3ObjectivesIdentify three major Health Effects Obesity causes for patients and importance of addressing and treating obesitySelect at least one treatment option for obesity for patients with major health conditions
4Metropolitan Life Insurance Table Ideal Body and BMIIdeal Body WeightMetropolitan Life Insurance TableMethod to CalculateWomen = 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 IndexHeight to Weight RatioMethod to CalculateBMI = Weight (pounds) X 703Height x Height(inches)
13Obesity 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.
14Obesity 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.
15Statistics US 33.8 % or one-third of the population Wyoming Resource: CDCWyomingIn 2010 was:25.1 %Resource: CDCWorldWorldwide 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
17Co-Morbid Medical Conditions DiabetesHypertensionHyperlipidemiaCardiac DiseaseSleep Apnea / HypoventilationLiver diseaseCancer riskHeartburnAsthmaOsteoarthritisDepressionUrinary IncontinenceMenstrual IrregularityInfertilityLeg SwellingRight side are potentially life threatening problems.Diabetic- tissues are insulin resistant
18Complications of morbid obesity are LETHAL 4Morbidly obese:die 10 to 15 years earlier3Mortality Ratio21Risk of Death is Exponential in the Morbidly Obese2025303540Body Mass IndexFontaine KR, Redden DT, Wang C, Westfall AO,Allison DB. Years of life lost due to obesity. JAMA. 2003;289:
19What Causes Obesity Environment ??? Genetics??? Takes many years Decreased Mobility dueto increased accessFast FoodVideo GamesSedentary JobsGenetics???Takes many yearsto these dramaticchanges
20Genetic Weight gain Environment Weight Gain CycleGenetic Weight gain EnvironmentAppetite cravingsreduced energy expenditureCo-morbid diseaseNatural history is progressive.BMI= 40 something changes. Satiety changes, full but not satisfied.MetabolicHormonal
21Other Causes Medications: Anti-psychotics Anti-depressants Anti-epileptic'sSteroidsDiabetes medsBirth Control medications
23WHAT DO YOU DO WITH THESE PATIENTS? How do you treat them?Treat as in attitudeTreat as is treatment
24Goals Long term vs Short term Realistic Small weight reduction can make a big differenceA good starting goal is 10% weight loss10% weight loss can make a big impact on multiple health conditionsPrevent more weight gain
26Screening History Physical Exam EKG Special Measurements and Tests LabsCBCCMPThyroid Panel (TSH, free T3, free T4)Lipid ProfileUAFasting Insulin, 2 hour post-prandial glucose25 (OH) D levelsHistory should includediet 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 habitsPMH and medications (may give clue to weight problems)Sleep HabitsPhysical Exam should includeSkinExtra Measurements: BCA, body fat %, Waist Circ, neck size, body shape
27DietCalorie – a way to measure energy Calories in = Calories out 1 Calorie = 1 kilocalorie = 1000 calories
28Diet 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 foodActivity Thermogenesis (AT)Energy used during exercisesand activities of daily living (NEAT)
30Diet Factors that Alter Metabolic Rate Body Composition (leaner have higher BMR)AgeGrowthHormonesStressTemperature ChangesFastingDietingCaffeine, Alcohol, and Smoking
31Diet Increasing Metabolism Regular Eating Habits Exercise Increasing muscle mass
32Diet Food Label RDA vs DV – Serving Size and amount per container DV is a % based on a 2000 calorie dietRDA is recommended daily allowance (guidelines to promote optimal health to prevent deficiencies) These are not on the food label.Serving Size and amount per containerCaloriesProteinSugarsDietary Fiber5%, 10%, 20% as low, moderate, highThink what you what high % and low %
33Diet 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 tissuesSources: meat, fish, legumes, dairy, peanutsCarbohydrates 4 kcal/gmDRI: 130 gm/dayEnergy SourceSources: grains, fruits, vegetablesFat 9 kcal/gmAcceptable Ranges: 20-35% of daily kcalHelps with digestion and absorption of fat soluble vitaminsSaturated, Monounsaturated, Polyunsaturated and EssentialAlcohol 7 kcal/gmNo nutrient value*DRI – Dietary References IntakeSat. Fat – no double bondsMono fat – 1 double bondPoly fat – 2 or more double bonds
34Diet Keys to Success Portions Planning Ahead (meal planning and spacing of meals)ProteinConscious EatingLiquid Calories vs Solid FoodWater IntakeConscious Eating – fullness vs hunger and eating away from distractions
36Diet VLCD Medically Supervised The lower the calories, the higher the proteinneeded (1.2 g/kg women, 1.5 g/kg men)Short termVitamin SupplementationSide Effects: GI, electrolyte, gout, psych, skin, neurologicalContraindications: manyMedically Supervised: electrolytes frequently, EKG every 30 pounds, weekly visitsWadden et al study showed no greater long-term weight loss than LCDContraindications:Absolute- T1DM, epilepsy, arrhythmias, recent MI, psychosis, substance abuse, pregnancy or lactation, medical diseases that is unstableRelative – CHf, TIAs, DVT, NSAIDS, psych, under 16 yearsSE: fatigue, cold intol., hair falling out, nutrient deficienciesNot long term use
37Diet LCD Medically Supervised More compliance Weekly Visits Done by portion control, low-fat, low-carb, orcalorie counting
38Protein and Weight Loss DietProtein and Weight LossChanges Body Composition by decreasingbody fat but protects lean tissue mass(protein synthesis in muscles and burning of calories)Stabilizes Blood Sugars (insulin levels)SatietyReference: LaymanInsulin is primary growth hormoneLose more weight rapidly, but long term may be similar results to WW
39Diet Protein Diets – Safety and Monitoring UA Vitamins Multi-vitamin Calcium if neededVitamin DFish OilUA to check for ketones
41Exercise Aerobic or Cardiovascular Uses fatty acids for fuel Cardiovascular fitnessLong bursts of activitiesOxygen dependant (breakdown of ATP)Anaerobic or ResistanceIntracellular glycogen as fuelImproves lean body massOxygen independent (lactic acid build-up)Reference: Williams Circulation 2007
42Exercise Preventing Injury Warm up and cool down and stretching Always warm up before stretching (optional)Cool down (below target heart rate level) then stretchBody Recovery (resistance needs rest day)Interval Training (not everyday)Use guide – ACSM’s Guidelines forExercise TestingInterval training pushes body into anaerobic phase and will get more lactic acidNeed light day on “rest day”
45Medications Most are short term use only (but obesity is chronic) SafetyAddictionCost**ALL MEDICATIONS NEED TO BE USED WITH BEHAVIORAL MODIFICATIONS OR THEY WILL NOT BE EFFECTIVE**Contraindications for mostHTN, arteriosclerosis, hyperthyroidism, glaucoma, drug abuse hx, anti-depressants, seizures, pregnancy and lactation
46Medications Regulatory Challenges Efficacy Safety Benefit-risk evaluationHistory of obesity medicationsPerceptionRegulatory Challenges articleHow long should trials be?
47Medications History of Obesity Medications DrugYear ApprovedYear RemovedShort Term UseDesoxyephedrine1947??????Phenmetrazine1956Phentermine1959Still On MarketDiethylpropionPhendimetrazineBenzphetamine1960Mazindol1973Fenfluramine1997Long Term UseDexfenfluramine1996Sibutramine2010Orlistat1999
48MedicationsEphedrine (available as a restricted prescription medication)Phentermine (FDA approved 1957)DiethylpropionPhendimetrazineBenzphetrazineXenicalMerida (pulled off market fall 2010)
49Medications Ephedrine Dose Range 12.5-75 mg/day Norepinephrine releaserUsed mainly for hypotension and bronchospasmsEphedra was herbal form that was banned in 2004Side Effects: tremors, nervousness, insomnia, increase HR and BPCautions/Contraindications: MAOI, breastfeeding, hyperthyroidism,CAD, HTN, arrhythmias, CV disease, DM, glaucoma, seizures, renalimpairment, prolonged use
50Medications Phentermine Phentermine HCL (Adipex-P, Fastin) Phentermine Resin (Ionamin)Dose mg/dayCNS StimulateSide Effects: palpitations, tachycardia, HTN, insomnia, dizziness,euphoria, tremors, HA, pulmonary HTN, valvular heart disease, irritabilityCautions/Contraindications: CV disease, pregnancy and lactation, HTN,hyperthyroidism, glaucoma, agitation, drug abuse, DMMost commonly Rx anerotic med
54Medications Xenical (Orlistat, Alli) Dose Range: 60-120 mg TID Mechanism of action: inhibits gastric and pancreatic lipases, reducingfat absorptionSide Effects: angioedema, fat-soluble vitamin deficiency,hepatotoxicity; oily spotting flatus with discharge, fecal urgency, fattystools, oily evacuation, fecal incontinence, URI, influenza, HA,abdominal pain, back pain, nausea, menstrual irregularities, UTI,fatigue, arthritis, rectal pain, dizziness, infectious diarrheaCaution/Contraindications: malabsorption syndromes, cholestasis,eating disordersKidney and Pancreas problems???Arch Intern Med. 2011 Apr 11;171(7): Orlistat and acute kidney injury: an analysis of 953 patients.
55Medications Off Label Use Antidepressants Insulin Sensitizers Anti-SeizuresCombination Therapy5-HTP / Carbidopa
565-HTP = 5-hydroxytryptophan Medications5-HTP = 5-hydroxytryptophanIncreases the production of serotoninOver the counterWide margin of safety Not been associated risk for serotonin syndrome Does not alter cardiovascular parametersRapidly Metabolized by peripheral decarboxylaseHigh Doses are needed to increase brain 5-HT since it is rapidly metabolized by peripheral decarboxylase (intestine, kidney, blood, liver)
58Medications 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) secretionSide Effects: dry mouth, insomnia, nausea, tremor, headache, sweating, decreased libido, Serotonin SyndromeWeight 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.
59Medications Antidepressants Bupropion (Wellbutrin) – Inhibits neuronal uptake of norepinephrine and dopamineChemically like diethylpropionSide Effects: dry mouth, headache, agitation, nausea, dizziness, constipation, tremor, sweating, abnormal dreams, insomnia, tinnitus, diarrhea, abdominal pain, anxietyWeight Loss Success: Can decrease appetite and cravingsArticle 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.
60Medications Insulin Sensitizers Metformin (Glucophage) Indicated for Diabetes Type 2Mechanism of Action: decreases hepatic glucose production andintestinal glucose absorption; increases insulin sensitivity andperipheral glucose uptakeSide Effects: nausea, diarrhea, flatulence, anorexia, headache,metallic taste
61Medications Insulin Sensitizers Byetta (exenatide) Victoza (liraglutide)Indicated for Diabetes Type 2Mechanism 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 appetiteLiraglutide contraindicated in pancreatitis and thyroid carcinoma
62Anti-Seizure Medications Topiramate (Topamax)Indicated for Seizures and Migraine headachesMechanism of Action: modulated GABA-A receptors, weak caronicanhydrase inhibitor, exhibits state-dependent bloackade of voltage-dependant Na and Ca channelsSide Effects: dizziness, parathesias, fatigue, difficulty concentrating,somnolence, weight loss, nervousness, ataxia, diarrhea, nausea,nystagmus, tremor, fever, taste changes, taste changes, myopia,nephrolithiasisContraindications: increased intraocular pressure
63Medications Others for thought Probiotics ??? Antibiotics ??? Vitamin D ???Vitamin D: vitamin D receptors found on the adipocyte and deficiency of vitamin D allows adipocyte enlargement
64MedicationsCombination 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
65Medications Combined Medications Phentermine + 5-HTP/carbidopa 5-HTP and carbidopa can counteract side effects of phentermineDual action with NE release (phentermine) and increased 5-HTreleaseDual mechanism can increase satiety and decrease food cravingDosingPhentermine dosing + compounded 5-HTP / carbidopa5-HTP = 5-25 mgcarbidopa = always 5 mg
66Combination Medications Both phentermine and wellbutrinhave norepinephrine effectsand therefore recommendednot to use them together
67Medications 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 PharmaceuticalsLorcaserin (expected to be named Lorqess) - Arena PharmaceuticalsTesofensine - NeuroSearchLiraglutideExenatideGLP-1 + PYY 3-36 – Emisphere Technologies
68Medications Thoughts for Research Safety Satiety Side Effects Long TermCostLook at gut hormones instead of CNS
69Thoughts for the Future OrexigensNeuropeptide Y (NPY)Agouti-related protein (AgRP)Orexin A and BMelanin-concentrating hormone (MCH)Ghrelin (activates NPY and AgRP)AnorexigensBrain-derived neurotrophic factorAlpha-melanocyte stimulating hormone (alpha-MSH)Pro-opiomelanocortin (POMC)SerotoninCocaine-amphetamine-regulating transcript (CART)Leptin ***Insulin ****** Inhibit NPY and AgRP
70Other ThoughtsNeed for a safe anti-obesity medication for long term use as obesity is a chronic condition; Short term control is not usefulMedications should always be used with diet, exercise and behavioral modification changesShould get informed consent
71Medications 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:
73Gastric restrictive Malabsorptive Weight Loss SurgeryGastric restrictive MalabsorptiveVertical Banded GastroplastyJI bypassBilio Pancreatic BypassDuodenal SwitchGastric BypassLong LimbGastric BypassR o u x – e n YGastric SleeveL A P A R O S C O P I CGastric Band SystemGastric BypassGastric SleeveGastric Band
74Typical Weight Loss surgery patient Weight Range (pounds)Number In Each RangeHow heavy is the average weight loss surgery patient?
75Candidates for Surgery Weight Loss SurgeryCandidates for SurgeryBMI >40BMI >35 with significant co-morbiditiesH&P to assess need for cardiac/pulmonary clearancesPsychological EvaluationDietary Screening
76Gastric restrictive Malabsorptive JI bypassBilio Pancreatic BypassDuodenal SwitchGastric BypassLong LimbVertical Banded GastroplastyGastric BypassR o u x – e n YGastric BypassLap Band
77Gastric restrictive Malabsorptive JI bypassBilio Pancreatic BypassDuodenal SwitchGastric BypassLong LimbVertical Banded GastroplastyGastric BypassR o u x – e n YGastric BypassLap Band
78Weight Loss Surgery Mal-absorptive Procedures JI BypassPerformed from 1950s-1970sProblems / Complications: mineral and electrolyte imbalances, protein malnutrition, abdominal discomfort including flatus and diarrhea, liver disease, renal disease, peripheral neuropathy, pericarditis, and more.BPD / DSMore demanding operation than the RYGBProblems / Complications: diarrhea, foul smelling flatulence, mal-absorption of fat soluble vitamins, protein malnutrition, ulcers, and dumping syndrome.
79Gastric Restrictive Procedures Staple line failure.
81Protein calorie malnutrition B12ironSince 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++DehydrationProtein calorie malnutrition81
82Gastric Restrictive Procedures Ghrelin receptorsStaple line failure.82
83Gastric Sleeve Gastric Bypass 2nd stage R o u x – e n - Y L A P A R O S C O P I CGastric BypassR o u x – e n Y2nd stageStaple line failure.83
84Gastric Restrictive Procedure Pure gastric restrictive procedures are common in Europe and Australia
86Weight Loss Surgery Risks of Surgery Complications may includeMortality (0.24%)Staple line leaks (RYGB) (0.73%)PE (0.25%)DVT (0.17%)Wound infections (1.8%)Marginal ulcersMalnutritionGI Bleed (0.44%)Small Bowel Obstruction (0.40%)These percents were 30 day mortality and complication rate, Source ASMBS
87Weight LossAACE/TOS/ASMBS Bariatric Surgery Guidelines, Endocr Pract. 2008;14(Suppl 1)
88Weight Loss Surgery Safety and Monitoring Routine lifetime follow up Lap Band: monthly for 6 months and fills based on symptoms but routine visits for lifeRYGB and Sleeve: 1 week, 1 month, 3 month, 6 months, 9 months, 1 year, 18 months, and annuallyRegular follow up visits help with compliance and better weight loss
89Weight Loss Surgery Safety and Monitoring Vitamin Supplementation Bands – multi-vitamin, calcium, fish oilRYGB / Sleeve – multi-vitamin (bariatric), calcium, B12, iron, fish oil
90Weight Loss Surgery Routine Labs Bands – general health screening (annually)RYGB / Sleeves – CBC, CMP, folate, thiamine, B12, total iron, TIBC, ferritin, A1C, lipids, vitamin D, TSHAnnual bone density
91Weight Loss Surgery Diet Slow diet progression Food Intolerances No No FoodsEating Behaviors that need changed
92Weight Loss Surgery DO NOT Prescribe NSAIDS after RYGB Prescribe steroids after RYGBPrescribe extended release medications after RYGBSMOKE
93lifelong. NIH Consensus Severe obesity is a Chronic, intractable, and progressive disorder;any therapeutic program must, therefore, belifelong.Just like any other CHRONIC illness
94ReferencesNational Institutes of Health (NIH) National Heart, Lung and Blood Institute (NHLBI) North American Association for the Study of Obesity. The practical guide: identification, evaluation, and treatment of overweight and obesity in adults. NIH; 2000; NIH Publication NoNational 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 NoCenter 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 GuidelinesAmerican 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):859-73Mahan L.K, and Escott-Stump, S. Krause’s Food, Nutrition, & Diet Therapy. 11th ed. Philadelphia, Pennsylvania. ElsevierEpocrates 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):
95References 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.Goutham RAO. Office-based strategies for the management of obesity. Am Fam Physician Jun 15; 81(12):American Society of Bariatric Surgery (ASMBS). Rational for surgical treatment.Gastrointestinal Surgery for Severe Obesity. NIH Consensus Statement 1991 Mar 25-27;9(1):1-20.Goldstein DJ, Rampey AH Jr, Roback PJ, Wilson MG, Hamilton SH, Sayler ME, Tollefson GD. Efficacy and safety of long-term fluoxetine treatment of obesity--maximizing success. Obes Res. 1995 Nov;3 Suppl 4:481S-490S.Stunkard AJ, Allison KC, Lundgren JD, Martino NS, Heo M, Etemad B, O'Reardon JP. A paradigm for facilitating pharmacotherapy at a distance: sertraline treatment of the night eating syndrome. J Clin Psychiatry. 2006 Oct;67(10):Fontaine KR, Redden DT, Wang C, Westfall AO, Allison DB. Years of life lost due to obesity. JAMA. 2003; 289:AACE/TOS/ASMBS Bariatric Surgery Guidelines, Endocr Pract. 2008;14 (Supp 1)