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Medical Management of Obesity Nirav Rana, MD Bariatric Surgeon Bariatrx Jeanne M. Ferrante, MD, MPH Associate Professor Robert Wood Johnson Medical School.

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Presentation on theme: "Medical Management of Obesity Nirav Rana, MD Bariatric Surgeon Bariatrx Jeanne M. Ferrante, MD, MPH Associate Professor Robert Wood Johnson Medical School."— Presentation transcript:

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 976-2010 Trends in Obesity Prevalence 1976-2010

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6 Determining Treatment BMITreatment 25-26.9Healthy Lifestyle 27-29.9Healthy Lifestyle; Medications if additional risk factors 30-39.9Intensive Behavioral Therapy; Medications; Surgery if BMI > 35 and co- morbidities > 40Intensive 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: 1200-1500 kcal/d Men: 1500-1800 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 Doesnt 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 http://www.the-gi-diet.org/lowgifoods/ 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

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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)

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)

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 5As: Assess, Advise, Agree, Assist, Arrange Not separately payable with another encounter

15 Medicare Codes BMIICD-9ICD-10 30-30.9V85.30Z68.30 31-31.9V85.31Z68.31 : : : 39-39.9V85.39Z68.39 40-44.9V85.41Z68.41 45-49.9V85.42Z68.42 50-59.9V85.43Z68.43 60-69.9V85.44Z68.44 > 70V85.45Z68.45

16 5 AsExamples AssessTell me what you typically eat for breakfast. How much activity do you do on a typical day? AdviseKeep a food diary and decrease your calories to 1200 a day. AgreeWould you agree to a low carb diet? AssistHeres a handout on low glycemic index foods. ArrangeCome back to see me in 1 week so we can see how youre doing. Lets 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)

18 DrugAlternatives 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) Optimize Medications

19 DrugAlternatives 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 DrugAlternatives 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 corticosteroidsAcetaminophen; 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)

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

24 Bariatric Surgery

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

26 BMI >40 kg/m 2 or BMI >35 kg/m 2 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 Silicone band Encircles proximal stomach Purely restrictive procedure

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31 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 A gastric tube of 60 to 120mL is created Induces weight loss by 2 mechanisms: 1) Mechanical restriction 2) Hormonal modification

33 %EWL57 % New GERD21 % (3% preop) Leak4.9 % Mortality0 Himpens J. Ann Surg 252: 319–324 2010 n=53, av. follow-up 6 yrs

34 Tice J. Am J Med. Vol 121, 10. 2008 Resolution % Preoperative Morbidity Bypass Band DMDyslipidemiaHTNOSA 90 80 70 60 50 40 30 20 10

35 Band % Sleeve % Bypass % %EWL495763 DM Remission 476383 Mortality0.210.6 Morbidity3397 Vit Def03258 Buchwald, H. JAMA 2004 Meta Analysis

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

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

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

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

41 Diet Adequate protein: 80 g per day Eat slowly, chew thoroughly, cut foods into small pieces Avoid fluids 15-30 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/day1,500-2,000 mg/day Elemental iron ---------18 – 27 mg/day Multivitamin with minerals One/dayTwo/day Vitamin B12--------- 350 mcg/day po 500 mcg/day SL 1000 mcg IM monthly Vitamin D400 to 800 IU/day 2,000 IU daily

43 Pregnancy after Bariatric Surgery Wait 12-24 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

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