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Medical Management of Obesity

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1 Medical Management of Obesity
Nirav Rana, MD Bariatric Surgeon Bariatrx Jeanne M. Ferrante, MD, MPH Associate Professor Robert Wood Johnson Medical School Family Medicine and Community Health

2 Disclosures Dr. 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.

3 Objectives Identify patients who would benefit from surgical intervention for the treatment of obesity and its associated co-morbid conditions. Discuss the clinical benefits of bariatric surgery Discuss the long term management of patients after bariatric surgery

4 Trends 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.

5 The 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.

6 Determining Treatment
BMI Treatment Healthy Lifestyle Healthy Lifestyle; Medications if additional risk factors Intensive Behavioral Therapy; Medications; Surgery if BMI > 35 and co-morbidities > 40 Intensive Behavioral Therapy; Medications; Surgery

7 Treatment Options Correct underlying metabolic problems
Diet, exercise, behavioral therapy Medications Optimize current medication Anti-obesity medications Bariatric Surgery

8 Diet and Exercise Low calorie diet:  500-1000 kcal/d
Women: kcal/d Men: kcal/d Very low calorie diet: 800 calories or less 3-6 months (BMI > 50) Before surgery or long term wt-loss program Daily aerobic exercise ~ 60 minutes Weight training after aerobic goals met

9 Low-carb vs. Low-fat diet
Doesn’t matter what kind of diet Weight loss similar (11% at 6 and 12 months, 7% at 24 months) Decrease in blood pressures similar Decrease LDL and TG similar Increase HDL (20%) in low carb Weight loss maintenance low glycemic index, higher protein diet

10 Low Glycemic Index
Fruits- cherries, plums, grapefruit, peaches, prunes, apples, pears, grapes, oranges, strawberries- avoid watermelon Most vegetables except beets, pumpkin, parsnips Wheat pasta, egg fettuccini, spaghetti, brown rice, white long grain rice Avoid white bread, bagel, french baguette


12 Behavioral Modification
Self-monitoring Goal setting Stimulus control activities, cues, circumstances, and practices that favor nonmeal eating and snacking Eat most meals at home Drink 500 ml water before each meal Optimal 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): )

13 Preventive Counseling Codes
Obesity screening and and dietary counseling (V65.3) Exercise counseling (V65.41) CPT 99401 (15 min) 99402 (30 min) 99403 (45 min) 99404 (60 min) Use these if separate from a preventive visit Use -25 modifier if in conjunction with E/M service 99401 ~ $20 99402 ~ $40 99403 ~ $60 99404 ~ $80 Do not use obesity ICD-9 codes such as for these CPT codes

14 Medicare Coverage for Obesity
Intensive Behavioral Therapy (G0447) Primary care physician or NP/PA/certified clinical nurse specialist- face-face x 15 mins Up to 22 visits over 12 months Every 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 monhts 5A’s: Assess, Advise, Agree, Assist, Arrange Not separately payable with another encounter Since Nov 29, 2011, Medicare has covered intensive behavioral therapy for obesity with no deductible or co-pay. Payment is about $25 per visit Not separately

15 Medicare Codes BMI ICD-9 ICD-10 30-30.9 V85.30 Z68.30 31-31.9 V85.31
: V85.39 Z68.39 V85.41 Z68.41 V85.42 Z68.42 V85.43 Z68.43 V85.44 Z68.44 > 70 V85.45 Z68.45

16 5 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.”

17 Medications Optimize current medications Anti-obesity drugs
Short term: benzphetamine, diethylproprion, phendimetrazine, phentermine Long term Inhibits fat absorption: orlistat (Xenical, Alli) Decrease appetite phentermine/topiramate (Qsymia) lorcaserin (Belviq) Short term: 8-12 weeks, all sympathomimetic amines that decrease appetite Phentermine 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.

18 Optimize Medications Drug Alternatives Antidiabetic agents
Insulin; meglitinides; sulfonylureas (glyburide, glipizide); thiazolidinediones Acarbose (Precose); exenatide (Byetta); glimepiride (Amaryl); metformin (Glucophage); miglitol (Glyset); pramlintide (Symlin) Neurologic agents Anticonvulsants (valproic acid [Depakene], gabapentin [Neurontin], carbamazepine [Tegretol]); lithium Lamotrigine (Lamictal); topiramate (Topamax); zonisamide (Zonegran)

19 Drug Alternatives Psychiatric agents
Antipsychotics (clozapine [Clozaril], olanzapine [Zyprexa], and risperidone [Risperdal]) Monoamine oxidase inhibitors (e.g., phenelzine [Nardil]) Some SSRIs (paroxetine [Paxil]) Tricyclic antidepressants (amitriptyline, imipramine nortriptyline) Aripiprazole (Abilify); ziprasidone (Geodon) Tranylcypromine (Parnate) Bupropion (Wellbutrin); venlafaxine (Effexor); fluoxetine (Prozac) Desipramine (Norpramin); protriptyline

20 Drug Alternatives Blood pressure agents Alpha-adrenergic blockers
Beta-adrenergic blockers (especially propranolol) Doxazosin (Cardura) Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers; calcium-channel blockers; selective beta blockers Other corticosteroids Acetaminophen; nonsteroidal anti-inflammatory drugs

21 Medications Orlistat (Xenical, Alli)
Lipase inhibitor: inhibits fat absorption 120 mg tid during or up to 1 hour after meal Side effects: flatulence, oily stool, diarrhea, and stool incontinence Reduces absorption of fat-soluble vitamins and beta-carotene: take vitamins 2 hours before or 1 hour after meal

22 Medications Phentermine-topiramate (Qsymia)
Low dose: 7.5 mg/46 mg  8.0% weight loss High dose: 15 mg/92 mg  10.5% weight loss Side effects: increased heart rate, palpitations, drowsiness, paresthesias, memory loss, confusion Contraindicated in pregnancy (orofacial cleft) and recent/unstable CAD or CVD Risk 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 investigated Zonisamide 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.

23 Medications Lorcaserin (Belviq) 10 mg bid
selectively activates 5-HT2C receptors on anorexigenic neurons in the hypothalamus  decreases eating and promotes satiety 4.5% - 5.8% weight loss Side effects: headache, dizziness, fatigue, drowsiness, nausea, dry mouth, constipation Contraindicated pregnancy, caution CHF Just 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.

24 Bariatric Surgery

25 Number of Bariatric Surgeries Performed
American Society for Metabolic and Bariatric Surgery

26 Indications BMI >40 kg/m2 or BMI >35 kg/m2 with an associated medical comorbidity worsened by obesity Failed dietary therapy Psychiatrically stable without alcohol dependence or illegal drug use Knowledgeable about the operation and its sequela Motivated individual Medical problems not precluding probable survival from surgery

27 Obesity Related Conditions
Diabetes Hypertension Hyperlipidemia Respiratory disease Sleep apnea Depression Menstrual irregularity Cardiovascular disease Urinary stress incontinence Asthma/pulmonary disorder Gastroesophageal reflux disease (GERD) Degenerative joint disease (DJD) Congestive heart failure Gallstones Coronary heart disease Stroke Osteoarthritis Cancer Amenorrhea Polycystic ovary syndrome Infertility Dysmenorrhea

28 Preop Evaluation Nutritionist visits Psychological evaluation
Exercise Physiology evaluation EGD with biopsies for H. pylori UGI series IVC filter placement Cardiopulmonary evaluation Routine bloodwork Vitamin levels

29 Adjustable Gastric Band
Silicone band Encircles proximal stomach Purely restrictive procedure


31 Rubino F. Annals of Surgery • Vol 244, Nov 2006
The Foregut Theory Exclusion of Duodenum from transit of nutrients prevents secretion of signal that promotes insulin resistance and DM type 2 Rubino F. Annals of Surgery • Vol 244, Nov 2006

32 Sleeve Gastrectomy A gastric tube of 60 to 120mL is created
Induces weight loss by 2 mechanisms: 1) Mechanical restriction 2) Hormonal modification 1)…by resecting the greater curvature of the stomach 2)…by removing a great part of the Ghrelin production tissue

33 Sleeve Gastrectomy Long Term results
n=53, av. follow-up 6 yrs %EWL 57 % New GERD 21 % (3% preop) Leak 4.9 % Mortality Himpens J. Ann Surg 252: 319– 33

34 Preoperative Morbidity
Bypass versus Band 90 80 70 60 50 40 30 20 10 Bypass Band Resolution % DM HTN Dyslipidemia OSA Preoperative Morbidity Tice J. Am J Med. Vol 121, 34

35 Comparison of Bariatric Surgery
Meta Analysis Band % Sleeve Bypass %EWL 49 57 63 DM Remission 47 83 Mortality 0.2 1 0.6 Morbidity 33 9 7 Vit Def 32 58 Buchwald, H. JAMA 2004 35

36 Bariatric Surgery versus Intensive Medical Therapy
Change in BMI Intensive medical therapy Gastric Sleeve Gastric Bypass Schauer P, NEJM 2012

37 Long-Term Management after Bariatric Surgery

38 Long-term complications
Short-term complications: stomal stenosis, incisional hernia, marginal ulcer, constipation Cholelithiasis Dumping syndrome: abdominal pain, N/V, diarrhea, tachycardia, flushing, dizziness Vomiting/GERD from pouch distention Stomal stenosis: persistent vomiting Ulcer along surgical anastomotic site: hematemesis, melena: long term avoidance of NSAIDs Constipation: poor fluid intake, malaption, avoid granular bulking agents Cholelithiasis: 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.

39 Long-term complications
Nutritional deficiencies: Calcium/Vit D, iron/folate, B vitamins, protein, potassium, Mg Panniculitis: antibiotics, skin hygiene, surgical excision Malabsorption of oral meds: avoid extended-release meds- use rapid release or oral solutions Excess skin can weigh 22 to 33 pounds

40 Laboratory Testing Follow-up period Laboratory Tests
Every 3 months x 1 year CBC, glucose, creatinine Every 6 months x 1 year Liver function tests, protein and albumin, iron studies, vitamin B12/folate, calcium, Mg, vitamin D, PTH if hypercalcemic Every year afterwards All of above

41 Diet Adequate protein: 80 g per day
Eat slowly, chew thoroughly, cut foods into small pieces Avoid fluids minutes before, during and after meals Avoid carbonated drinks/using straws Avoid very dry foods, breads, fibrous vegetables

42 Supplements Supplement Restrictive Malabsorptive Calcium citrate
1,500 mg/day 1,500-2,000 mg/day Elemental iron 18 – 27 mg/day Multivitamin with minerals One/day Two/day Vitamin B12 350 mcg/day po 500 mcg/day SL 1000 mcg IM monthly Vitamin D 400 to 800 IU/day 2,000 IU daily Vitamin supplementation will be required throughout the patient’s lifetime.

43 Pregnancy after Bariatric Surgery
Wait months Monitor nutritional status and deficiences Thoroughly evaluate GI symptoms Women with dumping syndrome may not tolerate 50-g glucose test Avoid NSAIDs during postpartum period Should not affect labor and delivery Wait months before conceiving so fetus is not affected by rapid maternal weight loss and so the patient can achieve weight-loss goals GI problems common in pregnancy require thorough evaluation and consultaion with bariatric surgeon to determine whether they are related to surgery.




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