
FRAME
Feet
Inches 5 2 3 4 6 7 8 9 10 11 1
HEIGHT
SMALL
MEDIUM
LARGE
(In Shoes)+
FRAME
Feet
Inches 4 10 11 5 1 2 3 6 7 8 9
Indoor clothing weighing 5 pounds for men and 3 pounds for women
Shoes with 1-inch heels
Source of basic data Build Study, Society of Actuaries and Association of Life Insurance Medical Directors of America, Copyright© 1996, 1999 Metropolitan Life Insurance Company Courtesy of the Metropolitan Life Insurance Company.

7. Definitions of Overweight and Obesity
Normal Range – BMI
Overweight – BMI
Obese – BMI
Severe Obese – BMI
Morbid Obese – BMI
Super Obese – BMI > 50
BMI is limited due to body frame

8. Obesity is a Growing Concern

9. Obesity Trends* Among U.S. Adults BMI > 30

10. Obesity Trends* Among U.S. Adults

11. Obesity Trends* Among U.S. Adults

12. Obesity Trends* Among U.S. Adults

13. Obesity Trends* Among U.S. Adults
We have never had an epidemic like this that we have been able to track so thoroughly and see. As I told you, this is conservative.
About 60 million adults, or 30 percent of the adult population, are now obese, which represents a doubling of the rate since 1980.

14. Obesity Trends* Among U.S. Adults
We have never had an epidemic like this that we have been able to track so thoroughly and see. As I told you, this is conservative.
About 60 million adults, or 30 percent of the adult population, are now obese, which represents a doubling of the rate since 1980.

15. Statistics US 33.8 % or one-third of the population Wyoming
Resource: CDC
Wyoming
In 2010 was:
25.1 %
Resource: CDC
World
Worldwide obesity has more than doubled since 1980.
In 2008, 1.5 billion adults, 20 and older, were overweight. Of these over 200 million men and nearly 300 million women were obese.
65% of the world's population live in countries where overweight and obesity kills more people than underweight.
Resource: World Health Organization

16. Risks of Obesity

17. Co-Morbid Medical Conditions
Diabetes
Hypertension
Hyperlipidemia
Cardiac Disease
Sleep Apnea / Hypoventilation
Liver disease
Cancer risk
Heartburn
Asthma
Osteoarthritis
Depression
Urinary Incontinence
Menstrual Irregularity
Infertility
Leg Swelling
Right side are potentially life threatening problems.
Diabetic- tissues are insulin resistant

18. Complications of morbid obesity are LETHAL4
Morbidly obese:
die 10 to 15 years earlier 3
Mortality Ratio 2 1
Risk of Death is Exponential in the Morbidly Obese 20 25 30 35 40
Body Mass Index
Fontaine KR, Redden DT, Wang C, Westfall AO,
Allison DB. Years of life lost due to obesity. JAMA. 2003;
289:

19. What Causes Obesity Environment ??? Genetics??? Takes many years
Decreased Mobility due
to increased access
Fast Food
Video Games
Sedentary Jobs
Genetics???
Takes many years
to these dramatic
changes

20. Genetic Weight gain Environment
Weight Gain Cycle
Genetic Weight gain Environment
Appetite cravings
reduced energy expenditure
Co-morbid disease
Natural history is progressive.
BMI= 40 something changes. Satiety changes, full but not satisfied.
Metabolic
Hormonal

21. Other Causes Medications: Anti-psychotics Anti-depressants
Anti-epileptic's
Steroids
Diabetes meds
Birth Control medications

22. Other Causes Health Conditions Endocrine Disorders Hormonal Disorders
Sleep Apnea
Diabetes
Orthopedic Injuries

23. WHAT DO YOU DO WITH THESE PATIENTS?
How do you treat them?
Treat as in attitude
Treat as is treatment

24. Goals Long term vs Short term Realistic
Small weight reduction can make a big difference
A good starting goal is 10% weight loss
10% weight loss can make a big impact on multiple health conditions
Prevent more weight gain

25. Treatment Options Screening Tests Diet Exercise
Psychological Evaluations
Medications
Surgery

26. Screening History Physical Exam EKG Special Measurements and Tests
Labs
CBC
CMP
Thyroid Panel (TSH, free T3, free T4)
Lipid Profile UA
Fasting Insulin, 2 hour post-prandial glucose
25 (OH) D levels
History should include
diet history (eating disorders), weight gain history, lifestyle behaviors (eating out, schedules), what do they feel are their “bad” habits (snack at certain times of the day, ect.
Exercise habits
PMH and medications (may give clue to weight problems)
Sleep Habits
Physical Exam should include
Skin
Extra Measurements: BCA, body fat %, Waist Circ, neck size, body shape

27. Diet
Calorie – a way to measure energy Calories in = Calories out 1 Calorie = 1 kilocalorie = 1000 calories

28. Diet Basal Metabolic rate (BMR) + Thermic effect of food (TEF)
The energy used to sustain life (breathing, cell functions) +
Thermic effect of food (TEF)
Energy used to digest food
Activity Thermogenesis (AT)
Energy used during exercises
and activities of daily living (NEAT)

29. Diet BEE calculation (Harris-Benedict estimation)
BEE Females = (9.563 * Weight) + (1.85 * Height) - (4.676 * Age)
BEE Males = (13.75 * Weight) + (5.003 * Height) - (6.775 * Age)

30. Diet Factors that Alter Metabolic Rate
Body Composition (leaner have higher BMR)
Age
Growth
Hormones
Stress
Temperature Changes
Fasting
Dieting
Caffeine, Alcohol, and Smoking

31. Diet Increasing Metabolism Regular Eating Habits Exercise
Increasing muscle mass

32. Diet Food Label RDA vs DV – Serving Size and amount per container
DV is a % based on a 2000 calorie diet
RDA is recommended daily allowance (guidelines to promote optimal health to prevent deficiencies) These are not on the food label.
Serving Size and amount per container
Calories
Protein
Sugars
Dietary Fiber
5%, 10%, 20% as low, moderate, high
Think what you what high % and low %

33. Diet Protein 4 kcal/gm Carbohydrates 4 kcal/gm Fat 9 kcal/gm
DRI: 0.8gm/kg of IBW (Increased amounts needed to protect lean body mass in restricted calorie diets)
Growth and repair of body tissues
Sources: meat, fish, legumes, dairy, peanuts
Carbohydrates 4 kcal/gm
DRI: 130 gm/day
Energy Source
Sources: grains, fruits, vegetables
Fat 9 kcal/gm
Acceptable Ranges: 20-35% of daily kcal
Helps with digestion and absorption of fat soluble vitamins
Saturated, Monounsaturated, Polyunsaturated and Essential
Alcohol 7 kcal/gm
No nutrient value
*DRI – Dietary References Intake
Sat. Fat – no double bonds
Mono fat – 1 double bond
Poly fat – 2 or more double bonds

34. Diet Keys to Success Portions
Planning Ahead (meal planning and spacing of meals)
Protein
Conscious Eating
Liquid Calories vs Solid Food
Water Intake
Conscious Eating – fullness vs hunger and eating away from distractions

35. Diets Types of Diets VLCD (very low calorie diets – 400-800 cal/day)
LCD (low calorie diets – cal/day)
Self Directed (Weight Watchers, Atkins)

36. Diet VLCD Medically Supervised
The lower the calories, the higher the protein
needed (1.2 g/kg women, 1.5 g/kg men)
Short term
Vitamin Supplementation
Side Effects: GI, electrolyte, gout, psych, skin, neurological
Contraindications: many
Medically Supervised: electrolytes frequently, EKG every 30 pounds, weekly visits
Wadden et al study showed no greater long-term weight loss than LCD
Contraindications:
Absolute- T1DM, epilepsy, arrhythmias, recent MI, psychosis, substance abuse, pregnancy or lactation, medical diseases that is unstable
Relative – CHf, TIAs, DVT, NSAIDS, psych, under 16 years
SE: fatigue, cold intol., hair falling out, nutrient deficiencies
Not long term use

37. Diet LCD Medically Supervised More compliance Weekly Visits
Done by portion control, low-fat, low-carb, or
calorie counting

38. Protein and Weight Loss
Diet
Protein and Weight Loss
Changes Body Composition by decreasing
body fat but protects lean tissue mass
(protein synthesis in muscles and burning of calories)
Stabilizes Blood Sugars (insulin levels)
Satiety
Reference: Layman
Insulin is primary growth hormone
Lose more weight rapidly, but long term may be similar results to WW

39. Diet Protein Diets – Safety and Monitoring UA Vitamins Multi-vitamin
Calcium if needed
Vitamin D
Fish Oil
UA to check for ketones

40. Physical Activity Exercise – planned activity
NEAT (non-exercise activity thermogensis)
Daily Activities

41. Exercise Aerobic or Cardiovascular Uses fatty acids for fuel
Cardiovascular fitness
Long bursts of activities
Oxygen dependant (breakdown of ATP)
Anaerobic or Resistance
Intracellular glycogen as fuel
Improves lean body mass
Oxygen independent (lactic acid build-up)
Reference: Williams Circulation 2007

42. Exercise Preventing Injury Warm up and cool down and stretching
Always warm up before stretching (optional)
Cool down (below target heart rate level) then stretch
Body Recovery (resistance needs rest day)
Interval Training (not everyday)
Use guide – ACSM’s Guidelines for
Exercise Testing
Interval training pushes body into anaerobic phase and will get more lactic acid
Need light day on “rest day”

43. Psychological Evaluation
Eating Disorders
Emotional Eating (depression)
Stress
Eating Patterns
Being Overweight “protecting” patient
Support Systems

44. Meds, Meds, and more Meds

45. Medications Most are short term use only (but obesity is chronic)
Safety
Addiction
Cost
**ALL MEDICATIONS NEED TO BE USED WITH BEHAVIORAL MODIFICATIONS OR THEY WILL NOT BE EFFECTIVE**
Contraindications for most
HTN, arteriosclerosis, hyperthyroidism, glaucoma, drug abuse hx, anti-depressants, seizures, pregnancy and lactation

46. Medications Regulatory Challenges Efficacy Safety
Benefit-risk evaluation
History of obesity medications
Perception
Regulatory Challenges article
How long should trials be?

47. Medications History of Obesity Medications
Drug
Year Approved
Year Removed
Short Term Use
Desoxyephedrine
1947
??????
Phenmetrazine
1956
Phentermine
1959
Still On Market
Diethylpropion
Phendimetrazine
Benzphetamine
1960
Mazindol
1973
Fenfluramine
1997
Long Term Use
Dexfenfluramine
1996
Sibutramine
2010
Orlistat
1999

48. Medications
Ephedrine (available as a restricted prescription medication)
Phentermine (FDA approved 1957)
Diethylpropion
Phendimetrazine
Benzphetrazine
Xenical
Merida (pulled off market fall 2010)

49. Medications Ephedrine Dose Range 12.5-75 mg/day
Norepinephrine releaser
Used mainly for hypotension and bronchospasms
Ephedra was herbal form that was banned in 2004
Side Effects: tremors, nervousness, insomnia, increase HR and BP
Cautions/Contraindications: MAOI, breastfeeding, hyperthyroidism,
CAD, HTN, arrhythmias, CV disease, DM, glaucoma, seizures, renal
impairment, prolonged use

50. Medications Phentermine Phentermine HCL (Adipex-P, Fastin)
Phentermine Resin (Ionamin)
Dose mg/day
CNS Stimulate
Side Effects: palpitations, tachycardia, HTN, insomnia, dizziness,
euphoria, tremors, HA, pulmonary HTN, valvular heart disease, irritability
Cautions/Contraindications: CV disease, pregnancy and lactation, HTN,
hyperthyroidism, glaucoma, agitation, drug abuse, DM
Most commonly Rx anerotic med

51. Medications Diethylpropion (Tenuate) Dose Range: 25-75 mg/day
Similar to bupropion chemically
Side Effects: tachycardia, HTN, pulmonary HTN, valvular heart disease,
seizures, psychosis, hallucinations, leukopenia, constipation, dry
mouth, N/V, diarrhea, abdominal discomfort, anxiety, dizziness, HA,
insomnia, arrhythmias, palpitations
Caution/Contraindications: pulmonary HTN, HTN, arteriosclerosis,
hyperthyroidism, glaucoma, agitations, drug abuse, valvular hear
disease, heart murmur, CV disease, seizure disorder, psychiatric
disorder
Should be 2nd consideration

52. Medications Phendimetrazine (Bontril) Dose Range: 35-105 mg/day
Mechanism of action unknown, CNS stimulant
Side Effects: tachycardia, HTN, pulmonary HTN, restlessness,
agitation, tremor, flushing, sweating, blurred vision, constipation,
nausea, diarrhea, gastric pain, anxiety, dizziness, HA, insomnia,
palpitations, urinary frequency
Caution/Contraindications: pulmonary HTN, HTN, arteriosclerosis,
hyperthyroidism, glaucoma, agitation, drug abuse, valvular hear
disease, heart murmur, CV disease, DM

53. Medications Benzphetamine (Didrex) Dose Range: 25-50 mg/day
Mechanism of action unknown, CNS stimulant
Side Effects: psychosis, tachycardia, HTN, cardiomyopathy, cardiac
ischemia, restlessness, agitation, tremor, flushing, sweating,
constipation, nausea, diarrhea, dizziness, HA, dry mouth, insomnia,
unpleasant taste, palpitations, urinary frequency
Caution/Contraindications: HTN, arteriosclerosis, hyperthyroidism,
glaucoma, agitation, drug abuse, valvular hear disease, heart murmur,
CV disease, DM, arrhythmias

54. Medications Xenical (Orlistat, Alli) Dose Range: 60-120 mg TID
Mechanism of action: inhibits gastric and pancreatic lipases, reducing
fat absorption
Side Effects: angioedema, fat-soluble vitamin deficiency,
hepatotoxicity; oily spotting flatus with discharge, fecal urgency, fatty
stools, oily evacuation, fecal incontinence, URI, influenza, HA,
abdominal pain, back pain, nausea, menstrual irregularities, UTI,
fatigue, arthritis, rectal pain, dizziness, infectious diarrhea
Caution/Contraindications: malabsorption syndromes, cholestasis,
eating disorders
Kidney and Pancreas problems???
Arch Intern Med. 2011 Apr 11;171(7): Orlistat and acute kidney injury: an analysis of 953 patients.

55. Medications Off Label Use Antidepressants Insulin Sensitizers
Anti-Seizures
Combination Therapy
5-HTP / Carbidopa

56. 5-HTP = 5-hydroxytryptophan
Medications
5-HTP = 5-hydroxytryptophan
Increases the production of serotonin
Over the counter
Wide margin of safety Not been associated risk for serotonin syndrome Does not alter cardiovascular parameters
Rapidly Metabolized by peripheral decarboxylase
High Doses are needed to increase brain 5-HT since it is rapidly metabolized by peripheral decarboxylase (intestine, kidney, blood, liver)

57. 5-HTP = 5-hydroxytryptophan
Medications
5-HTP = 5-hydroxytryptophan
Other Uses: anxiety, depression, alcohol withdrawal, headaches
Side Effects: anorexia, diarrhea, dizziness, drowsiness, eosinophilia, flatulence, N/V, somnolence, palpitations, insomnia, hypomania, stomach pain, taste disturbance, weight gain
Avoid Use: eosinophilia syndromes, MAOI use, mitochondrial encephalomyopathy
Caution in: antidepressant use, down syndrome, GI disorders, platelet disorders, psychiatric disorder history, PUD, renal disease

58. Medications Antidepressants
SSRI (selective serotonin reuptake inhibitors) – Increase 5-HT (serotonin) in the satiety center and down regulate 5-HT2A auto-receptors which increase 5-HT (serotonin) secretion
Side Effects: dry mouth, insomnia, nausea, tremor, headache, sweating, decreased libido, Serotonin Syndrome
Weight Loss Success: Limited results, but may be helpful for emotional eating or night time eating syndrome (sertraline)
Article in Obesity Research Nov 1995 showed some effectiveness of fluoxetine and weight loss.
A study by Stunkard et al in J Clin Psychiatry 2006 confirmed sertraline and NES.

59. Medications Antidepressants
Bupropion (Wellbutrin) – Inhibits neuronal uptake of norepinephrine and dopamine
Chemically like diethylpropion
Side Effects: dry mouth, headache, agitation, nausea, dizziness, constipation, tremor, sweating, abnormal dreams, insomnia, tinnitus, diarrhea, abdominal pain, anxiety
Weight Loss Success: Can decrease appetite and cravings
Article by Anderson, James et al in Obes Research 2002 showed 7.2% weight loss at 24 weeks and 10.1% sustained weight loss at 48 weeks.

60. Medications Insulin Sensitizers Metformin (Glucophage)
Indicated for Diabetes Type 2
Mechanism of Action: decreases hepatic glucose production and
intestinal glucose absorption; increases insulin sensitivity and
peripheral glucose uptake
Side Effects: nausea, diarrhea, flatulence, anorexia, headache,
metallic taste

61. Medications Insulin Sensitizers Byetta (exenatide)
Victoza (liraglutide)
Indicated for Diabetes Type 2
Mechanism of Action: activates glucagon-like-peptide-1 (GLP-1)
receptor, increasing insulin secretion, decreasing glucagon secretion,
and delaying gastric emptying (incretin mimetic)
Side Effects: nausea, vomiting, diarrhea, nervousness, dizziness,
headache, dyspepsia, decreased appetite
Liraglutide contraindicated in pancreatitis and thyroid carcinoma

62. Anti-Seizure Medications
Topiramate (Topamax)
Indicated for Seizures and Migraine headaches
Mechanism of Action: modulated GABA-A receptors, weak caronic
anhydrase inhibitor, exhibits state-dependent bloackade of voltage-
dependant Na and Ca channels
Side Effects: dizziness, parathesias, fatigue, difficulty concentrating,
somnolence, weight loss, nervousness, ataxia, diarrhea, nausea,
nystagmus, tremor, fever, taste changes, taste changes, myopia,
nephrolithiasis
Contraindications: increased intraocular pressure

63. Medications Others for thought Probiotics ??? Antibiotics ???
Vitamin D ???
Vitamin D: vitamin D receptors found on the adipocyte and deficiency of vitamin D allows adipocyte enlargement

64. Medications
Combination Therapy Obesity is a chronic medical condition and just like any other chronic medical condition multiple medications are usually necessary to proper control of the health condition. Example: HTN, Diabetes

65. Medications Combined Medications Phentermine + 5-HTP/carbidopa
5-HTP and carbidopa can counteract side effects of phentermine
Dual action with NE release (phentermine) and increased 5-HT
release
Dual mechanism can increase satiety and decrease food craving
Dosing
Phentermine dosing + compounded 5-HTP / carbidopa
5-HTP = 5-25 mg
carbidopa = always 5 mg

66. Combination Medications
Both phentermine and wellbutrin
have norepinephrine effects
and therefore recommended
not to use them together

67. Medications What may be to come
Naltrexone + bupropion (Contrave) – rejected by the FDA in February 2011 (Orexigen)
Topiramate + phentermine (Qnexa) – (Vivus)
Zonesamide + bupropion (Empatic) – (Orexigen)
Pramlintide + metreleptin – Amylin Pharmaceuticals
Lorcaserin (expected to be named Lorqess) - Arena Pharmaceuticals
Tesofensine - NeuroSearch
Liraglutide
Exenatide
GLP-1 + PYY 3-36 – Emisphere Technologies

68. Medications Thoughts for Research Safety Satiety Side Effects
Long Term
Cost
Look at gut hormones instead of CNS

69. Thoughts for the Future
Orexigens
Neuropeptide Y (NPY)
Agouti-related protein (AgRP)
Orexin A and B
Melanin-concentrating hormone (MCH)
Ghrelin (activates NPY and AgRP)
Anorexigens
Brain-derived neurotrophic factor
Alpha-melanocyte stimulating hormone (alpha-MSH)
Pro-opiomelanocortin (POMC)
Serotonin
Cocaine-amphetamine-regulating transcript (CART)
Leptin ***
Insulin ***
*** Inhibit NPY and AgRP

70. Other Thoughts
Need for a safe anti-obesity medication for long term use as obesity is a chronic condition; Short term control is not useful
Medications should always be used with diet, exercise and behavioral modification changes
Should get informed consent

71. Medications What not to prescribe – HCG diet
ASBP Statement on HCG diet:
1. The Simeons method for weight loss is not recommended.
2. The Simeons diet is not recommended.
3. The use of HCG for weight loss is not recommended.
ASBP Position Statement on HCG Diet:

72. Weight Loss Surgery Options

73. Gastric restrictive Malabsorptive
Weight Loss Surgery
Gastric restrictive Malabsorptive
Vertical Banded Gastroplasty
JI bypass
Bilio Pancreatic Bypass
Duodenal Switch
Gastric Bypass
Long Limb
Gastric Bypass
R o u x – e n Y
Gastric Sleeve
L A P A R O S C O P I C
Gastric Band System
Gastric Bypass
Gastric Sleeve
Gastric Band

74. Typical Weight Loss surgery patient
Weight Range (pounds)
Number In Each Range
How heavy is the average weight loss surgery patient?

75. Candidates for Surgery
Weight Loss Surgery
Candidates for Surgery
BMI >40
BMI >35 with significant co-morbidities
H&P to assess need for cardiac/pulmonary clearances
Psychological Evaluation
Dietary Screening

76. Gastric restrictive Malabsorptive
JI bypass
Bilio Pancreatic Bypass
Duodenal Switch
Gastric Bypass
Long Limb
Vertical Banded Gastroplasty
Gastric Bypass
R o u x – e n Y
Gastric Bypass
Lap Band

77. Gastric restrictive Malabsorptive
JI bypass
Bilio Pancreatic Bypass
Duodenal Switch
Gastric Bypass
Long Limb
Vertical Banded Gastroplasty
Gastric Bypass
R o u x – e n Y
Gastric Bypass
Lap Band

78. Weight Loss Surgery Mal-absorptive Procedures
JI Bypass
Performed from 1950s-1970s
Problems / Complications: mineral and electrolyte imbalances, protein malnutrition, abdominal discomfort including flatus and diarrhea, liver disease, renal disease, peripheral neuropathy, pericarditis, and more.
BPD / DS
More demanding operation than the RYGB
Problems / Complications: diarrhea, foul smelling flatulence, mal-absorption of fat soluble vitamins, protein malnutrition, ulcers, and dumping syndrome.

79. Gastric Restrictive Procedures
Staple line failure.

80. Gastric Restrictive Procedures

81. Protein calorie malnutrition
B12
iron
Since the stomach is involved in iron and Vitamin B12 absorption, these may not be absorbed adequately following bypass. As a result anemia may develop. The patient feels tired and listless, and blood tests show low levels of hematocrit, hemoglobin, iron, Vitamin B12. The condition can be prevented and treated, if necessary, by taking extra iron and B12. Since the food stream bypasses the duodenum, the primary site of calcium absorption, the possibility of calcium deficiency exists, and all patients should take supplemental calcium to forestall this.
Ca++
Dehydration
Protein calorie malnutrition 81

82. Gastric Restrictive Procedures
Ghrelin receptors
Staple line failure. 82

83. Gastric Sleeve Gastric Bypass 2nd stage R o u x – e n - Y
L A P A R O S C O P I C
Gastric Bypass
R o u x – e n Y
2nd stage
Staple line failure. 83

84. Gastric Restrictive Procedure
Pure gastric restrictive procedures are common in Europe and Australia

86. Weight Loss Surgery Risks of Surgery
Complications may include
Mortality (0.24%)
Staple line leaks (RYGB) (0.73%)
PE (0.25%)
DVT (0.17%)
Wound infections (1.8%)
Marginal ulcers
Malnutrition
GI Bleed (0.44%)
Small Bowel Obstruction (0.40%)
These percents were 30 day mortality and complication rate, Source ASMBS

87. Weight Loss
AACE/TOS/ASMBS Bariatric Surgery Guidelines, Endocr Pract. 2008;14(Suppl 1)

88. Weight Loss Surgery Safety and Monitoring Routine lifetime follow up
Lap Band: monthly for 6 months and fills based on symptoms but routine visits for life
RYGB and Sleeve: 1 week, 1 month, 3 month, 6 months, 9 months, 1 year, 18 months, and annually
Regular follow up visits help with compliance and better weight loss

89. Weight Loss Surgery Safety and Monitoring Vitamin Supplementation
Bands – multi-vitamin, calcium, fish oil
RYGB / Sleeve – multi-vitamin (bariatric), calcium, B12, iron, fish oil

90. Weight Loss Surgery Routine Labs
Bands – general health screening (annually)
RYGB / Sleeves – CBC, CMP, folate, thiamine, B12, total iron, TIBC, ferritin, A1C, lipids, vitamin D, TSH
Annual bone density

91. Weight Loss Surgery Diet Slow diet progression Food Intolerances
No No Foods
Eating Behaviors that need changed

92. Weight Loss Surgery DO NOT Prescribe NSAIDS after RYGB
Prescribe steroids after RYGB
Prescribe extended release medications after RYGB
SMOKE

93. lifelong. NIH Consensus Severe obesity is a
Chronic, intractable, and progressive disorder;
any therapeutic program must, therefore, be
lifelong.
Just like any other CHRONIC illness

94. References
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National Institutes of Health (NIH) National Heart, Lung and Blood Institute (NHLBI). Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. NIH; 1998; NIH Publication No
Center for Disease Control. Overweight and Obesity.
Center for Disease Control. Overweight and Obesity.
World Health Organization. Overweight and Obesity.
Build Study, Society of Actuaries and Association of Life Insurance Medical Directors of America, 1980.
Fontaine KR, Redden DT, Wang C, Westfall AO, Allison DB. Years of life lost due to obesity. JAMA. 2003 Jan 8;289(2):
Knight JA. Diseases and disorders associated with excess body weight. Ann Clin Lab Sci. 2011 Spring;41(2):
American Society of Bariatric Physicians (ASBP). Bariatric Practice Guidelines
American Society of Bariatric Physicians (ASBP). Position statement on HCG diet.
Millward D, Layman D, et. al. Protein quality assessment: impact of expanding understanding of protein and amino acid needs for optimal health. AJCN 2008 May; 87, (5), 1576S-1581S.
Gardner CD, Kiazand A, Alhassan S, Kim S, Stafford RS, Balise RR, Kraemer HC, King AC. Comparison of the Atkins, Zone, Ornish, and LEARN diets for change in weight and related risk factors among overweight premenopausal women: the A TO Z Weight Loss Study: a randomized trial. JAMA. 2007 Mar 7;297(9):
Shai I, et. al, Weight loss with a low-carbohydrate, Mediterranean, or low-fat diet. N Engl J Med. 2008 Jul 17;359(3):
Sacks FM, et. al, Comparison of weight-loss diets with different compositions of fat, protein, and carbohydrates. N Engl J Med. 2009 Feb 26;360(9):859-73
Mahan L.K, and Escott-Stump, S. Krause’s Food, Nutrition, & Diet Therapy. 11th ed. Philadelphia, Pennsylvania. Elsevier
Epocrates Rx Version San Mateo (CA): Epocrates, Inc.
Food and Drug Administration. FDA Approved obesity drugs.
Heal, D. Gosden, J. and Smith S Regulatory challenges for new drugs to treat obesity and comorbid metabolic disorders. BJCP 68:6:
Hussain, SS and Bloom SR. The pharmacological treatment and management of obesity. Postgrad Med Jan: 123 (1):
Cooke, D and Bloom S. The obesity pipeline: current strategies in the development of anti-obesity drugs. Nat. Rev Drug Discov Nov: 5(11):
Kaplan LM. Pharmacologic therapies for obesity. Gastroenterol Clin North Am Mar: 39 (1):

95. References Cont.
Kootte RS, et. al; The therapeutic potential of manipulating gut microbiota in obesity and type 2 diabetes mellitus. Diabetes Obes Metab Aug.
Ly, NP et. al.; Gut microbiota, probiotics, and vitamin D: interrelated exposures influencing allergy, asthma, and obesity? J Allergy Clin Immunol May; 127 (5):
Weir Ma, Beyea MM, Gomes T., et. al. Orlistat and acute kidney injury: an analysis of 953 patients. Arch Intern Med. 2011 Apr 11;171(7):703-4.
Brethauer SA, Chand B, Schauer PR. Risks and benefits of bariatric surgery: current evidence. Cleveland Clinic Journal of Medicine (2006) 75(11);
Anonymous. Perioperative safety in the longitudinal assessment of bariatric surgery. NEJM Jul; 361(5) 445.
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