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

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Presentation on theme: "Pharmacologic Treatment Considerations for the Obese Patient Shala Swarm, FNP-BC Cheyenne Regional Medical Center Cheyenne Physicians Group Weight Loss."— Presentation transcript:

1 Pharmacologic Treatment Considerations for the Obese Patient Shala Swarm, FNP-BC Cheyenne Regional Medical Center Cheyenne Physicians 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 Ideal Body and BMI Ideal Body Weight Metropolitan Life Insurance Table Method to Calculate Women = 100 lbs for lbs for each add. inch +/- 10% Men = 110 lbs for 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 HEIGHTSMALLMEDIUMLARGE (In Shoes)+FRAME FeetInches TABLE METROPOLITAN HEIGHT AND WEIGHT TABLE According to Frame, Ages MEN Weight in Pounds (In Indoor Clothing)* HEIGHTSMALLMEDIUMLARGE (In Shoes)+FRAME FeetInches TABLE METROPOLITAN HEIGHT AND WEIGHT TABLE According to Frame, Ages WOMEN Weight in Pounds (In Indoor Clothing)* 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.

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7 Definitions of Overweight and Obesity Normal Range – BMI Overweight – BMI Obese – BMI Severe Obese – BMI Morbid Obese – BMI Super Obese – BMI > 50

8 OBESITY IS A GROWING CONCERN

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

10 Obesity Trends* Among U.S. Adults

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15 Statistics World Worldwide obesity has more than doubled since 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 US 33.8 % or one-third of the population Resource: CDC Wyoming In 2010 was: 25.1 % Resource: CDC

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

18 LETHAL Complications of morbid obesity are LETHAL Morbidly obese: die 10 to 15 years earlier Mortality Ratio 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 ??? Decreased Mobility due to increased access Fast Food Video Games Sedentary Jobs Genetics??? Takes many years to these dramatic changes

20 Weight Gain Cycle Genetic Weight gain Environment Appetite cravings reduced energy expenditure Metabolic Hormonal Co-morbid disease

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?

24 Goals Long term vs Short term Realistic Small weight reduction can make a big difference o A good starting goal is 10% weight loss o 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 T 3, free T 4 ) Lipid Profile UA Fasting Insulin, 2 hour post-prandial glucose 25 (OH) D levels

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

28 Diet Basal Metabolic rate (BMR) 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 – –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

33 Diet Protein 4 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

34 Diet Keys to Success Portions Planning Ahead (meal planning and spacing of meals) Protein Conscious Eating Liquid Calories vs Solid Food Water Intake

35 Diets Types of Diets VLCD (very low calorie diets – 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

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

38 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

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

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 – ACSMs Guidelines for Exercise Testing

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**

46 Medications Regulatory Challenges Efficacy Safety Benefit-risk evaluation History of obesity medications Perception

47 Medications History of Obesity Medications DrugYear ApprovedYear Removed Short Term Use Desoxyephedrine1947?????? Phenmetrazine1956?????? Phentermine1959Still On Market Diethylpropion1959Still On Market Phendimetrazine1959Still On Market Benzphetamine1960Still On Market Mazindol1973?????? Fenfluramine Long Term Use Dexfenfluramine Sibutramine Orlistat1999Still On Market

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 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

51 Medications Diethylpropion (Tenuate) Dose Range: 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

52 Medications Phendimetrazine (Bontril) Dose Range: 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: 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: 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???

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

56 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

57 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)

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

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 Medications 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 ???

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 Medications 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 Weight Loss Surgery Gastric restrictive Malabsorptive 1. JI bypass 2. Bilio Pancreatic Bypass 3. Duodenal Switch 4. Gastric Bypass Long Limb 1. Vertical Banded Gastroplasty 2. Gastric Bypass 3. Gastric Sleeve 4.Gastric Band 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

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

75 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 1. JI bypass 2. Bilio Pancreatic Bypass 3. Duodenal Switch 4. Gastric Bypass Long Limb 1. Vertical Banded Gastroplasty 2. Gastric Bypass 3. Lap Band Gastric Bypass R o u x – e n - Y

77 Gastric restrictive Malabsorptive 1. JI bypass 2. Bilio Pancreatic Bypass 3. Duodenal Switch 4. Gastric Bypass Long Limb 1. Vertical Banded Gastroplasty 2. Gastric Bypass 3. Lap Band Gastric Bypass R o u x – e n - Y

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

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81 B12 iron Ca ++ Protein calorie malnutrition Dehydration

82 Gastric Restrictive Procedures Ghrelin receptors

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

84 Gastric Restrictive Procedure

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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%)

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, B 12, iron, fish oil

90 Weight Loss Surgery Routine Labs Bands – general health screening (annually) RYGB / Sleeves – CBC, CMP, folate, thiamine, B 12, 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 NIH Consensus Severe obesity is a Chronic, intractable, and progressive disorder; any therapeutic program must, therefore, be lifelong.

94 References 1.National 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 No 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. 4.Center for Disease Control. Overweight and Obesity. 5.World Health Organization. Overweight and Obesity. 6.Build Study, Society of Actuaries and Association of Life Insurance Medical Directors of America, Fontaine KR, Redden DT, Wang C, Westfall AO, Allison DB. Years of life lost due to obesity. JAMA Jan 8;289(2): Fontaine KRRedden DTWang CWestfall AOAllison DBJAMA. 8.Knight JA. Diseases and disorders associated with excess body weight. Ann Clin Lab Sci Spring;41(2): Knight JAAnn Clin Lab Sci. 9.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. 12.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 Mar 7;297(9): Gardner CDKiazand AAlhassan SKim SStafford RSBalise RRKraemer HCKing ACJAMA. 13.Shai I, et. al, Weight loss with a low-carbohydrate, Mediterranean, or low-fat diet. N Engl J Med Jul 17;359(3): Shai IN Engl J Med. 14.Sacks FM, et. al, Comparison of weight-loss diets with different compositions of fat, protein, and carbohydrates. N Engl J Med Feb 26;360(9):859-73Sacks FMN Engl J Med. 15.Mahan L.K, and Escott-Stump, S. Krauses Food, Nutrition, & Diet Therapy. 11th ed. Philadelphia, Pennsylvania. Elsevier 16.Epocrates Rx Version San Mateo (CA): Epocrates, Inc. 17.Food and Drug Administration. FDA Approved obesity drugs. Drugs.htmhttp://www.fda.gov/ohrms/dockets/ac/04/briefing/ B1_05_Approved- Drugs.htm 18.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. 1.Kootte RS, et. al; The therapeutic potential of manipulating gut microbiota in obesity and type 2 diabetes mellitus. Diabetes Obes Metab Aug. 2.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 Apr 11;171(7):703-4.Arch Intern Med. 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) 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. 8.Gastrointestinal Surgery for Severe Obesity. NIH Consensus Statement 1991 Mar 25-27;9(1): 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 Nov;3 Suppl 4:481S-490S.Goldstein DJRampey AH JrRoback PJWilson MGHamilton SHSayler METollefson GDObes Res. 10.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 Oct;67(10): Stunkard AJAllison KCLundgren JDMartino NSHeo MEtemad BO'Reardon JPJ Clin Psychiatry. 11.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)


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