Presentation on theme: "Medical Management of Obesity"— Presentation transcript:
1Medical Management of Obesity Nirav Rana, MDBariatric SurgeonBariatrxJeanne M. Ferrante, MD, MPHAssociate ProfessorRobert Wood Johnson Medical SchoolFamily Medicine and Community Health
2DisclosuresDr. Ferrante has received grant/research support from Horizon Health Innovations within the past 12 months. Dr. Rana has nothing to disclose relevant to this presentation.
3ObjectivesIdentify patients who would benefit from surgical intervention for the treatment of obesity and its associated co-morbid conditions.Discuss the clinical benefits of bariatric surgeryDiscuss the long term management of patients after bariatric surgery
4Trends in Obesity Prevalence 1976-2010 Obesity has reached epidemic proportions in the United States. The percentage of adults age 20 to 74 who are obese has been increasing since the 1970s with the largest increases occurring in the late 1980s and 90s. Similar trends were observed among men and women.
5The highest prevalence is in non-hispanic black women (58 The highest prevalence is in non-hispanic black women (58.5%) and those who are poor or less educated and these sub- populations are more prone to weight-based discrimination or weight bias.
6Determining Treatment BMITreatmentHealthy LifestyleHealthy Lifestyle; Medications if additional risk factorsIntensive Behavioral Therapy; Medications; Surgery if BMI > 35 and co-morbidities> 40Intensive Behavioral Therapy; Medications; Surgery
7Treatment Options Correct underlying metabolic problems Diet, exercise, behavioral therapyMedicationsOptimize current medicationAnti-obesity medicationsBariatric Surgery
8Diet and Exercise Low calorie diet: 500-1000 kcal/d Women: kcal/dMen: kcal/dVery low calorie diet: 800 calories or less3-6 months (BMI > 50)Before surgery or long term wt-loss programDaily aerobic exercise ~ 60 minutesWeight training after aerobic goals met
9Low-carb vs. Low-fat diet Doesn’t matter what kind of dietWeight loss similar (11% at 6 and 12 months, 7% at 24 months)Decrease in blood pressures similarDecrease LDL and TG similarIncrease HDL (20%) in low carbWeight loss maintenancelow glycemic index, higher protein diet
10Low Glycemic Index http://www.the-gi-diet.org/lowgifoods/ Fruits- cherries, plums, grapefruit, peaches, prunes, apples, pears, grapes, oranges, strawberries- avoid watermelonMost vegetables except beets, pumpkin, parsnipsWheat pasta, egg fettuccini, spaghetti, brown rice, white long grain riceAvoid white bread, bagel, french baguette
12Behavioral Modification Self-monitoringGoal settingStimulus controlactivities, cues, circumstances, and practices that favor nonmeal eating and snackingEat most meals at homeDrink 500 ml water before each mealOptimal sleep (7-8 hours)too little sleep leads to decrease in muscle mass and increase in fat mass (Nedeltcheva et al, 2010 Ann Intern Med; 153(7): )
13Preventive Counseling Codes Obesity screening and and dietary counseling (V65.3)Exercise counseling (V65.41)CPT99401 (15 min)99402 (30 min)99403 (45 min)99404 (60 min)Use these if separate from a preventive visitUse -25 modifier if in conjunction with E/M service99401 ~ $2099402 ~ $4099403 ~ $6099404 ~ $80Do not use obesity ICD-9 codes such as for these CPT codes
14Medicare Coverage for Obesity Intensive Behavioral Therapy (G0447)Primary care physician or NP/PA/certifiedclinical nurse specialist- face-face x 15 minsUp to 22 visits over 12 monthsEvery 1 week (Month 1), every 2 weeks (Months 2-6)If loses 3 kg, continue every 4 weeks (Months 7-12)If not, can reassess after 6 monhts5A’s: Assess, Advise, Agree, Assist, ArrangeNot separately payable with another encounterSince Nov 29, 2011, Medicare has covered intensive behavioral therapy for obesity with no deductible or co-pay.Payment is about $25 per visitNot separately
165 A’s Examples Assess “Tell me what you typically eat for breakfast.” “How much activity do you do on a typical day?”Advise“Keep a food diary and decrease your calories to 1200 a day.”Agree“Would you agree to a low carb diet?”Assist“Here’s a handout on low glycemic index foods.”Arrange“Come back to see me in 1 week so we can see how you’re doing.”“Let’s schedule you to see a nutritionist.”
17Medications Optimize current medications Anti-obesity drugs Short term: benzphetamine, diethylproprion, phendimetrazine, phentermineLong termInhibits fat absorption: orlistat (Xenical, Alli)Decrease appetitephentermine/topiramate (Qsymia)lorcaserin (Belviq)Short term: 8-12 weeks, all sympathomimetic amines that decrease appetitePhentermine increases the release and reuptake of norepinephrine and dopamine. Its anorexiant effect occurs as a result of satiety-center stimulation in hypothalamic and limbic areas of the brain.Orlistat side effects: flatulence, fatty/oily stool, increased defecation, and fecal incontinence.
21Medications Orlistat (Xenical, Alli) Lipase inhibitor: inhibits fat absorption120 mg tid during or up to 1 hour after mealSide effects: flatulence, oily stool, diarrhea, and stool incontinenceReduces absorption of fat-soluble vitamins and beta-carotene: take vitamins 2 hours before or 1 hour after meal
22Medications Phentermine-topiramate (Qsymia) Low dose: 7.5 mg/46 mg 8.0% weight lossHigh dose: 15 mg/92 mg 10.5% weight lossSide effects: increased heart rate, palpitations, drowsiness, paresthesias, memory loss, confusionContraindicated in pregnancy (orofacial cleft)and recent/unstable CAD or CVDRisk evaluation and mitigation strategy (REMS)Qsymia available since Sep 2012: Qsymia was covered by about a third of the patients' insurance companies, with an additional $50 co-pay. For those without insurance, the weight-loss medication will cost about $150 a month in cash.Phentermine is a sympathomimetic amine that increases the release and reuptake of norepinephrine and dopamine. The exact mechanism of topiramate’s effect is being actively investigatedZonisamide 400 mg, produced a weight loss greater than placebo, an average 16 lb (7.3 kg) at 1 year,compared with 8.8 lb (4.0 kg) in patients receiving placebo.REMS: medication guide, pt brochure, voluntary formal training program for prescribers (teratogenicity nad stress contraception), specially certified on-line pharmacies (in mid-April certified retail pharmacies) to dispense it.
23Medications Lorcaserin (Belviq) 10 mg bid selectively activates 5-HT2C receptors on anorexigenic neurons in the hypothalamus decreases eating and promotes satiety4.5% - 5.8% weight lossSide effects: headache, dizziness, fatigue, drowsiness, nausea, dry mouth, constipationContraindicated pregnancy, caution CHFJust came out June 7. Belviq's wholesale cost is a little under $200 a month, however, the price patients pay will all depend on their insurance coverage.Previous drugs fenfluramine and dexfenfluramine removed from market because of cardiac valvulopathy- due to activation of seotonin 2B receptors on cardiac interstitial cells.
25Number of Bariatric Surgeries Performed American Society for Metabolic and Bariatric Surgery
26IndicationsBMI >40 kg/m2 or BMI >35 kg/m2 with an associated medical comorbidity worsened by obesityFailed dietary therapyPsychiatrically stable without alcohol dependence or illegal drug useKnowledgeable about the operation and its sequelaMotivated individualMedical problems not precluding probable survival from surgery
31Rubino F. Annals of Surgery • Vol 244, Nov 2006 The Foregut TheoryExclusion ofDuodenum from transit of nutrientsprevents secretion of signal that promotesinsulin resistance and DM type 2Rubino F. Annals of Surgery • Vol 244, Nov 2006
32Sleeve Gastrectomy A gastric tube of 60 to 120mL is created Induces weight loss by 2 mechanisms: 1) Mechanical restriction 2) Hormonal modification1)…by resecting the greater curvature of the stomach2)…by removing a great part of the Ghrelin production tissue
33Sleeve Gastrectomy Long Term results n=53, av. follow-up 6 yrs%EWL57 %New GERD21 % (3% preop)Leak4.9 %MortalityHimpens J. Ann Surg 252: 319–33
34Preoperative Morbidity Bypass versus Band908070605040302010BypassBandResolution%DMHTNDyslipidemiaOSAPreoperative MorbidityTice J. Am J Med. Vol 121,34
35Comparison of Bariatric Surgery Meta AnalysisBand%SleeveBypass%EWL495763DMRemission4783Mortality0.210.6Morbidity3397Vit Def3258Buchwald, H. JAMA 200435
36Bariatric Surgery versus Intensive Medical Therapy Change in BMIIntensive medical therapyGastric SleeveGastric BypassSchauer P, NEJM 2012
38Long-term complications Short-term complications: stomal stenosis, incisional hernia, marginal ulcer, constipationCholelithiasisDumping syndrome: abdominal pain, N/V, diarrhea, tachycardia, flushing, dizzinessVomiting/GERD from pouch distentionStomal stenosis: persistent vomitingUlcer along surgical anastomotic site: hematemesis, melena: long term avoidance of NSAIDsConstipation: poor fluid intake, malaption, avoid granular bulking agentsCholelithiasis: common consequence of rapid weight loss (Cholesterol is activated from fatty tissue and secreted into the bile, leading to both cholesterol supersaturation and diminished gallbladder contractions)- occurs in up to 50% of patients (prophylactic cholecystectomy or use of bile salt therapy- ursodiol)Dumping syndrome: procholinergic symptoms from malabsorptive procedures, influx of undigested carbohydrates into the jejunum.Vomitting: cutting food into small portions, chewing food thoroughly, eating slowly, waiting 1 hour after meal before drinking anything.
39Long-term complications Nutritional deficiencies: Calcium/Vit D, iron/folate, B vitamins, protein, potassium, MgPanniculitis: antibiotics, skin hygiene, surgical excisionMalabsorption of oral meds: avoid extended-release meds- use rapid release or oral solutionsExcess skin can weigh 22 to 33 pounds
40Laboratory Testing Follow-up period Laboratory Tests Every 3 months x 1 yearCBC, glucose, creatinineEvery 6 months x 1 yearLiver function tests, protein and albumin, iron studies, vitamin B12/folate, calcium, Mg, vitamin D, PTH if hypercalcemicEvery year afterwardsAll of above
41Diet Adequate protein: 80 g per day Eat slowly, chew thoroughly, cut foods into small piecesAvoid fluids minutes before, during and after mealsAvoid carbonated drinks/using strawsAvoid very dry foods, breads, fibrous vegetables
42Supplements Supplement Restrictive Malabsorptive Calcium citrate 1,500 mg/day1,500-2,000 mg/dayElemental iron18 – 27 mg/dayMultivitamin with mineralsOne/dayTwo/dayVitamin B12350 mcg/day po500 mcg/day SL1000 mcg IM monthlyVitamin D400 to 800 IU/day2,000 IU dailyVitamin supplementation will be required throughout the patient’s lifetime.
43Pregnancy after Bariatric Surgery Wait monthsMonitor nutritional status and deficiencesThoroughly evaluate GI symptomsWomen with dumping syndrome may not tolerate 50-g glucose testAvoid NSAIDs during postpartum periodShould not affect labor and deliveryWait months before conceiving so fetus is not affected by rapid maternal weight loss and so the patient can achieve weight-loss goalsGI problems common in pregnancy require thorough evaluation and consultaion with bariatric surgeon to determine whether they are related to surgery.