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Role of Private Bariatric Medical Centres ARE WE READY? Dr. Sean Wharton, MD, FRCPC Internal Medicine Wharton Medical Clinic Adjunct Professor – York University.

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Presentation on theme: "Role of Private Bariatric Medical Centres ARE WE READY? Dr. Sean Wharton, MD, FRCPC Internal Medicine Wharton Medical Clinic Adjunct Professor – York University."— Presentation transcript:

1 Role of Private Bariatric Medical Centres ARE WE READY? Dr. Sean Wharton, MD, FRCPC Internal Medicine Wharton Medical Clinic Adjunct Professor – York University Lead Author – Obesity Section - CDA Guidelines CABPS, June 2012

2 Disclosures Grants/support Grants/support CIHR CIHR Heart and Stroke Foundation Heart and Stroke Foundation MITACS – Research MITACS – Research Honoraria/Advisory Board Honoraria/Advisory Board Novo-Nordisk Novo-Nordisk Merck Merck Bristol Myers Squibb Bristol Myers Squibb Abbott Pharmaceuticals Abbott Pharmaceuticals Eli-Lilly Eli-Lilly AstraZeneca AstraZeneca

3 Objectives Discuss the current environment of community based bariatric medicine Discuss the current environment of community based bariatric medicine Example of a publically funded community based weight management clinic. Example of a publically funded community based weight management clinic.

4 Current Environment of Medical Bariatric Centres Tertiary Tertiary HGH HGH Ottawa Civic Ottawa Civic Edmonton Capital Region – Weight Wise Edmonton Capital Region – Weight Wise Community Practices Community Practices Commercial Commercial Weight Watchers Weight Watchers Bernsteins Bernsteins Herbal Magic Herbal Magic Evidence Based Practices Evidence Based Practices BMI (Bariatric Medical Institute) BMI (Bariatric Medical Institute) Wharton Medical Clinic Wharton Medical Clinic Family Medicine Practices Family Medicine Practices Yoni Freedhoff, MD

5 Questions? Community Based Bariatric Programs Standardization Standardization Funding Funding Meal Replacements Meal Replacements Programs, Partial Programs, Partial Family Doctors or Specialists Family Doctors or Specialists Team Team Dietitians, nutritionists (bariatric educators), exercise specialists, behavioural therapist, pharmacist, social work etc. Dietitians, nutritionists (bariatric educators), exercise specialists, behavioural therapist, pharmacist, social work etc.

6 Answers Community Bariatric Medicine Efficient System – demand is great Efficient System – demand is great Multi-disciplinary Multi-disciplinary Cost-effective Cost-effective Family/childhood obesity a priority Family/childhood obesity a priority

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9 115 Programs Analyzed 31 Surgical Programs 2 Surgical Assessment Centres 82 Non-surgical Programs 32 Community-based (group session, gym) 41 Primary Health Care (MD, nurse, dietitian) 7 Hospital-based

10 115 Programs

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12 ASPQ Criteria for Bariatric Programs Rate of weight loss Rate of weight loss Multi-disciplinary Multi-disciplinary Dietary intervention (without long term use of VLCD) Dietary intervention (without long term use of VLCD) Physical activity Physical activity Effectiveness Effectiveness Safety Safety Approach to advertising Approach to advertising Cost Effectiveness Cost Effectiveness

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14 Pharmacotherapy Pharmacotherapy 3/31 – surgical programs 3/31 – surgical programs 12/82 – non-surgical program (11 PC, 1 hosp) 12/82 – non-surgical program (11 PC, 1 hosp) BMI Criteria BMI Criteria 32/82 nonsurgical programs did not use BMI as entry criteria 32/82 nonsurgical programs did not use BMI as entry criteria

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17 Primary care based programs show the greatest compliance. Encouraging – most accessible Primary care based programs show the greatest compliance. Encouraging – most accessible Access to hospital-based non-surgical programs is extremely limited. Access to hospital-based non-surgical programs is extremely limited. Bariatric surgery facilites are lacking in psychological supports, and physical activity compared to non-surgical programs. Bariatric surgery facilites are lacking in psychological supports, and physical activity compared to non-surgical programs.

18 Long-term weight-loss maintenance: a meta- analysis of US studies 13 Studies (VLCD and HBD) 13 Studies (VLCD and HBD) 1081 pts - F/U – 4.5 years 1081 pts - F/U – 4.5 years Initial weight loss 30.8 lbs (14%) Initial weight loss 30.8 lbs (14%) Weight-loss maintenance 6.6 lbs (3%) Weight-loss maintenance 6.6 lbs (3%) 40.2% of patients maintained - 5% loss at 5 years NNT of % of patients maintained - 10% loss at 5 years NNT of 5 Anderson et al. Am J Clin Nutr, 2001

19 Wadden et al. NEJM; Nov 14, 2011

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21 Comments Enhanced most effective, - but even the MD alone and the lifestyle coach were effective Enhanced most effective, - but even the MD alone and the lifestyle coach were effective MD + Coach MD + Coach 1/4 pts lost > 5% BW 1/4 pts lost > 5% BW Enhanced Lifestyle Enhanced Lifestyle 1/3 lost > 5% BW 1/3 lost > 5% BW Greater weight reduction with attendance at lifestyle sessions (greater with free MR, meds) Greater weight reduction with attendance at lifestyle sessions (greater with free MR, meds)

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23 Important aspects of a weight management clinic Cost Cost medical supervision medical supervision frequent visits frequent visits no pressure/non judgmental no pressure/non judgmental emotional support emotional support nutritional support nutritional support convenient location with parking convenient location with parking

24 How frequently would you like to come to a professional centre for a weigh in?

25 Wharton Medical Clinic Weight Management Centre Launch – May 2008 Launch – May 2008 A large community based bariatric clinic – government funded – no charge to patients A large community based bariatric clinic – government funded – no charge to patients 9 Internists – 3 Nephrologist, 1 cardiologist, 2 ICU, 1 rheumatologist, 1 haematologist, 1 GIM 9 Internists – 3 Nephrologist, 1 cardiologist, 2 ICU, 1 rheumatologist, 1 haematologist, 1 GIM 1 Dietitian/15 Nutritionist (Bariatric Educators) 1 Dietitian/15 Nutritionist (Bariatric Educators) Behavioural Therapy Team/Physiotherapy Team Behavioural Therapy Team/Physiotherapy Team Research Staff Research Staff

26 Bariatric Educators Education/Qualifications Education/Qualifications BSc Nutrition (Guelph, UWO, Ryerson) BSc Nutrition (Guelph, UWO, Ryerson) Post WMC - 2 MDs, 2 Masters, 4 dietitian internship Post WMC - 2 MDs, 2 Masters, 4 dietitian internship Supervision/Quality Control Supervision/Quality Control Dietitian/MDs Dietitian/MDs 1/2 – 1/3 - salary of a dietitian 1/2 – 1/3 - salary of a dietitian Significant dietary concerns – referred to the dietitian Significant dietary concerns – referred to the dietitian

27 WMC Clinic Adults Adults BMI with 1 comorbidity, or BMI>30 BMI with 1 comorbidity, or BMI>30 ? Change this to BMI 27 – 40 with 1 comorbidity, BMI > 40 (no comorbidities needed) ? Change this to BMI 27 – 40 with 1 comorbidity, BMI > 40 (no comorbidities needed) Treatment of cardio-metabolic conditions Treatment of cardio-metabolic conditions Pharmacotherapy Pharmacotherapy Surgical Referral/Medical and Psychological Support/Pre and Post Op Management Surgical Referral/Medical and Psychological Support/Pre and Post Op Management

28 Wharton Medical Clinic May 2012 May ,069 pts (76% women) 19,069 pts (76% women) 3,734 pts current 3,734 pts current new pts/week new pts/week No waiting list No waiting list min GROUP education session at every visit min GROUP education session at every visit MD sees patient at every visit MD sees patient at every visit Visits q 1 – 3 weeks Visits q 1 – 3 weeks Metabolic and CV Risk assessment Metabolic and CV Risk assessment Evening Educational Classes Evening Educational Classes Aggressive Diabetes Management Aggressive Diabetes Management

29 WMC Program Flowsheet Visit #1 BE/MD Visit PMHX/Meds/Exam/ Weight Hx/Consent to research and Goals Visit #2 BE/MD Visit Initiate Meal Plan 500 calorie/day deficit Pedometer – walking Resistance bands/Aqua Organized eating Visit q 3- 4 weeks BE/MD Visit SUPPORT GROUPS Manage medically Diabetic management CV management Referrals Baseline ECG Bloodwork RMR GXT Wt, Ht, BMR, WC/HC Blood pressure WEEKLY WEIGH-INS ENCOURAGED – not billed to OHIP 1. FD - ASK 2. ASSESS 3. AGREE 4. ADVISE 5. ASSIST

30 BE #1 Notes

31 BE #1 Notes

32 BE #1 Notes Weight, Ht, BP, WC/HC

33 BE #1 Notes BE #2 Presentations

34 BE #1 Notes BE #2 Presentations BE #3 Individual visit BE #4 Individual visit BE #5 Individual visit

35 BE #1 Notes BE #2 Presentations BE #3 Individual visit BE #4 Individual visit BE #5 Individual visit

36 BE #1 Notes BE #2 Presentations BE #3 Individual visit BE #4 Individual visit BE #5 Individual visit

37 WMC - Lectures Educational Seminars Topics Topics How to complete a food journal How to complete a food journal Macro and micronutrients/label reading Macro and micronutrients/label reading meal plans/eating out meal plans/eating out diabetic meal planning diabetic meal planning Emotional eating Emotional eating stress and weight, body image, support group stress and weight, body image, support group Activity – pedometers, resistance bands Activity – pedometers, resistance bands

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40 RMR Machine

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42 Comparison of Group vs. Individual Treatment for Weight Loss: 6 months Group Treatment Preferred Non-Preferred Individual Treatment Preferred Non-Preferred Weight Loss (in kg) p <.02 Renjilian, Perri et al. J Consult Clin Psychol 2001; 69:

43 Barry at 404 lbs, BMI 60 Past Medical History Diabetes Type 2 OSA – CPAP Hypertension High Cholesterol Urinary incontinence Hernia - ventral Obesity Class III Developmental Delay Intertrigo Medications Metformin, Glyburide Ramipril, Lipitor

44 Barrys Weight Loss Graph

45 Barry at 231lbs, BMI lbs lost, 43% WL Current Medical Hx OSA CPAP turned down Diabetes type 2 Diet controlled Obesity Class I Current Medications No medications Off – metformin, ramipril, glyburide. Lipitor

46 Feasibility of a interdisciplinary program for weight management in Canada Sean Wharton MD; Sarah VanderLelie B.A.Sc; Saaqshi Sharma M.Sc; Arya Sharma MD; Jennifer L. Kuk PhD Canadian Family Physician, Feb 2012;852:32-8 Canadian Family Physician, Feb 2012;852:32-8

47 Descriptive sample Descriptive sample 1085 pts (3 months), 289 pts (6 months) 1085 pts (3 months), 289 pts (6 months) 77% female 77% female Age – years Age – years BMI – kg/m 2 BMI – kg/m 2

48 Number of Patients Disease Canadian Family Physician, Feb 2012;852:32-8

49 15.2% - Discontinuation of program 15.2% - Discontinuation of program 14% within first 3 months 14% within first 3 months 2.2lbs (1.8%) weight loss 2.2lbs (1.8%) weight loss Wharton et al. Can FamPhys, 2012;852: % - Discontinuation of program (no visit in 3 months) 14% within first 3 months 2.2lbs (1.8%) weight loss

50 Wharton et al. Can FamPhys, 2012;852:32-8

51 Prevalence of WMC Patients attaining 5% and 10% Weight Loss (18 months) 1,562 patients

52 Discontinuation (no visit in 3 months) 28.9% (N=452) lost 4.3 kg ± % ± 5.0 of BW 31% - 5% weight loss 11% - 10% weight loss 8.4 ± 3.0 visits over 7.5 ± 1.4 months

53 Results- Prevalence of MNOB and MAOB BaselineFollow-up Prevalence (%) Clinical cutoffs Sub-clinical cutoffs Number of metabolic risk factors

54 Percent Weight Loss (%) Sex Ref Female Male Data adjusted for independent variables: sex, age group, BMI class, education, ethnicity and smoking status and treatment duration) Unadjusted data

55 Age Group * Ref Percent Weight Loss (%) ** * Unadjusted P trend = Adjusted P trend = >64

56 Weight Lost (kg) BMI Category Ref * Unadjusted P trend < Adjusted P trend < OW OBCI OBCII OBCIII

57 BMI Category Ref Percent Weight Loss (%) Unadjusted P trend = 0.60 Adjusted P trend = 0.84 OBCIII OBCII OBCI OW

58 Education Less than HSHS or GED CollegeUniversity Ref Percent Weight Loss (%) Unadjusted P trend = 0.46 Adjusted P trend = 0.33

59 Weight Lost (kg) Ref * * * WhiteAsian Other AFHeritage Ethnicity

60 Bariatric Educators (BE/nutritionists) Bariatric Educators (BE/nutritionists) Similar to Wadden NEJM study Similar to Wadden NEJM study Affordable staff with nutrition degrees – overseen by dietitian and MDs Affordable staff with nutrition degrees – overseen by dietitian and MDs MD has medical-legal responsibility for the BE MD has medical-legal responsibility for the BE BEs frees up time for the physician to concentrate on managing medical comorbidities BEs frees up time for the physician to concentrate on managing medical comorbidities Visit frequency correlated with greater weight loss Visit frequency correlated with greater weight loss Wharton et al. Can FamPhys, 2012;852:32-8

61 Next steps for Wharton Medical Clinic Research Current Studies Current Studies Comparison metabolically normal obese vs metabolically abnormal obese (submitted) Comparison metabolically normal obese vs metabolically abnormal obese (submitted) Economic analysis of effectiveness data Economic analysis of effectiveness data Analysis of attrition rates Analysis of attrition rates OSA in patients unwilling to use CPAP - randomized to GLP1 analogue vs placebo OSA in patients unwilling to use CPAP - randomized to GLP1 analogue vs placebo PGX fibre in diabetics (placebo controlled) PGX fibre in diabetics (placebo controlled) Application of model to family medicine clinics Application of model to family medicine clinics

62 Recent publication for the Wharton Medical Clinic

63 Research in non-surgical bariatric medicine We are obligated to complete research in this area – we are still in our infancy. We are obligated to complete research in this area – we are still in our infancy.

64 Conclusion and Questions Statement: Community based bariatric medicine is necessary Statement: Community based bariatric medicine is necessary Question: How are we going to pay for it? Question: How are we going to pay for it? Statement: Results from WMC are promising Statement: Results from WMC are promising Question: How can it get better, more efficient and even more cost effective Question: How can it get better, more efficient and even more cost effective Are we Ready for community based practice? Are we Ready for community based practice? Do we have a choice? Do we have a choice?

65 Thank You! Sarah Vanderlelie, BSc Sarah Vanderlelie, BSc Jennifer Kuk, PhD Jennifer Kuk, PhD Arya Sharma, MD Arya Sharma, MD Saaqshi Sharma, MSc Saaqshi Sharma, MSc Rebecca Liu, MSc Rebecca Liu, MSc Marcia Villafranca Marcia Villafranca Blair Leonard, MD Blair Leonard, MD WMC Team WMC Team


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